# introduction

Peer support (PS) is, in its most expansive sense, “a naturally occurring, mutually beneficial support process, where people who share a common experience meet as equals, sharing skills, strengths and hope; learning from each other how to cope, thrive and flourish” (1). Self-help and mutual aid was a common way of life until the 1850s when, particularly in white, Western jurisdictions, a culture of professionalism developed; important roles were extracted from communities and transformed into elite areas of expertise (2). In the Canadian context, one effort to reclaim and re-practice peer support is a tradition that traces its roots to the 1960s-1970s psychiatric consumer/survivor/ex-patient (C/S/X) movement, where participants engaged in political action to expose the dehumanization of psychiatric practices and to advocate for legal and social rights. They also developed their own independent alternative supports (3).

This C/S/X movement-inspired PS was initially available informally through naturally occurring interpersonal relationships and grassroots groups like Vancouver’s Mental Patients Association, formed in 1971, and the Ontario Mental Patients Association founded in 1977 (4,5). Increasing in the 1980s and 1990s, PS was intentionally fostered through government funding of community initiatives run by and for people with lived experience (PWLE) of mental health and/or substance use concerns as an alternative to conventional, hierarchical service models. Over the last 15 years, we have seen a growing recognition of the value of lived experience, an increase in paid PS roles, and the movement of these roles from grassroots initiatives into formal mental health services (6,7).

Although PS has been growing, it remains poorly resourced in Canada (8). In the national expansion of medical assistance in dying (MAiD) over the past decade, larger, well-established and funded health professions have been acknowledged as having a significant role and have had the resources to develop and disseminate discipline-specific position statements, policies, and educational materials on MAiD. PS has had scant resources to develop its own materials. Yet a study by one of our co-authors on patient and family perspectives on MAiD for persons with mental illness suggested the importance of ensuring access to peer supporters for those considering MAiD and providing peer supporters with relevant training on MAiD (9). In this paper, we share what we have learned from coming together to respond to this need.

Our colleagues in Mad Studies, the academic discipline that has developed from the C/S/X movement, have been weighing in on MAiD conversations (10-12). PWLE of mental health conditions have been providing testimonials (13-16). There has also been some discussion within C/S/X movement news sources, though these have largely not been noticed by academic scholarship (17-19). To date, lessons from the C/S/X movement’s historical and contemporary national PS practice have not been explicitly part of scholarly discussions about MAiD. We seek to address this gap. In doing so, we see this work as one of “Mad Ethics,” the elaboration of how PWLE of mental health and/or substance use concerns put values into action in the context of PS. To reflect this contribution, we draw on several common terms to refer to our communities, including peer (peer support participant), peer supporter, and people with lived experience (PWLE).

After briefly outlining our collaborative initiative over 2024 to develop tailored educational resources for peer supporters on MAiD, we share learnings from this initiative that have much to contribute to national conversations. We demonstrate how peer supporters play a unique and important role in peers’ explorations of MAiD, building on the PS discipline’s long experience supporting peers’ explorations of desires to die, possibilities for living, and options other than dying. This role is distinct in notable ways from those of regulated health professions or a peer’s informal support network of friends and family, offers a special contribution to MAiD discourse, policy, and care in Canada, and requires greater recognition and resources.
# Background: Project Design and
        Approach

Our work to facilitate opportunities for learning and dialogue for peer supporters on MAiD proceeded in seven steps.

## Exploring the Focus

Our initial work began over November 2023-January 2024, when there was uncertainty over whether MAiD for Mental Illness as a Sole Underlying Medical Condition (MI-SUMC) would be decriminalized on March 17, 2024, following a one-year extension of ineligibility announced the year before. We proceeded with the knowledge that regardless of whether the government extended the ineligibility date (as became the case), peer supporters had much to contribute to holistic support for people considering and pursuing MAiD. For example, through supporting peers already participating in PS who were receiving terminal diagnoses and planning for end-of-life, potentially through Track 1 MAiD for individuals whose natural death is reasonably foreseeable, as well as people experiencing unbearable suffering from chronic pain, illness, or disability who were considering Track 2 MAiD for those without a reasonably foreseeable death. Regardless of their identity or experience with respect to the mental health system, peers expressing desires to die sooner or differently than they might otherwise may seek or benefit from PS. We wanted peer supporters across the country to feel prepared for these conversations.

