Implicit Messages in Mental Health Peer Specialist Work
by Steve Fedele
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I stepped onto the inpatient unit and looked around. I had previously been a patient here and, now, I was here for my first day of work. My head felt compressed and it was difficult to think, my heart was fluttering with anxiety and I wasn’t sure if I’d be able to do the work. I wondered whether anyone from my hospitalization was still working on the unit which also contributed to my anxiety. I successfully made it to the nurse’s station and I was asked by the charge nurse, “What does a peer specialist do?” After being asked this question, and not having taken the peer training yet, I wasn’t quite sure. I mentioned I was there to provide support for others who have also had mental health struggles. I knew I was there to help others get healthier, but I had no idea how. When I first started, I was well-versed in my own mental health recovery from writing and lecturing, but I had no formal training on how peers were supposed to function within the hospital. My education in psychology began empirically from clinicians and I worked for about six months developing more medical model based skills. Afterwards, I attended the peer training and I had more formalized instruction on how to operate as a peer specialist.
Being in a psychiatric hospital while also being a peer sent me many conflicting implicit messages. During peer training, there was a strong anti-psychiatry sentiment, which was difficult to mitigate. Some of the stories told during the training seemed to be relatively truthful and there was a galvanizing of peers to act on behalf of others who were on the units. However, I had a conflicting notion as well that I knew everyone who was clinical staff and they all took really good care of me and they were my friends, and along with this, I’ve had very good experiences with psychiatry that have saved my life.
When I first started out, I sided very strongly with the people being served as that’s how I identified which also made me feel I had to be more versed within the peer model. The peer model has a saying of “being in but not of the system” which really resonated with me. I remember working individually with a patient on one of our units. This person had divulged a lot of personal information to me and hadn’t been talking much with the team. I asked if he wanted me to forward along the information he had mentioned and he told me no. After telling the team that I couldn’t forward this information, there was an immediate conflict between the two models of care. I wanted to honor this person’s privacy and autonomy but was simultaneously told I had an obligation to divulge the information to the team, so there was no clear or imminent duty to report. I wondered how his ability to trust me, the team, or anyone else in his life would be affected if I broke his trust and forwarded our conversation. I felt split between the two models where the peer model wanted to honor the individual’s privacy and autonomy. Being between the two models from the start of the conversation and not having a set way of doing things put me in a bind. Within our conversation, there were no immediate safety concerns that stood out to me which kept me caught in between. I wondered what would be best for this person’s overall well-being? However, I later realized there may have been information within what he was saying that could conceivably tie into safety concerns, even if these were seemingly innocuous bits of information.
As time progressed and I saw the excellence in care being provided by the teams while using medical and clinical approaches, my stance began to shift. I had been in therapy for many years and I originally had difficulty seeing clinicians as people as my psychiatrist, who I will say is very good, would never divulge any personal information. However, after several months of working alongside the teams, my eyes were finally opened and I realized clinicians have lived experience as well, even if it’s not to the degree of having psychosis. After a while, I found myself firmly rooted in the middle of the peer model and the medical model. Neither one was right or wrong but there were many conflicting implicit messages I was sifting through in terms of how I was supposed to provide care.
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I remember talking with someone on one of our units who was really struggling and was incredibly frustrated with the team. There was a medication that they used to take which they weren’t being allowed to take anymore. I felt an emotional pull to support this person in their frustration. In retrospect, I think it was helpful for this person to have someone to vent to and who had been within inpatient care. When I reported to the team the frustration and anger this person was experiencing, I received an answer that I didn’t expect. Over time, the symptoms and feelings the person had been experiencing had changed, and their diagnosis had changed as well. It was stated if the team was to give this person a stimulant when they had been experiencing mania, this would be really poor medicine. A stimulant directly feeds into causing mania which was the rationale. This was an instance where my stance shifted towards the team. There’s been years of research published on responsibly administering medication and their stance and explanation held sound logic. However, the person at the center of concern did not understand the rationale for it. It made sense after hearing from the team the reasons for how the medication works. Here, I was originally in favor of what the patient was saying but after further explanation, I realized the team was correct. It was a situation where I realized there was more happening than I knew. I still sided with both sides as there was a deep frustration for the person at the center of concern while the team was also working towards responsibly helping this person to the best of their ability. I felt torn between where I should side.
After realizing taking one side or the other wasn’t working, I came up with a third option; bridging the gap and being on both sides. I made the realization that the peer model had ways in which it worked really well while the medical model does too, so I worked towards developing a hybrid skill set that incorporated the best of both worlds and allowed me to waiver back and forth to provide the best possible care. There was an instance where someone was involuntary hospitalized and was incredibly frustrated with the team having felt their freedoms were taken away. I sat and talked with this person for a good twenty minutes. I shared how I know everyone and everyone is doing their best and really does have your best interest in mind. I talked about how I wouldn’t work here if I didn’t think they were providing good care because I believe in quality care. The person’s stance began shifting but there was still doubt. He said, “You just do this work because you want to make yourself healthier.” I replied, “I do become healthier as a result of the work, but the reason I do it is because I’ve been through the pain of it and don’t want to see anyone else go through it.” After having this conversation, he was more agreeable with the team and the rest of the hospitalization took a better course.
I realized that, if someone is becoming healthier, we’re all doing something right and that this was the common goal for the person being served, the team, and for me. This commonality unified us, while of course, there were many others that did so as well. I found a great deal of alleviation emotionally realizing I don’t have to choose between models and situate myself within one vantage point or another. I can just sit and stay in the middle of the models and not make a consensus on where I stand. Tolerating the uncertainty of non-consensus and feeling comfortable with it took time. The learning point I derived from the experience was measuring progress in terms of how someone’s health is progressing, and realizing I could use both models at once. There were times where I wanted to use peer support models to provide care to someone but they weren’t as effective so I’ve developed and learned a number of clinical skills as well. I like to waiver back and forth and not root myself firmly in one particular stance. I sometimes identify as a peer; however, I don’t mold myself to one school of thought. Sometimes I just identify as a person at the hospital providing care to other persons. Other times I identify as a mental health provider. I realized having multiple schools of thought gave me much more flexibility in the tool set I have available in providing care and this has immensely helped improve the quality of care I’m providing.