Now we see it happen again: an apparently new term appears in the sky of psychiatry: “peer work”. It means that now ill people treat the ill; and what are the professionals, also called skilled persons, going to do? They are, of course, still allowed to treat, but where are the differences? Is a new type of cooperation and common treatment developing here or have we not already been doing it this way? By the way, peer-to-peer work is not a new invention but has been practiced for decades by those concerned. What is new in the current peer development is, on the one hand, the peers’ qualification due to special training programmes such as EX-IN and, on the other hand, a more personal cooperation of the people concerned and professionals. Have peers been healed of their disease? Definitely NOT, it is not a matter of healing, peers have learned to accept and handle their disease. A mental disorder no longer seems to be a final stop; it can also offer new, hitherto unforeseen opportunities. Psychiatry isn’t pursuing new approaches, is it? Is a cure no longer the highest good and the primary objective of treatment? What makes the difference now, whether mentally ill persons are treated by persons who are or were ill themselves or by persons talking about their professional experience? According to Bock psychiatry has been deemed an empirical science based on practical experiences. If psychiatry really wants to become an experiential science, not only professionals will have to be taken as a benchmark but psychiatry will also be required to turn to those who experienced and still experience borderline experiences. Is it possible that this radical opening-up to subjective experiences will give rise to a different mental health system? And who will benefit from it? Really the persons concerned or will institutions save money because their employees are cheaper? Various fears are spreading in people’s minds and have to be tackled urgently. Is our present psychiatry already prepared to handle the new obstinacy of the persons concerned? And what does obstinacy mean at all? Is everybody now allowed to do what he wants to? Will professionals have to give up their sole decision-making power? Will peers decide from their experience which treatment offers will make sense and which not? And what will happen to our understanding of proximity and distance, do we have to reconsider it, too? In the course of his education every skilled employee was taught the importance of professional distance towards the patient. However, what happens now when former patients suddenly become colleagues?
Now there are so-called peers in psychiatry, persons with psychiatric experience who act confidently and also move in “professional territory” now. They are also called recovery companions or experts by experience.
For skilled personnel it was not an unusual picture that peers had participated in teaching. But will they, in future, also be involved in direct patient treatment or perhaps in research and quality management? This sounds unusual. May the professionals perhaps have to face a change? Will it be less comfortable for us or even easier or can we possibly speak of a source of enrichment? If only we did not have these fears and concerns in mind. In fact, will skilled employees have to fear they may lose their jobs? Peers as low-cost employees? Or will we not, under any circumstances, be confronted with overtime? Do these “new colleagues” have a better qualification because they also know the other side? Anyway, what will these peers do all day long? Fortunately, our neighbouring countries, for example the Netherlands, have already gathered some experience. In Germany, there are about 200 recovery companions working for mental health services at present. They shall be interpreters, in the literal and in the figurative sense, they shall build a bridge for an equal relationship offer. For this purpose, a special “EX-IN” training programme was developed in 2005. EX-IN stands for Experience Involvement; it covers approx. 300 hours of training and comprises 5 basic and 7 advanced modules. During the basic and advanced modules an internship in a mental health service or an educational institution has to be completed. In the course of the training persons with experience in psychiatry have the possibility to reflect their own experience and to learn methods and background knowledge so that they can work in mental health services afterwards. The central idea is the development from I-to-we-knowledge. Here, I-Knowledge is to be understood as the awareness of how the person with experience classes his life story, what sense he sees and what strategies helped him. We-knowledge comprises among other things common experiences such as stigmatization or shock. Because of their own experience and their training they shall be in a better position to reach other persons concerned, to encourage them and foster the trialogue, the equal encounter of persons concerned, relatives and professionals. Is there a more effective way to combat the prejudice of the “obstinate lunatic” than acknowledging that these persons with their experience and the particular sensitivity could be helpful for other persons concerned? From an ethic point of view some other aspects have to be mentioned. Is it perhaps too much to ask of a peer, does a peer reach his limits faster than a professional and does it make any sense to deal permanently with the disorder? Whether with one’s own disorder or with that of other persons concerned. Where is the balance, the happy medium? Aristoteles described the pursuit of happiness as a virtue already long before Christ was born. An abundance of happiness or a lack of it, however, is described as a vice. Is peer work, thus, a kind of pursuit of happiness? Being happy in spite of one’s disease or maybe just because of it? Is it, at all, possible to be happy with a disease and to pass on this feeling to other persons concerned? This sounds like a long and difficult way, however, it seems to be possible. But what will happen if a peer himself experiences a new mental crisis? Will he be able to continue his work or will it be possible to treat him even on the same ward where he works? Will a treatment in a different institution be advisable? And who will decide on it, the employer or the peer himself? Present studies suggest that recovery companions are strengthened by their work and fall ill rather less often than other employees (Moran et al. 2012). The decision what should be done exactly, if a new crisis occurs, has to be best discussed by the employer and the peer in advance. By the way, what shall be the exact work of peers? In case of many services offered by persons concerned for other persons concerned the transfer of information and awareness-raising will be of central importance but, as already mentioned, also the shared experience. Especially in the field of inpatient (but, of course, also in the field of outpatient) psychiatry, where the persons concerned are often particularly strongly confronted with stigmatization, discrimination and discouragement, the feeling of solidarity and the experience of solidarity and appreciation obtain a special significance. Peers can offer coping and problem-solving strategies from their own experience. The contact to experienced persons can enable persons concerned to get new contexts and explanations presenting a counter-model to the sometimes hopeless and demoralising experiences with psychiatry. Moreover, an „expert by experience“ gives the impression that there is light at the end of the tunnel by the sheer fact that he is able to act as an adviser, companion or advocate. A peer can convey the message that even a life with a disease makes sense and that it is always worthwhile to fight for one’s personal happiness. His future fields of work can be