What does it mean to offer care when the act of caring is wounding to its giver? For peer specialists—individuals with lived experience as patients in the psychiatric system—this question shapes how they use their own histories to provide support for individuals experiencing psychiatric crisis. Peer support is unique in the way it draws on empathetic resonance and depends on carefully deployed vulnerability; where one connects with others through the recognition of shared experience and mutual hurt. For peers, care works when this guidance, reassurance, and "being with"—all of which draw upon their own stories of traumatic history and variegated suffering—mitigate the present crisis being experienced by another. Drawing on twenty-eight months of fieldwork with a peer-staffed crisis respite center in the eastern United States, I argue that the peer specialist becomes the embodiment of a novel intersection of intimacy and compensation; one that poses vulnerability not as a consequence, casualty, or risk factor in the commodification of care, but as its principle vector of resonance and the assumption on which it is based. For peers, care that works—in that it creates a mutual resonance for the recipient—becomes simultaneously care that wounds its giver.
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The Soteria model developed by American psychiatrist Loren Mosher in San Jose, California sets the bar for peer-supported respite care. Mosher designed Soteria as a 12-room home-like environment, staffed by peers and professionals, to investigate supportive milieu therapy for early acute psychosis. Mosher et al.’ analyses of the first Soteria cohort showed significantly lower relapse and medication-use rates over 2 years (Mosher and Menn 1978). For Mosher, the effectiveness of Soteria lay in guiding people through the rough weather of crisis by offering a secure port, its ability to foster new relationships, and to help individuals build independent identities (Mosher 1992; Mosher, Hendrix, and Fort 2004).
Peer support models have become increasing popular in a variety of social, medical, and educational settings. There is a rich literature in disability studies (Rapp and Ginsburg 2011), chronic and terminal diseases (Jain 2014), and school bullying (Cowie and Wallace 2000) that identify the power of peer-based relationships to buttress individual resilience. As well as a long history of anthropological interest in the peer support systems of groups like Alcoholics Anonymous, where sponsorship roles are comparable to those of Peer Specialists, though significantly different in their sometimes hierarchical and patriarchal dynamics (Bateson 1971; Cain 1991).
The work of anthropologist Neely Myers provides one of the most in-depth ethnographic accounts of psychiatric peer support networks and relationships to date. Myers’ work reveals peer support as an innovative agentive practice, and how the sense of a morally tenable self hinges on certain forms of social recognition.
The different socioeconomic and racial backgrounds of peers sometimes materialized in conflicted understandings of the nature of crisis, and felt hierarchies in the daily tasks of respite management. In more positive iterations, the personal experiences of staff as they related to race and class corresponded to specialized skill sets, with certain staff members being better equipped to work with certain guests than others.
The newness of peer support as a professionalized category means that practical realities, like certification and determining appropriate pay, are still being worked out. Statewide criteria for peer certification have been developed, and peers are increasingly included in these professionalization discussions.
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Cubellis, L. Care Wounds: Precarious Vulnerability and the Potential of Exposure. Cult Med Psychiatry 42, 628–646 (2018). https://doi.org/10.1007/s11013-018-9577-8
- Mental health
- Peer support