Monday, August 12, 2013

Peers of the Mental Health Realm

The last decade has seen a flood of peer counselors in the public mental health system in the U.S., the basic idea modeled, if loosely, on the the practice of recovered addicts becoming counselors in the alcohol and other drug (AOD) treatment field.  In mental health it has the added gain of making public mental health treatment a more humane and understanding place.  Psychiatric survivor activists have long called for this move.  If services are provided by counselors who have themselves experienced mental health problems and have been on the receiving end of services, then services will inevitably be rendered in a more sensitive and user-friendly manner.

These things are true as intended, but I feel the need to point out there is also a dark tangled mass of contradictions, uncertainty, and politics that inhabit the practice of peer counseling like a hidden cyst threatening to break open and poison the entire initiative.  As always, I find myself the voice of doom and gloom in the fantasy land of Mental Health where fake positivism, false prophets, and general quackery goes hand in hand with unicorns, pixies, and evidence base practices.

Peer counselors come to the public mental health field like faerie-activists waving their magic "recovery" wands.  They go to the dark places of mental health--think Shutter Island, Sucker Punch, One Who Flew Over the Cuckoo's Nest, and hundred other examples--and these peers turn the dark places into sunlit gardens of recovery with doors broken open to let the sunlight in and to let the inmates out to discover they were never mentally ill to begin with--it was all a lie made up by psychiatry and Big Pharma.

The only thing is, it’s just another lie really.  Let me give you a smattering.

1. Peers do not necessarily have special insight into the experience of individual mental health system users.

Mental health peers are self defined.  It has to be so for simple legal reasons.  A prospective employer is not permitted to ask about an applicant’s disability.  It is contingent upon the applicant to decide if she or he is or is not a mental health peer.

In the AOD field, addiction disorders are a straightforward set of behavioral categories that are bound by a single phenomenon: addiction.  Straightforward, relative to mental health anyway.  By contrast, mental health disorders cover so vast an array of human behavior patterns so as to be absurd.  What does it mean to be a mental health peer?  Does someone who experienced adult attention deficit have some kind of special insight into what it’s like to experience schizophrenia?  Or vice versa?  If that seems like a stretch, it’s because it is.

Imagine, if you will, a world in which medical peers--people who have experienced medical problems and have received medical treatment in their lifetimes--replace nurses in your doctor’s clinic.  Will a medical peer who has experienced medical treatment for eczema have some special understanding, gleaned from experience, into the medical needs of a patient with necrotizing fasciitis?  Sound preposterous?  Why then is the idea of mental health peers any less preposterous?

2. In mental health, recovery is a word without meaning.

One of the basic rationalizations for peer counselors is that a peer is a living example of recovery, a person with a mental health condition who has persevered, and met their therapeutic goals, and now can work productively as a peer counselor.

It stands to reason.  This rationale works very well in AOD services where peer counselors are the norm.  In that field, peer counselors have beat their addiction--they are in recovery--and they can help other addicts on the path to recovery through the wisdom of their experience.

Okay, that’s all well and good.  But.  In the AOD field, recovery is black and white.  You are either using, or you aren’t.  Recovery is tested and assured by urinalysis.

If you think mental health has a standard of recovery, you are mistaken.  Recovery, like the peer identity itself, is entirely self defined.  Anyone, and I mean anyone, can walk through the door and proclaim they are a peer and they are in recovery.  There is no testing and such claims are accepted at face value, at least at time of hire.  This literally true.

Sadly, I have seen peer counselors (and therapists and psychiatrists for that matter) with untreated axis II disorders do great harm.

3. The sudden, poorly thought-out growth in peer services is driven by feel-good politics.

This true statement does not discount the possibility of benefit from having peers working in the system, but, it does tell us something about the process that led to the current situation and can illuminate how preventable problems were allowed to fester.  The peer counselor initiative may have a grassroots origin in the consumer/survivor movement, but it came to fruition because of state legislatures and state level department heads made the decision that peer delivered services is a good thing and made it so through law and regulation that, if not mandates, at least incentivises the practice in many states.

System changes driven at the state level are seldom well considered.

4.  And it is powered by cost cutting.

Medicaid reimbursement for services delivered by a peer counselor is considerably less than reimbursement for services provided by bachelors and masters level clinicians.  This impacts state budgets.

Need I say more?


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  2. There is no evidence showing that licensed therapists have better outcomes or cause less harm than peer counselors, so if we're going to choose among different snake oil varieties, better to go with the cheaper one -- and the one with the more humane/egalitarian structure.

    1. Yes, you make a good point, and while I was pointing out the hidden agenda in the promotion of peers at the state level, I did not mean to suggest that mental health peers are not a very important and valuable way of helping people.