Considering Outcomes for Peer-Run Crisis Alternatives

By Shery Mead and Eri Kuno

2/10/09

If peer approaches to “Crisis” are going to be any different than traditional approaches we must look at potentially different outcome possibilities. In the last paper, we talked about the fact that without a clear direction, it’s easy to fall back into “what’s been done to us” (using our “staff” role to control and direct the “client.”). We hope that this discussion paper will continue that dialogue and raise some of the questions about the difference between hope and fear based relationships, look at new potential outcomes, and help us consider the important aspects of creating true alternative approaches to crisis response. In this paper we will provide several typical scenarios that demonstrate the difference between a fear (power and control) response and a hope (defined as mutual growth) based response.

It’s easy to see the negative outcomes of a fear-based response (forced hospitalization, increased medication etc.) Unfortunately, without some clear direction, peer programs could be seeking outcomes that are not very different in their affect. For example:

• Convincing the other person that they shouldn’t (kill themselves, be afraid, etc)
• Using our story to “show” the other person a path (teacher/student)
• Keeping the other person out of more coercive situations.

Though on the surface these may look like quasi-positive outcomes it is essential that we ask ourselves, “how is this different?” In other words, we might ask:

• What’s driving you to convince me that I shouldn’t kill myself?
• Is it your discomfort, driven by your fear that you’ll be blamed if I do?
• Do you think this is what your job description means?
• Why are you telling this story now? Do you see yourself as protector, teacher, more recovered, mentor?
• Are you allowing your story to be influenced by our conversation or do you think of your story as “the way?”
• Just because I’m not ending up in seclusion and restraint doesn’t mean that you’re not using your power to be perhaps more subtly coercive.

Following is a scenario that demonstrates the types of interactions peers may have when they come from the traditional fear based response. The second scenario hopefully demonstrates the possibilities using a hope based response.

Scenario 1: Joe has been convinced to use the new peer crisis alternative by his friend who works there. Joe has been wondering why he should continue his life when he has no friends and feels miserable all the time. Up until this time, case managers have convinced him to take a few days of “safety” in the hospital. Now that he’s at this new program he does what he knows how to do which is to say, “I’m suicidal and nothing you can say can stop me.” Fred who has been working here for some time says, “but what about your kids Joe? If you kill yourself, what will happen to them?” Joe responds with the expected, “I’m no good for them anyway.”

Fred is getting concerned, he says, “I used to feel suicidal all the time and then I did WRAP and figured out what my triggers are and now I go for a walk whenever I’m feeling low. Maybe that would work for you. Joe says, “I tried WRAP but it didn’t do anything for me.”

Now Fred is really stuck, he says, “Joe, you don’t want to end up in the hospital do you? If we can’t get you to stop talking about suicide you may have to go there”. COERCION!

OK, What did Fred feel his job was right from the start? You guessed, change Joe’s mind. When it didn’t work right away Fred became more frightened but he’d been taught to use his own recovery story. When that didn’t work Fred became even more frightened and used the ultimate threat of force.

• What do you think happened to the relationship?
• When we operate from guilt or shame it leads to a relational dynamic where one person becomes the perceived victim while the other might fall into either a blaming position (persecutor) or rescuing position. In this case Fred might establish himself as “more recovered,” and see Joe as “less recovered.” These dynamics, once established are hard to get out of.
• What do you think Joe did with his suicidal feelings?
• If Joe feels shamed or afraid, he’s very unlikely to continue talking to Fred. When those feelings get pushed down, the pressure builds and he’ll likely feel a lot worse.
• Even if Joe stays at the peer crisis alternative, what will he have learned (perhaps more of the same)?
• How many times does this dynamic have to happen? The outcome here is simply that Joe stayed out of the hospital. Nothing changed in his understanding or his “helper/helpee” relationship dynamic, and even worse, Joe and Fred have fallen into static roles with one another.

Let’s re-look at this scenario using a focus on the relationship (mutual learning) and on creating hope and possibility for both.

Scenario 2

Again Joe comes to the peer crisis alternative, virtually nothing has changed and every time something bad happens at work he falls into another suicidal state. Fred has been thinking about his part in the dynamic and realizes that acting out of fear just puts him in the power position, and then he learns nothing but remains in control. He would like to develop a relationship with Joe that is interesting and stimulating for both of them.

This time when Joe tells him he’s suicidal Fred says,

 Fred: Yeah, that’s hard, It seems you’ve felt that way before, I’m sorry it’s been so difficult for you.

Joe: Well it does feel pretty bad, I feel like I’ve been spinning my wheels and that nothing ever changes. You know, I’ve been in this pattern for a long time and I have to admit, in some ways it’s pretty comfortable. I don’t mean like it feels good, more that it’s predictable and familiar.

Fred: I have to admit that feeling suicidal is something I fall into a lot so I have an idea about what you mean when you say you’re spinning your wheels. The only way I’ve ever known how to react is to let someone else take responsibility. Up until now Joe, I feel like I’ve been falling into that role with you; my immediate reaction when you tell me you’re suicidal is that I begin to assume I’m responsible for keeping you safe.,

Joe: Yeah I suppose that’s true, and then I get kind of angry because it feels like you’re doing to me what everyone else has ever done even if you’re nicer about it.

Fred: I wonder what would happen if we talked about what happens that get’s us stuck. And think about what we would be doing if we didn’t get stuck. Why do you think we fall into these patterns/reactions and then fall into old roles with each other?

Joe: I guess just because it’s what we’re used to.

Fred: I’d be willing to try something else. I don’t want to end up doing all the stuff others have done when they take charge and I’d like to think about changing that dynamic in some of my other relationships. What do you think would help us get out of that?

The hope-based dialogue in this example is created through two people’s willingness to look for a different way of talking about the experience as well as create a shift in role definition. In other words, without a starting point of fear, they can begin to create a new conversation in which they challenge one another to look at patterns both personal and relational.

Now, instead of talking about Joe’s outcomes (stabilization) that are compliance (fear) driven, they can work together on building a relationship that provides both people with new information, a structure for taking risks (trying on new ways of thinking and behaving), and potentially changing the dynamics in other relationships (co-evolution) Hope based relationships have fundamentally different implications than fear based relationships. Where fear creates a need to control, hope creates opportunities to shift meaning, dynamics, and ultimately communities

Systems theorists have been examining the elements that produce growth for a long time. In other words, when we start thinking about relationships as the thing to be studied, we are no longer focusing on individual outcomes (and, by default, individual ‘problems’) but we are looking at a range of relational qualities that promote growth for both individuals and also have implications for other systems/relationships. The idea of looking at the qualities of relationship that produce systemic growth is congruent with intentional peer support. We are not supposed to be there to act on our authority, but rather to use the peer connection to create an environment where risk taking is encouraged. This is the difference between fear and hope based conversations.

Questions for discussion

• What’s different about shifting our focus from the individual to the relationship?

Why might it be important?

• If we have made this focus-change, how do we respond to the whole issue of liability?...or do we?

• What kind of support/training/practice would we need to do this?

• What type of research would help us articulate the advantages of relational measurement?