Case Studies in Public-Sector Leadership: How to Help Peer Workers Succeed

The initial e-list responses were mostly supportive of peers working alongside those treating them at the same clinic. One respondent remembered a conversation with one of the first peer worker graduates hired by her program, who was a former patient. The respondent noted how strange it seemed to be having lunch with her as a peer. “There was shared laughter . . . and things went fine.” Another psychiatrist and self-identified consumer mentioned having no problems supervising people who were her current or former patients. She argued that this situation has existed for eons. Her three supervisees, who were also her patients, had initially wanted to seek treatment at another mental health center rather than the one at which they worked. However, there was no one else in the community willing or able to treat them. When the e-list respondent knew that she would be supervising the new peer workers, she asked them whether it would be all right. She said that hiring former patients as peer workers was a hallmark of recovery: “It is our duty to do this.” A third e-list respondent commented on the rarity of peers being directly involved with prescribers and thought that a peer worker would be in the best position to give personal testimony about a prescriber’s helpfulness and compassion.

In contrast, one psychiatrist was concerned about the potential for abuse, such as if a peer worker were hired at a lower wage than others for performing the same tasks. Another e-list respondent pointed out that because the use of peer staff has become a politically correct approach, much useful discussion of the difficulties involved has been precluded. He questioned why value is now placed on a person’s being “out” in regard to prior or current experiences with mental illness and expressed concern that traditional staff play by one “rule book” vis à vis boundaries while peers are held to a different standard. Another psychiatrist who works with peers said, “We will not hire folks getting their care here. I realize it is a problem in smaller areas, but any employee is responsible for doing a competent job. If he or she can’t, then the person shouldn’t have the job. Reasonable accommodation is the law, but if one prioritizes the need to support peer counselors over the need to provide quality care, then I would question the priorities of the organization. If the response is that the employee is a patient, one has entered a murky morass.”

There were two contrasting responses related to stigma. One respondent said, “I cannot imagine this conversation occurring in any other area of medicine. A cardiologist not treating his partner? Until conversations like this end, the problem we have is stigma, pure and simple. Our own stigma toward the illnesses we treat.” The other respondent said, “There is much ethical commentary . . . about treating someone with whom you have another relationship. . . . It can impair your objectivity, and if anything goes wrong, it can be emotionally devastating. This is not an issue of stigma, but one of setting up the best situation for competent care.”

Meetings were held at the WSC to discuss the issues outlined above with HPC clinical staff and administrators and with peer workers—some employed by HPC and some not. Almost all of the peer workers expressed feeling comfortable working alongside the nonpeer members of their treatment teams. Two peers described themselves as essentially open books and said that a large part of their work is wearing their history on their sleeves. As part of raising the issues, the program director and I presented examples of conflicts that had arisen at WSC in the recent past. Both administrators and peer workers were able to see how the dual roles of peer workers had given rise to conflicts. The need to actively involve everyone in discussions and thoughtfully consider issues from both the peer and nonpeer perspectives was emphasized. Peers were encouraged to seek counsel from local peer organizations and to decide how they would like to proceed with any concerns. Nonpeer staff were asked to consult with each other to accomplish the same goal.

The e-list discussion has made me feel more comfortable working in a clinic where peers work alongside nonpeer staff. It has also made me aware of my discomfort working with peer workers in our clinic who are treated by other providers in our clinic. It has been reassuring to learn that by using ongoing, clear, and open discussions, leaders in the field have made the situation work and that peer staff and nonpeer staff have thrived.

Many small towns have limited treatment options, and employing peer workers to work alongside the treatment team may be unavoidable. The situation offers staff the opportunity to grow from successes and failures, particularly when open and thoughtful discussions are the norm and can help mitigate possible harm. The discussion has begun, and we hope it will not end soon. To stop learning from those around us is to stop moving forward.

The author acknowledges the support of the American Association of Community Psychiatrists for access to its e-list.

The author reports no competing interests.