Limit-Setting in Peer Support: Unpacking Boundaries Kate Storey Recovery Educator - Osprey Training & Consulting PREFER Conference Sept. 21, 2012.

Limit-Setting in Peer Support: Unpacking Boundaries

Kate StoreyRecovery Educator - Osprey Training & Consulting

PREFER Conference Sept. 21, 2012

Boundaries in support relationshipsare the conditions that “limit” and/or prohibit behaviours to ensure safety,

comfort, privacy and reliability.

Existing legislation/regulation…

According to the College of Social Workers:•Boundaries define the set of roles andexpectations for the member and client, and establish ground rules for their work together.•To determine appropriate boundaries, it may behelpful to view boundary transgressions on a continuumfrom those which likely pose little risk of harm to theclient, to those which pose a major risk to the client,including lasting or permanent damage (such as suicidalbehaviour or completed suicide).

According to the College of Nurses of Ontario: •A boundary in the nurse-client relationship is the point at which the relationship changes from professional and therapeutic to unprofessional and personal. •Crossing a boundary means that the care provider is misusing the power in the relationship to meet her/his personal needs, rather than the needs of the client, or behaving in an unprofessional manner with the client. The misuse of power does not have to be intentional to be considered a boundary crossing.

In an advisory article posted on the Ontario College of Psychologists website:

Boundaries are the framework within which the therapist/client relationship occurs. Boundaries make the relationship professional…Except for behaviours of a sexual nature or obvious conflict of interest activity, boundary considerations often are not clear-cut matters of right and wrong. Rather, they are dependent upon many factors and require careful thinking through of all the issues, always keeping in mind the best interests of the client.

In standards defined by the College of Occupational Therapists:

…The client/professional relationship is…unequal…[OT’s] are responsible for anticipating…as well as setting and managing boundaries relating to personal dignity, privacy, control and professional detachment, to ensure that the trust…is not betrayed...maintaining boundaries…is a continuous process...boundary violations do not always occur at a single point in time… A boundary violation is an overt change in the nature of the client/professional relationship from…professional…personal… By comparison, a boundary crossing may be a subtle event in which the professional either initiates or allows the client conduct in which there may be a temporary excursion across appropriate professional lines…

Common Elements

• Recognizing the power differentials • Identifying the person in power as responsible• Best interests and safety of the client• Not a shift from professional to personal• Language defining Boundary activities – set,

established, crossed, transgressed, violated • Self-regulatory, with consultation/supervision

Underlying Components of Boundaries

LIMITS/TENSIONS –dual relationships, casual contact; compliments/gifts, home visits, touch, self disclosure…

PROHIBITIONS – sexual intimacy, financial exploitation, injury/harm

EXCEPTIONS – confidentiality…

Navigating: self awareness/reflection; critical & consequential thinking; and ethical decision-

making

According to Speight (2012), boundaries are intended to protect clients from the slippery slope that leads to harm ...such as sexualizing , financial exploitation, exposing health information.

An Exploration of Boundaries and Solidarity in Counseling Relationships: The Counseling Psychologist 40(1) 133-157.

Role of Solidarity

Connection

Rapport, interest, fondness, kindness - alikeness…

Are you married? Do you have kids? Have you ever….?

Self disclosure • Supports Solidarity• Risks shifting focus from the client to the clinician• Can elicit caring form the client to the clinician (role reversal)• Can undermine confidence….

It is unavoidable: pictures in offices, clothing/ presentation, gender, responses that betray experience.

It can be differentiated as an intervention (Olarte, 2003)

Boundaries in Peer Support

SELF DISCLOSURE & SOLIDARITY

•Peer support involves rich and complex relationships that are like but also very unlike conventional “therapeutic” relationships.

•They rely on the mutuality and reciprocity of equals who share similar but not identical experiences.

What is Peer Support?Peer support is an intentional relationship between people who can understand and deeply appreciate how they are “like” each other.

Peer relationships support transformation and growth for people with shared life experience.

Peer support is an important component of one’s recovery; it demonstrates hope, optimism &self-responsibility in a relationship between equals.

Peer support provides opportunities for people to “give back” & support others inwhat Shery Mead calls: mutual empowerment.

Peer Support is an integral part of supporting recovery!

Peer Support What is Peer Support? The following principles of peer support have been generated, refined and endorsed by the over 200 participants of the Like Minds Program:

Self-help & peer support acknowledges the value of personal lived experience as a demonstration of hope, recovery and ongoing personal growth and transformation.

The self-help and peer support relationship supports the person to explore, question, challenge, decide and exercise his or her free choice.

The self-help and peer support relationship supports the development and exercise of self-advocacy.

Self-help and peer support happens in distinct non-clinical relationships that are an alternate to, or compliment to, conventional services.

The focus of peer support is to be in relationship- individually or in groups.

Listening, accepting, sharing, questioning, practicing, crying, laughing, hoping!

To learn more about the understanding of boundaries in peer support, an on-line inquiry was distributed among groups known to be or to employ peer supporters.

