Mixed Bag #17: Julia Knopes on Boundary Ethics in Peer Support

“Mixed Bag” is a series where I ask an expert to select 5 items to explore a particular topic: a book, a concept, a person, an article, and a surprise item (at the expert’s discretion). For each item, they have to explain why they selected it and what it signifies. — Awais Aftab

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Julia Knopes, PhD is an anthropologist in the Department of Bioethics at Case Western Reserve University, studying lived experiences of mental illness. In particular, Knopes examines boundaries, which are physical, emotional, and social parameters of interpersonal relationships that are intended to protect people’s well-being and clarify social roles. She is also a peer support facilitator with the National Alliance on Mental Illness, leading support groups and educational programs for fellow individuals with mental health conditions. Knopes is currently conducting a qualitative, interview-based study on role boundaries and ethics in mental health peer support funded by a Making a Difference grant from the Greenwall Foundation. Her research approach incorporates elements of participatory-based research and autoethnography, honoring lived experience as a legitimate form of health knowledge. She has also written extensively about medical education, and teaches courses on disability, bioethics, and mental health at the undergraduate and graduate levels.

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Knopes: “Boundaries” are described in mental healthcare as the physical, social, and emotional parameters that people maintain in relationships to clarify social roles and ensure well-being. In the field of bioethics, “boundaries” also refer to the limits placed in relationships between clinicians and patients, with the goal of protecting patients from abuse and sustaining a shared understanding of the nature of the clinical relationship. I am interested in many manifestations of boundaries in the lives of people with mental health conditions as well as practitioners, be it the boundaries that people set with family members in their personal lives, the boundaries that clinicians set with patients and vice versa, and the boundaries that researchers set with their participants. Specifically, I have been focused in my scholarship lately on boundaries in mental health peer support: that is, the provision of mental health support and education between people with lived experience of mental health conditions/illnesses. “Peers,” or people trained to lead support programs drawing on their own recovery journeys, fill a unique role in the mental healthcare landscape where boundaries are dynamic, flexible, and especially fraught; peers are vulnerable with others in sharing their experiences and forming deeply meaningful and mutual healing relationships, yet must be careful to protect their own well-being by ensuring that others understand the paraprofessional nature of the peer support relationship. In this Mixed Bag entry, I invite readers to reflect further on boundary ethics especially as they emerge in peer support.

Concept—Boundary Ethics

Bioethicists including psychiatrist Glen Gabbard have written at length on professional role boundaries between patients and clinicians. Existing scholarship focuses largely on boundary violations and boundary crossings. Violations refer to harmful overstepping of boundaries with potential serious danger to a patient’s autonomy or well-being, such as financial or sexual exploitation of patients by clinicians. Crossings refer to situations in which clinicians soften or sidestep typical boundaries with anticipated benefit to patients, such as accepting a small gift or paying a nominal amount of money for a patient’s bus fare. Boundaries thus have important ethical ramifications, warranting both normative and empirical analysis. Boundary ethics in peer support are particularly complex given that peer support is premised on some degree of mutual sharing and receiving of aid between individuals, challenging notions of concrete boundaries that benefit patients in interactions with clinicians who have significant authority. While ethics is commonly taught in state-level certification of peer workers, little is known about how much information peers are given about boundary issues in the course of their work; likewise, peers trained through other agencies or who provide volunteer-based services may receive limited to no formal training on boundary setting. As I have found in my research, peers often receive little direction from agencies about whether or not to share personal cell phone numbers or emails with the people they serve, whether or not to friend them on social media platforms, or whether or not to have contact in general outside of designated programs. Boundary ethics have been underexplored in peer support, despite the growing utilization of peers in the community mental healthcare workforce.

Article—Dual Relationships in Mental Health Peer Support (2023)

My coauthor Maia D’égale-Flanagan and I recently published a piece in Psychiatric Services entitled “Dual Relationships in Mental Health Peer Support,” in which we grapple with the many ways that dual relationships emerge in peer support and lived experience research. Dual relationships are a type of boundary consideration, in which providers and researchers are familiar with their patients, clients, and/or participants in capacities beyond the professional relationship. For instance, a physician who is also friends with a patient in their community is engaging in a dual relationship: bringing with it concerns about the blurring of social roles and ethical obligations to the patient, as well as concerns of potential coercion and the threat (however legitimate or imagined) of loss of objectivity in treatment. Peer support providers similarly face dual relationships as they share about their own lives while aiding others, potentially laying the groundwork for friendships with people accessing peer services with whom they connect on a deeper, personal level than what is typical between clinicians and patients. In the article, we explore a number of ethical dilemmas, and opportunities, to dual relationships in mental health peer support. We also consider our own dual positionality in the study, as both qualitative researchers and as fellow peers who are familiar with some of our participants as we practice in the same region. Maia and I conclude that while dual relationships, like in other forms of clinical practice, can lead to deleterious boundary crossings and violations that harm both peer care recipients and peers themselves, peer support also benefits from flexible, context-dependent boundaries between people providing care and receiving it.