## Gathering the Team

Our team included an ethicist, PS learners, lived experience scholars, MAiD researchers, one of us with lived experience of a family member’s death with MAiD, and the Executive Directors of our national and provincial peer support associations. The mission of Peer Support Canada, formed in 2010 as the national voice for PS, is to “increase the recognition, growth, and accessibility of peer support within the mental health and substance use health spaces.” (20) PeerWorks, established in 1991, pursues a mission to “strengthen, amplify and deepen diverse peer voices in Ontario through community building, information-sharing, collaboration, advocacy and education.” (21) Both organizations play an active role in advancing PS in Canada, including through professional development for peer supporters.

## Searching for Information

Peer Support Canada and PeerWorks circulated a call for information to their national and provincial membership lists to inquire into existing — or desired — resources for peer supporters on MAiD. We also conducted an environmental scan of roughly 300 academic and community resources, aided by the reference lists provided by colleagues. We learned that peer supporters are eager for educational materials but did not identify any specifically tailored to their role.

## Curating and Developing Educational Content

A team of nine PWLE related to PS and the mental health system assessed resources for relevance and accessibility to arrive at a final list of 34 sources considered most helpful to our audience of peer supporters. To meet different learning needs, we ensured multiple formats (e.g., recorded webinars, government reports, podcasts) and summarized key points. The final 14-page list was graphically designed to reduce information overload (22).

Team members also felt that we should facilitate a tailored interactive learning opportunity. We therefore invited peer supporters with a basic knowledge of MAiD to attend a discussion series focused on the PS role. We designed the series as a 3-part discussion (90 minutes weekly over three weeks) so that participants had time to build rapport before the most challenging conversations in week 3. The series was based on five PS scenarios and associated prompts, which covered topics of death, dying, end-of-life, grief, suicide, and MAiD, seeking to situate MAiD within a broader, familiar context for peer supporters, encouraging them to bring forward a range of experiences to inform the discussion. Honouring the PS value of mutuality, facilitators positioned themselves as learners, highlighting that because there are no existing guidelines informing peer support’s relationship to MAiD, we would develop this knowledge together.

## Taking a Provisional Stance

In anticipation of mixed reactions to the resources, we included a preamble acknowledging diverse views in PS communities with respect to MAiD (13), and how peer supporters deserve equitable access to education and support:

> Peer supporters need to be prepared to have conversations about death, dying, and end-of-life, whether they are supportive or not supportive of MAiD. As people who have often personally navigated challenges associated with death and dying, peer support workers are naturally equipped to be able to navigate these conversations.

> [Peer supporters] should not be expected to participate in providing support that they feel unprepared and/or unable to provide due to a lack of training, guidance, support, and/or on the grounds of personal convictions and beliefs. Peer supporters are also entitled to the resources and support they need to be able to have these conversations.
> — 22

This focus is consistent with Peer Support Canada and PeerWorks’ mission statements and work to increase tailored education for peer supporters.

## Facilitating the Discussion Series

We advertised the series to peer supporters across the country through the membership lists of Peer Support Canada and PeerWorks. In keeping with our goal to involve a group diverse by geography and other identities, and to ensure that the series would meet participants’ needs, we developed a brief application form. We had over 250 people apply. To date, we have facilitated the series six times with a total of 67 peer supporters representing 8 provinces and 1 territory. 59.7% of participants identified as belonging to one equity-deserving community (beyond mental health/substance use), and 25.4% as belonging to two or more. Each series has included two co-facilitators, a person available to offer confidential PS in a breakout room, and a note-taker/technology support person.
# Conclusion: Valuing the peer support role in MAiD
        conversations

Peer supporters have an important role to play in conversation and care related to people exploring MAiD, building on long experience and values-based approaches to supporting people who express wishes to die. PS values and standpoints offer a different way of being in relationship, caring for and not abandoning each other, and supporting decision-making.

Yet, peer supporters cannot have the positive impacts described above when they are restricted from contributing (62,74), or when they feel they must work outside the lines of organizational policy in order to maintain integrity with PS values, as several worried about in our discussion series. We have not yet seen an organizational MAiD policy that references the role of peer supporters in the process — and we imagine very few, if any, peer supporters have been involved and consulted in such policy development at organizational, provincial, or national levels. Organizational policies that block (or fail to encourage) peer supporters from having meaningful conversations with peers about desires to die should be revised through consideration of PS knowledge (74).

