# Workshop: Advancing the Science on Peer Support and Suicide Prevention

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## Overview

Peer support services specifically intended to contribute to suicide risk reduction are becoming more prominent in healthcare systems and community settings. Such services can be used to address barriers to receiving proven interventions, while also improving hope, connection, recovery, and empowerment. Despite emerging research on the effectiveness and implementation of these models, there are research gaps that could lead to missed opportunities in optimizing them.

This two-day workshop brought together experts in peer support suicide prevention to discuss relevant conceptual frameworks, recent advances in understanding what worked and for whom, service settings and service-user characteristics that informed intervention strategies across the crisis services continuum, digital and telehealth applications, considerations for youth, and equity considerations. The workshop identified innovative advancements and areas that needed additional research as the field moved forward.

## Recordings

**Day One**

Read the transcript.

**Day Two**

Read the transcript.

## Sponsored by

National Institute of Mental Health’s Division of Services and Intervention Research

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## Additional Event Information

## Day One: Background and Purpose of the Workshop

**Jane Pearson, Ph.D.**,****Special Advisor to the NIMH Director on Suicide Research

**Stephen O’Connor, Ph.D.**,****Chief of the Suicide Prevention Research Program, NIMH

The National Institute of Mental Health (NIMH) convened a two-day meeting to bring together experts in peer support suicide prevention to discuss relevant conceptual frameworks, recent advances in understanding what works and for whom, service settings, and service-user characteristics that inform intervention strategies across the crisis services continuum, digital and telehealth applications, considerations for youth, and equity considerations. The workshop aimed to identify innovative advancements and areas that need additional research as the field moves forward.

NIMH convenes workshops on pressing topics to better understand the state of the science, which includes identifying the strengths and limitations of research being conducted, identifying gaps and opportunities for future research, and highlighting innovative research and programs for the broader field.

NIMH funds research that examines how effective preventive therapeutic services and interventions are at addressing a mental health concern. This evidence can inform how other federal agencies, state, and local governments, as well as clinical and community practice settings, choose what type of programs to implement. This process requires tailoring to optimize fit and sustainability when delivered locally. The intent of this workshop was to inform how future research can enhance and optimize peer support strategies to reduce suicide risk and contribute to person-centered recovery goals. NIMH clinical trials emphasize an experimental therapeutics approach to inform how intervention strategies work to improve distal clinical and services outcomes, while also complementing existing health care services.

Dr. Pearson welcomed attendees to the first day of the meeting. She stated that peer support has been expanding during the past several decades as the need for behavioral health services has increased. NIMH is interested in learning more about the practice and effectiveness of peer support. This understanding will inform how the field can optimize this approach to improve outcomes. Peers have the potential to fill gaps in low resource communities to address inequities in suicide care and increase hope. Dr. Pearson noted that the National Strategy for Suicide Prevention (NSSP) is being updated (anticipated release April 2024). The updated NSSP acknowledges people with lived experience in suicide prevention and the growing use of peer support, especially in crisis services. More research is needed in peer support, and this workshop is an important step in our knowledge of peer support.

The workshop was designed by a co-planning team of members from NIMH and the Miami Environment & Energy Solutions LLC. Workshop session summaries will be available on the NIMH website, along with a list of resources for investigators at all levels within the science to practice approach.

## Session 1: Conceptual Models Informing the Role of Peer Support

**Discussant: Joel Sherril, Ph.D.**, Deputy Director, Division of Services & Intervention Research, NIMH

The Origin Story of Peer Support: A Look at the Past, Present, and Future**Karen Fortuna, Ph.D.**, Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth

Dr. Karen Fortuna partners with peer-support specialists around the country to conduct research that focuses on developing technologies and programs to support the peer-support workforce. She presented a brief overview of the history of the peer support movement, including the moral treatment era of 19th century France where discharged patients returned to help others. In the 1960s, people with lived experience received training to help people with mental health challenges. She explained how institutions in the 1960s and 1970s were not trauma informed. Following de-institutionalization, people left hospitals and returned to the community, but there were limited services available. Peer-support groups began to form to fill this gap. She continued that these efforts continue today through digital support, such as text-messaging in rural areas and the return to land lines to connect with older adults.

Dr. Fortuna discussed how the role of peer support specialists continues to change. In 2001, peer support was accepted as a reimbursable service by Medicaid, which is now accepted in 47 states. In January 2024, Medicare offered a new physician fee schedule where a physician can integrate peer services into the workforce, refer people for peer services, and submit for reimbursement. Other groups are available that offer services and obtain reimbursement through other means.

Advocates have championed including people with lived experience in the development of programs and research to move the field forward (e.g., Unity Recovery, Emotional CPR). The results are being published in scientific journals. Peer support continues to evolve — where it is going, where it is being integrated, and where it can stand alone to support individuals in the community.

### Peer Support & Suicide Prevention: Conceptual Models & Recent Findings

**Paul Pfeiffer, M.D.**, Susan Crumpacker Brown Research Professor of Depression, University of Michigan

Dr. Paul Pfeiffer described the various ways ‘peer’ has been defined and discussed the use of peer support in suicide prevention. He examined the published literature on peer-support relative to suicide prevention and categorized the types of peer relationship as: 1) members of the general public (public service campaigns, public service announcement); 2) socio-demographic subgroups; and 3) organizations/institutions (military, first responders, college students, correctional facilities). He described features of empirical research (e.g., definitions, peer relationships, interventions points in the community, and practice settings). He and colleagues conducted a scoping review of the peer support literature related to suicide prevention, which he reviewed in his presentation.

Within the mental health system, lived experience is a commonality with mental health treatment, but those peer relationships are under-represented in the literature. Another conceptual model relative to peer-to-peer relationship explores a spectrum of services, extending from one-directional services (e.g., safety plans in an emergency department) to reciprocal and unstructured interactions (e.g., support groups). Peers play many roles along the continuum of care for suicide prevention (e.g., gate keeper public awareness, mobile crisis center, residential respite/inpatient emergency department, post-hospital follow-up). There are a range of services out there for an array of interventions.

Dr. Pfeiffer described how most of the peer-support literature reflects a focus on responding to crisis and identifying and assisting in helping people, but there is almost no research on access to lethal means and improving care directly. Some studies do examine post-hospital support, but the focus has not been on suicide prevention.

He also discussed a NIMH-funded study of the PREVAIL intervention, which explored the effectiveness of peer-mentorship by a paid peer specialist for adults. The PREVAIL study included 455 high-risk participants exiting inpatient psychiatric care. It addressed belongingness, hopelessness, and burdensomeness. The participants were randomly assigned into one of two arms: 12-weeks of a peer support intervention or standard care. Peer support consisted of one-on-one sessions and included general support and semi-structured conversation around hope, belongingness, safety, and wellness. Measurements were taken at baseline, three months, and six months. The program conducted a series of path analysis to determine how each intervention impacted interpersonal theory domains. Each theory domain was related to suicidal ideation at six months, but the PREVAIL peer-support intervention did not significantly impact those mechanisms or suicide intensity. Hopelessness and burdensomeness remained significant predictors of suicide ideation but belonging did not. Examining the impact on suicide attempt resulted in similar findings. The participants in the PREVAIL condition did not show any worsening. The quantitative results were counter to the qualitative feedback from the study.

Future directions could explore variations in structure and/or increase the focus on burdensomeness. Finally, intervention strategies could include more than one-on-one support and additional focus on living a life worth living and providing services in a less traumatizing environment.

### State Policy Trends and Challenges Affecting Implementation of Family and Youth Peer Support: Return to the Fundamentals

**Kimberly Hoagwood, Ph.D.**, Cathy and Stephen Graham Professor of Child and Adolescent Psychiatry, New York University

Dr. Kimberly Hoagwood began by describing how varied peer support can be. Lived experience of a young adult with mental health issues is different from families or someone living with mental health issues. It is important to tailor peer support to the lived experience of the individual/family/context being addressed. While peer support may be one strategy for addressing workforce challenges, this is a narrow view of what peer support can offer. Dr. Hoagwood focused on the value of peer support beyond workforce challenges, including policy initiatives, training, credentialling models, and implementation challenges.

The behavioral health workforce shortage is a serious problem affecting all aspects of the healthcare industry. Both the federal government and states are investing in workforce expansion, including peer support. Momentum is building for federal and state initiatives. States are receiving higher federal matching money through Medicaid. There is bipartisan support for family and youth peer support services. States are experimenting on ways to spend money to support peer services and addressing needs related to social determinants of health — 19 states are using Medicaid dollars in housing aid; 14 states are boosting child tax credits; and 29 states are using aid for community health workers.

Peer support can consist of adult peer support, family or caregiver support, and a youth/young adult model. Categories of support include: information/educational; skills development; emotional and affirmational support; instrumental support; and advocacy. Family peer support research shows how this service improves caregiver mental health and empowerment, reduces stress and stigma, and changes expectations of what is possible.

A number of training and credentialling models are expanding across the country. Dr. Hoagwood and her colleagues focused on New York state, where they have been researching training models and linking to state system and family run organizations. The goal is to make this sustainable and provide a career ladder for peer specialists. Right now there are provisional and professional credentials.

Skills come from the cognitive behavioral therapy (CBT) literature. There are challenges in implementation. States face competing needs to address workforce shortages. A lack of agreement on national standards means every state is creating their own approach and training models. There is a lack of cost-benefit analysis of implementing peer-support in behavior health, in terms of infrastructure and staff. Peer support could be a new way to explore personalized medicine in behavioral health. Technology could integrate lived experience and peer support to provide a broader understanding of health and how to offer more personalized and individualized care.

### Discussion

Dr. Joel Sherril invited the panelists to join a question-and-answer session.