Person—“Marcia,” A Research Participant

The experts of boundary ethics in peer support are peer support workers themselves. In the everyday provision of peer services, they are called upon to navigate complex interpersonal relationships as they draw upon their own lived experiences to aid others while enacting boundaries around how and what information they share to ensure their own mental health needs are met. Marcia (a pseudonym) is one of the research participants in my current study who is especially thoughtful about boundaries in her professional life as a practicing peer support worker. Marcia lives and works outside of a major metropolitan center, and in our interviews, she has reflected at length on how being a peer, a person of color, and a Christian has shaped her understanding of mental health, well-being, and effective relationships with others. Marcia encountered numerous boundary issues with people she served through peer support, such as one person she had a one-on-one mentoring relationship with who began texting her personal cell phone multiple times throughout the work day and weekends, even when Marcia expressed that she did not want to be contacted so often and at inconvenient times. The mentee then began coming to her agency’s office to ask for support in person, at which point Marcia ceased the relationship and connected the person with a new mentor. Another individual, a fellow peer support worker, used heart emojis in his text messages to Marcia, which Marcia felt crossed a line into inappropriate communication that was too casual and intimate for a relationship between peer support workers. She stopped speaking to the peer through texts. In reflecting on these cases, Marcia lamented, “I kind of felt like I was abandoning them some but I had to remember my own mental health and the position that I was in. I had to be able to use my own voice. I couldn't allow them to continue doing something to me that made me feel unsafe and unhealthy.” Marcia experienced tension between her desire to help others and her commitment to her own recovery, but ultimately, determined that in order to be an effective peer support worker she needed to prioritize her own mental well-being.

Book—Recovery’s Edge by Neely Laurenzo Myers (2015)

Recovery’s Edge: An Ethnography of Mental Health Care and Moral Agency documents three years of qualitative research at a mental health agency staffed by peer workers. The book argues that the recovery movement in the United States places the onus on individuals for healing from mental illness, substance abuse, and trauma, exploring the everyday lives of people who provide peer care while themselves striving to meet their mental health needs. I found this book to be a compelling, highly readable account about recovery that beautifully centers the narratives of people invested in the movement, who experience struggles and triumphs in their encounters with the mental healthcare system. Neely Laurenzo Myers grapples with her own privilege throughout the text, rendering the account sensitive to structural inequities and the complex relationships between ethnographers and research participants. The author briefly examines boundary ethics in later chapters of the book, finding as I have in my own work, that peers fill an unusual role in mental health care that renders boundary setting especially nuanced. I recommend this book to anyone practicing and researching in the community mental health space, as well as anthropologists and sociologists of the health professions seeking insider accounts of how a nascent profession—that of the peer worker—has developed within the framework of recovery in American culture.

Surprise Item—Social and Cultural Considerations Around Boundaries

As an anthropologist, I’m especially captivated by the cultural underpinnings of the notion of boundaries in contemporary American psychology and popular culture. Boundaries as they are taught in mental health care and described in media accounts at once honor autonomy (the ability to make free and informed choices about one’s interpersonal relationships) yet idealize independence (suggesting that someone’s psychological, social, and physical well-being is a product of their ability to separate themselves from the behavior of others.) This narrow view of boundaries fails to account for boundaries set by a community as a whole, and for structural and medical barriers that people—especially those with severe and persistent mental illness—face when attempting to mediate their relationships with others. As a peer support facilitator, I have found that boundaries can be collective, such as a support group deciding together not to share personal contact information, such that members of the community are not overburdened with requests for emotional validation and the sharing of resources outside of designated group meetings. I have also heard through peer support and empirical research countless stories of people with serious psychiatric disabilities who have limited power to set boundaries that would otherwise be productive for their mental health, such as those who rely on abusive family members for housing and other material support, or people whose mental health conditions are characterized by turbulent interpersonal relationships with others, as in the case of individuals diagnosed with borderline and narcissistic personality disorders. This is not to say that such people are powerless to mediate interpersonal relationships, and often find creative ways to locate their autonomy and safeguard their mental health, such as locking the door to their bedrooms so that an abusive family member is deterred from invading their personal space. People diagnosed with personality disorders in recovery also find new ways of forging meaningful and interdependent (not codependent) relationships with others. Put simply, the individualistic vision of boundaries in American psychology in some ways overlooks both collective relationships and the barriers to boundaries that are caused by structural inequity or the fundamental nature of someone’s mental health condition.

See previous posts in the “Mixed Bag” series.

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