Peer Support and Trauma Recovery
by Cameron Macauley, MPH [ Center for International Stabilization and Recovery ]
Peer support is becoming an important strategy to help survivors of war-related violence recover from psychological trauma. After a short training in counseling techniques, peer-support workers seek out trauma survivors in the community and help them reintegrate into society, find work, engage in sports and come to terms with their traumatic memories. Peer-support programs incur costs related to transportation and communication, but support groups may recover some costs through income-generating projects.
In 1996 when Kemal Karič was four years old, he was injured when an artillery shell severed his right leg below the knee. His mother was killed in the same blast. He received peer support from LSN Outreash Worker Nusret Pleho.
All photos courtesy of Reverend Paul Jeffrey.
For most people who survive injuries from landmines or other explosive remnants of war, friends and family can significantly aid in the recovery process. Survivors rarely recover in isolation; support from concerned people in the survivor’s life is often the single most crucial element in the period of healing.1
Survivors call upon their own inner resources to tolerate physical pain, mental anguish, flashbacks, nightmares, fear, difficulty with daily activities, loss of employment or school interruption, as well as stigma, discrimination and the humiliation of depending on others for assistance. Yet emotional support, companionship, sensitivity and affection are natural human responses and, in this painful time, often make the difference between suicidal depression and the desire to move forward and recreate a “normal” life.2
Some organizations providing victim assistance for survivors recognize the power of psychosocial support and incorporate it into their programs. In particular, many victim-assistance programs recognize the strength and power of bonds between peers—people similar in age, gender and social background, and especially those who share a history of trauma survival. Peer support has become a standard way to help survivors readjust during their recovery.
Peer support is particularly attractive in post-conflict settings because it encourages survivors to help one another, occurs in natural community settings, can be adapted to specific ethnic and cultural circumstances, avoids the stigma associated with psychiatric care, emphasizes outreach and people’s strengths, and is likely to be culturally sensitive since it is delivered by community members.3
Kadira Nukič lost her leg above the knee during the 1995 siege of Srebrenica (Bosnia and Herzegovina). Her husband and two children were killed in the fighting. She received peer support from LSN Outreach Worker Aladin Mujačič in 2006 and went on to establish a support group for female amputees in Bosnia and Herzegovina.
A Brief History
Peer-support programs for military veterans date back to just after World War I, according to The New York Times: “A corps of ‘cheer-up’ men, themselves cripples of various kinds, has been organized at the base hospitals in France and…in the United States. Through their efforts, example and precepts, the injured man is stimulated to use his brains on his own behalf.”4 Following World War II, amputee veterans were often employed in prosthetics centers to teach ambulatory skills, daily-living activities and residual limb care.5 Still in use and similar to the current peer-support model, Alcoholics Anonymous, a group for recovering alcoholics, developed the “sponsor method” in the late 1930s.6 In the late 1990s, the Amputee Coalition of America began training Peer Visitors to talk with new amputees while they recovered from surgery in the hospital.7 In 1997, Jerry White and Ken Rutherford established Landmine Survivors Network (later renamed Survivor Corps) to take this approach to mine-affected countries worldwide with the intent of creating a global network of landmine survivors to provide victim assistance services.8
The Implementation of Peer Support
A variety of nongovernmental organizations use peer support in programs for survivors of war-related violence, including but not limited to those injured by landmines or ERW. Peer-support programs exist for amputees, military-combat and torture survivors, refugees, and survivors of kidnapping and sexual violence related to war. Programs for landmine survivors use peer support as a principal tool in Afghanistan,9 Bosnia and Herzegovina,10 Cambodia,11 Rwanda,12 and Vietnam.13 Landmine Survivors Network established peer-support programs in 12 countries before closing in 2010.
Peer support is offered to survivors as either one-to-one individual counseling or in group sessions where all members are survivors. Peer-support workers receive some training on how to:
- Provide effective counseling
- Deal with suicidal behavior and substance abuse
- Help survivors obtain professional services, such as dealing with health problems, starting a business/finding work or applying for financial assistance
Because peer-support workers are survivors, some of their training includes how to deal with their own feelings of fear, anger and grief, which is important in coping with such emotions that other survivors’ stories may trigger.
Peer-support workers are sometimes referred to as “outreach workers” because they seek out survivors in the community who may not have received treatment or attention for their psychological trauma. Trauma survivors may isolate themselves and avoid social contact, remaining bitter and depressed for years. By visiting a survivor in his or her home, a skilled peer-support worker can encourage a survivor to return to the social network, which improves self-esteem, increases problem-solving capabilities and reduces the incidence of suicide.
Once survivors are comfortable in a social setting, they usually benefit from a survivor-support group. Support groups meet for a variety of reasons, not always overtly related to trauma recovery but frequently for more practical activities such as income generation, entertainment or sports. In the midst of these events, peer support takes place and survivors benefit from contributing to a group effort. Support groups expose survivors to others who are in different stages of recovery and are in the process of overcoming various types of trauma.