**Question:**Regarding the PREVAIL randomized control trial, do peers have input regarding what was assessed, what was targeted, and what measures were used? Why did you chose to look at inter-personal theory of suicide risk?

**Answer:**Dr. Pfeiffer explained that he included a wide range of measures (e.g., social support, quality of life, meaning/purpose) in the study but did not discuss those results today. Peers were involved in development of the intervention strategies but not the approach to assessment. The interpersonal psychological theory of suicide was selected because the model seemed to capture important factors that involved in the dynamic of peer-support.

**Question:**Dr. Sherrill said that state training models for family or youth peer support specialists have examined research designs to guide further state roll outs. What have you learned about sustainable impact from these roll outs?

**Answer:**Dr. Hoagwood explained that her team looked at social learning theory to determine mechanisms of action to change provider behavior and how to use and integrate it into the training module. Her team focused on changing the attitudes/beliefs/self-efficacy of caregivers during the training with the hope that it would improve the outcome for kids. She admitted that this is a leap. Only a few studies that provide support care for parents translate into change for kids. It takes extra focus and target to help kids. When the training model was finished, her team shared the model with the family organization.

**Question:** Does training and credentialing affect peer-support specialist skills?

**Answer:**Dr. Hoagwood said that it changes their sense and knowledge of knowing what to do. Her team did not examine how it changes their skills. They did examine how virtual training compares to in-person training, and the results are the same.

**Question:**To what extent has lived experience been examined in research, and how does it operate in the delivery of outcomes achieved?

**Answers:**Dr. Fortuna said that a systematic review of the scientific literature shows that when people with lived experience are trained, they provide support that leads to a decrease in psychiatric symptomatology for both mental health and substance use challenges. She also described how the literature supports an increase in engagement in services (e.g., traditional or in the community programs led by peers). Anecdotally, colleagues in the community say peer support can provide hope, increase quality of life, and provide empowerment by tapping into lived experience.

Dr. Pfeiffer said that this is one of the more fascinating questions — how much does lived experience matter, and how does its presentation matter? Just knowing someone has that experience may be all that is needed. Those questions are interesting. It remains an open question that would be challenging to study.

Dr. Hoagwood said that this is where clarity in the “lived experience” in caring for mental health is needed. It could help with being seen and recognized during a mental health problem. This may be unique to this population. It is important to understand what the population is gaining from the peer work.

**Question:**We recognize the importance of end-user informed research to identify important questions and results on strategies that are acceptable and feasible. At NIMH, we are focused on collaboration between various end-users and research partners. Good ideas often bubble up by people on the front line and in partnership with people with experience in research. What are your thoughts on the degree that existing models have been co-developed?

**Answers:**Dr. Fortuna said this is an interesting question. There is a big push on what is the science of engagement, and what type of engagement approaches should be used with a particular population. There is a continuum of engagement. Knowing that the science of engagement is in its infancy, the majority are around focus groups and co-produced programs. Because of what we know about the science of engagement, more marginalized populations will be more disengaged by research, but the best approach is community-based, participatory research.

Dr. Nev Jones said established power structures influence funding, and the reality is that alternative, critical models have not been funded for randomized controlled trials. In addition, randomized control trials to date have not been led by people with lived experience. This is an issue for the whole field. Consultation does not equal leadership.

Dr. Hoagwood said the power differential is seen in workforce as well. Peers are paid by Medicaid, and there is no career ladder. Figuring out how to construct services in a fair and even way needs to be done.

Mr. Eduardo Vega said it is important to recognize that the use of the term “peer specialist” and integration of “peer supporters” in publicly funded mental health system is in tension with early drivers of peer support and self-help. More specifically, we need people with lived experience in this work and we need to value the expertise they bring to the table, such as a distinctive specialty.

Dr. Linda Dimeff emphasized the importance of including these considerations for peer and lived experience involvement/leadership into the funding announcements themselves to ensure they are present.

**Question:**What do we know about peer specialists and the models to provide support to specialists?

**Answers:**Dr. Hoagwood explained that anecdotally, families say they find it restorative to have a position to give back to others. She is not aware of data on supervision and coaching in this clinical context, but both are essential and help in dealing with crises that emerge.

Dr. Pfeiffer purposely did not study peer specialists providing services. He did not want to treat them as study subjects. Anecdotally, there is a mixed component to it. Many peer specialists stated that this is a highly valuable experience in their career. Some have reacted poorly to patients’ adverse experiences. He provided weekly group peer support with a mental health clinician, which was received positively. This is still probably not sufficient.

Mr. Vega said benevolent stigma could apply to anyone in any helping profession. There is tension where there is hesitancy to build programs to integrate people with lived experience following a protectionist approach. We would like to know how people are experiencing things and counter perceptions out there.

Mr. Topher Jerome explained that he is a certified peer-support specialist and suicide attempt survivor. He spent many years supervising and developing peer-support programs. As a peer-support supervisor, there is something important about bringing his lived experience into the supervision role. Things can be triggering but also enriching. When he sits with someone who is struggling, it is deeply meaningful. He has a supervisor now with lived experience and that is meaningful because he does not need to hide anything. This is an important topic, and he is a strong advocate that peers should be supervising peers.

Dr. Fortuna said research supports that peers want to be supervised by peers. She ended the session by stating everyone deserves to feel value, respect, and purpose. It doesn’t matter your role. This is an area for more research. 

## Session 2: Support Real World Implementation: Training, Consultation, Supervision, Engaging as Research Partners

**Discussant: Linda Dimeff, Ph.D.**, Jaspr

Peer Support Real World Implementations: Training, Consultation, Supervision, Engaging as Research Partners**Topher Jerome**, Project Director, Harborview Behavioral Health Institute

Mr. Topher Jerome began by sharing his experience with substance abuse and mental health, and how service has helped his own health. He discussed his many roles in peer support (e.g., supervision, project development work, and transition programs). The effect of having peer support with lived experience has had a great effect on people receiving care. A life of service has been integral on his path to recovery.

He contributed to the evolution of a research project to humanize bedside research. He contributed to the development of the Jaspr Health Suicide Support app, bringing a video-based app into the emergency department for people at risk for suicide. The videos are designed to include evidence-based strategies and feature people with lived experience of suicide. He described how patients connected to the videos, and it was possible to connect with people with technology. He also created new consent scripts and videos to make the consent process more efficient.

Mr. Jerome described how people with lived experience need to be at the table throughout the research process not just on the periphery. Research needs to be approached with sensitivity and care and bringing lived experience to the research table will enhance studies. He suggested the creation of a board of review, similar to the IRB, for people with lived experience to review studies. Peer support with lived experience should receive pay at the same level as researchers.

He worked on a project funded by SAMHSA that paired the Jaspr Health app with peer support delivery in the emergency department. The peer-support occurred both in-person and via telehealth throughout Washington State. The outcomes were all positive and the project was considered a success.

He ended with his key priorities — focus on ways to centralize not marginalize, double down on safety, provide equal compensation, include a human in the loop, and produce trauma-informed research. His call to action is to embrace a transformative approach that truly partners with individuals with lived experience.

Peer Support: Implementation Gaps & Ways Forward**Nev Jones, Ph.D.**, Assistant Professor, University of Pittsburgh

Dr. Nev Jones began that the most effective studies often use group-based, semi-structured peer interventions (e.g., WRAP, BRIDGES, self-stigma reduction), but real-world peer specialist roles and responsibilities are many and varied. Peer specialists deploy different strategies to connect, engage, and inspire healing. This approach may not directly fit the linear approach in many clinical trials.

Dr. Jones discussed the gaps of knowledge in how peer support can help along the crisis continuum. The gaps span what works for whom, in what context, and at what dose. Alternatives to suicide is a peer-support program responding to many instances where a response to someone experiencing suicidal thoughts entails involuntary hospitalization that leads to distrust and disenfranchisement, which backfires in terms of suicide prevention goals and efforts.

Dr. Jones also discussed the need to properly match a peer to a person at risk in a real-world settings. Match is often made on shared experience (e.g., racial/ethnic, LGBTIA+, suicide intensity, combat experience, substance use, psychosis). Match may also need to address paranoia/delusions, command voices, severe depression, volatile relationships, grief, job loss, and terminal diagnosis. Optimizing match may be limited by financing. One peer specialist cannot match all of these experiences. She noted the disjuncture between what is happening on the ground and what is funded and makes its way into the research literature.

She described results from a national survey of peer specialists and found that peer support specialists are involved in more than one-on-one service delivery. This work often expands into steering committees, external boards, program development, hiring committees, administrative support, training, and community and education outreach and support. Research focuses on one aspect of peer support rather than the big picture. All of these factors could have a huge impact on culture. The field needs to take working conditions seriously (e.g., pay is low, positions held at part-time, lack of career ladder, lack of power).

A national survey of supervisors with and without lived experience found that a history of lived experience changes how the supervisor saw barriers. Supervisors with lived experience in peer support point to system, structural, and agency barriers. In a real-world setting, the support, training, time, culture, and standards for peer specialists remain inadequate.

Big picture, she said that we need to come together across regional, state, and federal levels to improve infrastructure and support. Research priorities include effectiveness in real-world settings, peer support in crisis prevention, the concept of match, impact of lived experience beyond peer support, and lived experience leadership in peer support research.

Lived Expertise! Transforming Suicide Prevention through Lived Expertise**Eduardo Vega, MPsy**, CEO, Humannovations

Mr. Eduardo Vega gave a brief background on his experience and the culture when he entered the field. Research shows that current suicide prevention efforts are not working. This may be a factor of looking at the problem in the wrong way. For some people with lived experience of suicide, this moment is a vital part of their personal growth and transformation.

