Workshop Day Two: Advancing the Science on Peer Support and Suicide Prevention

Transcript

DEBORAH KRAT: Welcome everybody. We will get started in five minutes. Just waiting patiently for everybody to come in. Again, we'll start in about five minutes, right at the top of the hour. Thank you. Again, welcome everybody that's joining us today for our second day. We will get started in about two minutes. So, thank you for your patience. We will get started right at the top of the hour. Okay, it is that time. It is 11 o'clock a.m. Eastern time. Welcome everybody, back to day two of advancing the science on peer support and suicide prevention. Just as a reminder for a few housekeeping notes, participants have entered listen only mode. Cameras off and mics are muted. Please submit your questions via the Q&A box at any time during the webinar. Questions will be answered during the discussion sessions of the workshop. If you have any technical difficulties hearing or viewing the webinar, please note these in the Q&A box and our technicians will work to fix the problem. You can also send an email directly to me, Deborah Kratt at dkrat@mn-e.com. And with that, I will now pass it over to my colleague, Lisa Jaycox. Lisa.

LISA JAYCOX: Thank you. I'm just going to get up my slides. Sorry, of course, it's taking me longer. There we go. Um, is that shared? Does it have my name up there?

DEBORAH KRAT: No, no, not yet.

LISA JAYCOX: Okay, now it is, I think. Okay. Thanks so much. We're really excited to get to day two of the workshop. And as Deborah said, we're going to use the Q&A function to receive your questions today, but we have a large audience and so your comments won't be visible to everybody. Rest assured that the NIH staff members who are on are noting every question and comment, and we'll try to accommodate as many questions as possible during the discussion section, but we will certainly not be able to get to all of them. So, if your question isn't answered, please contact the speaker or us directly and we'll try and answer it offline. We're going to start off with a quick poll today to find out more about the audience, so please answer the question you can see on your screen when it comes up, and I'll summarize it for everyone in a few minutes. We know these categories overlap, so please pick the choice that best represents your interest in the workshop today. And please fill it out, even if you did it on day one so we can know who's attending today. For those of you who missed day one, you will be able to watch the recording once it's posted on the NIMH website in a couple of months and you'll get a notification when it's posted.

But for those who missed it, I'm going to give a recap right now on some of the highlights from day one. I'm having trouble with my slides. I'm just going to go ahead and talk it through. So, after an introduction by Stephen O'Connor and Jane Pearson from NIMH about NIMH structure and the suicide research team, we started off with a panel that gave a general overview of the topic area. Karen Fortuna started us off with a recap of the history of the peer support movement, starting in 18th century France, mutual support groups starting in the 1930s in the US, the community mental health centers movement of the 1960s, deinstitutionalization and a new focus on rehabilitation and recovery in the 1970s, all the way up to the present and recent advances in digital support.

Paul Pfeiffer then talked more specifically about peer support in terms of suicide prevention. He described features of the empirical literature in regard to peer support related to suicide prevention, including some definitions about the types of peer relationships found in previous studies, and the places that peers may intervene in clinical and community practice settings. He then described an NIMH funded study of an intervention called PREVAIL, which involves peer mentorship by a paid peer specialist for adults at high risk who are exiting inpatient psychiatric care. And finally, he talked about potential mechanisms of action, such as thwarted belongingness, hopelessness, and burdensomeness, and described early results of the NIMH funded trial.

Then Kimberly Hoagwood described the federal landscape in terms of policy trends at the state level and funding trends for peer support specialists through Medicaid, and as just recently announced through Medicare. She discussed peer support as a means of shoring up mental health workforce shortages, but also through the unique categories of support, such as informational support, emotional support, instrumental support, and advocacy. She ended her talk with some specific information about family peer support and about different models for training and certification.

And then Joel Sherrill from NIMH led a discussion following these talks with lively participation from our other panelists and answers to some of the audience questions. In our second panel, we moved into real world implementation, and our three panelists all described their own lived experience relevant to training, consultation, supervision, and engaging as research partners.

