Dear Mad In Ireland Agony Aunt
I am writing because I am frustrated by the consequences of the mental health system
introducing peer support as a “nice to have add on” to their existing bio-medical menu of
services. On a good day, I want to say, “I know you mean well, but…” Most days it comes
out more like, “I know you want to save money, exploit cheap labour, or slash waiting lists,
but…” It seems to me that there is an inadequate understanding of what peer support is,
where it came from and why it was needed in the first place.
So let’s start with the basics and, to be clear, this is Peer Support 101 from the perspective
of activists and movement leaders NOT the service based definition. Because, let me tell
you, what I see being referred to as peer support within the mental health system is not peer support. So, lets start from the very beginning, a very good place to start (Von Trapp,
1965).
Peer support grew out of the user, survivor, ex-patient, Mad movements and was about a
desire, a need for more humane ways of supporting people. New ways to make sense of our experiences outside of the dominant, bio-medical perspective.
Here are some definitions from international peer leaders (many of these people have been
my mentors in my own peer support journey):
Shery Mead emphasises that peer support is not about fixing, but a “process of giving and
receiving support founded on key principles of mutuality, shared power, and respect.”
(Mead, 2014). Shery Mead believed that peer should should be based on:
● Mutual learning
● Building relationships
● Moving through uncertainty.
By Shery’s definition, peer support is transformational, not transactional. Darby Penney
consistently situated peer support as “people who have been through similar experiences
supporting one another in ways that challenge traditional power relationships and create
space for growth, connection, and change.” (Penney, 2018). She believed that peer support
should be:
● A practice embedded in social justice
● A way of challenging medicalised, deficit-based and pathologising approaches
● Rooted in collective experience rather than being seen as professional expertise.
Mary O’Hagan, an activist from Aotearoa. New Zealand now in Australia reminds us that
“peer support is a relationship where people draw on lived experience to support each other
in ways that are mutual, non-hierarchical, and based on shared humanity.” (O’Hagan, 2010) states that peer support should be:
● Built on equality and shared power
● Relational, not role-based
● A resistance to co-optation by the mental health system.
Sally Zinman (1986) was always clear that peer support:
● Must be voluntary
● Must not replicate professional hierarchies
● Is grounded in self-determination.
Peer support should not be viewed by systems and services as a clinical intervention or
professional helping role. Peer support should be community building, uphold human rights
and the intention should be to bring about wider social change. And herein lies the challenge when peer support is adopted by and integrated into systems that are hierarchical, coercive and individualistic. So, which one changes – does peer support adapt and dilute its values to fit into the existing paradigm or does the system change to be relational, social justice focused and voluntary? The answer to this often sits with “who holds the power?” and we all know the answer to that one, right?
Here’s my plea to mental health executives, leaders, funders, service managers and coin-
counting bureaucrats: peer work is not here to solve your underfunded, dysfunctional
systems. It is not a cheap fix for decades of neglect, harm and coercion. It is not an
opportunity to offload the human cost of your failures onto people who have already barely
survived the very services you now employ them to deliver.
Your actions—well-intentioned or not—are causing real harm: re-traumatisation, moral injury, and burn out for peer workers who are already carrying enough. So here is my request (well I feel it is more of a demand…): Hit pause. Reflect. Ask Why? And stop using peer support as a way of patching up the problems you refuse to properly fund or take time to understand.
The primary reason to integrate peer support into existing mental health systems should be
to dismantle and disrupt a system that, frankly, isn’t working. Imagine if psychiatry were held accountable to the same KPIs and outcome measures used to justify its funding. Where is the evidence supporting the dominant biomedical approach? Its been a couple of centuries since the mental illness model emerged—and with the DSM and ICD psychiatric bibles partnering with big pharma—shouldn’t we all be cured by now? Peer support grew out of the need to move away from coercive and harmful approaches during deinstitutionalisation. It was never the intention to be embedded within them.
Before implementing peer support, systems and services should make a commitment to
becoming more relational, less risk focused and more grounded in social justice. Peer
support is not supposed to be comfortable or easily slot into the existing paradigm. If peer
support doesn’t feel uncomfortable or jarring for the psychiatric system, it’s probably not
being practiced with fidelity.
I believe there are some core, values-based reasons that systems and services should
introduce peer support. They are:
- There is a commitment to providing care that is rooted in human connection and authentic, mutual relationships, rather than control and compliance
- There is a desire to dismantle power structures and disrupt the authoritarian, clinician-as-expert model
- The service is moving away from pathologising human distress and towards experiential, socially grounded ways of understanding suffering
- There will be a significant change – to learn, transform, and fundamentally re-imagine the purpose and practices of services
- You will radically shift the culture away from misuses and abuses of power and coercion
- You want to acknowledge your role in violating people’s human rights and dignity
- You are entering a period of intentional reparation by transferring power and control to those most harmed by systemic injustice
- This is an act of social and political change aimed at equity, liberation, and justice within our communities
- You are transforming so that people who are marginalised and oppressed are no longer disproportionately harmed by the system itself.
