This week The National Collaborating Centre for Mental Health (NCCMH) – a partnership between Royal College of Psychiatrists and University College London – released a draft of their proposed Peer Worker Competence Framework for Mental Health. It brought together various groups and departments, including Health Education England, to develop and expand peer support work with the aim “to support the mental health workforce, as outlined in the NHS Long Term Plan”.
It is an insult to the survivor movement and everything we value in peer support.
It would be impossible to sum up this 56 (!) page document – along with its 30 page supporting document – in a few sentences, so I won’t be going into the finer details in this blog. But among other recommendations, peers would “offer a recovery-oriented perspective” while carrying out coaching, group work, psychological interventions and contributing to care plans. This is something that’s become increasingly normalised in peer support work. A recent job description for a senior lived experience practitioner included the expectation that, “after a period of skill-swapping with their clinically trained colleague” they would provide psychologically-informed assessments, care-planning and treatment.
The framework also talks about embedding peer workers in specialist services, such as acute and forensic. An acquaintance who worked briefly as a Peer Support Worker at a mental health hospital had to undergo Prevention and Management of Violence and Aggression (PMVA) Training. PMVA training includes how to ‘safely’ restrain someone. Peer support work increasingly is asking those with lived experience to be nurses, psychologists or therapists in everything but name. It blurs the lines of responsibility about who provides care and why.
My most recent personal insight into NHS peer support was while I was under the care of the crisis team last year. I find the crisis team incredibly stressful, but because I was being threatened with the Mental Health Act, I accepted their involvement as the “least worst” option. The person doing the assessment suggested I see the Peer Support Worker in their team. I refused. They tried to persuade me. Apparently this person was “really special” and “could really get through to me”. I refused again. They tried to persuade me some more. I refused, more forcefully this time, and they finally got the message.
How is any of this staying true to the values of peer support? Is it really an offer of support when it’s an aggressive demand by an overstretched team? How can a peer stay true to the values of peer work when they are embedded in a team that by it’s nature sometimes uses detention and coercion? How often are NHS staff using Peer Support Workers to gain trust where they’ve previously lost it with patients, instead of addressing their own failures directly? Am I a peer worker if the majority of my job description is focused on ‘interventions’ and ‘treatment’?
How the hell have we got here?
The move to bring lived experience into mental health may have begun with noble intentions, but it’s been horribly exploited. I do not blame peer support workers themselves for these failings and believe they are just as in danger of being exploited as the patients they serve. But we are now feeling the effects of a system that actively refused to think through the implications of having lived experience in mental health, while ploughing ahead with embedding them uncritically in their services. This was done by design, not by accident. Too often peer support work in the NHS is used to plug gaps in overstretched and underfunded teams. Equality and mutuality, central to the values of peer support work, gets lost in a relationship that by it’s nature can never be equal. Are we really peers if you have access to my notes? How do peer workers deal with a conflict of interest between peer support values and the values of their employer? Why have divide and conquer techniques become a central tenet of peer support in services? It is co-option in the name of co-production.
In contrast to this version of peer support, I’ve received a great deal of brilliant ‘peer support’ through my involvement in the survivor movement, grassroots organisations and (despite their national mass-closure) at local drop-in centres. We don’t use the phrase ‘peer support’ much anymore – it has already been so co-opted by mainstream services that it often feels beyond repair – but that’s what I understand these experiences to be.
In this version of peer support we arrive at the conversation as equals. Recovery is neither a requirement nor an obligation – for either of us. I do not ‘coach’ or offer ‘interventions’ and am safe in the knowledge that they will never do the same in return. I can talk about experiences I wouldn’t share with mental health workers – peer or otherwise – because I don’t fear it being documented in my notes and shared amongst people I’ve never met. I am able to learn about the history of the survivor movement spanning 50+ years from people who have lived it. I gain strength from our conversations about this history, and about how we can use our collective knowledge to heal ourselves and, perhaps, society. I learn new ways of coping with my own struggles through understanding other peoples. Sometimes just having someone alongside me in my distress has made me feel less alone. Other times peers have been able to provide practical support and advice, for example, about benefits and navigating services. When I’ve faced mistreatment from mental health services, they have understood implicitly the trauma this can inflict. We are able to set boundaries and do our best to resolve conflict or disagreements authentically, without intermediaries. We are not a homogeneous group and we embrace that – our diversity is our strength.
Why are these voices no longer important in the debate about what a ‘Peer Worker Competence Framework’ should look like? Why is this the first we are hearing about a document that must have been meticulously planned for a considerable period of time? Peer support has been so badly co-opted by the establishment that it is no longer recognisable. If any of the major health and academic establishments currently claiming to be carrying out peer support work/consultancy really want to hear about what we value, the grassroots are here and ready to tell you.