“She really needs to go to a nursing home, but she won’t go willingly, and my father is not taking a stand on this with her. I’m worried about the strain this will have on him.”
I vividly remember this phone conversation with Dianne[1] years ago as she was talking about her father and stepmother who lived across the country. Dianne was with them for her semi-annual visit and was telling me how she was attempting to convince her stepmother that staying in her home was too difficult for her father to handle.
A tinkling bell sounded in my thoughts. At that time, Dianne was a guiding oversight to my efforts to finalize the writing of the MHCC Peer Support Guidelines. These guidelines represent the wisdom of over 20 peer support leaders who came together from across Canada to inform the content. Dianne and I often had in-depth discussions when she got her ‘niggling feeling’ that a phrase or word wasn’t quite right. We dissected the source of these niggling feelings as we worked together to ensure that the language we used fully and accurately represented the nuance and meaning of each peer support principle. To say the least, Dianne was a respected authority on the nuances of peer support principles.
The tinkling bell in my mind that day was my own niggling feeling that something was a bit ‘off’ when Dianne shared her concern about her father and his ailing wife not listening to her well-meaning advice. My delicate reply to her was, “Self-determination can sometimes be a hard concept to honour.” This brought a moment of silence and contemplation to Dianne as she realized she had potentially fallen into that ‘I know what’s right for you’ trap.
Self-determination is the term peer supporters use to describe the right each of us humans have to determine our own path forward in life. This is one of the cornerstones of Peer Support – the movement borne during the 70’s as psychiatric survivors fought the clinical and inhumane treatment of psych patients at that time and turned instead towards supporting and helping each other. Thankfully, mental health systems have advanced since then, but self-determination has firmly held its place as a key requirement of peer support services – for good reason.
As a Peer Support Training Facilitator, I have seen how the concept can be challenging to understand and honour. Sometimes its just the term that prospective peer supporters are unfamiliar with, but other times, it is the concept itself that can be hard to accept. In a word, I define it as choice. The choice as to what steps to take – or if steps will even be taken.
For example, peer supporters honour each person’s choice to see a doctor, or not; to speak to a therapist, or not; to take steps towards overcoming addictions, or not; to take their medications, or not; to speak to a peer supporter, or not. In fact, the only time peer supporters are expected to break confidentiality and take action is if a person is in imminent risk of harm to oneself, another person, or there is suspicion of child abuse or neglect. [2]
This sounds straight-forward but it can get tricky.
One of my favourite examples is a story shared by a peer supporter at a workshop in Nova Scotia. (I’m going to call her Candice for the purpose of this story.) Candice told us about meeting with a person who, among other concerns, was in constant pain and frustrated that she could not find a way to get sustainable relief. This in part was due to a lack of financial means, living on a limited disability pension, and the social determinants of health that accompany that challenge.
On this one day, the conversation between Candice and her peer touched on a variety of topics as it normally would. But as they neared the end and were ready to go their separate ways, the peer cheerfully told Candice that she had found a $10 bill earlier that day and her next stop was going to be the liquor store since she had some extra cash! This provided our training room of peer supporters an excellent real-life example. If you were the peer supporter in this situation, how might you respond, and why? What do you say or not say?
In addition to this being a self-determination question, this touches on the topic of ‘no judgement’.
It was obvious that Candice knew that Advil or some other form of pain relief would be the smarter choice for getting longer lasting relief from the pain, but she also knew the person she was supporting and that person’s willingness (or readiness) to hear an alternate viewpoint. She shared with us that she chose to not share her opinion, and simply wished the woman a good week until they met again.
So why is there wisdom in Candice’s decision to not speak up? To answer this question, I propose we look at the pros and cons of a situation like this:
- If Candice had suggested that an over-the-counter pain medication might provide a longer lasting relief from the pain:
Possibly the peer would have paused for a moment, considered this option, and decided to go to the drug store instead of the liquor store. Many of us would consider that a good outcome (based on our opinion).
Or, alternately the peer might have felt like she was being negatively judged by her peer supporter. If she felt judged, a number of things might happen such as not returning to peer support, or hiding (not sharing) some aspects of her life, and/or feeling alone in her struggle as no one else seemed to understand. This outcome would result in a setback in the development of a trusting (and helpful) relationship between supporter and peer.
- To be fair, there is a downside to saying nothing and not attempting to propose a different option for the new-found money.