The Theory Behind Peer Support
Researchers and clinicians feel there is a solid theoretical basis for peer support’s effectiveness as a therapeutic method. When someone recognized as a “peer” provides support to a survivor, a variety of psychosocial processes come into play, as described by Phyllis Solomon in 2004:14
- Social support consists of positive psychosocial interactions in which there is mutual trust and concern.15Healthy relationships contribute to positive adjustment and help survivors deal with stress and challenges through emotional support (esteem, attachment and reassurance), instrumental support (material goods and services) and information support (advice, guidance and feedback).14
- Experiential knowledge comes from dealing with a particular set of challenges such as substance abuse, a physical disability, a chronic illness or surviving a traumatic event such as military combat, a natural disaster, domestic violence, sexual abuse or imprisonment. When shared, experiential knowledge helps a survivor solve problems and improves a survivor’s quality of life.16
- Social learning theory postulates that peers, because they have undergone and survived relevant experiences, are more credible role models for others. When survivors interact with peers who cope successfully with stress, difficulties or illness, they are more likely to exhibit positive behavior changes.17
- Social comparison theory suggests people are constantly comparing themselves to those around them. They are more comfortable with others who share common characteristics with them, which helps them establish a sense of normalcy. Interacting with others who are perceived to be better than them gives them a sense of optimism and something to strive toward.18 Helping others, who they consider to be struggling or in need, enhances people’s own sense of self-worth.
- The helper-therapy principle proposes four main benefits for those who provide peer support.19, 20 As a result of making an impact on another person's life, the “helper” has an increased sense of interpersonal competence, experiences the reward of positive exchanges with others, learns useful skills while helping and receives social approval from the person they help and others.17
Ardie Sabahudiv and Popovič Dragan are landmine survivors who fought on opposite sides during the Bosnian civil war. They both work as professional sculptors and received peer support through the Association of Disabled Persons in Banja Luka, Bosnia and Herzegovina.
Establishing New Peer-support Programs
In spite of peer support’s effectiveness in promoting recovery from trauma of survivors and of those who help them, peer-support programs have drawbacks. Individual one-to-one peer support is expensive to implement because peer-support workers need transportation to visit survivors in their homes, and this may require programs to cover the costs of public transportation, or provide peer-support workers with a bicycle or a motor scooter and associated expenses such as fuel. Many peer-support programs pay for or subsidize mobile phones for peer-support workers so they can stay in contact with survivors as well as with their own supervisors and can help survivors set up appointments, or network for jobs and other opportunities.
Peer-support workers are sometimes volunteers, but many programs pay them salaries commensurate with their experience and training. Supervisors (usually social workers or program managers) are also necessary, and there may be a need to hire specialists in employment opportunity and advocacy. Peer-support groups can be more cost-effective, but costs are still associated with transporting survivors to group meetings, except in very small communities. Support groups may request contributions from members in order to cover costs, or they may organize income-generation projects such as vegetable gardens, theater or crafts. In some cases peer-support groups for landmine survivors have grown into independent NGOs, as in Bosnia and Herzegovina21 and El Salvador.22
Lastly, some psychotherapists argue that support from a peer with only brief training in counseling may in some cases be harmful to survivors suffering from severe psychological trauma.23 Special training is needed to help survivors deal with suicidal depression, hallucinations, drug and alcohol abuse, and flashbacks. Inappropriate counseling has the potential to worsen some conditions or at the very least, interfere with the healing process.24 In addition, peer-support workers can experience “vicarious trauma” from hearing survivors’ trauma stories.25 Although there is some risk, most peer-support programs have access to professional psychotherapists to whom they can refer survivors with problems that are too severe for the peer-support worker to handle. Peer support is never considered to be a substitute for psychotherapy, but it is a useful supplement, especially in areas where health-care services are sparse. The training of peer-support workers is growing more sophisticated and now emphasizes the limits of peer support, as well as its benefits.
Trauma specialists worldwide recognize that most survivors are capable of full recovery from psychological trauma under the right circumstances and that an accepting, supportive social environment is a key factor in preventing long-term psychological dysfunction. Peer support encourages survivors to provide that supportive network for the trauma-stricken, and it can often help survivors recover quickly without seeking help outside the community. Peer-support programs for trauma survivors can supplement thinly-stretched mental-health services in post-conflict settings and promote vital social reconstruction following a war.
Cameron Macauley joined CISR in August 2010 as Peer Support and Trauma Rehabilitation Specialist. He holds degrees in anthropology and psychology and became a Physician Assistant in 1983. He has worked in a refugee camp on the Thai-Cambodian border, at a district hospital in Sumatra, as a Peace Corps volunteer in Guinea-Bissau, in Mozambique where he taught trauma surgery for landmine injuries, in an immunization program in Angola and in a malaria-control program in Brazil. Between 2005 and 2010, he taught mental health courses for Survivor Corps in Bosnia, Colombia, El Salvador, Ethiopia, Jordan and Vietnam.