People with lived experience with suicide are utilized in different areas of behavioral health systems. It is starting to be utilized more in mobile crisis services and peer respite, but people with lived experience work in all areas of behavioral health. Peer support in the classic mental health field have been excluded from places where things get tough. We need to bring this experience into areas of distress, crisis services, sub-acute programs, intensive programs (e.g., inpatient and intensive outpatient) where people are having their hardest moments. If we see suicide differently, we will start talking about suicide recovery in terms of dignity and growth. For example, loneliness is strongly associated with suicidality, but a therapist or hospitalization does not address loneliness.

Mr. Vega discussed the need to shift the lens and see suicide differently. Rather than focus on suicide as a point of crisis, see it as a way to lead to personal growth. He described different places peer support can help as a psychosocial intercept along the crisis continuum and ways to reframe traditional views of suicide to a more growth- or recovery-oriented perspective.

Change is happening. He discussed a six-month study to create a suicide attempt survivors peer support group that was co-led and -designed by people with lived experience. The study was met with hesitancy, fear, and shaming. The small, pilot study showed an increase in hopefulness and perceived ability to control suicide thoughts and a decline in frequency of suicide thoughts and duration of suicide thoughts. He concluded that peer support makes a difference. Resistance continues to be a barrier but this workshop is one step in the right direction. He recommended people review *The Way Forward*** document that contains two recommendations from a national committee of suicide attempt survivors on how to create new directions to reduce suicide death based on lived experience.

### Discussion

Dr. Linda Dimeff invited the panelists to join a question-and-answer session.

**Question:**If it were up to you, what are the top three things you would do right now to translate peer-support into the real-world?

**Answers:**Dr. Jones began that she would first convene a commission nationally to look at what is happening (e.g., leadership, deep dive into policy analysis, workforce issues). Second, there is a disjuncture in research space between who is getting funded and leadership (PI roles) and push for change to do things differently for more fundamental and transformative thinking. It needs to be addressed in a more systemic way. What can NIMH do to support leadership to create a pipeline of researchers grounded in lived experience who are thinking differently about the issues to get research on those topics. Third, we need to engage in national research priority setting that centers around people with lived experience and family members.

Mr. Vega said that a body to focus the science should be created and led by the communities impacted. New things need to be done. Going to people at the core of that experience to drive the process and the questions. We need to inquire and move away from fear-based or taboo-based discussion on suicide.

Mr. Jerome said that the pay inequity for peer support specialists is a huge issue. We need to tackle stigma. The stigma impacts who is in leadership, pay, and respect. We need more than a seat at the table. We need to bring our experience to a common understanding.

**Question:** How much do we hold the existing paradigm of doing research? There is so much about the existing paradigm that doesn’t work for a recovery/peer-based model. I am curious what you think about this. There is this tension. Do we accept the existing paradigm or is there a both/and solution to bring all of the wisdom of people with lived experience and peer services that is not confined to a narrow space?

**Answers:**Mr. Vega said the participatory action research model and the community research model are not radically different. A lot of these models depend on who is shaping and driving the process. He would love to see other models of evidence.

Dr. Jones said that she wrote a piece on transforming NIMH research through participatory methods and building a lived experience research pipeline. NIMH provided a lovely response. A workshop like this but on transforming research through collaborative methods would be important. NIMH could develop some guidance or a white paper to support more happening in this space.

**Question:**Can you briefly describe the certification process to become a peer-support specialist?

**Answers:**Mr. Vega said specialist designation can be a barrier. Many locations/jurisdictions have their own process for this. We need to focus on lived expertise and combine that in meaningful discussions.

Mr. Jerome said Washington State has their own process (e.g., online training and participatory training, increasing training experience). It is a state-by-state process. You will have to do some internet research to find out the process in your state.

**Question:**What is the difference in training for a peer specialist and a mental health provider?

**Answer:**Mr. Jerome said a mental health specialist is a masters level clinician. Harborview Behavioral Health Institute set up a series of apprenticeships. In Washington, you have to take training to be a peer counselor. More training and opportunities will help address pay inequities.

**Question**: Do people who are not peer specialists have to be out for their lived experience to matter? There can be risk to self-disclosing lived experience. Peer specialists bravely take on this risk every day. Some people cannot disclose this information. Some peer specialists state that if you are not open then the experience doesn’t count. How might you respond to this opinion? 

**Answer:**Dr. Jones said lived experience can infuse work even when it is not disclosed. Disclosure on a mass scale has potential to shift societal attitudes and stigma. She encourages checking out the Out, Open and Proud program. It is important to be clear and honest about whether a person does or does not have lived experience.

**Question:**What kind of lived experience matters to help people who are suicidal? How do you find out?

**Answers:**Mr. Jerome admitted that it is tricky. You can’t ask. We all have struggles. Using your own lived experience is an art form. It is finding a way to use the experience to build trust. When hiring, be clear in the job description what you are looking for and during the interview ask about how a person meets those requirements. This is a delicate issue and may require conversations with HR.

Mr. Vega said the term “peer” is problematic. We are all peers in suffering. Sharing specific lived experience with crisis and suicide is crucial because of the effect of isolation and stigmatization. The intersection of peer support and crisis and suicide is a huge topic. Disclosure can be confusing. People need to make informed decisions about how much to disclose and with whom. There is shared strength in struggle and the distinctive competency in peer support.

## Session 3: Peer Support Tailored for Active Duty and Veteran Service Members

**Discussant: Marianne Goodman, M.D.**, Department of Veteran Affairs

### Mental Health Peer Support in the Department of Veterans Affairs

**Matthew Chinman, Ph.D.**, Senior Behavioral Specialist, Department of Veterans Affairs/RAND Corp.

Dr. Matthew Chinman discussed mental health peer support at the Department of Veterans Affairs (VA). Veterans face a host of behavioral health challenges (e.g., substance abuse, mental health, homelessness). Many vets do not get the treatment that they need. There is also a significant problem with suicide (~6,000/year). The VA has its own national strategy for suicide, which includes peer-intervention. VA “peers” are veterans in recovery from serious mental illness trained to work in traditional clinical settings.

This approach started in 2006 with 125 peer specialists. Today, the VA employs more than 1,400 peer specialists. The VA program contains a career path (e.g., VHA employees, GS-5 to GS-10). Peer support draws on lived experience and focuses on sharing empathy, insights, and skills. A peer specialist has to be a veteran without a hospitalization or mental health event in past year. Peer specialists talk about their experiences and obtain peer certification (any state). A review of the key tasks/activities of peers include sharing experience, develop trusting relationships, showing empathy, etc. Peers also help other veterans improve management of medications/side effects, connect veterans to community resources, help veterans set goals, and serve as a liaison to other health providers. Psychosocial processes that underly effectiveness of peer specialists include social support, experiential knowledge, social learning theory, and social comparison theory.

Research shows multiple ways in which peer specialists are effectiveness, including fewer in-patient days, greater satisfaction with life, improved symptoms, fewer problems and needs, better social functioning, better recovery, and greater housing stability. Peer-support services provided by VA include inpatient/outpatient/residential and individual/group/telephone across many departments. Peer specialists work with people who are high risk. Of the 80,000 veterans that were served by peer specialists, 7% were veterans with a suicide risk flag in their VA health record.

Dr. Chinman’s group adapted the PREVAIL model to the VA. The team interviewed stakeholders and providers and conducted a pilot study to determine feasibility. The interviewees were positive but noted the need for appropriate support and supervision. They felt peer specialists could demonstrate a better understanding of veterans than other providers. The team conducted a small trial that included five veterans. Pre- and post-assessments showed improvement in suicidal ideation and decrease in burdensomeness. The peer specialists in the VA mirror the people they work with (e.g., older, male, veterans). There could be a close connection between peer specialist and the veterans they work with, which may be a slight advantage compared to the original PREVAIL study.

The VA is also exploring multiple suicide research initiatives featuring peer specialists, including, Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT), Peer Engagement and Exploration of Responsibility and Safety (PEERS), and Peers for Valued Living – VA (PREVAIL-VA).

### Military Member Networks: A Key Suicide Prevention Target

**Peter Wyman, Ph.D.**, Professor, University of Rochester

Dr. Peter Wyman discussed military member networks as suicide protective relationships — a key suicide prevention target. The field has focused on identification/treatment/prevention of individuals, but this approach doesn’t always work for strengthening suicide prevention relationships. His research focuses on interventions that build protective relationships beginning early in a military member’s career and addresses limitations in current prevention programs. A one-size fits all mass training can miss key groups and does not promote culture change that can be sustained over time.

Wingman Guardian Connect provides natural peer networks and leverages social organizations in a preventative approach. The focus is on early-career personnel during their technical training in the Air Force. In the program, groups of Airmen are structured into blocks that focus on kinship, purpose, guidance, and balance. This distributed learning is critical for skill and relationship formation that are important for developing protective strengths. Formal in-person training is followed up with text messages and theme-based activities.

Dr. Wyman created 215 classes that placed 1,500 participants into the Wingman Guardian Connect program or an active control. The program had high rates of follow up with 93% at one month and 84% at six months. Dr. Wyman believes the results are generalizable across populations. Participants in the program reported lower suicide risk scores and depression scores at one-month, which were largely maintained at the six-month follow-up. He examined clinically meaningful depression ratings and found that every 21 participants in the program would result in one fewer airman with a depression diagnosis at any of the follow-up points. Participation had an effect on reducing suicide risk scores by increasing feeling of connection and cohesion. Natural Social Networks brings protective relationships into the intervention. The vulnerable members in the Wingman Guardian Connect group became more connected over time, whereas the vulnerable members in the active control became more isolated. Natural network-based approaches may be essential for enhancing exposure to social protective members for vulnerable members.

This approach is being explored in Black churches and the New York state police department. The research at the Air Force will be continuing. A NIMH grant will allow a hybrid effectiveness implementation trial that will examine the transition from a research-delivered program to one that’s being delivered by setting.

