Peer Specialists in the Mental Health Workforce: A Critical Reassessment

Since its origins during the late 1980s, the use of peer specialists in traditional mental health agencies has grown tremendously. There are now an estimated 30,000 people with psychiatric histories employed in such positions across the country.¹ The term “peer specialist” was coined nearly 30 years ago in a federally funded research and demonstration project in the Bronx, New York. ² The position was created for workers with a psychiatric history who were trained to provide peer support and to assist people in developing self-help skills, support systems, and strategies to deal with emotional distress and extreme states.³ The goal of establishing this role was to bring genuine peer support to people receiving traditional community-based mental health services. “Peer support” was defined as a “reciprocal process through which people with shared experiences support each other’s healing and growth in the context of community.”⁴

The Bronx Peer Specialist Project came about at a time when the US federal government invested considerable funds to demonstrate that bringing “consumers” into the mental health workforce and supporting “consumer-operated projects” would have a transformative impact on the wider system and that service recipients would benefit from this type of engagement. While some of the projects showed that former psychiatric patients could provide support services like any other staff, the Bronx Peer Specialist program was first to demonstrate that peer workers’ personal experience directly correlated with certain improved outcomes for people receiving services.

Following this early enthusiasm,⁵ states began to implement a variety of programs for hiring peer specialists in various mental health settings. Based on our experience in the Bronx, New York became the first state in the nation to approve a non-competitive civil service position under the title “Peer Specialist” in 1993, based on an analogy with counselors who had relevant personal experience in the substance abuse field.

Over the intervening years, it became clear that being trained and hired as a peer support worker/peer specialist offers opportunities for people with psychiatric histories who might otherwise not have found their personal career path, as well as for those who benefit from participating in peer support. And yet, the inherent difficulties of working as a former patient in the system became apparent early on, but this did not result in serious consideration of how to address these issues. Recent research on peer workers suggests that these staff are often used to carry out paraprofessional and even menial tasks within traditional mental health programs, rather than provide genuine peer support. In most situations, relationships between peer staff and service users are construed hierarchically, in contradiction to the horizontal relationships of grassroots, user/survivor-developed peer support. Staff based in traditional mental health agencies are seldom exposed to the principles and practices of peer-developed peer support, nor do they usually receive supervision from seasoned peer experts. Cooptation of peer staff, where peer support values directly conflicted with the practice and beliefs espoused by the people in charge of those work settings, was frequently mentioned by peer workers, but never led to substantive changes in hiring and employment practices.⁶

One of the key concepts of peer support is that it must be voluntary, and such voluntariness is anathema to many, if not most, mental health services.⁷ There are indications that peer workers are increasingly being employed in situations where people are being coerced into “treatment,” secluded and restrained, and forcibly medicated. The original idea of peer workers was never meant for them to work under such conditions. For example, peer workers are frequently employed on Assertive Community Treatment (ACT) teams, which are coercive by definition. In addition, research found that peer staff are often required to perform tasks that conflict with peer support values, such as pressuring clients for medication compliance, reporting clients’ behavior to clinicians, and enforcing adherence to outpatient commitment orders.⁸ As a particularly notable example, Kings County Medical Center in Brooklyn, New York, one of the largest providers of emergency and inpatient psychiatric services in the country, hired many peer workers in a settlement with the US Department of Justice after the wrongful death of Esmin Green in their psychiatric emergency admission unit. While these peer workers may indeed facilitate the usually involuntary admission process, they are certainly not empowered to advocate for ethical and effective alternatives.

Recently, Resilience Inc., a “wellness” consulting firm run by Lori Ashcraft, the founder of Recovery Innovations and an early promoter of the expansion of peer specialists in crisis settings, announced that it is merging with Crestwood Behavioral Health of California. According to Ashcraft, “95% of people in their facilities are on involuntary holds.”⁹ Such a development epitomizes the ethical quandaries facing peer workers and will likely cause serious conflicts with respect to their commitment to the values of empowerment and rights preservation. It is apparent that, increasingly, traditional community mental health organizations and hospitals are using peer workers to create the appearance of a recovery orientation, human rights compliance, or community integration. This is an exploitative practice which will undermine peer workers’ ability to provide peer support and advocacy.

We believe that the time has come for a comprehensive reassessment of the practice of hiring peer specialists in traditional mental health programs, and for a moratorium on hiring people with psychiatric histories in coercive environments. This should include inpatient units and psychiatric emergency rooms, as well as mobile crisis and ACT teams, and other programs that do not have the capacity or dedication to provide alternatives to involuntary interventions. Such a moratorium would be an opportunity to reconsider and articulate the most ethical and mutually beneficial role for peer workers.

Rethinking the role of peer specialists would also be an opportunity to establish a dedicated funding stream for independent peer advocacy, provided by peer-run programs or other non-clinical organizations. A peer advocate is a person with a psychiatric history trained in mental health law and policy whose role is to represent the interests and desires of a mental health services recipient who voluntarily requests his or her services.¹⁰ Peer advocates can actively support people who want to reject coercive interventions and help them identify alternatives of their choice. They can also assist people working on crisis plans and advance directives. Peer advocacy has been part of some peer-run programs for over two decades, but its impact on mental health services remains largely unknown.¹¹ Looking at the research on peer support, it is clear that not only have researchers failed to define peer support in a way that is consistent with the definition of genuine peer support, they routinely conflate peer support with peer advocacy. Thus, there is not a reliable body of research on the outcomes of peer advocacy.

There is a history of peer advocacy from which we can take inspiration, a legacy of the early consumer/survivor ex-patient movement. Probably one of the stronger peer advocacy projects of the time was the Oakland Independent Support Center, run by Howie the Harp, who subsequently came to New York where he began to put together an autonomous peer specialist training program, the development of which was curtailed by his early death. In New York State, other local groups, including the Mental Patients Liberation Alliance, came together in the 1980s and 90s to provide advocacy services for people faced with involuntary commitment. The New York State Office of Mental Health implemented a policy in 1995 requiring all state-run psychiatric facilities to allow such advocates access to inpatients. In addition, New York funded peer advocates who were incorporated into federally funded Independent Living Centers for people with disabilities. It is time to seriously consider re-focusing our energy and resources away from placing peer staff in roles where they support the mental health system’s status quo, and toward the goal of making high-quality peer advocacy available to people faced with coercion by the mental health system.