Topher Jerome started us off with a description of his multiple roles in peer support and described one role in particular on a study that brought peer support and a video-based app into the emergency department for people at risk for suicide. He then described his key priorities to centralize, not marginalize, to double down on safety, equal compensation, having a human in the loop, and trauma-informed research. His call to action is to embrace a transformative approach to research that truly partners with individuals with lived experience.

Then Nev Jones talked about some of the challenges in peer support and gaps in knowledge related to how peers can support people in different parts of the crisis continuum. In particular, she discussed gaps in terms of knowing what works for whom, in what contexts, and at what dose, whether and how matching peer to person at risk is important, and how to do research on real world implementation. She described results from a national survey of peer specialists and closed with her research priorities and policy priorities.

And then Eduardo Vega described his own personal mission and talked about shifting the lens to see suicide crises differently, specifically how a suicide crisis can lead to personal growth. He described the different places peer support can help as a psychosocial intercept in the crisis continuum and discussed ways to reframe the traditional views about suicide to a more growth or recovery-oriented perspective. Then Linda Dimeff led a discussion among these panelists, including a question about their top three priorities related to peer support and lived experience.

In the final day one panel, the panelists described the role of peer support and suicide prevention for active-duty military and veterans. Matthew Chinman started us off with a discussion of a robust peer support program within the VHA. He described the role of peer specialists within the VHA structure as VHA employees who can be a VA peer support specialist, and then described a pilot study they did to test the PREVAIL model modified for veterans.

Next, Peter Wyman described the Wingman Connect program within the U.S. Air Force, an upstream prevention program that relies on the service member network as the unit of intervention and which seeks to strengthen the individual by strengthening the group. He discussed results of their studies on this model and also recent adaptations to other settings.

Finally, Craig Bryan talked about another Air Force program, Airman's Edge, that includes training peers for a role that includes direct intervention with peers, referrals to mental health treatment and other resources, and developing crisis response plans. He emphasized the need to weave this program into the daily fabric of unit life. He also described strategies to optimize the role of peers and peer relationships as related to efforts to improve lethal means safety. And Marianne Goodman led the discussion of this panel and asked panelists to further discuss their models and also answer questions about potential for expanding their efforts.

So, I'm going to describe the results of the poll as it comes up. I think everyone can see it. You can see that we have about a third of our participants are peer support specialists. We have about a quarter that are licensed clinical providers, about a fifth from government employees, either federal, state, or local, and an array of different people participating. So, this is great. We have a really broad audience and a lot of interest in this topic area.

So today our focus is going to be on peer support and suicide prevention among young people and how they relate to crisis services and young people and crisis services. We have two panels on crisis services. So, I'm going to turn it over to Christina Borba as soon as I can get here and she'll kick us off with the first meeting.

CHRISTINA BORBA: Great. Thank you. Good morning, everyone. My name is Christina Borba. I am the director for the Office on Health Disparities and Workforce Diversity at NIMH. I'm really excited about this session, session four, which we will be focusing on youth peer support. We have three amazing speakers today. I will introduce them now. Dr. Lily Brown from the University of Pennsylvania, Dr. Katrina Roundfield from Appa Health, and Dr. Sherry Molock from George Washington University. I'm going to turn it over to our first speaker, Dr. Lily Brown, to get us started this morning.

LILY BROWN: Thank you so much. It's a real honor to get to be with you this morning and to have an opportunity to participate in this inspiring workshop. I'm going to go ahead and pull up my slide deck.

I'd like to begin by orienting you to the focus of the presentation today. I'll have about 15 minutes to talk to you about this topic. Today, we're going to be talking about helping the helpers, that is, supporting peer navigators, peer mentors, or peer support specialists in their work in suicide prevention, particularly as it relates to their work supporting youth who are at risk for suicide.

