What, then, do we know thus far about the provision of services or supports that are uniquely based on—and therefore require—the person's own history of disability and recovery? Returning to , an example of such a possibility lies closer to the other end of the spectrum and is indicated by the letter “B.” This second alternative represents the case in which a person with a history of serious mental illness is employed by a mental health agency to lead peer support groups for others with serious mental illnesses. Following closely on the heels of peer-delivered case management, this has been an especially appealing service for many clinical providers to add as an adjunct to their existing services in an effort to become more recovery-oriented. As a hybrid between professional-led support groups and naturally occurring self-help, this practice shares some features of each, while lacking the reciprocity that is core to mutual support. In this case, the person may be attempting to facilitate the same kinds of activities that typically occur in mutual support groups in the community, all the while being a paid employee of the clinic. In contrast to professional leaders of support groups, this person also has his or her own experience of the condition shared by all of the other members. The fact that these groups are neither fish nor fowl can generate a significant amount of tension, confusion, and concern among both group members and clinical staff, as well as for the leader him or herself.
The issues of confidentiality and boundaries offer examples of such tensions. From the perspective of the group members, the leader is a peer who is expected to uphold the value of privacy traditional to self-help/mutual support, in which nothing discussed inside of the group is to be shared with others outside of the group. But from the perspective of the agency, the expectation is that the peer leader abides by the same standards of confidentiality held by other clinical and rehabilitative staff, with necessary provisions for breaches in cases of imminent risk to self or others. This kind of divided loyalty for the peer leader represents only the tip of the iceberg of the conceptual confusions that reside in such hybrid combinations of peer and conventionally based practices.
An even more potentially contentious issue relates to opposing views of boundaries and friendship. Peer support staff may be viewed more like friends than non-peer case managers or clinical staff for several reasons. First, by virtue of drawing on their own experiences and the lessons they have learned from their own challenges and accomplishments in living with mental illness, peer staff are not only allowed but are in fact expected to disclose personal information and to share intimate stories from their own lives. Unless they are confined to service settings, peer staff also are more likely to gravitate to non-office settings such as coffee shops, restaurants, or other public spaces for meetings with group members, spaces that traditionally have been associated more with friendship than with health care. It is finally important for clinical staff to appreciate that self-help/mutual support and consumer-run programs typically do not have prohibitions against friendship between members but rather encourage the support that occurs between people to transcend what are perceived to be artificial group or program boundaries. For peer support leaders hired by clinical agencies, this often poses an uncomfortable but crucial issue. Are they able to maintain friendships they may have had with other people in recovery prior to being hired by an agency that provides services to these same people? How can they succeed in being “friendly” toward their clients without actually becoming friends with them? Regardless of its importance to the agency, is this a distinction that even makes sense to the clients? Can peer staff accept support offered to them by the people they serve? If not, then does this not move them closer to behaving and functioning like non-peer staff? If so, then when is a chat over coffee a reimbursable service and when is it just a friendly interaction? Perhaps partly because of these very sticky and largely unresolved issues, we were able to find no empirical studies examining the effectiveness or utility of this increasingly common phenomenon.
Which leads us, finally, to peer support proper, indicated in the figure by the letter “C.” In peer support, as we are defining it, a person in recovery from a serious mental illness is employed to offer services and/or supports to others with mental illnesses. As in examples A and B, this person is a paid provider of care who enters into an intentional relationship with others with the aim of assisting and supporting them in their own recovery. Like A but unlike B, it is clear in this case that the person is not a paid friend and is only to disclose personal information when it is in the client's best interest (as opposed to for the staff member's own benefit). Like B but unlike A, however, it also is clear in this case that the services and supports that the person will provide will utilize explicitly his or her own experiences of recovery. The question begged by this definition, however, is precisely what services and/or supports the person is providing. Our challenge is to identify those specific interventions people in recovery can offer that are based at least in part on their own personal history of disability and recovery such that other people who do not share this history would be unable to provide them, or at least be at a distinct disadvantage in their efforts to do so. The question marks appearing in box “C” in the figure indicate that this is an area in which there is much still to discover about what these services might entail.
To begin, the mutual support literature suggests a list of possible functions that are based on the person's shared history, including the following: acceptance, understanding, empathy, and a sense of community, thought to lead to increases in hope, autonomy, efficacy, and assumption of personal responsibility; role modeling and the provision of concrete and practical information to promote vicarious learning, modeling, and enhancement of coping and problem-solving skills; and exposure to alternative worldviews, ideologies, and contexts, which offer cognitive and environmental antidotes to the isolation, despair, and demoralization many people experience as a result of their contact with conventional mental health services.14,38,39
As useful a starting point as these concepts provide, they represent activities and potential impacts that have yet to be operationally defined, not to mention subjected to measurement. There have been a couple of attempts to begin to do so, however, which we will consider briefly as suggesting directions for future research on this topic.