### Peer-Based Suicide Prevention Efforts in the Military

**Craig Bryan, Psy.D.**, Director, Division of Recovery and Resilience, The Ohio State University

Dr. Craig Bryan discussed two peer-based programs: Airman’s Edge and Project Safeguard. Both programs are predicated on several core concepts: 1) the majority of suicide decedents do not pursue mental health treatment; 2) half do not have a mental health condition; 3) context-dependent, decision-making is associated with suicidal behavior (e.g., behaviors and choices in a particular time and situation may deviate from other circumstances); and 4) targeting the social context could reduce the occurrence of suicidal behavior. The programs are developed around a prevention through design approach (i.e., remove hazard, replace hazard, isolate from hazard, change behavior, and protect from hazard). The programs also emphasize strategies at the top of the inverted triangle to provide the greatest impact for the largest number of people. As one moves down the hierarchy, the strategies become less effective, influencing a smaller pool of the population. The most effective strategies to prevent injury are to remove hazards followed by substitute, barriers, etc.

The focus has been on the least effective strategies (e.g., education and anti-stigma campaigns, suicide prevention briefings, resiliency trainings, and mental health treatment). A focus on environmental factors and social conditions where a person works and lives would be more effective (e.g., relationships, social support, quality of life).

Airmen’s Edge is a peer-to-peer education program to empower the community. Military personnel nominate their peers to work in this education format. Peers are trained to deliver health-focused content and training in crisis-response planning. Peers met monthly for ongoing feedback, assistance, and support. The 88 trained peers had almost 600 interactions to help airmen and service members with day-to-day problems, referred 43 peers to mental health professionals or other non-mental health support resources (e.g., chaplains, sexual assault prevention response, legal, family support networks, financial counseling, etc.), and delivered 15 crisis interventions. The program integrated concepts into the busy military schedule by using existing meeting and educational materials to promote information in a non-intrusive way.

Project Safeguard focuses on firearm access and firearm safety. Military personnel disproportionally use firearms compared to the general population when attempting suicide. Project Safe Guard looked at how military personnel can adopt secure firearm storage at home. The idea of firearm safety is openly embraced by military personnel, and research showed that peers are more trustworthy on this topic. Surprisingly, military personnel rarely discuss secure firearm storage. This conversation needs to occur on multiple levels  to produce universal social norms shifting and targeted skills training. By talking about this in natural peer groups, it is effective to leverage peer connections to share information more broadly.

### Discussion

Dr. Marianne****Goodman invited the panelists to join a question-and-answer session.

**Question:**Who are the peers in these interventions? What is the role of lived experience of these peers? With the caveat that veterans have a higher suicide rate and access to firearms compared to civilians, to what degree are these interventions applicable to civilians?

**Answers:**Dr. Wyman said his team is adapting and extending the Connect program to civilian groups (e.g., Black churches and police officers). His group found that the four core strengths seem translatable to teams. They have been looking for opportunities to include working people in middle years. He is interested in creating opportunities for proactive, as opposed to reactive, interventions in other workforces.

Dr. Bryan said there is applicability outside of the military. There is transference of ideas in schools, college, and other social organizations. He has been looking at this around gun ownership. Gun owners have a shared sense of responsibility for protection of themselves, family, and friends. His group is finding that the way we talk about it is important and being able to connect concepts of protection and safety from external threats as well as internal threats resonates.

**Question:**How difficult is it to bring this work to the community?

**Answer:**Dr. Chinman said some of it is an open question. When you see two veterans meet each other, they have a connection that moves them closer to becoming friends faster than two non-veterans. It would be a good research study to look at differences of interventions in a purely civilian context. His team is still trying to figure out the degree of match that is needed to have benefit.

**Question:**On the topic of match, there were many questions about gender differences. For Wingman Connect, there were questions about women’s involvement in the study.

**Answers:**Dr. Wyman said his study had 19% women, which is proportional to the Air Force population. It was not a large enough group to examine efficacy, but he did find that the impact remained similar. His group is now looking at how interventions affect formation of important connections.

Dr. Bryan said 15–20% of peers in his study were women. When seeking peer nominations, his team deliberately sought diversity in gender, race, and rank. They wanted to take into consideration work schedules to ensure peers were available for all shifts. His team received good feedback from the military on how to consider different occupational specialties or career fields to get representation across the military community. The diversity ensured people had multiple options when seeking help to feel safe. Regarding firearm safety, men and women acquire guns for different reasons. It is important how we navigate these conversations. It is important to think of different subcultures within the community.

Dr. Chinman stated that he does not have data to directly answer this question. The VA is working to hire more female peer specialists. Anecdotally, the match of people who vibe on an issue is what is important. Depending on the type of trauma, sometimes it makes more sense to have multiple peer support options (gender, minority, rank).

**Question:**How can you apply these concepts to other cohorts in medical fields (e.g., adolescent/teen suicide, chronic pain)?

**Answers:**Dr. Bryan addressed the question from the lens of chronic pain. It is something we have thought about a lot. Veterans have to navigate back pain, amputations, and other injuries. Pain is often a driver of suicide intensity. Being able to connect people with other service members who live with chronic pain can provide the empathy that is really important and provides a nice supplement from medical services provided by healthcare providers.

Dr. Wyman focused on teens. The Sources of Strength program incorporates parts of the active training model. It is intended for large high schools to train diverse teens to spread information to their peers to build social health. When implemented with a high degree of adult support and fidelity, the program can have positive benefits.

**Question:**Do virtual social networks produce natural social networks?

**Answers:**Dr. Chinman does not believe there is one answer. Under some circumstances, the virtual format may be adequate.

Dr. Wyman focused his response on teens and young adults. For this subgroup, online may be a good source of connection and belonging. There is going to be a lot of variability and more research is needed to understand how to leverage those efforts effectively.

## Summary and Future Steps

**Stephen O’Connor, Ph.D., Chief of the Suicide Prevention Research Program, NIMH**

Dr. O’Connor acknowledged the importance of the issues discussed during the first day of the meeting. These topics are under-appreciated and contribute to ongoing disparities and lack of effectiveness of care. He thanked the participants, presenters, moderators, and NIMH leadership for supporting this workshop.

He closed day one with a summary of his thoughts. There is evidence to support the effectiveness of peer support strategies to improve quality of life and social outcomes. There are programs that are acceptable, feasible, and effective when focused on helping people with suicide intensity and/or suicide experience. There is room for improvement. We need assistance from leadership and engagement from peer support and people with lived experience who can provide their expertise in co-designing and conducting research to move the science forward.

The video recordings will be posted in approximately one month. Day 2 of the workshop will be focused on suicide prevention and peer support for youth and crisis services. NIMH has invested in peer support suicide prevention research and continues to do so. Potential applicants are encouraged to look at the NIMH strategic plan and Division of Services in Intervention Research website to learn about research priorities. Funding opportunities emphasize a deployment-focused approach, including end-user perspectives (e.g., youth, adults, and families who access support services) throughout the intervention development and testing process. As a program officer at NIMH, please contact me to discuss research concepts and consider the stated priorities in funding opportunity announcements. 

## Day Two: Background and Purpose of the Workshop

**Lisa Jaycox, Ph.D.**, Senior Behavioral Scientist at RAND Corporation

Dr. Jaycox welcomed the participants to the second day of the NIMH workshop on Advancing the Science on Peer Support and Suicide Prevention. She began the day with an overview and highlights from the first day of the workshop. She concluded with a focus on peer support, especially among young people and how they relate to crisis services (e.g., two sessions). She turned the meeting over to Dr. Christina Borba to begin Session 4.

## Session 4: Youth Peer Support

**Discussant: Christina Borba, Ph.D.**, Director, Office for Disparities Research and Workforce Diversity, NIMH

### Helping the Helpers: Supporting Peer Navigators in Suicide Prevention Work

**Lily Brown, Ph.D.**, Assistant Professor, University of Pennsylvania

Dr. Lily Brown discussed her research supporting peer support specialists in their work in suicide prevention, particularly in their work supporting youth who are at risk for suicide. In this effort, she described a program called STARS, a clinical trial supported by NIHM. This small exploratory project focused on emerging adult period in the LGBTQ+ community which faces specific risk factors such as low social support, difficulty tapping into positive emotions, and difficulty coping with discrimination. Participants must report suicidal ideation during the past month. Eligible participants complete a baseline evaluation and are assessed to understand the history of suicide attempts and the intensity of current suicidal ideation. In addition, all participants completed a safety plan intervention with a psychologist. The participants were randomized either into the STARS or on-going assessment with check-ins at two, four, and six months after completion of safety planning intervention.

The STARS arm of the study consists of a mobile app that offers a touchdown space to access safety planning intervention, which can be edited and updated. The app is pre-loaded with life skills-focused content. The program also consists of six sessions of peer mentorship that promote positive affect, connect individuals to safe spaces, promote social support, and work through discrimination and stigma. Peer mentors check with the participant on the safety plan (e.g., need for changes and assess what is working). The remainder of the session focuses on core skill development (clarifying values and setting goals, coping with negative self-talk, scheduling pleasant events, dealing with people who hurt you, investing in relationships).

The peer mentor completes intensive training (eight sessions, two hours each) that covers motivational interviewing procedures and implementing skills into sessions as well as role playing. Peer mentor sessions were scheduled once per week during randomization. Throughout involvement, peers had weekly supervision from one of two clinicians. Every two months, peer mentors received standard training boosters. The study also included ongoing fidelity monitoring related to content and style.  

Peer mentors rated their comfort with the session content and stress level to identify if support is needed after discussing difficult topics. At end of the study, peer mentors completed an interview to describe their experience and what is needed to thrive in this role while maintaining their safety.