My collaborators on this project include Dr. Jose Bauermeister, who's my MPI on this project, as well as Jessica Webster and Jennifer Tran. I'd like to thank them for their involvement in this project and support of this presentation. By way of background, you all likely know that emerging adults who are in the 18 to 24-year-old age range who identify as a member of the LGBTQ plus community are at significantly higher risk for suicidal ideation and suicide attempts.

The prior research in this age range and in this population has revealed a few unique risk factors that appear particularly important for understanding suicide risk. Three of those include low ratings of perceptions of social support and low ratings of actual social support, as well as low experiences of positive affect or the ability to tap into positive emotions, as well as low perceptions and the ability to cope with the real-world discrimination that members of this community are facing as they're transitioning into adulthood. In this project, we'll be focusing on explaining how we're approaching peer mentorship in our suicide prevention initiative for this population.

And our core focus for today's presentation is about understanding how best to support the peer mentors in their role. This project, called the STARS Project, is a clinical trial that's supported by NIMH as part of a center grant awarded to Dr. Maria Aquendo and Greg Brown at the University of Pennsylvania. Our project is a small exploratory project.

This project is focused on the emerging adult period among individuals who identify as part of the LGBTQ plus population. Participants in this study needed to report past month suicidal ideation, and those who are eligible for the study completed a baseline evaluation, during which we conducted a Columbia assessment to understand history of suicide attempts, intensity of current suicidal ideation, etc. Then all participants completed a safety planning intervention with a psychologist.

Following completion of the safety planning intervention, participants were randomized to either our STARS intervention, which I'll tell you about in just a moment, or to ongoing assessments and checking in with the study at two, four, and six months after completion of the safety planning intervention. Let me tell you a bit about our STARS intervention.

STARS includes two components. The first is a mobile app, which includes a touchdown space for participants to access their safety planning intervention. The safety planning intervention can be updated and edited on the basis of the patient and participant experience of attempting to use their safety plan, learning about what worked, learning about what didn't, and adjusting it accordingly. There's lots of life skills focused content pre-built into the app focused on things like experiences of discrimination, making a change in your life and setting goals to support you in making those changes, understanding more about your emotional experiences, using substances in a safe way, as well as getting connected to safe spaces for all sorts of health care, be it mental health care or otherwise.

In addition to access to the app, though, participants who were randomized to STARS also received six sessions of peer mentorship. The sessions of peer mentorship were operationalized to really try to highlight what we know is effective in terms of promoting positive affect, trying to connect individuals to safe spaces, promote social support, and promote confidence in the ability to work through experiences of stigma and discrimination. In the first peer mentor session, the peer mentor checks in about the safety plan. They ask things like, what do you think about the safety plan? Is this relevant to you? What would you like to change about this? Have you used it since you met with the psychologist? What worked? What didn't?

Every session thereafter, there was a brief part of the session dedicated to checking in on the safety plan, but the remainder of the sessions focused on core skill development. Session two included the peer mentor supporting the participant and clarifying their values and setting goals in the service of what's important to the participant. Session three is about coping with negative self-talk.

That is, what kinds of self-defeating thoughts come up for the participant during important windows that contribute to them feeling more like they want to die? And how can we deal with those thoughts in a way that help promote reasons for living and building confidence?

Session four is about scheduling pleasant events. You could think of this similar to behavioral activation. The idea here being building and opportunities for the participant to boost their confidence that they can do things that are important to them or engage in tasks that have a chance of increasing joy, love, a sense of connection to things that are important to them and people that are important to them. Session five is about dealing with people who hurt you.

And session six is about investing in close partnerships and close romantic and non-romantic relationships to build that life worth living. The peer mentors completed an intensive training that included a standardized portion and role plays. In the standardized training, there were eight training sessions, each of which was two hours.

And in this training, individuals were trained in motivational interviewing procedures to learn how to reflect back what the participant was saying, to use non-judgmental language about, you know, complicated topics. And to support them in practicing implementation of these skills in these peer mentor sessions. So, peer motivational interviewing was the overall framework for all of the sessions.

