Peer Support Work in the Face of Psychiatrisation: A conversation with Aimee Sinclair
Note: Discusses suicide.
I was sitting in the car, driving aimlessly, imagining how I could use it to end my life. I was under mountains of pressure in my professional life and it had taken me to breaking point. Having worked in the public mental health system, I was scared of accessing the public mental health system. To date, I’d been able to use private services and avoid it minus some voluntary community services.
Instead, I spoke to a colleague. A peer worker. I knew in doing so, there would be a shared understanding of distress and trauma, but also a shared understanding of the sociopolitical landscape that we work in. What’s wrong, and why we’re constitutionally wired to try and fix it. Often at all costs.
Peer work is little known and largely misunderstood. Often characterised narrowly as being a sharing of disclosures about ‘mental illness’, peer work is often included only where it assimilates to existing biomedical ideologies and constellations of power.
Aimee Sinclair is an expert in both peer work, and the work to limit peer work. Aimee is a PhD candidate at Curtin University and has written multiple publications (email below if you cannot access) on power structures that impact the theory and practice of peer work. I wanted to talk with Aimee to better understand their work and share it with you.
So, an impossibly broad question, but what is peer support work?
An impossible question with an impossible answer! Peer support has a diverse set of practices, knowledges and histories.
Very generally, peer support work within the Australian mental health system is understood as walking alongside someone who has similar experiences; of disabling distress, trauma and/or experience navigating mental health systems. It involves valuing experience as expertise; upholding the rights of individuals to define what they might need, and how best they might be supported. Whilst the mental health system may be beneficial to some, peer support knowledges and practices recognise that for others, ‘care’ has been, and continues to be, harmful. Similar to you Simon, during times of suicidal crisis, I’ve been scared to access the mental health system, and instead have turned to peers to support me through, knowing I would be supported in a way that didn’t take away my power, dignity or safety.
In Australia, peer support is increasingly being defined as a discipline, with a specific set of values and practices. Yet I think there continues to be a tendency for individuals to be employed within the Australian mental health system for their lived experience alone (particularly lived experiences that enable one to present as ‘recovered’), rather than their understandings and practices related to anti-oppressive care.
In my work, I try to conceptualise peer support work as something that is always ‘becoming’. That is, it is not one set thing or practice, but is rather always in motion, always becoming something new as people, processes and practices interact. I think its important that we continue exploring how best peer support work can develop to ensure socially just care and belonging.
In my research, I talked to a bunch of peer support workers, all of whom practiced and conceptualised peer support differently, at different times. There were some common threads; a recognition of humanity, a valuing of connection, and the importance of taking time to listen and understand. Several peer support workers spoke about the difficulty of being able to practice what they felt was vital to peer support within the confines of the mental health system, particularly within hospital/clinical environments.
How and why did peer support work originate?
Practices of peer support, sometimes referred to as mutual aid, have been around for-ever. I think its important when we talk about peer support work that we recognise there are multiple histories, and that more often a certain white, colonised history is prioritised at the expense of others.
Leah Lakshmi Peipzna-Samarasinha, in Care Work for example, describes how, with the arrival of white settler colonialism, for “sick and disabled Black, Indigenous and brown people…there was no state-funded care”, and such communities had to “find ways of caring for ourselves or being carers for by our families, nations, or communities”. Peer support practices have developed out of necessity, as a way to support one another outside of mental health systems that were either unavailable or experienced as harmful.
Peer support work, though as a formal occupation within the Australian mental health system, is relatively new. Whilst there are examples of consumer/survivor workers employed within the system during the 1990s, it wasn’t until The Fourth National Mental Health Plan (2009-2014) that a national policy called for the ‘establishment of an effective peer support workforce’. The hard work of activists, building on similar consumer/survivor movements in the UK, Canada, US, must be acknowledged for this progress towards inclusion. In the book ‘Peer work in Australia’, Meagher & Naughtin (2018, p.5) describe the process in which peer work in Australia progressed from a barely recognized ‘disruptive consumer led practice’ within the 1970s - 80’s to today’s situation whereby peer work is often mandated within mental health policy and practice. Whilst not specifically about peer support, Merinda Epstein has also written about the history of consumer work in Australia, and Lyn Mahboub about the history where I am from, in Western Australia.
One of the things you’ve written about is psychiatrisation and peer support work. What is psychiatrisation and what kind of challenge does peer work pose to it?
Psychiatrisation involves the ways in which distress, trauma and other experiences deemed deviant from the norm become medicalised; understood predominantly as a problem internal to an individual and in need of fixing. Psychiatrisation silences alternative ways of thinking and feeling about ourselves, our distress and others. The concept of psychiatrisation also recognises the ways in which certain groups of people are more likely to me labelled as ‘mentally ill’.
Psychiatrisation is closely linked in with other oppressive processes and structures within society, including capitalism, colonialism and heteronormativity. For example, numerous reports have documented the high percentage of trans youth who are more likely to want to end their life (I have not linked to these reports here as they often perpetuate psychiatrisation!). Psychiatrisation leads us to believe this is related to an individual’s internal capacities and processes, rather than the unfathomable exclusion and hate that trans youth often face on a regular basis.