In the study, 32% of participants were randomized into STARS. While the sessions are on-going, 81.5% of the participants did complete six sessions. Peer mentor comfort levels at every session averaged around 8 or 9, with 10 being very comfortable. Peer mentors also rated their level of distress at an average of 2 or 3 with 1 being no distress. The fidelity ratings showed consistently high ratings for both content and style. Participants reported a value of 3 to 4 for their confidence in the peer mentor, with 4 as strongly agree.

Dr. Brown found converging evidence that the peer mentor and participants are comfortable and confident in the partnership. She said the team continues to collect data from the peer mentors on the perception, acceptability, feasibility, and appropriateness of this intervention. Data continues to be collected. Peer mentors who joined the study expressed an interest in a potential career in the mental health field and a desire to support LGBTQIA+ community.

### Appa Health Peer Mentorship

**Katrina Roundfield, Ph.D.**, Co-founder and CCO, Appa Health

The nation is experiencing a crisis of children’s mental health. The CDC has found 25% of teens have contemplated suicide in last 30 days. Another study by Blue Cross Blue Shield found 90% of adolescents have reported mental health as major life challenge. Public school systems have found 30% of students are chronically absent from school, something that is thought to be related to mental health challenges.

Dr. Katrina Roundfield introduced Appa Health, a for-profit company she co-founded in 2021 in Oakland, CA. It provides near-peer mentorship for teens to develop mental health skills. The intervention is delivered on an app that is 100% virtual similar to telehealth. It is a mentoring relationship scaffolded with digital tools, primarily serving public high school students. Public schools are partnering with Appa Health so children and families do not pay. Since inception, Appa Health has served about 250 teens.

The program employees vetted, college-educated near-peer mentors (young adults with lived experiences). Teens choose a mentor that reflects their identity. The pair connect each week via virtual platform for one-on-one video session that provide support and keep teens accountable to the digital cognitive behavioral therapy curriculum. The students learn CBT skills from short-form videos. The peer mentors model their use of the skills and support the teens to use the skills themselves.

The results of the pilot study are published in the *Journal of Medical Internet Research***. The study used a depression score (PHQ8) and anxiety score (GAD 7) and found that teenager scores improved during the 12-week period of the program. Teens stated that they found the mentor’s lived experience inspiring to continue to learn and implement the skills in the program.

Appa Health received a $2 million NIMH SBIR grant to conduct a randomized clinical trial to study the effectiveness of the intervention among public school students. The study has three arms 1) Appa Health complete (program described); 2) video content only to understand the value of near-peer mentorship; and 3) waitlist control. Participants are 13–17 years old. The study will also evaluate the experience of parents and peers.

The program provides teenagers with CBT skills and strategies to improve mental health. They are also receiving peer mentorship and experience. In addition, they are receiving instrument, relational, and emotional support. Dr. Roundfield believes it is the peer mentor mechanisms and identification with the mentor that leads to general self-efficacy based on social cognitive theory. She concluded that the program provides participants with someone who understand them and provides hope.

### Advancing The Science of Peer Support and Suicide Prevention

**Sherry Molock, Ph.D.**, Associate Professor in Clinical Psychology, George Washington University

Dr. Sherry Molock introduced HAVEN (Helping Alleviate Valley Experiences Now), a suicide prevention program for youth integrated into predominantly Black churches. The program combines church engagement, a faith-based curriculum that teaches pastors how to integrate information about suicide prevention into their sermons, Bible study, and youth suicide intervention prevention that builds on the Wingman Connect program.

Dr. Molock explained that suicide is the second leading cause of death between 10–19-year-olds. Suicide rates for Black children 5–12 years old is double that for white peers in similar age groups. The Black church is an excellent venue for promoting positive mental health. It is an influential institution in the Black community. Over 60% of youth attend church regularly. While church membership has been declining across all racial ethic groups, Black churches have 81% retention rates.

Black churches foster naturally occurring social networks for youth, especially through youth ministries (e.g., youth choirs, liturgical dance, sponsoring scouts and athletic teams) in a non-evaluative context (no grades or reports on behavior). These institutions have the capacity to change norms and reduce stigma with mental health challenges and help seeking. They also have a built-in monitoring system for peers and trusted adults, and the concept of mattering is built in.

The first component of HAVEN-Connect is church engagement. At this time, the program has developed partnerships with three churches: 1) First Corinthian Baptist church, Harlem (virtual application); 2) Rochester First Genesis Missionary Baptist Church (in-person application); and 3) Macedonia Baptist Church in Albany (hybrid). Each church has a church champion who is a liaison between community and the researchers.

The second component of HAVEN-Connect is faith-based curriculum based on an earlier course Dr. Molock developed for depression. It provides a 90-minute educational overview for pastors and youth leaders on mental health education and suicide. It focuses on four cores: 1) kinship (healthy bonds), 2) guidance (support from mentors and access to mental health and medical expertise), 3) purpose (goals and values), and 4) balance (selfcare and support). The program shows pastors how to integrate these concepts into their sermons and programs.

The third component of HAVEN-Connect is based on Dr. Peter Wyman’s Wingman Connect program, an upstream, strengths-based universal suicide prevention program, to build health and acceptance, support social networks, foster adaptive coping skills, and increase social connection. The program also seeks to change norms about help seeking. The goal is to identify kids before they fall into crisis. Youth Connect is an engaging interactive training of group members learning and modeling the four core skills.

Youth participate in three 90-minute modules with specific learning objectives and activities (reason for engaging in the community group, identifying personal goals, introducing the four cores that promote resilience, balance and strengthen each core, extend learning in a natural environment). At each meeting, they discuss which core they had and tried to strengthen in the prior week, and which cores they wanted to strengthen.  The study also involves recruitment of adult group leaders who get 10.5 hours of training to facilitate break-out sessions, or 2-hour training to enable them to serve as trusted adults. This gives youth access to support from peers and adults.

Preliminary findings from the pilot found participants agreed with strong thoughts on connection (90%) and more prepared to handle challenges in life, identify purpose, identify people who can offer support, and benefit from the program. Dr. Molock leveraged data from the pilot study to obtain funding from the American Foundation for Suicide Prevention for a project scaling the program to 12 churches (six in Rochester and six in Harlem/NYC).

### Discussion

Dr. Christina Borba invited the panelists to join a question-and-answer session.

**Question:**What characteristics of the peer mentor (i.e., gender, age, sexual identity, education) are important in terms of program?

**Answers:** Dr. Brown began that the peer mentors are paid employees. To follow employment law, the team did not ask specifically about their lived experience but rather asked the applicant to describe why they wanted to work with the LGBTQ community on suicide prevention. The people interviewed had outstanding lived experience to complement the participants in the program. The peer mentors in the program self-disclosed information that showed alignment with the goals of program.

Dr. Roundfield stated that school system requirements shaped how they designed the program. As such, Appa Health abides by screening and background procedures of the school customer. This is why the program has focuses on college graduates who meet baseline requirements. Many kids are coming from foster care, are homeless, or have parents who are incarcerated. This would require mentors with experiences outside of a college background. In the future, Dr. Roundfield would like to discuss with school systems how to expand these options to provide mentors who more closely match teen participants.

Dr. Molock stated that volunteerism in the church is highly valued. There is an expectation for people to give back. Most adult mentors are school teachers, counselors, or retirees. Young adults who have struggled with depression and anxiety give back by volunteering. Dr. Molock did not limit the age group of the trusted adult and allowed the church to decide who is a trusted adult.

Regarding a question about inclusion of LGBTQIA+ youth in the church setting, the program is operating in open and affirming churches and gay-affirming churches. People do struggle with this, and the program provides information in the faith-based curriculum on how the church can address concerns. All churches who are participating are very aware that young people are in crisis, and the church could play a positive role by being more supportive to young people. A one-size-fits all intervention is not always possible. Dr. Molock tells churches struggling with this issue to take a hopeful message and leverage the natural community of the church to support the community in need. You can continue to struggle with the theology but still be supportive.

**Question:**How do these programs address mandated reporting by peer mentors, and how is training conducted to provide mentors the skills for more clinical-based applications?

**Answers:**Dr. Roundfield began that all mentors are mandated reporters and take government required mandated reporter training. The Appa Health program does not require the mentors to teach the CBT skills, rather the short videos provide that information. The mentors support the implementation of skills. The mentors go through the training as part of their orientation. We ask mentors to use their lived experience without requiring them to be experts in CBT.

Dr. Brown stated that the STARS program is set up so that a participant is first screened by a licensed clinician to determine eligibility and develop a safety plan before randomization. Peer mentors do not focus on suicide risk assessment. They discuss the safety plan and how it might need to change. They also focus on session content. Their role is not to implement an emergency response planning beyond connecting with a licensed clinician. Dr. Brown welcomes discussion on how to improve this approach. The goal is to preserve the rapport between the peer and the peer mentor and not confuse it with a clinical hierarchical relationship. A licensed clinician is on call during all peer mentor sessions and follow up if there is a concern. This has not happened for peer mentor sessions to date. It has happened during participant check-in sessions.

Dr. Molock stated that the program aims to reinforce reporting, but clinicians are available and screen participants prior to entering the program. Kids flagged in the screening are contacted by a clinician within 24 hours, and a clinician can set up a safety plan or refer then for further assessment/treatment. If they tried to train adults to be mandated reporters, she thinks they would be less successful. They conceptualize themselves as a team. The kids, trusted adults, and licensed clinician are part of a team with different roles.

**Question:**What are the pros and cons of virtual versus in-person meeting in the era of telehealth?

**Answers:**Dr. Molock stated that their team struggles with this. They initially designed HAVEN to be an in-person intervention but then the pandemic started. The pilot was virtual, and it went really well. She believes the virtual approach was conducive to attracting more kids. She does wonder if the group dynamics and social connectedness is the same compared to in-person. She noted that marginalized groups may need more visible interaction with their tribe.

