Peer Support - day to day, moment to moment

Being on a ward for twenty-four hours a day, means the influence of clients on each other is much greater than that of staff. You learn to communicate very rapidly because you have no choice. What remains incomprehensible speech and bizarre behaviour to staff, becomes more and more understandable amongst peers. What looks like nonsensical behaviour to the outsider who spends most of their time away from the ward makes sense to those within it. Equally amongst new workers, what might be called a ‘myth of inarticulacy’ grows up. There is no sense to the client’s world, when viewed by those who are confident that they are ‘normal’ and living in the ‘real world’, therefore the obligation remains with the client to fit-in by making themselves understandable - staff come to have a an ethnocentric outlook. And the only way out for the client is to start performing for the staff; you learn what it takes to get what you want, and do your best to manipulate the situation you find yourself in.

If you start from the position of never knowing outcomes, and of most encounters happening by chance, then the focus of informal peer support can be positively framed in terms of; what can I do today that might make a difference? The chance element gives flexibility, freedom and autonomy, but does not imply a lack of commitment or responsibility. Most obviously, you don’t have to be nice to whoever walks through the door! Greater honesty and less role-playing are possible, but equally you can be more emotionally and intellectually honest with yourself. You can observe real client confidentiality; not record or pass on information to other staff or mental health services. There can be a free exchange of information; you can give advice when you feel it is appropriate (especially about the competency of mental health staff and the value of different medications). You can walk away at a time you deem appropriate, whether it be after five minutes, five hours, five days or never! You can express feelings of emotional attachment towards other clients and use touch if it feels appropriate.

Many client’s ‘fear of madness’ is less than that of staff; you can discuss topics staff are often uncomfortable with, particularly self-harm, certain psychotic behaviours and suicide. You don’t have to stop anyone doing anything, or start anything you don’t want to. You can ‘work’ anywhere, anytime. You can use any ‘therapeutic’ techniques learnt over the years, in therapy or as a patient on hospital wards, to bring some temporary relief to others in extreme mental distress. And there is a greater ‘spirit’ of equality; you retain credibility with other service users, no one is paying you to be there; time and expertise are freely given, and in times of your own distress gratefully received. But in part the effectiveness of informal peer support is dependent on a willingness to stay within the ‘world view’ of your fellows and therefore sometimes look ‘mad’ to others. So the consequences of being responsible and loyal, can lead to longer periods of confinement and disapproval or censure from mental health professionals.

Peers are often harder on each other than workers are towards their clients. Sharing common experience often means less opportunity to delude oneself. Divergence in experience means that although the process of informal peer support may seem very similar to common forms of counselling when the subject is mild anxiety or depression, methods increasingly differ when it comes to communicating about psychosis, self-harm or suicide. This becomes apparent when attempts are made to formalise peer support. The devising of rules of good practice, the regularising of contact between people who would otherwise not choose to meet, and the assumption that anyone can learn the ‘appropriate’ skills, leads to systems that look very like the kind of therapy they were intended to replace.

For the service user there is only one thing worse than the sinking feeling you get when you realise that others are saying they hear what you say, but are looking upon you as ‘mad’; and that’s the moment when you express suicidal thoughts and the worker stops listening, at the same time as insisting on not leaving your side - until you stop sharing those thoughts!

For all mental health workers and the vast majority of the public there can only be one ‘model’ in response to expressed suicidal thoughts and that is ‘prevention’. And yet eventually everyone must be left alone. If your model is prevention then over a long career you must inevitably accrue a series of failures. But within that approach workers share ‘responsibilities’ and seek to support each other, whilst ideally enlisting other workers to support the carers of a client.

Although negative ‘outcomes’ are sometimes known - all outcomes remain unknowable beyond today! More often information on how clients are doing is simply lacking. And in terms of personal outcomes, a ‘helper’ never knows the actual contribution they have made to a client’s decision to act, whether it be in a way they regard as positive or negative. For a peer (someone who has shared similar experiences to the client) to seek to ‘prevent’ a suicide usually seems nonsensical; not only is it obviously impossible, but you know from past experience that at times it is something you have positively desired. Besides, what preoccupies your peer, is what might be called the issue of ‘is life worth living?’ What my experience of trying to be supportive has taught me; is that you end up trying to help someone come to a decision for themselves, free of the pressures they feel from the other people in their lives. You know a decision to live or die must be made by and for oneself - only then can it be powerful enough to carry you, either out of despair, or over the fear of death and the pain of dying. For the worst outcome is another ‘botched’ attempt, whereupon the cycle of despair simply beings again.

You walk away, preferable leaving them alone, when you judge yourself to have had the optimum impact on their freedom to choose. Clients confide in their peers for a reason, often for the confidentiality and understanding you can give because you are not staff. Much peer support is ‘unseen’ because the client chooses a time and place away from staff, relatives and carers. Clients do ‘intend’ to kill themselves, it is the most real solution there is to intolerable psychological pain. They fail because of incompetence. They then learn from experience, as do those who seek to prevent them. But it requires effort and organisation, energy and clear headedness.