If, however, the reasons for introducing peer support into systems and services are any of
the following:
● To save money
● To have a cheaper workforce
● To plug a gap in the existing system
● To give people something to do while waiting for “the professionals” to intervene.
● To increase the compliance of service users.
Then please, just don’t.
Thank you, with love and hugs from Scotland
Lisa Archibald
Hi Lisa.
Thanks for a superbly well-informed article. I respond only for myself and with my experience of peer support in the HSE in Ireland. I took it to be, that you’re writing about a system co-opting peer support, rather than individual peers not working well enough in their roles.
I read your article and listened to the podcast above it regarding peer support in the services. I’ve subsequently had a few conversations with peer colleagues.
My reflection is that many peer support workers wrestle with the concepts you’ve written about on a regular basis. Many question the, “are we influencing the system or being influenced?” It’s most likely both.
I think that most peer support workers still adhere to the definitions by Shery Mead, Mary O’Hagan and Sally Zinman you referenced. Do I regularly challenge the status quo? Yes but not nearly as much as I’d like. However, by virtue of being here on the ground, in the acute units, in community teams, attending care plans, (when/if requested by the person we are working with), I am challenging business as usual. Sometimes this challenge takes the form of a more formal disagreement, sometimes not.
On no day will I attend work and finally convince the psychiatrist that their entire framework is incorrect, and we need to dismantle it. Sometimes I have wins or else I wouldn’t keep coming back. I know many colleagues who fought hard every day. Fought everything, every time, everyplace and had to leave the role due to burnout. Am I, who stay, complicit in the system? Yes. Have I who stayed been involved in change of the system for the better? Yes.
What’s the alternative, if we all leave will the system improve on its own? Or by us trying to intervene externally? Have I had uncomfortable conversations with MDT colleagues? Yes, but I always made a point of asking them about their holidays or made small talk after. I’ve always tried to never make it personal.
Have the peer relationships become transactional? I’d say no, on a micro/individual level but on a macro/wider level, I am being paid so yes it involves an inferred transaction. The same could be said for private peer support outside of statutory services. Apologies if I’ve taken that up wrong.
Peer work, in the HSE at least, has probably evolved into a bridge to community (a good thing in some opinions) as well as a bridge to the services (a bad thing in some opinions). Like the services themselves, peer support workers are not a homogenous group. There are, have been and will continue to be bad services. There are also bad peer support workers. I’d hope to see, at least initially, a parallel system of peer led care, (the beginnings of which I think I see in some countries), however, many of these systems in existence pass over to the traditional system once it becomes “high risk” or involves forensics. And some of those systems are only evolving because, despite having budgets to do so, they cannot recruit “traditional” MDT members and waiting lists are growing.
The question we are left with, should peer support be in services at all? If I reflect on the improvements I’ve seen in almost a decade of peer work in the HSE, and I think we’ve been a major part of that. My answer is yes. Could we be doing more elsewhere like G.P/primary care, again my answer is yes. Would I prefer to have an alternative non-pathologising peer led system of care? Yes.
Is the system saving money by employing cheap peer work? Yes, in one way. Most of the peer workers I know feel undervalued for the work they perform. Less remuneration compared to others. Less annual leave compared to others. But I know that every peer support position has to be fought for to be funded and implemented. There doesn’t seem to be anyone saving money by hiring cheap peers in lieu of some other discipline.
Until we have that non-medical, non-pathologising alternative option, I’ll stay here and try to improve this one.
Best wishes Feargus.
Thanks Feargus. I appreciate you sharing your thoughts.
I actually think that peer support is humanising the existing system and I am veering increasingly towards being an abolitionist.
Just like the witchcraft trials died out as a dominant system used to maintain social order for a couple of centuries, psychiatry will die out too. And we will look back in disgust at how we allowed people to be treated in the say way we are disgusted that women were tortured and killed as witches.
But as long as we continue to prop it up and support the harm it causes through coercive “treatment” we are prolonging the inevitable.
Its time for new compassionate and collective ways of supporting people to grow in momentum.
Here in Ireland services that deal with distress have been co opted by health services and an infamous ‘mental health’ organisation that deals with framing depression as an illness of the brain. These peer support workers have sold their soul and are inadvertently doing harm. Promoting such organisations as they are linked to where they are working. Hearing peer support workers evangelise about peer support is naive. Their hurts are used, they are used as staff. Darren McGarvey wrote in the Trauma Industrial Complex about how people with lived experience are used. Peer support workers have drank the cool aid, instead of being revolutionary and creating real safe spaces they’ve chosen against that. It’s similar to counselling and psychotherapy here in Ireland there’s a huge push for that to be more compliant with the medical model, CORU regulations will eventually force that.
Thanks Katie – I love Darren’s work too. Its incredibly powerful and makes it clear to see how transactional and performative lived experience has become when it is embedded in systems.
So beautifully said!! Yes yes yes, thanks Lisa for sharing this with us all. Articulating such important messages so well and capturing the heart and essence of our Why and continue to show up 🙂
Thank you, Donna. I am a big fan of you!