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Peer Support in Mental Healthcare

Prateeksha Sharma (prateeksha.sharma@nalsar.ac.in) is with the Bright Side Family Counseling Center, Faridabad and does part-time doctoral research at the National Academy of Legal Studies and Research, Hyderabad.

“Peers” are a resource that can be tapped into to support a wide variety of people in the mental health system. These are people who have lived experiences of recovery in mental health. This kind of support offers the peers a meaningful work opportunity, financial and social empowerment, and consolidates their recoveries. It also helps those who are currently suffering by enabling them to experience a peer’s caring and supportive assistance, patient listening and helpful advice in view of the hurried and professional approaches of mental health professionals.

Persons with lived experience of recovery need to occupy senior leadership roles impacting social policy, system management, planning, education, programme development, and evaluation, according to Bryne et al (2018: 76). In citing evidence from many locations around the globe, where the recovery approach has been incorporated in the mental health systems, these authors investigate the role of people with lived experience in success of the recovery approach. People who have lived experiences of mental health are known as “peers,” and though peer support has been around in minuscule ways in India, herein lies a potential resource that can be tapped into to support a wide variety of people in two ways. First, it offers to the people who take on such roles a meaningful work opportunity, empowering them financially, socially and psychologically, while consolidating their recoveries significantly. Second, this potential workforce can have significant impact on people who are currently suffering by enabling them to experience a peer’s caring and supportive assistance, patient listening and helpful advice in view of the hurried and professional approaches of mental health professionals, who are often hard pressed to respond to large numbers of patients.

To understand the full potential of the role that peers can play in the recovery of individuals who currently suffer from mental health issues, one may want to cast a brief look at the historical development of this phenomenon. In its contemporary manifestation, the peer support movement began in the mid-1970s, in the United States (US), as ex-patients began to gather around the country and lobby collectively for reforms in mental healthcare and against the discrimination associated with mental illness that they had experienced. In addition to political advocacy, the origins of this movement were in the established tradition of self-help and mutual support, a tradition that permeates American culture (Davidson et al 2006: 443). Peers are persons with mental health conditions who, though without professional credentials, are employed as service deliverers in the mental health provider system. They are hired as role models, counsellors, educators, providers of assistance to meet the needs of daily living, and as advocates to empower people with mental health conditions (Gates and Akabas 2007).

The first thing that we derive from this is that the peer support movement developed in the US, in a politically robust climate of the mid-1970s, where ex-patients had been at the forefront of this development, which was later adopted by psychiatric services. The distinctive element of peer support is that it explicitly draws on personal lived experience of emotional distress (Repper and Watson 2012: 70). Davidson et al (1999: 165) draw attention to the fact that peer experiences could act to counter stigma and prevailing cultural stereotypes about mental illness, and might offer the person hope and motivation to work for a better future. Peer support benefits not only the person receiving support but also the peer support worker and the service they work in (Repper and Carter 2010; Moura et al 2014). There is sufficient evidence from many locations to reliably gauge that effects of peer support mostly lie in a positive domain, yet not entirely. Some of these locations are from Australia (Franke et al 2010), the United Kingdom (Wallcraft et al in Faulkner and Basset 2012), Japan (Miyamoto and Sono 2012), US (Pfeiffer et al 2011; Davidson et al 2012; Salzar et al 2013; Naslund et al 2016), etc.

Evaluating the role of peer support organisations in the US, Goldstrom et al (2006: 93) note that beliefs that recovery is possible, and that mental health consumers and families must be the drivers of decisions about what they need, are new in the policy climate prevailing in the US. The ultimate goal of a transformed mental health system of care is to provide community-based, resiliency-building and recovery-oriented treatment and support services. Extending this analysis beyond the US, to the countries of the Southern Hemisphere, Bryne et al (2018: 77) note that the recovery approach is largely confined to Australia and New Zealand. Citing evidence they remind that, “The remainder of the Southern Hemisphere, including Asia and South America, emphasises concepts of biological illness and external control of symptoms, predominantly through the use of medication.”

Experimenting with Peer Support

This brings us to India where peer support is at a nascent level, incubating within some non-profits and certain psychiatrist-led programmes. In an analysis of one such experimental venture which has been recently tested in Gujarat, Pathare et al (2018) provoked some ideas in the context of peer support and peer support workers. I would like to underscore and offer some countervailing ideas that I believe merit reflection.

I invite a little scrutiny of this triad: the recipient, service provider and service/organisation to ascertain whether peer support is likely to have similar outcomes in India, in the manner it has in the West. Further, I would like to contrast the model of peer support workers which Indian psychiatrists have given evidence of with available evidence from other locations.