Peer supporters also require support that is rarely available, due to a lack of dedicated funding towards peer support within community mental health care in Canada and severe underfunding of independent PS initiatives (8). Talking about desires to die is emotionally challenging. Peer supporters in our discussion series made difficult decisions about how they might be able to support a peer’s journey based on whether their employer would provide the support needed to replenish. Most peer supporters face significant employment precarity, such as low pay, part-time roles, lack of paid sick days, bereavement, or holidays, or health benefits. They are often working in isolation on interdisciplinary teams without PS from colleagues with lived experience (8). There is much work to do to ensure PS programs across the country are properly resourced and supported, with tailored educational opportunities, particularly on the topic of MAiD. Peer supporters are owed this social solidarity and reciprocity in recognition of their love labour to honour the painful stories entrusted to them.

All people experiencing social and existential suffering, loneliness, and the emotional and spiritual impacts of societal prejudice deserve access to the support, information-sharing, power, and alternatives offered by social movement-inspired PS initiatives. MAiD policies and programs should require the offer of PS to people exploring MAiD, and access to it, if desired. Registered health professionals who have benefited from increasing professionalization and associated disintegration of informal supports have a duty to ensure every patient they treat also finds opportunity for belonging and connection in their community.

## Références

1PeerWorks. Frequently asked questions. PeerWorks; 2024.

2Starkman M. The movement. Phoenix Rising. 1981;2(3):2A-9A.

3Shimrat I. Call Me Crazy: Stories from the Mad Movement. Vancouver: Press Gang Publishers; 1997.

4Davies M. The inmates are running the asylum: Stories from the Mental Patients Association (MPA). History of Madness Productions. 16 Jan 2014.

5Weitz D. On our own: A self-help model. In: Lumsden DP, editor. Community Mental Health Action: Primary Prevention Programming. Ottawa: Canadian Public Health Association; 1984. p. 312-20.

6Boschma G, Devane C. The art of peer support: Work, health, consumer participation, and new forms of citizenship in late twentieth-century mental health care in British Columbia. BC Stud. 2019;(202):65-97.

J, Shepherd M, Boydell KM, Leff A, Crawford E. Beyond the service paradigm: The impact and implications of consumer/survivor initiatives. Psychiatr Rehabil J. 1997;21(2):132-40.

8de Bie L, Michetti-Wilson E. Drift from peer support values and standards: A position statement and call for action. PeerWorks; 2024.

V, Bastidas-Bilbao H, Gupta M, et al. Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: a qualitative study of patient and family perspectives. BMC Psychiatry. 2024;24:120.

A. Theorizing the intersections of ableism, sanism, ageism and suicidism in suicide and physician-assisted death debates. In: The Disability Bioethics Reader. New York: Routledge; 2022. p. 221-31.

A. Undoing Suicidism: A Trans, Queer, Crip Approach to Rethinking (Assisted) Suicide. Philadelphia: Temple University Press; 2023.

G. The necropolitics of psychiatric euthanasia and assisted suicide (pEAS). Can J Disabil Stud. 2024;13(1):50-86.

E. Testimonial of Ellen Cohen. Can J Disabil Stud. 2024;13(2):201-4.

S. Testimonial of Sean Krausert. Can J Disabil Stud. 2024;13(2):244-6.

G. Testimonial of Georgia Vrakas. Can J Disabil Stud. 2024;13(2):304-11.

16Empowerment Council. Mental health service users and medical assistance in dying (MAID). 2017.

17Our Voice / Notre Voix. Emergency edition: Saying NO to our euthanizing - Why Bill C-7 to extend medical assistance in dying to cases uniquely involving “mental illness” is WRONG!. Our Voice / Notre Voix; 2023;76.

18Walker TO. Bodily autonomy or state sanctioned death? Asylum Mag. 2024;31(3).

19Wedlake G. MAID and mental illness: An interview with Dr. Jeffrey Kirby. Mad in Canada: Science, Psychiatry and Social Justice. 5 Oct 2023.

20Peer Support Canada. Vision and mission. 2025.

