It is well documented that people with mental illness and substance use disorders (MI/SUD) are stigmatized across all levels of society. So, it is not a surprise that peer support specialists regularly experience stigmatization in the workplace, including negative messages from colleagues about their role and their MI/SUD (Firmin et al., 2019). Additionally, those of us with lived experience of MI/SUD often face other forms of discrimination. Therefore, it is important to acknowledge and address these workplace harms through an intersectional lens (Grappone & Carr, 2022). Microaggressions experienced by peers in mental health care settings can be considered examples of institutional betrayals (Gómez, 2015 as cited in Benedict et al., 2026; Jones et al., 2017). These happen when the workplace that the peer support specialist depends upon for support mistreats them. Institutional betrayal can also come in the form of harmful workplace responses to reports of stigmatization and is associated with decreased job satisfaction, higher intentions to leave the job, and increased somatic symptoms (Smidt et al., 2023). Gómez et al. (2023) state: “Institutional courage, which is an institution’s commitment to seek the truth and engage in moral action by protecting those who depend upon it, can be the antidote to institutional betrayal.”
Freyd (2018) developed her Steps to Promote Institutional Courage to guide institutions in implementing policies and practices to effectively address and eliminate harm and the harmful responses within institutions. I list her Steps below with my additional commentary on each one. I suggest specific strategies for institutions to consider when addressing the stigmatization experienced by peer support specialists.
12 Steps to Promote Institutional Courage
(based on Freyd, 2018; updated March 2022, August 2025)
1. Commit to seek truth and engage in moral action, despite unpleasantness, risk, and short-term cost.
Some of the potentially unpleasant truths that are important to seek include: identifying how stigmatization toward peers (related to MI/SUD, racism, sexism, and other forms of discrimination) is operating in your workplace — Who is perpetrating it? What policies are not being enforced? Who is staying silent when they witness it for fear of retaliation?
2. Comply with civil rights laws and go beyond mere compliance; beware risk management.
This means being willing to listen and believe what peers say they are experiencing in the workplace and actively responding to any violations of civil rights laws. It means providing accommodations when requested and creating an environment where peers are encouraged to ask for what they need to succeed in their position. It will likely require a shift for those in Human Resources (HR) or Risk Management who say, “It’s too risky to ask those questions of employees because what if they give us information that shows our employees are being harmed or at risk?”
3. Educate the institutional community (especially leadership).
Ongoing training related to peer support is needed for all staff; engaging HR staff is important in this effort (Byrne et al., 2022) since many institutions rely on HR to respond to reports of discrimination and workplace conflicts. Lack of clarity around their role can cause peers to feel stigmatized and excluded from their workplace team (Shaw et al., 2026). Therefore, leadership must be involved in these trainings to not only learn what policies are needed to clarify peer roles, but also to show all staff their leadership’s commitment to helping peers succeed.
4. Add checks and balances to power structure and diffuse highly dependent relationships.
This step will be difficult because those in power may feel threatened and become defensive at the prospect of upsetting the status quo and their positions in the power structure (Mental Health Commission of Canada, 2023). Peer supervisors need organizational support and require authority to effectively do their jobs (Gillard et al., 2024). Peer specialists need to be included in decision-making processes related to their work and to be a respected part of the team with which they work. The organization’s leadership, board of directors, and advisory board must include individuals with lived experience of MI/SUD so discussions of policies and resource allocation always include those voices and perspectives.
5. Respond well to victim disclosures (& create a trauma-informed reporting policy).
A common response when someone who has perpetrated harm in a workplace is confronted with their actions is a term Freyd (1997) coined called DARVO: Deny, Attack, Reverse Victim and Offender. An example of this would be if a peer overheard colleagues speaking about the role of peer support specialists negatively and offensively and, when confronting those colleagues with the harmful nature of those comments, the colleagues do not take responsibility or apologize. They then start referring to that peer as “crazy” or “just a junkie” when discussing them with colleagues as a way of diminishing the credibility of the peer. If an organization does not have a trauma-informed reporting policy (a clearly defined policy that the peer could follow to report this experience without the fear of being retaliated against) for this type of situation, the peer will likely suffer further harm (Harsey et al., 2017).
6. Bear witness, be accountable, apologize.
This means acknowledging the harms you (as a colleague or institution) perpetrate or witness, apologizing for those harms, and transparently defining what steps will be taken to repair those harms and keep them from happening again.
7. Cherish the whistleblowers; cherish the truth tellers.
Thanking peers (and other colleagues) who call out harms directed at peer support specialists and shutting down any attempts at DARVO by the perpetrators of the harm is important. Reward those who speak out.\
8. Conduct scientifically sound anonymous surveys.
Consider including the Institutional Courage Questionnaire (ICQ)-Individual and ICQ-Climate for Employees (Smidt, Adams-Clark, & Freyd, 2023) in ongoing quality assurance efforts and allow all employees to complete them anonymously. These short yes/no questionnaires assess how well institutions respond to harassment of employees. Some examples: Responding adequately to the experience, if reported? Handled your case well, if disciplinary action was requested? Not covering up the experience? Your employer created an environment where this type of experience was safe to discuss?