42 thoughtful responses from Peer Supporters revealed themes about how peer support relationships promote the safety and trust (boundaries) crucial to one’s journey of wellness and recovery.

First, how do peer supporters define a boundary between peers?

•Boundaries are a framework that provide interpersonal safety & therefore support trust.•They cannot be a barrier to the relationship.•Respect and trust are essential when soliciting, receiving and keeping confidential the info between the peers.

“There are times when I am vulnerable - talking about my deepest fears or hurt to a peer - I expect that Peer to relate to and keep that

thought or feeling shared in confidence. Sharing my personal experience from the heart is sacred

and should be respected as such. I can share ideas and thoughts that are not scared to me -

and I don't mind if these are repeated.”

According to Peer Supporters, Boundaries limiting behaviour for the peer supporter & the peer.

•For a few, “boundaries” are used to limit the behaviour of the peers they support, regarding details of the contact (frequency, location, time). •For more, “boundaries” limit their own behaviour. A common example is: depth of disclosure – both in terms of respecting primary focus on the peer as well as being mindful of the effects of disclosure on their own wellness.

Second – the importance of Co-creation or Negotiation of conditions was noted

“It requires an ongoing conversation throughout the relationship. We should discuss such things as mutually

comfortable places to meet, respecting one another's time, personal space, how we like to be addressed, what topics we do/do not wish to discuss, whether there are cultural/religious or other considerations in how we intend to BE with one another, what personal information can/should/ wish to be shared (such as personal contact info). Both parties need to state their limits. Restate or redefine if necessary. Adjust along the way”.

“Boundaries are mutually set; flexible to the greatest extent possible.”

“Agreed upon (negotiated) space between what I need to preserve my wellness and what the other needs to preserve their wellness. Ideally at various

times one or both of us will venture far enough into discomfort to learn and grow, but not so

irretrievably far that we can't together move back to safety and wellness…Boundaries are context-

specific and also shift based on deepening relationships, trust and resilience of both of us at

any given moment of time…”

Regarding Self- Disclosure

“A peer may feel more trusting towards a person who has been able to tell them their own story and can see that recovery is possible and be encouraged

in continuing treatment.”

“They are one of us who understands the day to day struggles. They ask me what I think I should to solve a problem & then they help me weigh all the pro’s

and cons. They let me make my own decisions, even if it is the wrong one.”

“When the supporter is able to show their own vulnerability first, I am more able to open up.

Honesty, authenticity, empathy Knowledge about recovery, freely shared. Not feeling like the

supporter has all the answers, is the "expert" - they must be willing to open up a space for shared exploration, be non-judgmental, patient, willing to meet me where I am & offer to walk beside me as

we explore new ways of being & seeing the world - without taking the lead & directing me where I am

not yet ready to go (but hopefully offering new directions that I may chose to explore)”

…Having someone with lived-experience and who is on their own journey of recovery (discovery) - Having

someone who supports my right to make decisions and does not feel obliged to agree with me - Having someone who accepts and loves me for being simply me. - Having

someone who exhibits great hope for me - Having someone who talks in terms of wellness - Having

someone who is honest and sincere with me - Having someone who neither condemns or criticizes my mistakes

- Having someone who believes in me.

“A growing relationship includes reciprocal sharing. Acknowledging my experiences, “you’ve been through a lot”, “that must have taken a lot of courage”, I admire your strength through....”, “I have a lot of respect for you”. Appropriate eye

contact, not interrupting, “that reminds me of an experience that I had. Honour, respect, not asking for details of my life that aren’t relative

to what I am sharing.”

However…“I can't feel safe talking about my stuff if the other person

needs to out-do me with their more shocking story.. I won't be safe with anyone who seeks to insert themselves

into my situation…”

“…if you overtalk me, or out-talk me, or compete with me (you think that's bad, here's what happened to me...)

then I will clam up.”

“Not horror stories. Stories about what went right are especially good. Or even what went wrong and how you

came out the other end.”

Boundaries in action…“… it is how [a] person TALKS ABOUT OTHERS that will tell the tale…If they tell me personal information about someone else, I should be

worried what they tell others about me.. If I rant about someone or something, and they listen and validate I will feel safe but if they join in my rant I should be worried. If they label or judge or bad-mouth the people or organizations I am upset

with, or are overly disturbed or triggered by my 'stuff' I should be worried that they are

personalizing my issues.”

Third – Peer Supporters work to Resolve boundary “encroachments”

We “struggle through trying to support each other” - learning experiences for both parties when handled with sensitivity.

Defining, negotiating & navigating boundaries can be tiring. In the short term, some peer supporters avoid (short term) the people or activities that produce boundary challenges

With only one or two exceptions, people resolved these events by addressing them directly with the other person. For the most part the issue was resolved in a way that exceeded their wishes, led to personal growth for them and improved the ongoing relationship.

Appreciating boundary tensions and challenges in peer relationships

•Preserving/protecting personal information in a relationship that welcomes disclosure. •Understanding “triggering”. •Want/need to “help” can be experienced as intrusive especially with peer colleagues

“...I listen very carefully to an individual to discern who they are. I watch their gestures and listen to responses.