21PeerWorks. About PeerWorks. 2024.

22de Bie L, Brown S, Dhadwal E, et al. Medical assistance in dying resources for peer supporters. PeerWorks and Peer Support Canada. Mar 2024.

23Editors of Phoenix Rising. Editorial: Coming together; making changes. Phoenix Rising. 1981;2(3):2-3.

24Peer Support Accreditation and Certification (Canada). National Certification Handbook. 2016.

25Peer Support Canada. Peer Support Core Values. 2019.

26National Association of Peer Supporters. National Practice Guidelines for Peer Supporters. 2013.

AC, Halpin M, Phillips K, Skerritt F, Beales A, Cheng V, Davidson L. The growth of peer support: An international charter. J Ment Health. 2019;28(6):627-32.

28World Health Organization. One-to-one peer support by and for people with lived experience. Geneva: WHO; 2019.

L. Kant, autonomy and bioethics. Ethics Med Public Health. 2017;3(3):381-92.

30National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington: Department of Health, Education, and Welfare; 18 Apr 1979.

31Beauchamp T, Childress J. Principles of Biomedical Ethics. 1<sup>st</sup> ed. Oxford: Oxford University Press; 1979.

32Moore KL. Disabled autonomy. J Health Care Law Policy. 2019;22(2):245-79.

33Chamberlin J. The ex-patients’ movement: Where we’ve been and where we’re going. J Mind Behav. 1990;11(3-4):323-36.

34Chamberlin J. On Our Own: Patient-Controlled Alternatives to the Mental Health System. New York: McGraw-Hill; 1978.

N. Critics and dissenters: Reflections on anti-psychiatry in the United States. J Hist Behav Sci. 1989;25(1):3-25.

A. Empowerment and the psychiatric consumer/ex-patient movement in the United States: Contradictions, crisis and change. Soc Sci Med. 1995;40(8):1053-71.

M. Force in mental health services: International user and survivor perspectives. Ment Health Pract. 2004;7(5):12-7.

DJ, Rissmiller JH. Evolution of the antipsychiatry movement into mental health consumerism. Psychiatr Serv. 2006;57(6):863-6.

History Group. Survivors History Group takes a critical look at historians. In: Barnes M, Cotterell P, editors. Critical Perspectives on User Involvement. Bristol: The Policy Press; 2011. p. 7-18.

C. MAID resistance in Canada: sounding the five-minute entreaty. Can J Disabil Stud. 2024;13(2):1-175.

D, Cyhlarova E. Ethical issues in mental health peer support. In: Sadler JZ, Fulford KWM, van Staden W, editors. The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press; 2015. p. 244-54.

42Bennett H. Friendship. In: Zalta EN, Nodelman U, editors. The Stanford Encyclopedia of Philosophy. Fall 2023 Edition.

43Onken SJ. Contextualizing self-determination within a mental health recovery oriented service and support system. In: Jonikas JA, Cook JA, editors. The National Self-Determination and Psychiatric Disability Invitational Conference. Chicago: University of Illinois at Chicago, National Research and Training Center; 2004. p. 96-128.

E. The role of drug users’ advocacy group in changing the dynamics of life in the Downtown Eastside of Vancouver, Canada. J Subst Use. 2014;19(1-2):213-8.

Y, Hayes D, Fancourt D. Promoting social prescribing in psychiatry—using shared decision-making and peer support. JAMA Psychiatry. 2023;80(8):759-60.

C, Kumar K, Smith P, Ivanyi K. The ‘means available to relieve suffering’: Translating medical assistance in dying safeguards in Canadian policy and practice. Soc Policy Soc. 2025;1-14.

47Sunderland K, Mishkin W, Peer Leadership Group, Mental Health Commission of Canada. Guidelines for the Practice and Training of Peer Support. Calgary, AB: Mental Health Commission of Canada; 2013.

48Hardaker D. Self-determination and peer support. 2012.

49Boyce S. Helping your friends who sometimes wanna die maybe not die. Tiny Lanter; 2019.

S, Mazel-Carlton C. The “alternatives to suicide” approach: A decade of lessons learned. In: Alternatives to Suicide. San Diego: Academic Press; 2020. p. 179-99.