But we embedded these really CBT based skills into the sessions with this motivational interviewing framework where the goal here is building motivation to use your safety plan the next time that you're in a suicidal crisis. The peer mentor sessions were essentially scheduled about once per week. And we had in the study no more than three peers at a time.

And peers were completed with the study either at the end of randomization, which wrapped up about three weeks ago, or because peers left the study for different reasons. Throughout their involvement in the study, peers had check ins with standardized training, you know, boosters every two months. They also had weekly supervision with two clinicians on the team.

And we completed ongoing fidelity measures as they were going throughout the study to make sure that they were on track with the content and the style of how to engage participants in a way that felt supportive and non-judgmental. So once a peer was randomized, they were assigned to a peer mentor and completed those sessions one through six. Every session, the peer mentor completed a rating of how comfortable they felt as the peer mentor in that session and how much distress they felt during the session.

This is really important from our perspective because we're having peer mentors talk about really difficult topics that are personally relevant on the basis of experiences of discrimination because of their own identity as a member potentially of the LGBTQ plus community. Or on the basis of their lived experience with prior suicide risk or ongoing suicide risk. And so, we wanted to make sure that the peer mentors were feeling supported in their role.

And as I mentioned, we completed fidelity ratings to check in about how the sessions were going. And at the two month follow up with the participants, we asked the participants to rate their sense of how comfortable do they feel with the peer mentor. Then when the peer mentors are completely done with the study, we're doing interviews with them to understand their experiences as well as the survey to figure out how we can make sure that future peer mentors in this role receive the support that they need to be able to thrive in this role and do so in a way that is not at all threatening to their safety in their journey with their lived experience.

So, in terms of the participants, we're providing some demographic details on the left hand side about the participants themselves. We had intended to randomize 30 participants into this arm. We actually randomized 32, which is really exciting for us.

You can see the mean age of the participants as well as their sex assigned to birth, self-reported race, and self-reported ethnicity. You can see on the right-hand column that peer mentor sessions are still ongoing. We're almost done.

We've got about three more weeks to go before we're completely done. 81.5% of participants completed all six of the peer mentor sessions. So, this is really helpful for us to understand feasibility and potentially acceptability of this protocol. Some are still active in this study. Not all participants completed all of the peer mentor sessions. And you can see some data on that.

So, two participants completed only one session. One only missed the last session. Two participants missed the last two sessions. When we think about how the peer mentors were doing in this project. So, I mentioned we asked them about their comfort level and their distress. So, the comfort rating, they completed every session that they administered a peer mentor session or facilitated a session.

And so, we asked them on this scale from one to 10, how comfortable did you feel during this session? And you can see the average comfort ratings for each of the six sessions reported here with the means consistently between an eight and a nine, where 10 is very comfortable and one is most uncomfortable. In terms of distress ratings, we also asked the peer mentors to rate the highest level of distress that they experienced during the session on a one to 10 scale, where 10 is the highest possible distress that they would have experienced, and one is no distress at all.

We see similar trends here with the scores between a two and a three at all sessions, demonstrating generally low ratings of distress, not non-existent distress, which we might expect that some of the content that we cover in these sessions is intentionally emotional. We're talking about difficult things. And by and large, the peer mentors are reporting that they felt generally comfortable doing this and generally low reports of distress.

It's not the easiest thing that they've ever done. But on average, our takeaway from this data, these data so far are that this feels feasible and acceptable to the peer mentors. In terms of fidelity, the peer mentors are doing a wonderful job with fidelity. The maximum score for fidelity ratings for each of the sessions varies based on the content for the session. So, you can see that the maximum score, for instance, for session one is a 16. And on average, the peer mentors are scoring a 15 on that session.

And that general trend is consistent throughout. We also rated each of the sessions in terms of the style. That is using metrics to rate motivational interviewing style. So, it's not just about did you cover the content? It's did you do it in a way that felt warm and inviting and nonjudgmental and in a way that invited dialogue as opposed to finger wagging or didactics or lecturing? And you can see that style points on average were very, very high.