Dr. Roundfield’s program is fully virtual.  She looked at numbers of teen in a mental health crisis and the statistics of who is serving the teens. Appa Health wanted to expand access, which pointed to a virtual platform. This approach is important for marginalized teens. She stated that 78% of teenage users are Black, Indigenous, and people of color and 28% are LGBTQIA+. They sometimes connect a teen in Wisconsin with a mentor in New York, but she acknowledged that building connection and relationship in physical environment likely does matter. The company is trying to build into the curriculum a way to identify and connect with trusted individuals in the participant’s community.

Dr. Brown stated that the baseline evaluation is a one-on-one in-person meeting. Sessions with the peer mentor were entirely virtual. During the sessions, peers had option to toggle their video on or off as well as engage solely through the chat function. Participants were keeping their video on even though it was not required. Future implementation will be all virtual. Part of intervention is mobile health application. A virtual application will be helpful to reach a broader community.

**Question:**What is the support system is in place for the peer mentors?

**Answers:**Dr. Brown stated that the peer mentors participate in weekly consultations led by a peer mentor but also includes two clinicians. During the consultation, peer mentors share experience and feedback. It is an opportunity to model their humanity, and clinicians try to take lead and sharing genuine human reaction that hopefully is validating for the peer mentors. The group also discussion having permission to set boundaries and describe when things are difficult. Finally, they discuss what is helpful in their journey as a peer mentor.

Dr. Roundfield said that they use a mentorship and consultation model. Appa Health pays the peer mentors and requires them to come to consultation group similar to that described by Dr. Brown. The program supports and mentors the peer mentors. There is a licensed clinician and mentor manager (a mentor in a supervisory role) who facilitate the conversations.

Dr. Molock noted that her program is an upstream approach. The program is for young people to learn how to support each other inside and outside of the church. Not all youth participants are members of the church. Not all trusted adults in the program are members of the church. People are encouraged to strengthen the four cores inside and outside of the church. They also receive motivational text messages.

**Question:**What are your thoughts on how to make these programs scalable and sustainable?

**Answers:**Dr. Roundfield began that Appa Health wants to expand the program so it is scalable across the nation. This will require broadening who is considered a peer supporter. Peers can also be experts and have incredible value for the whole spectrum of care for young people. She encouraged the field to push the research forward to determine what is safe and what works to ensure the medical and healthcare systems can sustain this work and pay peer mentors.

Dr. Molock wants to examine if it is possible to affect change for an entire system. She aims to implement the program on a denominational level. She is also interested in adapting this program for non-religious settings (e.g., Boys and Girls clubs).

Dr. Brown wants to scale the pilot program and develop a nationwide hybrid implementation effectiveness trial. There is value to speaking to someone who lives where you live. She is looking at how to promote connection when scaling for a broader application and how that will affect the peer mentor recruiting strategy. 

## Session 5: Peer Support in Crisis Services Part 1

**Discussant: Rajeev Ramchand, Ph.D.**, Senior Behavioral Scientist, RAND Corp.

### Providing Peer Services on a Crisis Warm/Hotline

**Brandon Wilcox**, Crisis Program Director, Rocky Mountain Crisis Partners

Mr. Brandon Wilcox began by addressing the evolution of peer support within crisis services. Psychiatric crises have placed a large emphasis on licensed providers providing service for risk management and regulatory services. He presented on how peer support can be used on a crisis hotline.

Mr. Wilcox is the crisis program director with Rocky Mountain Crisis Partners (RMCP), and also identifies as a peer from his own lived experience.  RMCP is a statewide hotline that provides crisis counseling 24–7 by bachelor- and masters-level clinicians. The peer support line is an expansion of the crisis line. Peer support is offered 17 hours a day seven days a week. The support line uses a triad of models (i.e., alternatives to suicide model; intentional peer support; and the Colorado core competencies for peer services (required for peer specialist certification in Colorado)). RMCP also has a hospital follow-up program. A person entering an emergency department can enroll in a hospital follow-up program that consists of phone calls for follow-on service to build connection, check on a safety plan, check on post-hospitalization care, and identify other needs to be addressed. Peer support specialists are engaged within this program so people feel supported as they integrate back into their life.

RMCP views peer support as the intersection of identity and service delivery.  They define identity as having lived experience with a mental health condition, substance abuse problem or prior experience with trauma.  Peer support is an alternative to traditional crisis counseling. Peer support specialists do not access, screen, or conduct traditional counseling services. People want something different as post-care, follow-up to an acute care setting. They want a human connection, and peer support is popular. Peer support calls on the Colorado crisis support line have increased from about 14,000/month in January 2023 to ~19,000/month in January 2024.

Peer support offers an alternative to the traditional approach that focuses on validation, curiosity, vulnerability, and connection. This approach creates a sense of security, safety, and empowerment. All of this leads to autonomy and choice in how to deal with the crisis. Peer support aims to avoid hospitalization, mobile dispatch at the house, or law enforcement.

Peer support struggles with misperceptions on how and when support can be offered. Regulatory and funding sources maintain certain requirements (e.g., welfare check, life saving measures, call police), but many of these measures do not align with peer support philosophies. Another struggle is how to reconcile these issues and find ways to integrate peer support into the system to reduce harm. Mr. Wilcox noted that peer support struggles to define and measure outcomes and how to balance peer well-being with exposure to traumatic experiences.

### Bringing Peer to Peer Support to Every Youth

**Craig Leets**, Deputy Director, Youthline

Mr. Craig Leets introduced Youthline, a peer-to-peer support program that began in 2000, headquartered in Oregon. This organization defines peer as youth-supporting other youth. The program uses teen and young adult volunteers. Youth are already having these conversations, and this program provides a structure that includes a variety of facets to ensure that the youth have the support to do this work. It has three components: 1) help, support and crisis line; 2) education and outreach; and 3) workforce development.

Youthline serves youth ages 10–24 across the United States. Youth volunteers and interns range in age from 15 to early 20s. Teens understand what it is like to be a teen today. The peer-to-peer service is available 4–10 p.m. PST every day. Adults are available other times. The program uses an autoresponder on chat and text to encourage youth to use the Youthline or call 988. Youth peers are supervised by trained clinicians who review all content to ensure youth have support to do this work.

The core of Youthline is a help the support and crisis lines. The program has served tens of thousands of youth over the years. During the pandemic, youth reached out due to isolation and loneliness and it has gotten advertised through TikTok. The program’s motto is no problem is too big or too small. Youthline serves about 25,000 youth a year.

Education and outreach is the prevention component of the work that aims to destigmatize mental health, encourage help seeking behaviors, enforce skills and resources, and reinforce how to identify a trusted adult. Four components of outreach and education include: 1) social media; 2) free promotional materials; 3) community events to advertise Youthline and recruit volunteers; and 4) mental health lessons delivered in middle and high school classrooms across Oregon that meet mental health curricula standards.

Youth mental health ambassadors get classroom training (65 hours) that include youth mental health first aid and safeTALK before starting on the crisis line. The ambassadors also take their Youthline experience into their community. At the moment, the line has 130–150 youth volunteers. The program provides a monthly stipend to those volunteers who face financial barriers to volunteering.

Safe Social Spaces is a crisis intervention for youth online. The program has trained young adult crisis intervention specialists who look for posts on social media (e.g., Talk Life, Wisdo, Discord, Vent) that focus on injury and suicide and reach out to them proactively through direct message to offer resources.

### Peer Support – a Vital Part of Crisis Services

**Aaron “Arrow” Foster**, Vice President, Peer & Crisis Program Development and Training, Recovery Innovations (RI) International

**Charles Browning, M.D.**, Chief Medical Officer, RI International

Mr. Aaron “Arrow” Foster introduced himself as a peer specialist with lived experience, and began the presentation by explaining every organization, state, and federal agency has their own definition of peer support. For Recovery Innovations (RI) International, a peer specialist walks alongside and creates spaces for people to become empowered, use the things they identify as services, tools, and activities, and to be with the person mutually. This approach recognizes that the person is the expert about themselves and knows what they need. He defined recovery as being able to handle situations and move forward without having a major disruption in life, and to address symptoms quickly and effectively and reach out for support.

Dr. Charles Browning continued that peer specialists provide diversity to the team and reflect the make-up of the community, which impacts community engagement and inclusivity. The diversity of the team creates a sense of safety and belonging.

He then addressed the question of whether peers can effectively work in crisis services, and whether it might be too stressful for them.  He indicated that peer support specialists receive training and can handle the stress of the crisis line while building mutual relationships. Peers can listen, provide empathy, and refer to emergency services. He gave examples of successfully integrating peer support specialists into mobile crisis teams in Phoenix, AZ and RI’s Living Room Model.

He described how it works to integrate peers into the crisis services at RI, a process they call fusion.  Peer support is integrated and infused at each step of the process, with a peer being the first person and the last person they see while they are there.  For example, a person in crisis is met by a peer along with a nurse, who assesses the person’s needs,  helps with engagement, and is a champion for the person receiving care. About 60–75% of people who come in for service return to the community in less than 24 hours, while in a traditional system they might be sent to an emergency department or jail. A vital part of this process is trauma-informed care led by peer support specialists that focus on empowerment.

Peers translate what the person in crisis is trying to say to the clinician as well as translate what the clinician is saying to the person in crisis. A person in crisis may be more inclined to share more information with a peer specialist than a clinician.  Clinicians can learn from peers about how to improve their role and their interactions.

The RI International fusion approach has a peer leader, similar to the leadership hierarchy in other medical teams. This approach also provides a ladder to for job advancement. The peer manager sits at the table with the other subject matter experts and has a voice in all decisions.

