Peer Specialists in Community Mental Health: Ongoing Challenges of Inclusion

Our case study underscores the uncertainties a hiring manager may face in discerning what qualities or characteristics are most important in a peer specialist—for example, specific diagnoses, a background similar to that of the patients with whom the peer specialist will work, or other relational or interpersonal qualities. Hiring managers may also grapple with the degree of disability they are able or willing to accommodate.

Our case also raises significant ethical questions regarding disclosure of mental illness as a de facto requirement of employment, often built into both peer specialist titles and job responsibilities. Although some employers head off potential misunderstandings by clearly communicating that prospective applicants should “feel comfortable disclosing or sharing their story,” the pros and cons of a decision to disclose—and concerns about the effects of disclosure and potential threats to self-identity and future career prospects—are rarely clear cut, and the ethics of mandating such disclosure are fraught. At least one state, Illinois, has opted to use the title “recovery support specialists” in place of “peer specialists” within its state certification program because the former designation does not automatically convey mental health status. Ethical inquiry may also raise questions about the rationale for mandatory disclosure among one class of workers (peer specialists) but not other providers who may also have personal experience of mental illness.

By definition, peer specialists have had experiences with mental health services, potentially both positive and negative, and likely have experienced mental health–related discrimination in some form (6). In addition to influencing self-esteem, negative past experiences may lead to heightened sensitivity to power differentials (particularly with providers), anger or resentment about past treatment, and strong feelings about perceived coercion. A peer specialist may identify more with patients than with providers, and providers may similarly view peer specialists as patients rather than as support staff, seeding subtle but powerful in-group/out-group dynamics in mixed teams. Although existing guidelines emphasize preparing all staff for the integration of a peer specialist, deeper tensions—including ramifications for an individual with negative past treatment experiences of working in a setting that may elicit difficult emotions and memories—easily go unaddressed. Because both internalized and perceived stigma can lead to greater emotional discomfort or relapse (7), even among those with ongoing support (8), appropriate procedures are needed to address the potential challenges that peer specialists and the staff who work with them may encounter. Additionally, decisions to use employment-related accommodations may be fraught for peer specialists who may feel that they risk exacerbating stigma or undermining perceptions of their competence. Meanwhile, supervisors may worry that offers of assistance risk offending or even discriminating against employees who may not want additional support. Since the disruptive behaviors in the case study happened in nonclinical settings, there was no direct impact on patients. However, any potential impact on patients should also be considered as the field works to shore up policy and practice. Finally, accepted best practices, such as mandatory disclosure of personal health challenges by peer specialists, should be more deeply researched on both ethical and empirical grounds, and worker identity implications should be carefully considered.

Our case also raises questions regarding the distinction between “true” misconduct, or disruption of the work environment, and misconduct directly tied to symptoms or disability. Such disruptions may unfold during nonclinical interactions with coworkers, as in our case study, or in the context of direct client work. From a legal perspective, ADA rulings have generally deferred to employers and held that the ADA provides no prima facie protections against firing or demotion when an employee’s behaviors disrupt workplace function in a way that cannot be accommodated without “undue burden.” Still, this legal situation does not address the deeper ethical and political challenges involved in negotiating such situations, especially in the case of peer specialists who are hired precisely because of their experience of disability. Supervisors must strike a difficult balance between upholding conventional expectations for performance and professionalism and probing the limits of disability-based accommodation, modification, and flexibility.

In our case study, other clinicians’ concerns also played a significant role in Shirley’s termination. Many people, including providers, are likely to have internalized at least some negative stereotypes about individuals with serious mental illness—associations that are likely to be triggered by behavior perceived as aggressive or hostile (9). The low-wage, entry-level status of peer specialists may also reinforce power hierarchies in which the de facto value of lived experience is minimized relative to professional expertise. As such, norms of peer specialist compensation and status may exemplify structural stigma (10). As sociologists have long argued, attitudinal and structural stigma are reciprocally related, and their synergistic interactions in organizational settings can be difficult to analyze.

General best practices in peer specialist hiring and support—for instance, detailed policy regarding accommodations, protocols for peer provider wellness plans, and steps for supporting employees through relapses and symptom exacerbation—might circumvent some of the problems that arose in our case. However, situations occur where disruption and disability overlap in confusing and complex ways, and decisions are likely to be overshadowed by structural and attitudinal stigma from providers in community mental health settings. Further development of best practices requires that we grapple with truly complex ethical and legal challenges.