manifold; e.g. he can lead different groups, participate in case supervision, leisure activities or in organisational development and quality management. But can professionals ever keep up with this exchange at „eye level“? After all, they have not had the same experiences; they are not concerned themselves and only draw on their alleged expert knowledge. But who is truly the expert now? The person who has learned the expert know-how during his education complemented, of course, by a number of training measures or the person who has really experienced and gone through all this expert knowledge? This is a difficult question. Does one thing necessarily have to rule out the other or can both be complementary and may both groups mutually benefit from each other? How shall the co-operation look like? Peers and professionals have the same task, is to say they have to accompany the person concerned in all phases of the individual recovery process. The purpose is to enable the persons concerned to accept themselves with their limitations. Therefore it is, for example, important to understand one’s own stigmatization tendencies which, by the way, neither professionals nor peers are protected against. Is it not possible that peers may give completely opposite advice than professionals? May they not even stir up the persons concerned against psychiatry and the staff working there? Are these concerns legitimate? Of course, there will be different opinions and attitudes; these are, in general, important for a team. Here, peers can introduce important aspects which the team will be able to discuss just the same way as always. An open and honest exchange is the key aspect. As everybody knows, this is not that easy because nobody likes to be exposed to criticism. Another point is that among professionals there are many persons who have experienced mental crises themselves. Why do they never talk about it? Wouldn’t it be a source of enrichment for the professional, even a door opener towards the persons concerned whom we treat. However, will we not break the professional distance we have learned tediously, no which we were taught, in all the years of our career? Can there not be a professional proximity, too? I think it would be a good step to reconsider this understanding of distance and proximity in order to contribute to a better mutual understanding. How can I expect that a person concerned tells me everything about himself as a matter of course while I do not reveal anything? In my opinion, this does not seem to be helpful to build a relationship. However, what support will peers need for their work? It is important that they are supported by leaders and can use supervisions regularly to be able to reflect the new experiences linked to their work. Naturally, the peer should also have a mentor in his working environment who accompanies him and gives him the necessary support. To fulfil the requirements and avoid misunderstandings peers need clarification regarding their own capacities, competences and powers. If the peers’ tasks are not exactly described, there will be the danger that they will adopt sadly well-known, traditional roles just in a new look. It does not make sense to introduce special treatments for them. Peers should comply with the same rules as the other employees. So concerns e.g. regarding the observation of professional discretion can be met directly. The question is, of course, who will be responsible to give the teams in which the peers will work in future the required safety? Here, in my opinion, the executives must take action. They must prepare their teams and provide information to avoid the emergence of competitive thinking and fears. Structural questions will arise, for example, if peers shall be present in team meetings and turnover briefings. How are the working hours specified in general? For a peer the definition of the remuneration will also play an important role. The integration of persons experienced in psychiatry can be considered as a type of organizational development; it requires an open-minded project culture whose most important criterion has to be the openness for a common learning process. Rose points out that the integration of peers will be most effective if “soft” changes at the level of organizational culture go hand in hand with „hard“ changes at the level of organizational structure. Important elements in realizing this goal are mutual respect, interest, courage, self-confidence of the parties involved as well as tenacity and endurance.
It is very clear that peers will bring modifications in our current mental health system. Concerns, worries and the large numbers of questions are legitimate but a solution can only found by trial and error. Professionals must have the courage to overcome their own limits and to be open for new ideas. Certainly, we, as professionals, will often realize that we find it very difficult to perceive and accept the peculiarities of others and to treat their obstinacy with respect. Decisions in the treatment setting have to be taken together. Who would be better qualified to assist persons concerned, to give them hope, to comprehend their obstinacy and to even support and advise them without the known professional distance unless those concerned themselves? Here, professionals will experience an additional support in their daily work which they might not have expected in such a way. Anyone who managed to overcome and handle his own disease is also in a position to pass this power along to other persons concerned. According to Bock it seems logical to assume that the help of those concerned for other persons concerned may bring about a new quality of support which is solution-oriented and realistic and not stigmatizing. Me too, I fully share this opinion. Of course, not everything will change. Naturally, there may be conflicts and problems. It may happen that those experienced overtax themselves on this road or go astray at times. And there will be professionals who thwart the efforts. It will take some time before everybody has found his personal place. New structures have to be created and some professionals must change their views. Peers are neither a threat to us nor competitors but clearly a source of enrichment. We can learn from them and, step by step, we can break down our acquired barriers of distance. We should give up obsolete traditions of thinking and see the experienced colleague not as an ill person who is restricted but as an equal employee with his own skills. By linking the peers‘ knowledge with the traditional knowledge it will be possible to create a new culture in psychiatry. New ways of support, the life experience as well as the experience in crisis management of all persons involved are given room to unfold and can be used as a resource. Every change creates resistance to change. For this reason, it is necessary to prepare this change in organization carefully and to accompany and reflect it continuously. The future road will continue in this direction. According to Bock we must get away from a purely deficient view of mental diseases towards more tolerance and community, more normality and diversity, more equality, courage, hope and, in my opinion, also to an improved acceptance of the personal perception of happiness. And this personal happiness does not have to meet the professional’s expectations. We, as professionals, should allow obstinacy to unfold so that, in the end, we can really speak of a more diverse relationship culture, perhaps even of fluid boundaries and of psychiatry as an experiential science.
Written by Anja Ross
Utschakowski, J. (2015). Mit Peers arbeiten (1st edition), Köln: Psychiatrie-Verlag.
Utschakowski, J., Sielaff,G., Bock, T. (2009). Vom Erfahrenen zum Experten. Wie Peers die Psychiatrie verändern (4th edition 2012). Bonn: Psychiatrie-Verlag.