Significantly, even though Pathare et al (2018: 3) propose peer support for India, they also point towards the problems they visualise in the implementation of the same. Some of these issues are lack of policy orientation towards recovery, absence of local evidence, asymmetrical power relations in the provision of mental health services, dominance of the medical model and under-resourced setting of mental healthcare. Despite this recognition they recommend peer support for India, identifying it as an “underutilised resource.” I think in this recommendation the ethos of peer support workers and their work has been misunderstood or given a short shrift for what it represents in other parts of the world. But since peer workers are being universally acknowledged as a big potential, the same is advocated for India. It cannot be forgotten that the only thing India has in common with other settings is a change in focus from institutional to community-based mental healthcare, a recent phenomenon at that.

As noted above, peer support began from the efforts of ex-patients—both towards supporting peers and supporting recoveries of people. Two things must be emphasised here. First, the Indian Mental Healthcare Act has been passed only in 2017. This act mentions about “fostering recovery,” and conceptualises it as a “clinical” recovery, as opposed to the internationally prevalent “personal” recovery (Pathare et al 2018). In other words, the act neither sees “personal recovery” as a reality or a goal worth pursuing, nor makes recommendations in that regard. Second, if there are any ex-patients in India they are not significant in numbers, nor are they a part of the mental health system anywhere. Whoever is a part of the system from the perspective of lived experiences are either caregivers, or current patients/consumers of psychiatric services. This also indicates another reality, namely recovery is neither widely occurring in India, or recognised as a goal, nor are ex-patients/users working in mental health in any significant or transformative manner. In the US, the challenge of transforming the nation’s mental health system with the goal of recovery has been set in motion from 2003 onward (Frederick J Frese III in Davidson et al 2010). In India the idea itself, in a nascent, professional version borrowed from overseas, has appeared on the horizon.

The Triad

The triad as I mentioned above is the service providers and the recipients as the core dyad. Going by what Pathare et al (2018) recommend, here is a case of psychiatric organisations (third arm of the triad) employing current consumers of mental health services, called peer support volunteers (PSVs), who are “individuals with lived experiences of mental illness who assist other service users with similar experiences in enabling their personal recovery (emphasis mine) by helping them in preparing recovery plans.” Conceptually, PSVs are meant to provide “hope for recovery, and show that it is possible to work despite a mental illness, which is important both in the battle against stigma and for social inclusion” (Franke et al 2010).

Two issues stand out in this model, being tested in Gujarat currently. First, by the employment of PSVs in the manner reported, Pathare et al (2018) foreground “personal recovery” as a goal. “Personal recovery” is not even a goal of the Mental Healthcare Act, 2017. Are they saying that they are already making recovery a goal the way it is internationally operational? Second, to me this seems to be a case of dual marginalisation by a socially powerful and dominant group (psychiatrists) of another group (current patients) in the name of employing them in low paying “jobs,” reportedly “empowering” both groups of patients simultaneously. The small sum of money, “to cover their travel and expenses (approximately $50 per month) and flexible working hours may give few a sense of solvency and/or respectability, yet it does not empower them either sustainably or socially, except giving them part-time employment on a variable, temporary basis. Neither does it give them any independent, employable skills—except for a narrow set of abilities for the miniscule work they are assigned, within the confines of psychiatry-led frameworks.

It begs the question, who could these people be, who are willing to work for $50 a month and why? Would they be the educationally advanced or school/college dropouts, women, elderly, or anyone in the working age group? Why would anyone accept employment at such low wages? Are these really the people who can help in anyone’s “recovery”? Are they really those peer supporters and activists who can become bridges for the recovery of others—when they are themselves so weak, that they have no bargaining power in the market for any employment? Does their labour not amount to anything meaningful, so that they ought to only be paid a travel allowance and an insignificant amount over that?

Notwithstanding the gains that expatients, activists or consumers of mental health services have made in the developed, Western world in rallying for their rights, inclusion and dignity, their replicas duplicated, adopted or developed in the developing or underdeveloped parts of the world are vastly different—in terms of their social bargaining ability, wage negotiating capacity and acceptability within their own communities. The latter have developed mostly due to stimulus provided by the socially dominant, educated, professional groups who create versions best suited for the dissemination of their own goals and professional practices. In the West, psychiatry has reoriented itself to focus on “recovery,” whereas in India the goal of psychiatry is to fill what is identified as the “treatment gap in mental healthcare” (Kaur and Pathak 2017).

This model, appearing to be empowering and inclusive only seems to empower the psychiatric community in terms of giving them an international respectability, and putting India at par with what is happening globally, at least theoretically. In reality, as another Indian psychiatrist reflects in another context, “the psychological sophistication of our patients, or the resources that we have to make the concept workable” (Sarin 2015: 120) makes the whole venture a significantly watered down version in its current form.

And here arises the question that Read et al (in Fabris 2013: 131) raise: “will peer services simply augment biomedical approaches that stigmatise, or will they advance self-help, self-advocacy, mutual aid, and choice?” I concur with Boyle and Harris (in Bryne et al 2018: 77) who say, “There remains a risk of tokenistic participation as long as power is not shared and the lived experience contribution does not have equal authority.” Are we in India anywhere close to a social reality where people with lived experiences will offer but a tokenistic presence?

