I’m sometimes asked whether peer support is treatment. I always answer “no,” though others may not. In my mind, treatment seeks to cure the disease, rehab the injury, or slow the progression of symptoms. Peer support helps with the process of living with or through the disease. In the case of physical diseases, the distinction is clear. For example, cancer treatment involves chemotherapy, radiation, drugs, surgery, or some combination of these. Peer support allows patients to share fears, tips, and recommendations.

I figure the easiest way to illustrate the difference between treatment and peer support is to hold a grudge match between a popular treatment for PTSD (prolonged exposure therapy) and a particular model for peer support (OSISS). Like the famous tennis matches between Bjorn Borg and John McEnroe, there will be a lot of back and forth before a winner is finally decided.

We’ll start the comparison by describing therapy and peer support separately.

Prolonged Exposure Therapy

Prolonged exposure therapy  (PET) is considered the gold standard in treatment for PTSD for both military and civilian patients. Using the therapy for 8-15 sessions of 90 minutes each, patients do get much better. In a typical session, the patient is asked to recount a traumatic event repeatedly in order to reduce fear and anxiety responses.

The theory behind this (and other treatments) is a concept called “extinction,” which is a fancy way of saying unlearning a learned response. Remember Pavlov’s dogs? The dogs would start salivating when they saw food, so Pavlov taught them to associate the sound of a bell with food. Soon after, the dogs would start salivating when they heard the bell. In this situation, extinction is playing the sound of the bell in the absence of food. Do this often enough and the dogs stop salivating.

In theory, repeatedly re-telling a traumatic event reduces the strength of the negative associations. If this sounds incredibly unpleasant, that’s because it is. The drop out rates for PE are high. It’s not unusual for 90% of the patients to drop out before the sessions are completed. David J. Morris has written his experience with PET. His traumatic event was an encounter with an IED in Iraq. After about a month of therapy, he had told the story about a hundred times.

But after a month of therapy, I began to have problems. When I think back on that time, the word that comes to mind is “nausea.” I felt sick inside, the blood hot in my veins. Never a good sleeper, I became an insomniac of the highest order. I couldn’t read, let alone write. I laced up my sneakers and went for a run around my neighborhood, hoping for release in some roadwork; after a couple of blocks, my calves seized up. It was like my body was at war with itself. One day, my cellphone failed to dial out and I stabbed it repeatedly with a stainless steel knife until I bent the blade 90 degrees.

When I mentioned all this to my therapist, he seemed unsurprised.

Peer Support

They are many ways to provide peer support. The method that is most commonly used on the internet is the “clubhouse,” where a group of people with the same difficulty are placed into a discussion group together. The key advantage of this model is the group can be grown easily. On Facebook, Send Up the Count has about 10 000 members, and PTSD Buddies has about 5000 (along with other regional groups). Peer support through an online network alleviates issues regarding geographical location and access to mental health services. Peer support in an online forum allows individuals to remain anonymous but still receive the mental health support necessary for their PTSD symptoms. The online forum also allows individuals struggling with insomnia to still receive support at late hours in the night.

OSISS (Operational Stress Injury Social Support) is a program run by Canadian Forces Morale and Welfare Services, which is part of Department of National Defense. For more details, read “Better Off Dead” by Fred Doucette, which we have reviewed previously. There is a small number of paid peer supporters distributed across the country. The supporters are individuals who are further along in the OSI recovery process and they receive intensive training before they start work. Peers (individuals requiring support) are referred to OSISS through a variety of channels, including padres, fellow soldiers, and chain of command. Peer supports meet with peers one on one, in locations such as coffee shops and the homes of peers. The meetings can vary in both length and frequency, depending on the needs of the peer at any given time.

The three key pillars of peer support are: listen, assess, and refer. The job of peer supporter is to provide a sympathetic ear, figure out what kind of assistance is needed, and refer the peer to services as needed. As with therapy, many do not make use of the peer supporter.

Peer support allows a military member to speak about their trauma to someone who has done through the experience. The peer supporter provides hope: that PTSD can be overcome, that medication and therapy are viable and effective, and that the peer is not alone. Peers often feel as though others will not understand their circumstances and they will feel a great stigma from speaking out about their PTSD. The peer supporter is a trained specialist, but not a clinician.

These explanations of the PET and peer support, we’ve laid the groundwork for comparing them, which we will do in the next post. We’ll wrap up with a couple of questions for you.

Did we miss anything in the descriptions? Are there any details that you’d like to add?