I would like to hope that peer support work challenges these ideas by recognising and respecting a broad range of ways in which individuals understand their distress, and acknowledging the context in which experiences of distress and trauma are sustained. As you mention Simon, the peer worker you reached out to acknowledged and understood the pressures of the socio-political landscape that drove you to breaking point.
I also acknowledge that as peer workers working within mental health systems, it is easy for psy- ways of thinking, feeling and acting to infiltrate our thinking and practice. This is why practices such as peer supervision are important, so that we can continue to challenge psychiatrisation. I wrote a little bit about this in my chapter in ‘Peer work in Australia’.
You’ve written a lot about peer support work within mainstream mental health systems. In particular you’ve written about the challenges of ‘inclusion’. What are they?
As I mentioned before, I think of peer support as always evolving and changing as it comes to interact with different forces. Thanks to the enduring work of so many activists, peer support is increasingly incorporated within mainstream mental health systems through the employment of peer support workers.
These practices, policies, discourses of inclusion can have varied effects. We often hear of the positive effects of inclusion, and these are important. Those of us who have experienced peer support done well know how powerful it can be. So having peer support accessible within mainstream mental health systems is important.
However, I think its important we acknowledge that some of these inclusionary measures can have problematic effects, as well as how these effects can vary depending on relations with other systems including race, socio-economic status, diagnosis, gender and so forth. The mental health system works to constrain and contain peer support practices, such that they come to reflect the needs of the system rather than provide radical alternatives to care and support for people experiencing distress. Some of this is more obvious- for example, I have heard many examples of peer support workers being asked to support clinicians with restraint and medication compliance. Others are more subtle; influencing the ways in which we might think and feel. For example, becoming frustrated with people we are walking alongside because they are not “progressing” on their ‘recovery goals’.
Only certain people tend to get employed as peer support workers; thus there is potential for a divide to develop between those “well enough” to be peer workers, and those seeking support. Many peer support workers I have spoken to talked about needing to “perform” as well, so as not to risk judgement or discipline from others within the mental health system.
Through inclusion, there is risk that the mental health system doesn’t change, but rather certain individuals deemed ‘recovered’ are simply ‘included’ into the system asl long as we meet certain conditions.
There is also the risk through inclusion of peer support workers specifically, that funding for other important lived experience/peer work, such as systemic advocacy, as well as consumer/survivor led projects outside of the system, is diverted.
Are there things that systems leaders or middle-managers should do to address these issues?
I think its vital that leaders and managers deeply reflect on the value of peer support. Is your workforce learning from peer support workers ways in which systems and practices need to change, or are peer support workers simply being used as handmaidens to pre-existing practices and ways of thinking? Are there opportunities for sharing knowledge and practices?
How are peer support workers being supported? Educate yourself and your organisation on the myriad of workplace issues that peer support workers face, and what might be done about this.
Do all peer support workers have access to peer supervision or co-reflection spaces? Are peer support workers given access to resources, time, and support to think critically about how to provide support in ways that is just and care-full within a system that tends towards psychiatrisation?
How can you increase the diversity of peer support workers? Are you only employing individuals who have certain lived experiences and/or ways of understanding distress?
Workplace policies, forms, processes, objects such as Ipads, name badges, recovery stars, KPIs, all shape the way in which peer support workers do their jobs: and sometimes these have effects that are not in line with peer values and practices. Provide space for peer support workers to critically reflect on this, and listen to them when they say things need to change.
Employ leaders with lived experience who have a commitment to social justice and anti-oppressive practice!
What is the role of universities and ‘the academy’ in addressing these issues facing peer support workers?
In my article I co-wrote with my PhD supervisors, we talk about the ways in which research can replicate some of the issues regarding inclusion. Research addressing peer support workers needs to centre knowledge from individuals with lived experience during all aspects of the research: from conceptualisation of the ‘problem’ being investigated, through to design, analysis and recommendations. I also argue that the inclusion of lived experience is not enough. We need to think critically about how our thinking and actions are shaped by dominant forces such as psychiatrisation.
Knowing that this shouldn’t sit primarily with peer support workers to fix, do you have any advice or reflections for them?
You are right. I think its important that we acknowledge that peer support workers are just one part of a much wider assemblage of forces that impact how support is understood and practiced within the mental health system.
I am concerned by thinking (which also happened to be partially my thinking not so long ago) that peer support work is not as important as the work done at a systemic level by activists and advocates.
When we are in pain, in distress, navigating multiple systems of oppression – connection is vital. Non-pathologizing support is vital. Its literally lifesaving.
We need to remember this.
Doing this work is tough. We are underpaid, undervalued and often provided little time, support and resources to critically reflect on the way we connect with, and support others.
Seek out community, whether face to face or online: spaces like Mad studies reading groups, podcasts, Alt2Sui groups.
I have often found comfort in remember I am just a tiny, tiny part of a movement that has a long history, and there are people all over the world doing this work. It is okay to rest sometimes.
Learn from diversity of lived experiences that differ from your own.
