Connection, Trust, and Recovery: A New Series About Peer Support

Editor's Note: If you’ve ever needed help but weren’t sure where to turn, then you know how important just one trustworthy guide can be. This blog post is the first of an occasional series called “Connection, Trust, and Recovery,” by Michele Easter. The series is about how peer supporters can help people who are returning to the community after incarceration. Today’s installment highlights the voice and experience of Nancy Lloyd, a peer support specialist working with Durham county’s mental health court program. The logo for this series was created by Pitch Story Lab, the student-run creative agency at Duke University.

By Michele Easter

Returning community members face many challenges. To succeed in the community, they will need income and a place to live. But they may experience barriers to both employment and housing, made worse by stigma and possibly having lost the support of family or friends. Those with mental health, trauma, substance use and other behavioral health issues face additional challenges.

When given a second chance, it is hard to succeed if you don’t know what to do, where to go to find help, how to bounce back from challenges, and maybe most important, who you can trust.

Peer supporters are people whose lived experiences (of mental health challenges, substance use disorder, criminal legal system involvement, etc.) helps them support others who have gone through something similar. Because they have “been there,” there is less fear of stigma and judgement from those who they are helping. They can also serve as a role model, help to navigate the “system,” and provide other recovery assistance as needed. They may have formal training and certification (e.g., NC’s peer support specialist certification), or not (e.g., recovery support groups).

Nancy Lloyd is a peer support specialist who works as a Case Management Assistant with Durham’s Mental Health Court diversion program. Before that, she worked with the Jail Mental Health Team, which assists people with psychiatric medication, discharge planning, and connection to community services after they are released. Durham county’s Criminal Justice Resource Center (CJRC) operates both programs.

Mental health court is a type of problem-solving court that works with people to solve the underlying problems that may lead to their offending. The website states the program is “designed to reduce the recidivism of individuals with Serious and Persistent Mental Illness or Serious Mental Illness on medication by offering treatment and the chance to have charges dismissed as oppose[d] to going through more traditional court procedures.”

In an interview with Lloyd, she shared information about her work with me and Wilson Center research assistant Deniz Ariturk.

Regarding the reentry experience and what kind of help is needed, Lloyd noted that the experience of incarceration is “detrimental. People lose their supports because they’ve been judged, feel given up on, betrayed, and lose services while they’re in there. Everything stops. You lose your Medicaid, SSI [Supplemental Security Income], housing, mental health provider, if they haven’t heard from you. You walk out the door and it’s like you’re naked… People who come out, especially after 20 years, so much has changed, they don’t know how to use cellphone, a computer, they don’t have access, others have died or don’t want anything to do with them.

"So, it’s heartbreaking when you’re limited in what you can offer someone. Some of them don’t have clothes, they are released with what they have in a bag. If they do have money, how far can it go. They don’t know where to go, what resources to align with. The only thing for most of them is to reoffend.”

This graphic from Policy Research Associates illustrates the many ways that peer supporters can help people with mental health or substance use issues avoid the criminal justice system, from avoiding police contact during a crisis to putting in place the elements of success for a new life when returning to the community after incarceration.

Lloyd observed that when people are released, there should be coordination in the transition from incarceration to community.

“It’s a middle management that needs to be set in place, it’s just that gap that causes the issues,” she said.

Without coordination, some people will fall through the cracks, lose their chance at community integration, and return to offending.

Lloyd’s duties include intensive outreach and consistent contact with clients and close collaboration with the court coordinator. Clients may be with the court for a 6- or 12-month period. During this time, the “first thing is to work on housing, then see if the client is eligible for SSI or Medicaid or Medicare, and see if they can get food stamps,” she said.

She provides intensive support for people with serious mental health challenges so their recovery is not destabilized by challenging events or “triggers” that could lead to a crisis. Triggers might include interruptions in medication, unstable housing, family conflict, financial issues, being around drug users, a medical need such as diabetes, etc.

“Just because you’re getting services, it can still be strenuous for the consumers,” Lloyd said. “You have two days of medication and can’t come next week, and nobody’s hearing how pertinent it is to your stability.”

Lloyd said she does what she can “to make sure everything is aligning so nothing triggers.”

“It could be a perfect dynamic two days ago, but then the person receives SSI and it’s a few dollars more and family members want that money and the person refuses so they put him out,” she said.

She may follow up several times a week, making home visits, providing transportation, picking up medication, coordinating with health care providers, obtaining release forms, and doing whatever it takes to keep the person stable.

