Turning Blue in the Break Room – What is a Peer Worker Exactly?
(NB: The thoughts and opinions expressed below are not official HRVic policy. This is a thought piece. It makes no accusations, only suggestions - ones that may hopefully prove helpful.)
Peer participation is central to the world of drug-related harm reduction and, increasingly, to the Hep C treatment effort. Peer workers can be particularly effective at educating and influencing the drug using population. Humans, after all, are far more inclined to accept advice from someone they see as their equal, their friend, a member of their circle.
HRVic is a peer-led organisation, and our idea of what constitutes a peer is pretty baked-in. We see a peer as a current member of the drug using community. Our peer workers are not recovered ex-users who have moved on with their lives, but current users with a social network of other current users. As such, they are trusted, respected, and on the pulse when it comes to emergent behaviours, shifts in attitude or circumstances.
In the wider health sector, however the definition of ‘peer’ has a tendency to bleed into the margins. It has also become something of a buzzword. As a result, organisations have been hiring peer workers with a flawed understanding of the role, and of its implications in the workplace.
Let me cite an example.
Last year, as a response to worsening overdose figures, the Victorian Government initiated a two-year trial called Reducing Drug-Related Harms Through Peer Led Networks (RDRHTPLN – A ghastly acronym to be sure.) Six urban zones with noteworthy levels of drug-related activity were identified. In each the primary AOD service provider was awarded funds to hire peer workers who would perform outreach activities (with an accent on overdose) among local drug using communities.
Each agency was able to ‘develop a locally tailored model to cater to the specific population needs of their… area. The peer workers will draw on their local knowledge and experience of drug use to identify those at risk of overdose and other harms and provide peer support to people who may not utilise mainstream mechanisms. This support will include education and information on how to reduce the risk of drug related harm, access to sterile injecting equipment and other tools to reduce the risk of overdose.’
The intentions of this plan are certainly positive, and the notion of local tailoring might have advantages, but to someone familiar with peer outreach it seems pretty much like a bog-standard program. Similar initiatives, albeit with insufficient resources, are already being widely and successfully performed across Melbourne.
What’s more, the actual hiring and oversight of these RDRHTPLN ‘peers’ may have presented unexpected challenges.
(Let me note that I am working largely from anecdotal evidence and, again, that any criticism is intended to be constructive.)
When employing a peer worker, those working in the conventional office environments of the RDRHTPLN clinics may be inclined to act within their comfort zone. They are accustomed to interacting with drug users from behind a high bench and a glass screen - and inviting one or more of these clients to cross this barrier and join their staff may be intimidating. It may expose unconscious prejudice, and previously concealed stigma. (I was once the only known user in a straight office space. When a purse was stolen, I was immediately accused and then fired.)
A reaction to this may be to massage the definition of ‘peer’; prioritizing the comfort of office personnel over their clientele on the streets.
One of the government bureaucrats tasked with developing the program assumed, quite unaccountably, that ‘peer’ described an ex-user: one of those individuals commonly referred to as having ‘lived experience’ (a euphemism often used in polite circles for someone who has successfully put their using history long behind them.)
The RDRHTPLN documentation defined ‘peer worker’ as 'a person engaged … to connect directly with drug consumer/client/user and who, though (their employer) responds proactively to drug harms and engages with key stakeholders on emergent issues.'
No mention of the peer worker’s drug-using habits, whether current or past, leaving it up to the organisation itself to fine-tune the definition. Why then would they not make it easy on themselves, veering towards a more relaxed description that mitigates any (perceived) need to hide purses and wallets in the workplace.
It may be that a mainstream health organisation may simply not like hiring peers (as defined by HRVic) but cannot openly admit it – particularly given the popularity of ‘peer’ in the current AOD sector taxonomy. Disturbed by visions of erratic, untamed junkies roaming their office spaces, they may tap their instinct for self-preservation in spinning the definition of ‘peer’ to their liking.
The RDRHTPLN experiment has generated a few troubling accounts in this regard. I can’t verify them officially, but I’ve no reason to dismiss them either. Let’s consider them hypotheticals…
One prospective job applicant was informed that they were required to be on methadone or buprenorphine if their application was to be successful - a prerequisite not in the project guidelines and which may diminish a worker’s ability to function as a peer (as well as unnecessarily excluding worthy applicants). Who benefits? Coworkers with a prejudice (whether conscious or not) who struggle to imagine such folk being effective employees, and who would rather not risk the danger of choosing a bad egg.