AL, Mbao M, Kadakia A, Collings S, Fortuna KL. Experiences of community members engaged in eCPR (Emotional Connecting, Empowering, Revitalizing) training: Qualitative focus group study. JMIR Form Res. 2022;6(6):e32219.

L, Swarbrick M. Peer-run respite approaches to supporting people experiencing an emotional crisis. Psychiatr Serv. 2024;75(11):1163-6.

53Venner F, Noad M. A beacon of hope: Alternative approach to crisis — learning from Leeds Survivor Led Crisis Service. In: Coles S, Keenan S, Diamond B, editors. Madness Contested: Power and Practice. PCCS Books; 2013. p. 332-48.

J, Nelson G, Janzen R, Trainor J. A longitudinal study of mental health consumer/survivor initiatives: Part 3—A qualitative study of impacts of participation on new members. J Community Psychol. 2006;34(3):273-83.

55Health Canada. Fifth Annual Report on Medical Assistance in Dying in Canada, 2023. Ottawa. 11 Dec 2024.

C, Kelly M, Spiegel L, Baylis PJ, Dembo J, Wiebe E. Patient experiences with requests for medical assistance in dying: Perspectives of those with complex chronic conditions. Can Fam Physician. 2024;70(1):41-7.

A. The somatechnologies of Canada’s Medical Assistance in Dying Law: LGBTQ discourses on suicide and the injunction to live. Somatechnics. 2017;7(2):201-17.

M. Countering the rational suicide story. Int J Fem Approaches Bioeth. 2021;14(1):73-102.

V. Hate kills: A social justice response to “suicide”. In: White J, Marsh I, Kral MJ, Morris J, editors. Critical Suicidology: Transforming Suicide Research and Prevention for the 21st Century. UBC Press; 2016. p. 169-87.

60Thom KC. I Hope We Choose Love: A Trans Girl’s Notes from the End of the World. Vancouver: Arsenal Pulp Press; 2019.

A. Suicidism: A new theoretical framework to conceptualize suicide from an anti-oppressive perspective. Disabil Stud Q. 2020;40(3).

A, van Bergen DD. Peer specialists in suicide prevention: Possibilities and pitfalls. Psychol Serv. 2019;16(3):372-80.

63Trans Lifeline. Why no nonconsensual active rescue? In: Dixon E, Piepzna-Samarasinha LL, editors. Beyond Survival: Strategies and Stories from the Transformative Justice Movement. AK Press; 2020. p. 80-2.

G. Complicating theory through practice: Affirming the right to die for suicidal people. Can J Disabil Stud. 2020;9(4):89-110.

65Davidow S. Suicidal tendencies, Part III: So, when do I get to call the cops? Mad in America. 8 Aug 2018.

S. A reconceptualization of suicide and social workers’ duty to report. OMEGA. 2022;86(1):157-73.

67Fisher D. Emotional CPR: A way everyone can recover their life in the time of COVID. In: Chuck R, Maisel E, editors. Humane Alternatives to the Psychiatric Model. Ethics International Press; 2023. p. 179-92.

Bergen D, Henseler T. Peers specialists and mental health nurses who work with patients who are suicidal: A comparative interview study. Int J Nurs Stud Adv. 2024;8:100285.

H, Hamilton BE, Hill N, et al. Our wished‐for responses: Recommendations for creating a lived and embodied sense of safety during mental health crisis. Health Expect. 2024;27(3):e14122.

H, Glover H, Castles C, et al. We can do better: Recommendations for mental health crisis care from people with lived experience. Emerg Med Australas. 2025;37(1):e14528.

M, van Rooijen G, Kuijper L, Kiverstein JD, Denys DA. Patients requesting and receiving euthanasia for psychiatric disorders in the Netherlands. BMJ Ment Health. 2023;26(1):e300729.

72American Association of Suicidology. Statement of the American Association of Suicidology: “Suicide” is Not the Same as “Physician Aid in Dying”. 30 Oct 2017.

LD, Bastidas-Bilbao H, Cappe V, et al. Medical assistance in dying for mental illness as a sole underlying medical condition and its relationship to suicide: A qualitative lived experience-engaged study. Can J Psychiatry. 2024;69(5):314-25.

74Dunning A. ‘Thank you for sharing. Do you have a plan?’ Outdated policies preventing peer supporters from saving lives. Healthy Debate. 13 May 2024.