Our peer mentors have done a fantastic job in implementing this protocol, both with a high degree of fidelity to the content, but also retaining their warm and inviting approach, with their most important role being a welcoming peer mentor to these participants. When we asked the participants, how confident did you feel talking to a STARS peer mentor? These are rated on a one to four point scale.

Participants are reporting between a three and a four on that metric. And when we asked them, were peer mentor sessions offered at times that worked for my schedule? Again, that was rated between a three and a four for the participants themselves. So, we see some converging evidence that both the peer mentors are feeling comfortable in this role and that the participants are reporting, feeling comfortable and confident in their in their partnership with the peer mentor. We are collecting data from the peer mentors on things like their perception about acceptability, feasibility, appropriateness of this intervention. This data collection is ongoing because a few peer mentors are continuing to administer these sessions or facilitate these sessions.

And so, we'll be done in about three more weeks. But so far, the ratings of acceptability and feasibility are high. Appropriateness is a little bit lower, but still fairly high. We also wanted to ask them about their reasons that they chose to become a peer mentor in the first place. And I'll highlight some quotes on the next slide in just a moment. But in general, their feedback reflected content like I wanted to learn more about this in the future. Maybe I want to be a clinician myself and I want to know how to best support people who are struggling with suicide risk or part of the community that I'm a part of. And in general, a desire to support the LGBTQ plus community.

Here's some exemplar quotes. So, “I was very prepared to do everything in relation to the like discussing safety plans and sort of working to brainstorm a safety plan that wasn't quite working for someone”, “We did a lot of role plays in our supervision and I felt like that was very helpful in preparation with some participants”,” Always I would have to reach out in between sessions because they miss a session or be late. And I was kind of reaching out multiple times asking if they were coming. So, yeah, probably like almost always, you know, it was working. But sometimes we struggled”, “And I think that some of the sessions felt a little bit more jam packed with content than others. But that also depended on the person that you were with.” So, this is not to say that our intervention is perfect.

We still have a bit more work to do, but overall, the feedback has been very positive. And in summary, what our data thus far are showing us are that this approach is showing to be feasible and acceptable for training peer mentors in suicide prevention to support LGBTQIA plus youth. In terms of limitations, this is a pilot study with a relatively smaller sample, and we still have efficacy outcomes to follow in the next six months. Six months, all of those data will be collected, and we'll be eager to share them with the community. Those are all of my slides. So, I am very delighted to turn the presentation over to Dr. Roundfield. Thank you.

KATRINA ROUNDFIELD: Thank you, Dr. Brown. I will pull up my slides in just a second. All right. Thank you for having me. I'm very, very delighted to be here and very excited to speak with you about our program Appa Health and its role in peer-based support in terms of supporting teenagers. So, a little bit more about what we do here. Just as background, I think many of you may be well aware of some of these statistics, but we are in a national crisis of children's mental health, specifically based on data from the CDC. We find that, unfortunately, nearly 25% of teens have contemplated suicide in the last 30 days.

A more recent Blue Cross Blue Shield study has shown that nearly 90% of adolescents have reported their mental health as a major life challenge. And relevant really for one of the most salient context for teenagers is their school system. And in the public school system, we are in another state of crisis in terms of chronically absent students, which we believe is really associated with mental health challenges. So nearly 30% of students in public school systems are chronically absent from school.

UNKNOWN SPEAKER: Dr. Roundfield, sorry to interrupt. We are seeing your presenter version. I don't know if you want to switch the view.

KATRINA ROUNDFIELD: Oh, my apologies. Is this better?

UNKNOWN SPEAKER: That's great.

