Brief History 

The Center for Psychiatric Rehabilitation (CPR) at Boston University has partnered with the voices of those with lived experience from its’ earliest days – that is, the voices of those who would eventually populate the peer support specialist workforce.  Luminaries in the field such as Pat Deegan, Judi Chamberlin and Dan Fisher, were among the many people with lived experience who collaborated with Bill Anthony and colleagues in the formative days of the CPR.  Due to the strong parallel in values of the CPR and the consumer/survivor/ex-patient (c/s/x) movement, it was only natural for each to support the work of the other.

The CPR was an ally in the advocacy work of movement activists.  Those early days focused on “consumer” voice and participation in mental health policy and practice, under the motto, “Nothing About Us Without Us.”  Simultaneously, the power of peer relationships in peoples’ healing and recovery, called “peer support” today,  was highlighted in Judi Chamberlin’s  seminal book, “On Our Own,” and incorporated into the values and practices of psychiatric rehabilitation.

Prior to Medicaid funding, some headway was made with the creation of a “consumer liaison” role in some states, and other nominal “consumer” roles in services.  However, even the willing were hindered by the usual issue, i.e., funding.

The “Certified Peer Support Specialist”

In 1999, the Georgia Mental Health Consumer Network gained Medicaid approval (i.e. funding) for a new role – “Certified Peer Specialist” By 2005, states across the country began to follow Georgia’s lead and when the Center for Medicare and Medicaid Services (CMS) not only endorsed peer support as an emerging best practice in 2007, but encouraged states to utilize peer support,[1] the flood gates opened.  By 2016, there were at least 25,317 peer support specialists in the US.[2]  The rare “consumer” role of the 1990’s has now become a common role throughout behavioral health.[3]  It should be a time to celebrate all that has been accomplished, right?  Well, maybe….and maybe not.

Unintended Consequences

The word “peer” in “Certified Peer Specialist” is intentional and signifies the mutual relationship between two people with shared experience that was the hallmark of peer relationships in the c/s/x movement communities.  The intent of the “Certified Peer Specialist” role was simply to bring this impactful community role into services to create access for people who couldn’t access and get the benefit of peer-run agencies in the community. Peer support is meant to offer the comfort of “been there, done that” and the hope of “…and I’m not there now.” The peerness of the relationship – that is, no one holds power over the other – is what separates peer support from other roles and is often what opens the door to connection and trust.  There are many more professionals working in mental health, sharing their lived experience..  However, with or without lived experience, the traditional workforce still holds power over people in services.  An authentic peer specialist does not.  They are meant to be “in but not of” the system as a new and different type of provider unconnected to the culture of the medical model.

With hindsight, it’s clear that implementation of the role skipped the vital steps of preparing agencies and their staff for the influx of Certified Peer Specialists, resulting in a clash of cultures. (Byrne et al., 2019.  “The emphasis was initially on bringing the values and principles of peer-developed peer support into paid peer staff roles, but the ability to keep the focus on these values [is]often compromised by clinicians and administrators who do not understand or support the principles (Jones et al, 2020; Stastny & Brown, 2013).

Inevitably, the role has become co-opted, with “mutuality”, the first critical component of peer support to be set on a shelf to get dusty and forgotten. Similarly, “relationship,” is often sacrificed as peer support work often prioritizes the “deliverable” task at the expense of the relationship.   Here’s how one peer provider described their role,

“They changed the scope of what peer support really is… Now there’s that movement that kind of makes people, what I like to refer to as mini clinicians. Minus the white coat, they’ve got their clipboard and they’re taking notes, ‘How does that make you feel?’” (Adams, W. 2020)[4]

Changing the Tide

The Center is dedicated to preserving the “peerness” of peer support specialists.  The Recovery Education Center, provides recovery/wellness education classes, many facilitated by people with lived experience who also provide one-to-one support to students in their classes.  Many former students go on to become facilitators and peer support specialists, themselves.

Research projects, in addition to having people with lived experience involved in research project design  have also focused on delivery of authentic peer support in services.  One example is the Vocational Peer Support (VPS) training that was developed and researched at the Center.  Another is a current study developing a way of providing Executive Coaching for peer supporters.

The Center’s Post-Doctoral Fellows have also focused on authentic peer support. The most recent example of this is Wallis Adams who, partnering with the National Association of Peer Supporters (NAPS) performed two studies:  The Impact of Covid on Peer Support Specialists and Barriers and Facilitators of Implementing Peer Support Services for Criminal Justice-Involved Individuals.

Continuing this tradition, the Center will be dedicating a series of webinars ( “Ask Me Anything”) on the peer support specialist workforce in 2023. Announcements will be made when registration is open for these.

The role of people with lived experience, as well as the peer support workforce, will continue to be at the heart of research, training and services at the Center.

[1] CMS Letter dated August 8, 2007 (SMDL #07-011).

[2] Wolf, J. (2018). National trends in peer specialist certification. Psychiatric Services 69 (10), 1049. This number does not include thousands of non-certified peer support workers as well as those employed in forensic, youth, parent partners, substance use and other behavioral, primary and integrated health settings as well as serving specific population groups.

[3] Cronise, R., Teixeira, C., Rogers, E. S., & Harrington, S.(2016) The peer support workforce: Results of a national survey.,  Psychiatric Rehabilitation Journal, 39(3), 211-221.

[4] Adams, W. 2020. Unintended Consequences of Institutionalizing Peer Support Work in Mental Healthcare. Social Science & Medicine, 262.

Notice: The contents of this post were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90RTEM0004). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this post do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.

Tags: peer support, psychiatric rehabilitation