9. Regularly engage in self-study.
Once an organization has decided on the best evaluation tools, commit to implementing them on at least an annual basis. When I work with healthcare organizations, I encourage them to embed them in their quality improvement process.
10. Be transparent about data and policy.
This requires leadership to share the outcomes from anonymous staff surveys and other quality assurance measures. Share these outcomes with staff, service recipients, and the community.
11. Use the organization to address the societal problem.
Examples of this step can be found in the current Office of Addiction Services and Supports (OASAS) Strategic Plan Objective: Goal 4: Reduce racism and stigma surrounding addiction, and the Office of Mental Health’s (OMH, 2024) funding of projects that specifically work to address intersectional stigmatization.
12. Commit ongoing resources to 1-11.
Commit organizational resources to all previous steps. Fund trainings, devote staff time, and consider linking promotions and departmental funding to staff who perform well on outcome measures related to the Steps of Institutional Courage.
Wall et al. (2022) include this quote in their research on experiences and challenges of peer support workers: “Courage was considered an important personal quality for building genuine relationships. The peer supporters described it took courage to be present and harbor the patients’ narratives, and never to abdicate from standing up for the patients’ perspective.” I encourage institutions who employ peers to honor that courage by committing to the difficult task of implementing the Steps of Institutional Courage in their workplace.
Gretchen Grappone (she/her), LICSW, is a New York City–based training consultant. She writes from the perspective of a gay, cis, white woman, with lived experience of mental illness. She can be reached at grappone@ggrappone.org.
References
Benedict, M., Quezada-Horne, N., & Asher BlackDeer, A. (2026). The Institutional Trust Restoration Model: Restorative Repair to Institutional Betrayal in Social Work. Journal of Progressive Human Services, 1–15.
Byrne, L., Roennfeldt, H., Wolf, J., Linfoot, A., Foglesong, D., Davidson, L., & Bellamy, C. (2022). Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice. Adm Policy Ment Health. 2022 Mar;49(2):283–297.
Collier, K., Halvorsen, C., & Fortuna, K. (2024) Assessing Mental Healthcare Worker Experiences of Workplace Fairness and Organizational Value: A National Survey of Peer-Support Specialists. Workplace Health Safety, 72, 14–20.
Durland, M., Harsey, S., & Freyd, J. (2026). Assessing Perpetrator Responses to Confrontation: Associations with a DARVO-SF and Post-trauma Symptoms in Two Different Populations, Journal of Trauma & Dissociation, 27, 221–237.
Firmin, R., Mao, S., Bellamy, C., & Davidson L. (2019). Peer support specialists’ experiences of microaggressions. Psychol Serv. 16, 456–462.
Freyd, J. (1997). Violations of power, adaptive blindness, and betrayal trauma theory. Feminism & Psychology, 7, 22–32.
Gillard, S., Foster, R., White, S., et al., (2024). Implementing peer support into practice in mental health services: a qualitative comparative case study. BMC Health Serv Res. 11, 24(1):1050.
Gómez, J., Freyd, J., Delva, J., Tracy, B., Nishiura Mackenzie, L., Ray, V., & Weathington, B. (2023). Institutional Courage in Action: Racism, Sexual Violence, & Concrete Institutional Change, Journal of Trauma & Dissociation, 24:2, 157–17.
Grappone, G. & Carr, J. (2022). Acknowledging the effects of intersectional stigmatization. Behavioral Health News, Vol. 10, Number 1, 33.
Harsey, S., Zurbriggen, E., & Freyd, J. (2017). Perpetrator Responses to Victim Confrontation: DARVO and Victim Self-Blame, Journal of Aggression, Maltreatment & Trauma, 26, 644–663.
Jones, N., Godzikovskaya, J., Zhao, Z., Vasquez, A., Gilbert, A., & Davidson, L. (2017). Intersecting disadvantage: Unpacking poor outcomes within early intervention in psychosis services. Early Intervention in Psychiatry, 1–7.
Mental Health Commission of Canada. (2023). Dismantling structural stigma in health care. An implementation guide to making real change for and with people living with mental health problems or illnesses and/or substance use concerns. Ottawa, Canada. https://mentalhealthcommission.ca/wpcontent/uploads/2023/12/MHCC_22-187_DSS_report_e_ACC.pdf
OASAS Strategic Plan 2025–2029 https://oasas.ny.gov/agency-strategic-plan
OMH Summary of Activities Funded by the New York State Tax Check-Off Funds CY 2024: Mental Health Anti-Stigma Fund | https://omh.ny.gov/omhweb/statistics/2024-stigma-annual-report.pdf
Shaw, S., Shirley, L., Schroeder, E., Thompson, et al., (2026). A systematic review of the barriers and facilitators to lived experience involvement in mental health services. Frontiers in Public Health. Jan 23:13:1737709.
Smidt, A., Adams-Clark, A., & Freyd, J. (2023). Institutional courage buffers against institutional betrayal, protects employee health, and fosters organizational commitment following workplace sexual harassment. Jan 25;18: e0278830.
Wall, A., Lovheden, T., Landgren, K., & Stjernswärd, S. (2022). Experiences and Challenges in the Role as Peer Support Workers in a Swedish Mental Health Context – An Interview Study. Issues in Mental Health Nursing, 43(4), 344–355.