KATRINA ROUNDFIELD: Thank you. And in terms of what is Appa Health, so a little bit about what we are doing here at Appa Health is, in light of these statistics and in light of where we are as a country with children's mental health and teenage mental health specifically, we started a company. My background is actually as a clinical and community psychologist and researcher. And I have kind of moved into this space really thinking more about how do we design, evaluate, and implement novel approaches to teenage mental health. And so that led us, myself and my co-founders, to develop a company called Appa Health. And what we do here at Appa Health, it is a for-profit company founded in 2021 based in Oakland, California. We provide near-peer mentorship and mental health skills to teenagers.

And it's 100% virtual. So, what that looks like is actually one-on-one sessions that are very similar to a telehealth model, but really focused on building that lived experience connection between a mentor and a mentee teenager. It's also app-based services. So, we also provide digital content, which I'll talk about in the next slides. And that all comes together really looking like a mentoring relationship, all scaffolded by digital tools. Also, we primarily serve public school students. And so, what that looks like is partnering with public school systems so that none of the children or families have to pay for this service, but the public school systems support our work through partnerships. And since 2022, when we actually launched the program, we've served over 250 teenagers. So, what is it that we actually provide? What this looks like is first, connection. And I'll speak a lot more about connection. I saw in the comments that there's a lot of peer support specialists on this call.

And I think, I hope, and we may talk about this in discussion, that some of this really resonates around really, you know, what are we providing as peers? And we think at Appa Health, it's really this lived experience connection. And that connection really can help facilitate change. And so first, we start with connection. We pair teenagers with vetted, college-educated, near-peer mentors. So, really important to emphasize here that our mentors are not teenagers. They are young adults. And so, they are all college graduates who have importantly gone through their own lived experiences. They have turned their mental health trials into triumphs. And then they are able to kind of reach back and connect with teenagers who have similar shared experiences to them. So, they connect each week via virtual platform, looks very similar to what is on the screen here, which is basically a one-on-one video session. And they really provide support to teenagers.

They build connection. They have fun together. But really importantly, they also provide supportive accountability. And that supportive accountability is to keep teens accountable to our digital curriculum. That curriculum is a CBT, so Cognitive Behavioral Therapy-based skills program. And we deliver this in short-form videos that teach mental health skills. So, we teach 30, 60, 90-second skills per week that boil down an important CBT skill, an SEL, or social-emotional learning skill. And then the teens work on those skills. They implement those skills. They talk to their mentors about the skills. And the mentors also role model their use of the skills. I also want to emphasize here that the mentors are not teaching CBT.

They are not teaching skills. They are actually simply role modeling and supporting teenagers to learn the skills themselves, and then talk about those skills, use those skills, and then see results in their lives. I do want to emphasize that what we do believe is really important here is this idea that teens choose a mentor that reflects their identity. So again, that connection piece and that peer-based component is really focused on the idea that there's something about that mentor that really helps them feel seen, that helps them feel like they can do it too, and really inspires them to change. Now I'll just move into a little bit of our research now that you understand the program. So, of course, this is a bit of a novel approach to supporting the mental health of young people.

And what we want to talk about here is just rigorously analyzing what might be going on in this program. This pilot study is based on a feasibility and acceptability study that we recently published in 2023. I will briefly go over these results. I want to mention here on the left, you can see the PHQ-8, which is a depression score, and then the GAD-7, which is an anxiety measure. We see results that indicate that over a 12-week period of the program, because the program lasts about 12 weeks, that teenagers improve in their depression and anxiety scores. And importantly, you know, I think a lot of peer support services are typically sometimes in more SMI programs or higher acuity.