Peer powered scales provide an internal tool to measure peer practices at the organization, which is evaluated every six months. This approach measures peer voice in culture, the use of peer power practices, and tools and systems to execute the practices. RI International also created a free access website that any organization can use to measure workforce readiness at their organization.  Finally, they have developed three asynchronous training modules for peers in crisis services including topics of ethics, workforce relationships, and an overview of a day in the life of a peer.

### Discussion

Dr. Rajeev Ramchand invited the panelists to join a question-and-answer session.

**Question:**Is there value in distinguishing between peers being defined by the concept of shared lived experience versus based on characteristics (e.g., age, lived experience, gender, LGBTQIA+)?

**Answers:**Mr. Wilcox agreed that this is a difficult question. A peer who has a shared experience and has been in a similar mindset or similar place, helps categorically with the individual receiving support. When we define peer as someone who has a similar experience with a mental health or substance abuse challenge, the receiver of the service knows who they are dealing with.

Mr. Foster comes to this from a training perspective. First, peers are engagement specialists and change agents. Peers know how to use their lived experience to help others. If a person knows how to make the connection, it doesn’t have to be the same experience. Recovery is a common human experience.

Dr. Browning noted that it can help to have training and a diverse workforce to provide a wide range of support; however, support should not require a particular life experience to be effective.

Mr. Leets noted that the Appa Health app in Session 4 allows the participant to choose a mentor. Youthline callers may ask for a particular identity. Our program does not transfer to a volunteer with a particular lived experience but may refer to another service (BlackLine, Trevor Project, Trans Lifeline), which may be a better fit.

**Question:**People who answer 988 are not well trained at responding to self-injury. How does Youthline respond to a person mentioning self-injury?

**Answer:**Mr. Leets noted that the main goal of Youthline is to validate feelings. The volunteers affirm that the caller’s feelings are natural and normal. The peer specialists de-escalate, which 97–98% of the time works. Our peer specialists listen to youth in crisis and explore how they are feeling and what is leading to thoughts of self-injury. They brainstorm with the caller to identify other activities (e.g., hold an ice cube, scream into a pillow) to reduce harm and move forward with them for safety planning and self-care.

**Question:**Several questions address the tension between fully integrating and elevating the role of peer support specialists, versus potentially elevating them above their training level and having them operate outside the scope of practice.  Can you comment on how you handle this tension?

**Answers:**Dr. Browning referred to the fusion model. There are many opinions on how to bring the team together the right way. He stated that fusion leads to an incredible richness when everyone respects each other as teammates. Organizations can invest in how culture is built throughout the whole organization. It takes workplace culture to make this happen. It also requires constant adjustment to balance the components to get the best out of it.

Mr. Wilcox agreed with the concept of fusion and said this is what probably moves the needle. He stated that peer support has only grown with more responsibility and opportunities to work with people in many healthcare settings, and that they have had to fight against stigma for that scope to grow. He worries, however, that some of the underlying and foundational principles of peer support could be lost by folding it into a more traditional or fusion model. There is a power differential in traditional support, and he does not want to see peer support fall into a power differential. He pointed out that there is a lot of lived experience within people who provide services, and that a degree of separation creates integrity around the service. As far as scope issues, it is not necessarily an issue of the specialist rather than a more general issue of training and supervision, which are universal to any job.

**Question:**How are services funded? How can we both pay people adequately but also have a model that is sustainable?

**Answer:**Mr. Wilcox noted that it is a really difficult conversation. In community mental health work that is Medicaid reimbursed, finding the right Medicaid code to receive the highest rate of reimbursable to pay peer support specialists adequately is difficult. He stated that we often have to challenge hiring models or salary grades. When it comes to public funding (e.g., Medicaid and Medicare), he said we need to show the value of services as a reduction in hospitalizations, suicide, and improved outcomes. Insurance will save money over time, which could support higher salaries, but there is a bias at organizations toward education rather than lived experience.

**Question:**With respect to research, do you seek out research collaborators? What do you think is the most beneficial model for researchers working with you to study peer support?

**Answer:**Mr. Leets said that historically, researchers have reached out to the program. He stated that Youthline collaborates with researchers but they need to understand that their program has limitations on how to measure outcomes. He said it would be ideal to reach out to people who called to find out how the service impacted them, but that their role is to provide support in the moment. For their program, success is having the caller commit to safety, and successful partners understand that and are flexible in their approach.

**Question:**We have not discussed mobile crisis. Is there a model for integrating peer support specialists into a mobile acute scene?

**Answer:**Mr. Foster said that there is a model (Crisis Now) that is being put forth for mobile crisis care. He said this is complicated because each state has a different definition of what peers can do. Peer support, if trained and interested in engaging in crisis work, can be a part of a mobile team. The Senate is proposing to have Department of Labor develop a new code for peer support differently (right now they are viewed as community health worker or psych tech). He stated that having a national definition would also reduce the disparate definitions around the country.

**Question:**All people who work in the mental health space encounter stressors and experience burn out. How do you care for peers who encounter a traumatic event in the course of crisis work?

**Answers:**Dr. Browning began that peer support does not need additional protection compared to other team members. It is important to work on self-care and post-event strategy with the entire team. When the team feels it is making a difference during a crisis then it makes a huge difference in burn out.

Mr. Leets noted that youth are already having these conversations with their friend groups, but at Lifeline they do it with adults in the room, who are monitoring contact and can step in if a call is becoming too acute. He pointed out that their youth work one shift a week for 3.5 hours, and not all of that includes acute contacts.  He sees their youth as very capable of processing difficult situations and doing the work.

Mr. Wilcox said the program is not hypervigilant about peer support well-being. RMCP trusts the plans and techniques that the peer specialists have put in place to get them to this point and trusts their recovery process. The program is open to conversations in a supervision space to have plans in place for well-being. This approach is used across the entire board, not just peer support specialists. No one is siloed or stigmatized. He stated that it is their jobs as leaders to challenge concepts at an organization level that do not lead to a healthy workforce.

Mr. Foster agreed and said that there is a need to build selfcare into the line of supervision.

## Session 6: Peer Support in Crisis Services Part 2

**Discussant: Matthew Goldman, M.D.**, Medical Director, King County Crisis Care Center

### Training peer specialists in the Safety Planning Intervention for Suicide Prevention: *Feasibility, acceptability, and peer provider experiences*

**Christa Labouliere, Ph.D.**, New York Office of Mental Health

Dr. Christa Labouliere discussed her collaboration with Recovery Innovations (RI) International on training peer specialists with safety planning interventions for suicide prevention. She explained that peer specialists have been integrated in many recovery-oriented services, but suicide prevention has been behind the curve. There are several contributors, including fear of contagion, reliability, benign stigma of protecting peers, and lack of clarity of the peer specialist’s role. This study aimed to evaluate how acceptable/feasible/safe it is to train peer specialists in an adapted version of the safety planning intervention in crisis settings at RI International. The study introduced peers to the safety planning intervention, a clinical intervention, and provided training on this task.

During the first phase of the program, peer support specialists received training, as well as asked the peer specialists what was appropriate for their population (11 peers). Dr. Labouliere and her team provided training that was similar to clinicians with an emphasis on finding out how to tune the training for peer specialists (e.g., emphasizing the parts that felt appropriate and safe). The training was well-received and the peer support specialists believed it was appropriate. Peer support specialists offered feedback on how to adapt the training with greater emphasis on developing a connection with the person at risk and ways to balance self-disclosure when forming a connection. Peer specialists also gave feedback on how to instill hope into the process. The peers noted that handling triggers is already a part of their jobs. They suggested changing certain language and jargon on the form to make it more appropriate for their roles (less like a clinician). The team incorporated these changes and created a manual for peer-focused training administered in Phase II.

Dr. Labouliere and her team rolled out the training during five virtual training sessions to 76 peer specialists from RI International. The peer specialists had a wide range of experience. All reported history of serious suicide intensity or attempt at least two years in the past, and all felt they were capable of doing this work.  Her team measured feasibility, the peers’ own symptoms of suicidality, and positive and negative affect.  Although historically, the sample was vulnerable, rates of ideation did not increase or illicit suicidal behavior after training. Most levels of negative affect decreased during training. Participants expressed high satisfaction and thought it would be effective, appropriate, and suitable for their work in crisis setting. Next steps will include looking at the quality and completeness of the safety plans.

### Peers for safety planning in the ED

**Michael Wilson, M.D., Ph.D.**, assistant Professor in the Department of Psychiatry, Department of Emergency Medicine, University of Arkansas Medical Sciences

Dr. Michael Wilson began by repeating the findings from a California study that found that a person who presents to an emergency department with thoughts of self-harm is 57 times more likely to die by suicide and 14 times more like to die from any other cause one year after visiting the emergency department. He said screening in the emergency department is tricky because you have to figure out how to treat someone after screening.

Dr. Wilson described the ICAR2E tool, a collaborative effort between the American Foundation for Suicide Prevention and the American College of Emergency Physicians. The tool was designed to help emergency physicians know the steps for screening a mental health crisis (i.e., Stanley-Brown safety plan). The tool is built on the largest systematic review of emergency department trials to date and adhered to Institute of Medicine criteria for creating clinical practice guidelines. This approach has many barriers for safety planning: 1) feasibility of conducting an intervention (20–45 minute) in the midst of emergencies on the floor; 2) acceptability by patients; and 3) time and staffing.

Peers offer an innovative solution. Dr. Wilson ran a randomized control trial to see if peers could help with safety planning in the emergency department (Level-1 Trauma Center in Alabama). He randomly assigned people arriving in the emergency department with thoughts of self-harm to either peer-delivered or provider-delivered safety planning. Their IRB was nervous about this study and initially limited their sample size to 30, although they were later able to increase it to 37.

He measured feasibility of this approach in an emergency department (e.g., length of stay), acceptability, and preliminary effects (e.g., safety plan completeness, safety plan quality, , emergency department returns after three months, and deaths).