Possibly the person is bringing this topic forward because they subconsciously want their peer supporter to help them make different choices. I have heard stories where a person hints at having an issue that is too embarrassing to state outright, but they hope that their peer supporter will read between the lines so that they can begin to work on the it together. Knowing this, was there a chance that the person was hinting at something that she wanted Candice to pick up on? I knew Candice well enough to trust her instincts.
Hopefully, you are not throwing your hands into the air and thinking, “I give up. How will I ever know what to do?” It’s true. There is no cut and dried answer – no flow chart to follow where you can track, “if they say this, then I do that.”
Supporting a person through some of their toughest times is complex. Which is why peer support is all about empathy and drawing on the wisdom gained through your own lived experience. You also have been through some challenging times with challenging day-to-day decisions. When supporting another, the most important goal that you have is to connect with them empathetically and to strive to develop a relationship that is based on trust. Each person is unique which means that your responses to each person you support will also be unique.
In this situation, as stated above, if Candice had mentioned that Advil might be more effective than alcohol over the long term, she would have been exposing her judgement. Judgements happen – we all have them now and then even though we try not to. Its what you do with your judgement that is important. By keeping her opinion (judgement) to herself Candice was placing more value on continuing to build trust in the relationship.
I do not remember the specifics that Candice shared but possibly she could relate to her own past where she might have ‘needed’ to have that alcohol to get a couple of hours of relief – even though it was temporary. Possibly she remembered what it was like for her in some of her more difficult days and how much she wished there was someone who could relate to that need and continue to hold her in high regard.
I turn to one of my favourite quotes to help summarize the value of building non-judging trust in a relationship:
“When a person feels that they are truly accepted by another, as they are,
then they are free to move …. to begin to think about how they want to change,
how they want to grow, how they can become different, how they might
become more of what they are capable of being.”
-Gordon 1970, 1975, 2000
With this sincere attitude of non-judgemental acceptance of the person’s choices in how to cope, we are meeting the person where they are at, and demonstrating that no judgements will happen if and when they wish to discuss other difficult topics.
There is also no guaranteed prediction of how this is going to play out, but here are a few possibilities:
The person being supported might speak at a later date about the on-going physical pain and wished they had used that extra cash differently. That would be an opportunity to listen and chat with them as they think through their options making them more prepared for the next time some extra money arrives.
Or, some time later, the person might have another similar opportunity to make a different decision. Possibly Candice feels that the relationship has evolved enough that she can say something like, “Are you in the mood to brainstorm some other ways to spend that money?”. Notice that this approach is still striving to honour self-determination. Candice has floated another option that does not specifically contradict the peer’s original intention, but rather it offers an opportunity to discuss options. If the peer supporter’s instinct is correct that the person has an interest in considering options, then a conversation might happen. If the peer prefers to go forward with the original plan, that is okay too, but hopefully the message was heard that the peer supporter is willing to talk through options if/when it comes forward again.
Let me return to Dianne’s story and her concern for her parents. It is never straight-forward. Dianne was the concerned daughter in this story, not a supporter, and possibly it was becoming unsafe for both her Stepmom and her Dad. If I were in her shoes, I might have done the same thing. But a calm reminder about this very important principle helped her to consider options from a more open-minded point of view. And, it was a demonstration to me that honouring self-determination can be difficult to do in some situations, even for those of us who are respected leaders in the peer support field.
When situations like these come forward for you, talk it over with another trusted peer supporter, and compare your responses with the guidance of the Peer Support Canada Standards of Practice and the MHCC Peer Support Guidelines.
I give the closing words to Theresa Claxton, a contributor to the MHCC Peer Support Guidelines (page 20):
“For me a key principle of peer support means working from a position of choice and therefore respecting the choices each individual makes. It is a principle of peer support to encourage self–determination and respect the fact that people will make their own choices, whether or not I, as their peer support worker, agree or would choose the same for myself. I hold respect for every human being; for their capabilities, their possibilities, their hopes and dreams, for the humanity that connects everyone, so I can respect a field or an intervention because there are people behind it, and a peer has identified it as their choice.”
[1] The name has been changed.
[2]Note that a peer supporter has the responsibility to break confidentiality and call for help from others (such as 911) if a person is in imminent risk of life-risking harm to oneself, another person, or suspicion of child abuse or neglect. In this example, imminent harm to oneself or another was not a concern, but if there is ever a situation where your instinct tells you otherwise then you must ask more questions to assess the risk.