Our teens, though they do sort of go up and down in their symptoms, are generally mild-moderate, but we do serve a number of teens who also are under the care of psychiatrists and psychologists who are a bit more acute, though this data really represents more mild and moderate teens. In terms of our qualitative results, I'll just read one quote here just around the results that we heard from teenagers talking about why the program mattered to them. I'll quote this one in green. “When I started the program, I was in a really low spot, and I think that my mentor, she really kind of helped me through that.” And this was from a 12-year-old teenager who was going through a difficult time and really talked a lot about how she used both the mentor's lived experience and how the mentor said, yes, I understand what it's like to be really anxious and really depressed, and I can get through this, and I've done this before. And this really inspired that teenager to change and also to apply a lot of the skills she was learning in the program. I'll talk a little bit more now about an RCT that we were just very, very fortunate to receive. I want to acknowledge my co-PI, Mike Pullman from the University of Washington, who is my co-I on this project, where we are now right in the middle of an RCT studying the effectiveness of our intervention among public school students. We received a NIMH Small Business Innovation Research Fund, and there are three arms to this intervention.

We're going to look at Appa Complete, which is the actual program that I just described. And then we're also going to look at just the video content, because we want to pull out what is different about the actual near-peer mentorship. So, what is different about near-peer mentorship than just watching videos and watching a curriculum? And then we have a waitlist control. We have 75 students in a pilot, and then another 400 in the expanded trial. And our participants are 13 to 17 years old, youth and teenagers. And then we will also be looking at parents and caregivers, as well as our mentors and their experiences. A little bit more of a visual to kind of visualize what that looks like. Appa Complete, Appa Light, and our waitlist control. And we'll be looking at folks from time point one all the way through week 12. And I want to stay here and pause a little bit on the logic model. And this is where I want to speak about the value of this model, potentially for suicide prevention.

So, you know, really kind of simplifying this model down, there are two pathways. Teenagers are learning CBT skills and strategies, and that's going to help them, you know, improve in their mental health, as well as they're having this peer mentorship experience in which they are getting instrumental support, relational and emotional support. But we believe that it is actually this peer mentor mechanism, this identification with the mentor that really leads to general self-efficacy. And this is really based off of the social cognitive theory. And I'll just end by saying that, you know, we actually had a teenager in our program, 15-year-old teenager who identified as LGBTQ+. He came to the program, asked for an LGBTQ plus mentor. We paired him up with one of our amazing non-binary mentors who identifies as queer. And they were off to the races working together each week in their one-on-one sessions. You know, they were doing that together for six weeks.

And unfortunately, around week six, we heard that the teen ended up being hospitalized. And, you know, thankfully, the teen did recover from that hospitalization, did a little bit better and returned back to mentorship. And I actually reached out to this teen's mother and talked to the mother about, hey, you know, is there any other way that we could support your teen in this program? How's he doing? And the mom said, you know, first, I just want to thank you, which I was very humbled by that gratitude. But the mom explained that this teenager, you know, lived in a rural community, that he felt like he was the only person who was LGBTQ+.

He felt like he was really alone. And he didn't know anybody who had gone through his same experience. And she shared with me that on his safety plan that he made while he was in the hospital, he identified only three people who he felt cared about him. And those people were his mom, his sister, and his Appa mentor. And she said, you know, your program gave my son someone who understood him, someone who was a peer to him. And, you know, that gave him a lot of hope. And I think, as all of us know on this call, hope absolutely saves lives. And I'm just so grateful for the work that so many of you all do as peer mentors’ day to day. So, I want to thank all of you for being here and for doing this work.       And with that, I will send it off to Dr. Molock.

SHERRY MOLOCK: Thank you, Dr. Roundfield. Thank you all so much, NIMH staff, for inviting me to participate in this important workshop or program. And particularly hats off to my colleagues, Dr. Lily Brown and Dr. Katrina Roundfield for their wonderful work. As mentioned earlier, my name is Sherry Davis-Molock. In addition to my work as serving on the faculty at George Washington University in the Department of Psychological and Brain Sciences, I also want to share that I'm bivocational, so I also wear another hat. Dr. Brown and I are the co-founding pastors of the Beloved Community Church United Church of Christ, which is a Christian church in the D.C. metro area. We are the founding pastors, and we were pastoring that church for 15 years and recently retired. So, I wanted to share that because that informs my work. So, I'm going to be talking with you today, as soon as I pull my slides up, about a suicide prevention program called HAVEN.