The study assessed 96 people for eligibility but excluded people where were too ill or intoxicated. The 37 adult participants were randomized to either peer- or provider-delivered safety planning. The peer-delivered arm had a more complete and higher quality safety plan. Emergency department length of stay was not different between the two groups. There was also no statistical difference in emergency department visits before intervention but after the intervention the participants in the provider group made slightly more visits to the emergency department. Participants liked making safety plan equally well with both groups. There were no deaths in either group. The results of the study were published in the journal*Psychiatric Services*.

He concluded by saying that safety planning in the ED may help reduce suicide risk. The emergency room trials suggest this risk could be reduced if patients cooperate with the process. This is difficult to do in an emergency department setting but peers could be helpful in this effort.

### Arizona Crisis System: Alignment of crisis services toward common goals of care in the least-restrictive setting

**Margie Balfour, M.D., Ph.D.**, Chief of Quality & Clinical Innovation, Connections Health Solutions and University of Arizona

Dr. Margie Balfour explained the variety of services available within Connections Health Solutions in Arizona, and how peers are woven throughout their crisis system. She pointed out that the system covers the whole spectrum of care, from the least restrictive to the most restrictive, and that there are also possible interactions with law enforcement at each step. She explained that the system of care is supported by Medicaid, state and local funds, and SAMHSA funds that are then subcontracted to the different providers who all work together as a system. She gave some examples that incorporate peers. Hope Incorporated’s Warm Line, a peer run organization that is helping to handle some of the repeat callers to the crisis line to get them peer support. She also described Pima County’s 16 mobile crisis, two-person teams that operate 24–7.  A new state requirement says that 25% of these teams must include a peer, working alongside a mix of other professions (e.g., behavioral health clinician, law enforcement, paramedic, psychiatric, unlicensed behavioral health specialist, peer support, medical director, nurse). There are some calls for more inclusion of peers as part of a mobile crisis response team to more closely reflect the community they are serving.

She also discussed crisis stabilization services, which are highly varied (low to high acuity) with a lot of local variation (licensing nomenclature, reimbursement, involuntary process, locked vs unlocked, police drop off, and length of stay). Low acuity living rooms and peer respite include a lot of peers already. High acuity patients need facilities to provide care outside of the emergency room. Data from crisis center in Tucson follows a ‘no wrong door’ approach to take everyone. The program wants law enforcement to use these crisis centers that provide engaging and recovery-oriented services. The program avoids security but has staff who are trained to de-escalate. The intake process includes a peer to decrease seclusion and restraint.

She described a brochure about the various roles that peers created to describe their work, including groups that focus on goals, coping, community resources, safety planning, and pet therapy. They engage in waiting areas. They de-escalate and proactively engage to prevent agitation. They reduce stigma for self-disclosure. Having peers embedded also improves the culture of the organization, including when peers move into other positions within the organization.

She explained how one crisis stabilization program is collaborating on the THRIVE study, a group safety-planning intervention, including phone follow-up contacts after crisis. Dr. Balfour plans to adapt the THRIVE intervention in a high-acuity crisis setting to see how to fits into the workflow. The second step is to test this plan followed by a randomized control trial.

Finally, she discussed the intersection with law enforcement officers who co-respond with behavioral health teams for special populations. The mental health support team responds to a threat to public safety and reduce involuntary hospitalization from 60–20%. She concluded that the field needs to stop asking should peers do this work. They are already working in crisis settings.

### Discussion

Dr. Matthew Goldman shared reactions and themes in the Q&A. There is a forming consensus that peers should be part of crisis response. Peer specialists are not unique in having lived experience; clinicians also have lived experience and substance use experience. Additional sensitivity concerns are misplaced, but workforce need to be supported across the spectrum. Peers need to be partners in developing new initiatives to make materials more accessible. The current workforce crisis has led to new approaches to task-shift to address key functions that the current workforce cannot. It is helpful to have a workforce that represents the people being served. But of course, more research is needed.

He also shared how King County is handling some of these issues. Voters of King County approved a property tax levy to fund five crisis care centers across the county. Over $1 billion in support will create the crisis care centers, expand and restore residential treatment facilities, and invest deeply in the behavioral health workforce. These crisis care centers are meant to be a place for people to go in a health or substance abuse crisis (e.g., behavioral health urgent care that is open 24–7 for a 23-hour stay and 14-day crisis stabilization unit). Peer specialists will play a critical role in all parts of this new program.

Dr. Goldman invited the panelists to join a question-and-answer session.

**Question:**Is the mobile crisis intervention program in Pima County prosecutor’s office still running, and is it connected to the behavioral health and crisis teams?

**Answer:**Dr. Balfour stated that particular program is no longer running, but that the county is doing activities to reduce justice involvement and include peers. In addition to post-crisis follow-up to help people navigate after being in jail, the INVEST program helps people who are high-risk for future misdemeanors. They are creating transition centers to help people who were diverted from being booked into jail to spend time and get services. The city has a civilian response team to find ways to remove law enforcement from an episode of crisis, but jurisdictions are still being figured out.

**Question:**Are crisis response teams always male and female? What are your thoughts on gender matching and gender response?

**Answer:**Dr. Balfour noted that the realities of staffing and staffing strain make it difficult to do matching. If a specific composition of mobile team is needed, there is an opportunity to see who can address the crisis, but it can’t always happen that way.

**Question:**Does peer respite help more than low acuity patients?

**Answers:**Dr. Balfour said that it is important to note that all crisis facilities are not the same (e.g., Level-1 trauma center, Level-2 trauma center). There needs to be a clear understanding of the population to be served at each facility to ensure safety for service intensity and reimbursement for needed skills. A community should have a range of crisis options.

Dr. Wilson noted that despite the centers available, people will still come to the emergency department, especially in lower resourced areas.

Dr. Balfour agreed and said that some crisis facilities should be attached to emergency departments for economy of scale and can still incorporate peers.

Dr. Labouliere said peer-based services can be different even if they are using the same skill set. Staffing shortages are real concerns. Trained peers can step up and do some of the jobs completed by physicians and mental health professionals to address workforce limitations and at the same time bring something special to the table.

**Question:**There was a SAMHSA report that describes the role of peers in crisis services around concept of both organizational and individual peer drift. Did you receive feedback from peers, and how do you navigate that tension?

**Answers:**Dr. Labouliere noted that RI International may have the best answer to this question. In her study, most peer support specialists were already doing the task. Our focus was on providing the skills and making the task more peer-like.

Dr. Wilson received a lot of feedback before the trial, with people warning that the trial should not be done. Peers were questioning why they were being tasked with clinical work. The study reconceptualized how we look at intervention vs. collaborative intervention and how it falls into the scope of peer practice.

Dr. Labouliere noted that they faced concerns from IRB and clinical partners. But then she learned that at RI International, peers were already doing this work and doing it well. She wanted to assess how peers felt about this task. It was eye opening to hear from peers of their conceptualization of safety planning. This qualitative piece has democratized the process. A good clinician should already be making the process collaborative and peers shine in this area.

Dr. Browning noted that the majority of safety planning is completed by clinicians, but RI International has been pleased with the impact of peer-support-specialist driven safety planning.

**Question:** How do you see the role of peer support specialists in crisis services to support longer-term needs?

**Answers:**Dr. Balfour said Phoenix has started a transition program. People are told to interact with healthcare system like they were not just in crisis. People often return, because services are not available. A bridging function is needed, and Phoenix created a program that includes a provider, licensed clinicians, and a peer component to help people navigate systems. Care can be given for several weeks to several months. It helps the participant access resources, which is an important part of post-crisis care.

Dr. Wilson said that no one questions if peer support would benefit a patient after visiting the emergency department during a crisis. Post discharge care and contact works. Substance use navigators work. No one questions that. We proposed that model for the emergency department. We would like to take what we did in the emergency department and turn it into safety planning intervention and follow people after the emergency department visit. We are hoping to convince NIMH reviewers that this is a worthy thing to do.

**Question:**Will you talk about the need to respond to the needs of parents when their child/teen is in crisis?   One of the King County crisis centers will be dedicated to serve youth, and they are putting in place a peer role for the youth as well as caregiver advocates. What other work is related to supporting parents?

**Answers:**Dr. Balfour noted that the Tucson facility has a youth facility and youth urgent care. Peers play a huge role in that unit. Anecdotally, if the peer has had a child in that situation, they can be really helpful to the youth on the unit, but this has not been formally studied it. their peers are also involved in family meetings.

Dr. Labouliere noted that this needs to be studied. There is great need for peer support to help youth and families navigate the crisis. It was hard enough to get the study discussed through IRB with adults. It may be more complicated with minors.

Dr. Balfour noted that peers are already doing this work on the crisis unit. It is important to get that message across to IRBs. The work is already happening so why not study it.

## Summary and Future Steps

**Stephen O’Connor, Ph.D., Chief of the Suicide Prevention Research Program, NIMH**

Dr. O’Connor thanked the participants, presenters, and moderators for attending the two-day workshop. The video recordings for both days of the workshop will be posted in approximately one month. This workshop was focused to characterize the state of the science on a topic of particular importance in mental health and this day focused on suicide prevention and peer support for youth and crisis services. NIMH has invested in peer support suicide prevention research and continues to do so.

Potential applicants are encouraged to look at the NIMH strategic plan and the Division of Services in Intervention Research website to learn about funding opportunities. Funding opportunities emphasize a deployment-focused approach, including end-user perspectives (e.g., youth, adults, and families who access support services) throughout the intervention development and testing process. The role of peer support was discussed during this workshop in the planning and development of research projects. As a program officer at NIHM, please contact me to discuss research concepts and think about priorities in the funding opportunity announcement.