Limit-Setting in Peer Support:
Unpacking Boundaries
Kate Storey
Recovery Educator - Osprey Training & Consulting
PREFER Conference Sept. 21, 2012
Boundaries in support relationships
are 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 and
expectations for the member and client, and establish
ground rules for their work together.
• To determine appropriate boundaries, it may be
helpful to view boundary transgressions on a continuum
from those which likely pose little risk of harm to the
client, to those which pose a major risk to the client,
including lasting or permanent damage (such as suicidal
behaviour 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 clearcut 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 in
what Shery Mead calls: mutual empowerment.
Peer Support is an integral part of supporting
recovery!
What is Peer
Support?
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 contextspecific 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 badmouth 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