The work is intensive and time-consuming: It’s “a lot of coaching, counseling, hands-on– some days my days don’t end. I could start getting calls as early as 7 a.m. and all the way till 2 in the morning, and I’m OK with that, because there is less to be fixed if I answer the phone and am proactive than if I wait till the next day. This population doesn’t work off of our common schedule – it’s 5:01 p.m. – 8:59 a.m. for most people. Everything happens after 5 pm. Get up, pick people up, call housing, middle of the night.”

Sometimes, helping people with their needs requires a lot of trust and a strong relationship.

“Our program is to ensure the person does not reoffend,” Lloyd said. “People like to look at it as simple, but you have to spend infinite unwanted hours because you have to be really close to a person, allowed to be in their personal space. For some people their humility is on the line – you need to make sure they don’t feel embarrassed.”

Sometimes clients are facing very difficult issues that are hard to talk about. It is common for women “to come in abused physically and sexually, and we have had surprisingly more men. You don’t make them feel weak or less of a man because they report these issues to you. It’s a form of catering to each client, individually to make sure their back is straight. You can’t help someone you don’t respect.”

Lloyd’s personal experience helps her empathize with her clients.

“I’m from Durham so I know about 85% of the consumers… it’s hard to see people left out on the sidelines because they are deemed ‘crazy,’” she said. “I grew up in a one of the not-better parts, McDougald Terrace, and I’ve experienced personally the drugs, mental health, criminal and everything that is entangled in that.”

Like other peer supporters, Lloyd helps people navigate resources while also navigating a complex professional role: “Being a peer is complicated because I need to abide by the agency and court policy and not overstep my bounds and borders – to be a friend, case manager, and borrow some of my personal experience to a certain extent. It’s important that I don’t over-cross my job title and my duties.”

Specifically, “I can do the baseline personal counseling – nothing clinical – and I can tell them my referrals and recommendations.” But compared to a clinician, she may have more options that meet the person where they are: “There are only so many ways a clinician can approach a situation. A peer supporter has more flexibility, I can say ‘let’s try it my way and see if it works‘. If they have ideas, I don’t shoot them down.”

Lloyd also helps clients engage with the mental health court program itself.

“The majority of the time I feel like a translator for our court coordinator, DA [District Attorney], attorneys, mental health provider,” she said. “Consumers sometimes don’t hear the different language we [professionals] speak; their comfort zone is more with me than everyone else. It’s an easier delivery from me than the case worker. They may tell their case worker nothing is going on, but they do tell me. Most people [consumers] think the clinician is on a different level, they’re here ‘to tell me what I have to do, give me recommendations. Well she’s the peer, I’ll tell her how I feel about what the clinician tells me.’”

This kind of honest communication builds trusting relationships that help keep clients engaged in the program and build a new life. I asked Lloyd how she establishes trust with clients.

“The ones that don’t know you, when we introduce ourselves, I let my coworker go first, she is coordinator and clinician,” she said. “Then they look at me, ‘who are you,’ and I say ‘She’s Tick and I’m Tock.’ I tell them, I’m no stranger to where you are, I know where you grew up, I’ve had people in my life that have been arrested. My oldest son, his dad used to be an active gang member so I’m knowledgeable of gang activity. And when I tell them my son will be 27 they get more comfortable because I was a teen Mom, had my oldest son at 15; I grew up in McDougald Terrace; my mother was a heroin addict.

“I let them know my experience and if they have a question, they come to me. At some point in my life I might need to come to them. We have to be here for each other for the program to work for them. And I don’t mind telling them, anything they ask me about my background and personal history. I’m open and honest with them: ‘I had a lot of trauma in my childhood. If it can help you, I’ll discuss it with you.’”

I was grateful for the time Lloyd took to speak with us, and moved by the respect and equality she conveyed as she discussed her work with clients. I was also impressed by her combination of knowledge, dedication, flexibility, and ability to translate information in ways that clients can hear.

To be honest, I felt a little worried about how demanding this kind of work is. People like Lloyd are supporting clients by heroically binding the threads our frayed social safety net, but they may be stretched very thin in the process. I think peer supporters could use some support themselves.

For some clients, successful case management requires a 24/7 commitment and a 360-degree perspective that goes well beyond medication and treatment to include housing, food, employment, improving relationships, and other social determinants of health. There are many reasons why people are not able to succeed in the community without intensive assistance. It would not be fair for our ‘system’ to rely on peer support specialists to fill gaps left by under-investment in social and health needs of communities.

I hope this blog post will raise awareness about peer support specialists and the important work they do.

Michele Easter is an Assistant Professor in Psychiatry and Behavioral Sciences at Duke University’s School of Medicine. She is also part of the Behavioral Health Core at the Wilson Center for Science and Justice.