A bleak Sunday. Feelings of isolation and disorentedness. A friend arrives and you share memories, memes, a cup of coffee, and each other’s lives. The day goes from potentially terrible to marginally better. “I get by with a little help from my friends” has never rung truer, especially in a post pandemic world challenging the very foundation of living as we know it. The act of listening has been especially redefined and Peer Support, albeit not very widely implemented in the Indian context, garners attention for all the right reasons.
Peer support is a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful. Peer support is not based on psychiatric models and diagnostic criteria. It is about understanding one another’s situation empathically through the shared experience of emotional and psychological pain. It is the help from a friend, or a colleague at work, not a professional counselor in a monetary and or professional relationship and there exists no ‘client’. The social climate is of the greatest relevance in threading experiential narratives, practicality and empathy in peer support relationships. It can be administered both by trained individuals or untrained friends/peers willing to lend a helping hand and a patient ear. Peer support is essentially different from other forms of social support in the fundamentals of the name itself: the help is administered by peers or those considered equal on a social paradigm. The same age group is often a criteria of being the peer.
While the psychiatric benefits are being rediscovered in even greater light in the aftermath of a pandemic, the origins of the concept are embedded into French mental health institutions of late 18th century France. The governor of Bicêtre Hospital in Paris, Jean Baptiste Pussin, recognized the value of employing recovered patients as hospital staff. The chief physician at the hospital, Philippe Pinel, praised these peer staff for being “gentle, honest, and humane”, “averse from active cruelty”, and “disposed to kindness”. Hiring former patients marked a shift in the philosophy of mental health care that ushered in the “moral treatment” era. This also helps in the destigmatization of labels such as patients and the connotations it bears (most oftenly noted stereotypes range from being called mad and infantilization of adult capable human individuals). Peer support gained popularity as backlash of the poor conditions of mental health patients in hospitals grew and released or recovered patients became vocal about the same. Deinstitutionalization sprung up as an organized movement with the process of replacing long-stay psychiatric hospitals with less isolated community health services for those diagnosed with a mental disorder or developmental disability however the concept of deinstitutionalization they may have purported independence, improved qualities of living and a call to basic dignity of the institutionalized patients did not translate well in practise. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all. The individuals who were to receive the benefits of deinstitutionalization were often homeless, isolated, and victimized. Some individuals with severe mental illnesses who were released from institutions deteriorated, were reinstitutionalized, and some lost their lives. The community at large is frequently afraid of people with mental illness, believing them to be dangerous. This belief often caused rejection, stigmatization, victimization, and harassment (French, 1987). Mentally ill clients thus become unsupported and at high risk for self harm. Instead of being integrated into the community, people with mental illness traded the isolation of the hospital for the isolation of the house or apartment. In a medical study, it was concluded that individuals with severe mental illnesses were victims of violent crime at a rate 11 times higher than that of the general population . An additional challenge that resulted from deinstitutionalization was the incarceration of above mentioned individuals. A study investigating the relationship between deinstitutionalization and homelessness and crime found a statistically significant correlation between deinstitutionalization and homelessness, and a more pronounced correlation between homelessness and criminal activity. Peer support thus becomes an imperative force in instigating a movement of care and empathy from institutions into community. This means that communities are being asked to absorb such individuals into the community setting. The goal should be a focus on returning to a state of wellness or mental well being, not just psychiatric treatment with psychotropic drugs.
The assumptions about mental illness and the internalizations of “otherness” have significantly contributed to the cultural acceptance of “problems” as illness, or abnormal. We see ourselves in the role of the “mental patient” and learn to make meaning defined by the roles that keep us feeling hidden and separated from others. These are the feelings and assumptions peer support combats. It is a way of making people feel welcome into fully realised identities beyond the connotation of “damaged goods”. There is affiliation building between people helping us recognise and acknowledge our commonalities to build consequent trust. It helps us understand each other as “whole” people with a range of experiences that are familiar and therefore acceptable. Some of the ways peer support programs train individuals into the required actions are as follows:
Participatory listening which involves going beyond simple passive listening but engaging in actual dialogue about the incident or concerns plaguing the distressed individual. The desired outcome is establishing a new sense of self and faith in peers and the general community. The fear of infantilization is overcome when the feelings or experiences are shared without any fear of “fragility” of the psyche of the other. One begins by admitting that personal change is necessary and that one’s peers will be able to assist in that process.
Understanding perceptual frameworks through story telling and the reconstruction of self is another important step. To move out of the perceptions of ourselves as innately broken, the following metaphor of perceptual framework is often recommended – imagining the house as “Self”. Each of us lives within a house. It has an outside that others see as well as an inside that no one else can see or fully know. Its basic framework is the physical, emotional and spiritual self that we are born with. Over the years, many changes are made to the house – the decorations and the positive memories may make for the attractive colours, plush furnishings and comfortable rugs. The dark secrets, unpleasant memories and traumatic experiences inhabit the dark basement. Feelings of isolation and otherness may make the attic. The house needs to be viewed from every room, no one can stay confined to one of the rooms for utility purposes. If we spend too long in the basement we may find ourselves defining ourselves solely from that dark perspective, and even forget there are other rooms in our house. Describing our “house” to another person is a broader description of our whole self – if we don’t get stuck in one room or view (e.g. a negative identity). If we find ourselves stuck in one room, effective peer support environments can help us break out of this room and begin to explore the rest of our house and the community in which it sits. If we think about our houses in the context of relationships, we see that we are constantly re-constructing the house and rearranging the contents of its rooms based on our interactions with other people and environments, and the meaning we attribute to our past and present experiences. If we think about our house as being in a neighborhood of similar looking houses, we can begin to understand how our “stories” about ourselves are embedded in the culture and language of the “neighborhood.” (a metaphor for our society and our peers acting as the representative of societal attitudes)
Innate understanding of trauma worldviews is also another method of peer support. While violence is a truth of our society, we are somehow involved in the implicit or explicit machinations of violence as perpetrators or victims. The toxic culture of victim blaming, especially in the Indian context of domestic violence or sexual assault and associated trauma is to be replaced with an attitude of care and concerns and reflected in questions such as “What happened to you?” . The implicit attitude of guilt and responsibility we are conditioned into believing needs to be broken through peer support.
Thus, peer support can be seen as an important burgeoning institution with relevance that plays into conditions beyond the payee/payer constructs of mental well being.
– Bipasha Bhowmick
Picture Credits: psychiatryadvisor.com