Former or even ongoing mental health patients are a huge asset to learn from to improve our systems. Survivors of inpatient and outpatient mental health care are best placed to understand the strengths and challenges of these systems. This can only happen when lived experience roles are created and empowered to have a real voice in our systems and have the knowledge and tools to make sure systematic change happens. This means grassroots change at the coalface through roles like peer workers (also known as peer support workers) as well as designated lived experience roles at the executive and board level of all organisations delivering mental health services.
The language of âconsumer participationâ in design and delivery of mental health services has been co-opted by institutions in a similar way to how they have bastardised the language of the recovery movement. âCo-productionâ is a term meant to designate the equal relationship between those who deliver services and those who consume them but is often another facade used to obscure the traditional process of clinicians and managers making decisions and pretending to consult their stakeholders after they have already made the decisions.
Even when co-production is genuine, by developing services with equal decision-making power as clinicians or managers, you still have a 50/50 split of power that then tips in favour of the existing institutions. The legal structures reinforce the old guard, the norms of the past persist and the way we think – our cognitive frames persist to repeat these old mistakes including through how ex-patients think about how future services should be designed.
Intelligent and empowered ex-patients are unconsciously drifting towards the way things have always been done and the system repeats many tragic mistakes. Improvements can and are being made with proper involvement of ex-patients in service design and delivery. Peer Workers are becoming professionalised through values-based training like Intentional Peer Support and formal qualifications -usually through vocational training or community colleges.
In what is often seen as a positive âfull circleâ moment, Peer Workers are often employed in the same health systems that incarcerated them as an involuntary patient. They are retraumatised by working in the same or similar places as when they were very unwell or unfairly kept in hospital. Most develop a unique form of resilience to survive an ongoing process of recovery and renewal.
When Peer Workers are involuntarily admitted to the same systems that employ them, they become awkward colleagues with their former (or even current) treating team. I am someone who was involuntarily treated in four public hospitals, then became a Peer Worker and then Senior Peer Worker for the same public system that ran the hospitals that incarcerated me. I naively thought I could âchange the system from withinâ and even was told by managers and clinicians that I was having this sort of positive impact.
The process I went through transitioning from a mental health patient to someone who worked professionally with patients still has many genuinely positive outcomes for me and the patients I helped. It was only 3 years in when I decided to leave Peer Work that I finally realised I was brainwashing myself. I had drunk the kool-aid of the recovery movement and allowed the biggest employer in Australia -the NSW State Government, to use me as a pawn in the ongoing mistreatment of our patients.
I believe that I and many Peer Workers like me actually suffer Stockholm Syndrome. This is a term from a bank robbery that describes the perversely positive bond some kidnap victims develop with their captor (as in the work by Namnyak and colleagues). The guilt and trauma of the hostage situation are for me, akin to traumatic memories of psych ward admissions. Peer Workers are like ex-consumers now working for their former âcaptorsâ â the clinicians, managers and policymakers who design and maintain restrictive locked wards. Like in other settings where the term Stockholm Syndrome has been applied and adapted including for victims of domestic violence or human trafficking, Peer Workers are sometimes victims who seem to voluntarily collaborate with captors.
Peer Workers are psychological hostages in terms of being coerced to psychologically surrender to the attitudes, beliefs, and will (analogous to other settings researched by Childress in 2014). A clash between professional and personal identities creates ongoing conflict that can be resolved by patient values being subsumed by clinical and institutional values. This clash could be better resolved where mental health systems genuinely value and empower diverse survivor voices.
I did not see my managers and colleagues as my captors but they were still instruments of the same institutions that crushed me and spat me out. I had great friendships with junior doctors, some nurses and most of the allied health teams I worked with. Just as the hostage must join forces with their captor to perpetrate further crimes, I was reinforcing the same punitive approaches to mental health care and gradually my obligations to my employer had to be prioritised above bonds with fellow survivors. Positive bonds can still exist between Peer Workers and consumers simultaneously with new bonds among colleagues.
Peer Workers are regularly retraumatised working in settings that are similar to previous admissions. This retraumatisation is mostly self-managed with limited or no support albeit with many insufficient attempts at debrief and emotionally-supportive supervision. Peer Workers may feel the need to be adversarial to enable systemic change but almost always fail to bring change because it conflicts with performance management processes that jeopardise their already precarious employment.
âChange from withinâ by ex-patients becomes near impossible. A near-universal catch cry of Peer Work is to work in a way that you are âin the system not of the systemâ. When you are coerced by the norms and ways of thinking of your employer and financially dependent on this employer, you cannot free your mind completely from the dispassionate and cold clinical logics.
Some Peer Workers are also having their ability to transform systems perverted through clinical training. To feel seen and validated by the systems they work for, many pursue university degrees and professional recognition in disciplines such as social work or psychology. In doing so, they are indoctrinated into the status quo and only some will be able to retain the values and approaches only possible due to experiences of being an ex-patient. Some even wake up to the need to unlearn their clinical training if they relapse and are rehospitalised to fully recall how systems failed them in the past.
This example of working with the enemy is not just relevant to workers with lived experience. Clinicians and administrators learn from their textbooks and observe how things are done and are forced to replicate this. The ancient system of apprenticeship replicated through student placement or internship remains important for clinical skills and medical intervention but scope for the apprentice to outperform their master must be quickly encouraged. Junior doctors and student nurses need more scope to break down some of their unneeded boundaries to share their own experiences and really authentic and empathetic connection. We shouldnât have to teach empathetic communication -we should employ and nurture empathetic clinicians.
I still believe the vast majority of clinicians enter health to help others. The money is good for senior nurses and obscenely high for doctors (despite their recent strikes for pay increases) but I have also observed that with ongoing work experience, empathy can quickly wain. Those who care too much can also lose their empathy if they cannot prevent or manage compassion fatigue â a logical barrier of self-protection where those who are too empathetic must become numb to trauma or face burnout and their own mental illness.
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