References

Bryne, L, A Stratford and L Davidson (2018): “The Global Need for Lived Experience Leadership,” Psychiatric Rehabilitation Journal, Vol 41, No 1, pp 76–79.

Davidson, L, C Bellamy, K Guy and R Miller (2012): “Peer Support among Persons with Severe Mental Illness: A Review of Evidence and Experience,” World Psychiatry, Vol 11, pp 123–28.

Davidson, Larry, Matthew Chinman, Bret Kloos, Richard Weingarten, David Stayner and Jacob K Tebes (1999): “Peer Support among Individuals with Severe Mental Illness: A Review of Evidence,” Clinical Psychology: Science and Practice, Vol 6, No 2, pp 165–87.

Davidson, Larry, Jaak Rakfeldt and John Strauss (2010): The Roots of the Recovery Movement in Psychiatry—Lessons Learned, Wiley-Blackwell.

Davidson, Larry, Matthew Chinman, David Sells and Michael Rowe (2006): “Peer Support among Adults with Serious Mental Illness: A Report from the Field,” Schizophrenia Bulletin, Vol 32, No 3, pp 443–50.

Fabris, E (2013): “Mad Success: What Could Go Wrong When Psychiatry Employs Us as “Peers”? Mad Matters: A Critical Reader in Canadian Mad Studies, LeFrancois, Brenda, A, Robert Menzies and Geoffrey Reaume (eds), Toronto: Canadian Scholars’ Press Inc.

Faulkner, A and T Basset (2012): “A Helping Hand: Taking Peer Support into the 21st Century,” Mental Health and Social Inclusion, Vol 16, pp 41–47.

Franke, C C D, B C Paton and L A J Gassner (2010): “Implementing Mental Health Peer Support: A South Australian Experience,” Australian Journal of Primary Health, Vol 16, pp 179–86.

Gates, L B and S H Akabas (2007): “Developing Strategies to Integrate Peer Providers into the Staff of Mental Health Agencies,” Administration and Policy in Mental Health & Mental Health Services Research, Vol 34, pp 293–306.

Goldstrom, Ingrid D, Jean Campbell, Joseph A Rogers, David B Lambert, Beatrice Blacklow, Marilyn J Henderson and Ronald W Manderscheid (2006): “National Estimates for Mental Health Mutual Support Groups,” Self-help Organisations, and Consumer-operated Services, Administration and Policy in Mental Health and Mental Health Services Research, 33, pp 92–102.

Lawton-Smith, S (2013): “Peer Support in Mental Health: Where Are We Today? The Journal of Mental Health Training, Education and Practice, Vol 8, pp 152–58.

Kaur, R and R K Pathak (2017): “Treatment Gap in Mental Healthcare: Reflections from Policy and Research,” Economic & Political Weekly, Vol LII, No 31, 5 August.

Miyamoto, Y and T Sono (2012): “Lessons from Peer Support among Individuals with Mental Health Difficulties: A Review of Literature,” Clinical Practice & Epidemiology in Mental Health, No 8, pp 22–29.

Mourra, S, W Sledge, D Sells, M Lawless and L Davidson (2014): “Pushing, Patience and Persistence: Peer Providers’ Perspectives on Supportive Relationships,” American Journal of Psychiatric Rehabilitation, Vol 17, No 4, pp 307–28.

Naslund, J A, K A Aschbrenner, L A Marsch and S J Bartels (2016): “The Future of Mental Healthcare: Peer- to- Peer Support and Social Media,” Epidemiology and Psychiatric Sciences, No 25, pp 113–22.

Pathare, S, J Kalha and S Krishnamoorthy (2018): “Peer Support for Mental Illness in India: An Underutilised Resource,” Epidemiology and Psychiatric Sciences, Cambridge University Press, Vol 27, No 5, pp 415–19.

Pfeiffer, R N, M Heisler, J D Piette, M A M Rogers and M Valenstein (2011): “Efficacy of Peer Support Interventions for Depression: A Meta-analysis,” General Hospital Psychiatry, Vol 33, No 1, pp 29–36.

Repper, J and E Watson (2012): “A Year of Peer Support in Nottingham: Lessons Learned,” The Journal of Mental Health Training, Education and Practice, Vol 7, No 2, pp 70–78.

Repper, Julie and Tim Carter (2010): “Using Personal Experience to Support Others with Similar Difficulties—A Review of the Literature on Peer Support in Mental Health Services,” Downloaded from https://www.together-uk.org/wp-content/uploads/downloads/2011/11/usingpe..., on 20th August 2018.

Salzer, M S, G Calhoun, R E Loss, E Schwenk, N Darr, W Boyer, J Goessel and E Brusilovskiy (2013): “Benefits of Working as a Certified Peer Specialist: Results from a Statewide Survey,” Psychiatric Rehabilitation Journal, Vol 36, No 3, pp 219–21.

Sarin, A (2015): “The Curious Case of the Advance Directive in Psychiatry,” Indian J Soc Psychiatry, Vol 31, No 2, pp 119–22.

Updated On : 8th Jul, 2019

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