Peer Support and Trauma Rehabilitation Specialist
Center for International Stabilization and Recovery
James Madison University
800 South Main Street, MSC 4902
Harrisonburg, VA 22807 / USA
Tel: +1 540 568 4947
Website: http://cisr.jmu.edu or http://maic.jmu.edu
- Figley, C. “Traumatic stress: The role of the family and social support system.” In Trauma and Its Wake: The Study and Treatment of Post-Traumatic Stress Disorder, edited by C. Figley. New York: Brunner/Mazel, 1986 (39–58).
- Herman, J. L. Trauma and Recovery. New York: BasicBooks, 1997.
- Fisher, D. and L. Miller, D. Romprey, B. Filson. “From Relief to Recovery: Peer Support by Consumers Relieves the Traumas of Disasters and Recovery from Mental Illness.” Presented at the After the Crisis: Healing from Trauma after Disasters Expert Panel Meeting, The National GAINS Center and the Center on Women, Violence and Trauma (CWVT) through The Center for Mental Health Services, SAMHSA. Bethesda MD, 24–25 April 2006, http://www.gainscenter.samhsa.gov/atc/pdfs/atc_concept_paper.pdf. Accessed 27 October 2010.
- The New York Times Current History of the European War, XVII (Oct–Dec. 1918: 123).
- Care of the Combat Amputee. Washington DC: Borden Institute, Walter Reed Army Medical Center, Office of the Surgeon General, United States Army, 2010 p. 20.
- “Questions & Answers on Sponsorship.” Alcoholics Anonymous World Services, Inc., 2005. http://www.aa.org/pdf/products/p-15_Q&AonSpon.pdf. Accessed 27 October 2010.
- National Limb Loss Information Center (2005). “Understanding ACA’s National Peer Network,” Amputee Coalition of America, Knoxville, TN. http://www.amputee-coalition.org/fact_sheets/peer_network.pdf. Accessed 27 October 2010.
- White, J. and K. Rutherford. “The Role of the Landmine Survivors Network.” To Walk Without Fear: The Global Movement to Ban Landmines, edited by Maxwell A. Cameron, Robert J. Lawson and Brian W. Tomlin. Cambridge: Oxford University Press, 1998.
- Afghan Landmine Survivors’ Organization (ALSO). http://www.afghanlandminesurvivors.org/. Accessed 26 October 2010.
- Landmine Survivors Initiatives (LSI). http://www.ipm-lsi.org. Accessed 26 October 2010.
- Clear Path International (CPI). “Cambodia.” http://www.cpi.org/regions/cambodia.php. Accessed 26 October 2010.
- The Advocacy Project. http://advocacynet.org/wordpress-mu/lrogoff/blog/tag/association-of-landmine-survivors-and-amputees/. Accessed 26 October 2010.
- For information about The Association for Empowerment of Persons with Disabilities (AEPD), see The Advocacy Project. http://advocacynet.org/files/People_Power_2009_Annual_Report.pdf. Accessed 22 December 2010.
- Solomon, P. "Peer support/peer provided services underlying processes, benefits, and critical ingredients". Psychiatric rehabilitation journal, 2004, (27 (4): 392–401).
- Sarason, I. and H. Levine, R. Basham, B. Sarason. "Assessing social support: The social support questionnaire." Journal of Personality and Social Psychology, 1983, (44: 127–139).
- Shubert, M. and T. Borkman. "Identifying the experiential knowledge developed within a self-help group." In Understanding the self-help organization, edited by T. Powell. Thousand Oaks: Sage, 1994.
- Salzer, M. and S.L. Shear., "Identifying consumer-provider benefits in evaluations of consumer-delivered services." Psychiatric Rehabilitation Journal, 2002, (25: 281–288).
- Festinger, L. "A theory of social comparison processes." Human Relations, 1954 (7: 117–140).
- Riessman, F. "The 'Helper-therapy' principle." Social Work, 1965 (10: 27–32).
- Skovholt, T M. "The client as helper: A means to promote psychological growth." Counseling Psychologist, 1974 (43: 58–64).
- The Balkans Project. “Interview with UDAS.”http://balkansproject.ips-dc.org/?p=221. Accessed 26 October 2010.
- Red de Sobrevivientes y Personas con Discapacidad. http://reddesobrevivientes.org/. Accessed 26 October 2010.
- Cori, J. L. and R. Scaer. Healing from Trauma: A Survivor's Guide to Understanding Your Symptoms and Reclaiming Your Life. Da Capo Press, 2008, p. 138.
- Greenberg, N. and V. Langston, et al. "A cluster randomized controlled trial to determine the efficacy of Trauma Risk Management (TRiM) in a military population." Journal of Traumatic Stress (23(4): 430–436).
- Trippany, R. L. and V. E. W. Kress, et al. "Preventing vicarious trauma: What counselors should know when working with trauma survivors." Journal of Counseling & Development, 2004, (82(1): 31–37).