One applicant recounted interviewers who were extremely concerned that the peer they employed might present for work ‘intoxicated’. This concern may be legitimate, if one regards a peer worker as one regards other workers. But if the aim is to hire a bona fide peer, then requiring them to be sober may be counter-productive. A good percentage of users function perfectly well on their substance of choice and, what’s more, can barely function without it.
If a peer worker’s chemical state is an issue, one answer would be to hire through a peer-based organisation like HRVic which is overflowing with relevant experience, expertise and, most importantly, personnel – whether intoxicated or not. HRVic does indeed have an oversight/advisory role in RDRHTPLN, but responsibility has ultimately devolved to the clinics themselves.
RDRHTPLN was a response to a surge in overdose deaths. It is somewhat ironic then that an applicant claimed they were told that having OD’d (at any point in their life) would disqualify them from employment. One would think that having experience of the precise thing for which the program was created would improve a job-seeker’s chances. But, no. From the employer’s standpoint, it meant either that the applicant was suicidal or did not sufficiently understand the risks of overdose. It may have also meant that someone was envisaging their outreach worker turning blue in the break room - and the various official repercussions that might follow.
Another thing I heard – and this may be straining it in terms of credibility – is that one prospective peer-worker was judged on their personal appearance – or lack thereof. I don’t think I need to break this one down. When dress-code violations become significant in the hiring of peer workers, then serious reflection is required. One also should consider how such things are experienced by the peer worker themselves. Employers may feel they’re being helpful and benevolent, but when they automatically assume an applicant is on benefits, or when they make the ability to read one of the prerequisites for employment, they are, in truth, being condescending. And no one enjoys being treated that way.
HRVic considers a peer to be an actual member of the community in question. If that is a community of dependent heroin-injectors at significant risk of overdose who frequent the locality of Victoria Street, Richmond, then the relevant peer worker would be a dependent heroin-injector at significant risk of overdose who frequents the locality of Victoria St, Richmond.
But having someone like this relaxing by the water-cooler at work may be asking that little bit too much.
If a person hasn’t used for eighteen months, if they’re preaching recovery, if they’ve replaced injecting with smoking, if their drug history amounts to something sketchy in their youth that never involved dependence, if all they did was smoke ice at a party, or dropped a few mollies at a rave; if they were a devotee of pharmacy-obtained codeine, or knew someone who bought fentanyl patches from an elderly, one-eyed cancer patient in the flat next door…
Then they’re something different to a peer. Of course, they may have plenty to offer. Perhaps they are able to counsel from a position of reasonable understanding, drawing from similar lived experience - but whether they’d be trusted and accepted on the streets is another thing.
Now, whatever their level of veracity, the anecdotes I’ve described above all speak to a certain discriminatory attitude. Peer workers are different to normal workers. They require a different kind of supervision. Their employment, usually part-time, is a kind of beneficent consolation prize for a person who is considered unlikely to qualify for any other kind of job.
With this in mind, it seems to me that such hirings would better be performed by a peer-led organisation like HRVic which, as I’ve already said, has all the necessary experience - as well as a large peer network operating from eight sites in metropolitan Melbourne. Wouldn’t this be an excellent first port of call, if one is looking to hire peer workers?
It is also important to consider that peer outreach may sound easier than it is – and no one knows this better than HRVic. Workers must abide by the responsibilities of their job and operate effectively, regardless of any physical or drug-related issues. They should be trusted within what is, ideally, a broad network of users, and ought to have the requisite communication skills.
Not every drug user is cut out for peer work and maintaining a pool of good workers is a constant challenge for HRVic. But we have been doing it a long time and have a solid understanding of what training procedures are effective, and what divides a good peer worker from an ineffective one. We are, if you like, fully tooled up for the task.
Our sadly departed ex-boss Jenny Kelsall offered some wisdom on this subject which it is certainly worth repeating. She described how at HRVic there is an accent on encouraging professional development, something that can be stymied in the case of peers working for non-peer organisations. She described how peers can be kept ‘in-system’ with little or nothing to aspire to in what is often their first job; that their position might ultimately be ‘tokenistic’, a ‘gift for people on benefits who couldn’t get a real job anyway’. ‘At HRVic’, she said, ‘we work to build their sense of self-image, rather than plonk them in as a diseased outsider in a straight mainstream office. There are very few jobs for peers; it’s a shame that when they do come up they may not be given to real peers.’
If organisations expend energy learning from the ground up, they may be squandering resources by not utilizing the experience that we have spent long decades accumulating. Doubling up on the work that HRVic has already done could be an opportunity wasted. Funds might instead have been spent building upon what HRVic has already achieved, broadening and strengthening our peer networks, opening new avenues of outreach, discovering new approaches and generally supercharging a proven model of harm reduction.
The Golden Phaeton