I try to understand somewhat of who they are, who they have been and who they want to be. In trying to

deduce some of who they are, I begin to formulate how safe I feel with that person and how much I will share...

I seldom if ever give all of me to anyone. And sometimes I give very little of who I am.”

“So many topics are triggering for me, so it's been really hard to grow in relationships without trying to 'control' what other people are talking about. So I monitor my own internal reactions to what people say, and I sometimes need to explain my reactions, and my comfort levels/and what makes things easier for me. I find that by modeling this, other people feel more free to be honest with me about their comfort zones too.”

Having said this, it is clear that these conversations are hard…

“Learning how to say no in a way that still invites the relationship to continue is an art and

takes lots of practice.”

System Issues Peer workers in settings that are not peer-run, for instance in peer support roles embedded in conventional teams, describe struggles related to working within mandates that may exclude their peers, as well as operating with policies that require reporting all comments regarding self-harm, and regulations regarding documentation. It is recognized by some respondents that disallowing these “boundary” processes compromise peer relationships & limit open sharing.

• As peer support is “proceduralized” it becomes less “equal” in terms of power and access.

• Some responses express concern about peer supporters competence at recognizing and responding to distress – and there is a wish to learn more about being a peer supporter.

• Supporting trust and safety requires the peer supporter to sit with extreme emotions. This is an area that requires discussion and agreement at the outset because some peers may be more comfortable than others in being with distress.

“Freedom to express emotions e.g. cry, be angry, express feelings of hopelessness without being

judged To be validated. Encouragement. Listening without comment, feedback or

judgment…Feeling safe to express myself and work on my recovery. To express feelings of

hopelessness without a 911 call. “

“ This (boundary negotiation/limit setting) is one of the most difficult aspects of peer work…Often the hardest area to set and maintain limits is not with other peers, but is with fellow co-workers. Many of us work in environments which are not peer-based, and are often either explicitly or implicitly clinical, medical-model based & not truly recovery-supporting (although the words may be used)”

“In a formal peer support relationship…I must first comply with whatever boundary rules the organization sets. (Even if they seem stupid - in

which case I must work behind the scenes to have them changed, while complying)”

Many respondents see “deeper distinctions” between peer and professional supports that comprise how interpersonal power affects the relationship.

“A peer is more of a equal relationship and [there is] less of a power differential”.

They describe differences regarding who directs, determines and is responsible…the intellectual vs experiential understandings of service differ.

“ I can be more myself with peers, I think. That's what this whole thing is about - the freedom to be

ourselves, to know that we are not alone in our struggles, to be able to relate to the struggles of each other and to know there are others like us. I believe that there is information and insider tips

about coping that we can only get from each other…”

And there are structural and liability differences that affect the relationship:

“Peer support relationships provide time and patience for a relationship to develop…it isn’t all

written down in a file…[there is time to] allow you to express & explore your feelings, including

thoughts of hopelessness and suicide in a supportive manner that is not automatically judged as a safety issue i.e. I must call 911, get you to a hospital…Peer support realizes that relapse is recovery. That every experience is a learning opportunity to improve our

wellness and adapt our recovery journey…”

It was reiterated by Peer Supporters that they want to know when and how to use conventional

supports if required.

“it is important that peers not attempt to reach beyond their experience… Peers should be careful to remember the nature of their role…”

Still, there is an important distinction between peer & professional support that should remain intact.

The following conditions would support and provide comfort & safety in a conventional service

provider relationship: That I be asked open-ended questions - That I be actively listened to - That I not be interrogated - That I not be given unsolicited advice - That I not

be judged - That I be accepted for being me - That I be acknowledged for my strengths - That I be

treated as a human and not an illness - That it be clearly understood that the journey of recovery is ultimately mine alone and mine to own - I must

have the right to make my own mistakes.

Discussion.

What does this mean to my program/organization?

Kottler & Hunter (“Clients as Teachers: Reciprocal Influences in Therapy Relationships”) cite these examples that support transformation in the therapeutic relationship:

•...Deep presence in the relationship; empathic transcendence•Loosening boundaries•Parallel journeys•Stepping aside from the professional self; deep intimacy (personal connection not sexual)

•Receptivity to feedback from clients•Being a witness to change…

(The Australian and New Zealand Journal of Family Therapy Volume 31 Number 1 2010 pp 4-12)

So, how do we support peers to negotiate and set limits?

1. Do not be limited by conventional, professional “boundary” legislation/regulation.

2. Consider the fundamental role of solidarity and self-disclosure.3. Peer Supporters already see the value in (re)negotiation, conversation, feedback… 4. Model, Teach and Trust – self awareness, critical

reflection, consequential thinking and ethical decision-making

Self awareness, critical reflection, consequential thinking, & ethical decision-making

•Education (such as WRAP, LMPSE, PREFER)•Proactive consideration of consequences – limits, prohibitions and exclusions•Role of solidarity/self-disclosure – triggering•Comfort to talk freely with peers, as peers•Peer support for peer supporters •Organizational guidelines for embedded Peer Supporters