And HAVEN stands for Helping Alleviate Valley Experiences Now. It's a comprehensive depression and suicide intervention program for youth. It's designed for Black youth and predominantly Black churches. HAVEN Connect combines church engagement, a faith-based curriculum which teaches pastors how to use information about suicide prevention in their sermons, Bible study, and or Sunday school lessons. And then there's a youth suicide depression intervention, which was developed by Peter Wyman and his team in the University of Rochester. And I think many of you all heard Peter, hopefully heard Peter talking about the original program, which was Wingman Connect on Thursday in this conference. So, HAVEN Connect, why Black youth? Well, unfortunately, suicide, we know, is the second leading cause of death for youth ages 10 through 19. The suicide attempts rose 73% between 1991 and 2017 for Black adolescents.

And a lot of that increase was due to increases in attempts among Black boys. And suicide rates for Black children ages 5 through 12 are approximately double that for their white peers of similar age groups. Why the Black church? So, we think that the Black church is an excellent venue for promoting positive mental health because it continues to be one of the most influential institutions within the Black community. Churches have naturally occurring peer supports. Eighty-seven percent of Black Americans are affiliated with the church and over 60% of youth attend church regularly. And this is really important because about 70 to 75% of churches across the country, their membership is made up of women. And women are also the people, moms are the people who decide whether or not their children go to church. So, this is a naturally occurring multilevel support network system that's in the community.

In general, it is true that their church membership has been declining across all racial and ethnic groups. But the decline is much slower in Black churches with Black churches having about an 81% retention rate. We know from the research from the Pew Foundation that most Blacks attend church in predominantly Black congregations. They're more likely to report they believe in God. They're more likely to report attending religious services. And even during the pandemic, I noticed even in my own church that we could not meet in person, but we met online, and we met on Zoom and the church continues to do that. And we actually had an increase in numbers of people who attended those services. And then about the majority of them also say religion is very important in their lives. Why the Black church?

Well, one of the wonderful things about the Black church, it's not unique to the Black church, but it's important, is that it fosters social connectedness. So, in the Black church itself, there are naturally occurring social networks. There are youth ministries. Almost every church that I've ever been involved in has a youth ministry, even if it's a very small church. And youth ministries is a wonderful infrastructure upon which you can embed a prevention program. They have youth choirs.  They have youth liturgical dancers. They sponsor scouts. They sponsor athletic teams. Also, the church, which is different from the school system, is churches have a non-evaluative context. So, there's no grades that go on. There's no report card that goes in about your child's behavior.

If children are misbehaving, it's dealt with in a non-punitive way. And there's no connection to more punitive institutions outside of the church. It also really importantly can help change norms to reduce stigma associated with mental health challenges and help seeking. People are exposed to normative social influences on coping and adaptation. And I love it because it really is a built-in monitoring system for the well-being of not just peers, but also trusted adults. I know when I was pastoring the church, many times I could see people in multiple contexts. And my role as pastor was I would not have seen them in these multiple contexts or really only one context as a clinician. Church is also important because in the church, we have the concept of mattering. Mattering is a concept that I love.

I call it just because love, which is basically I love and care about you, not for something you've done for me or what you've accomplished, but just because I love you because you're a child of God. Mattering is you're important to us. We miss you when you're absent. We celebrate with you when things are going well. But we also lament and give you a shoulder to lean on when things are not going as well. And the extent to which people feel they matter is the extent to which you can minimize a lot of mental health challenges, including depression and anxiety. So, the first component of Haven Connect is church engagement. So, we were really fortunate to be given some seed money by New York State Office of Mental Health, particularly the Suicide Prevention Center at New York State level. And Jake Carruthers, who was the director of that program, called me out of the blue and asked me if I had data associated with Haven.

And I had written an article about Haven and was published in 2008. I had not been able to get funding for it. And so, they provided us with the seed money to do the pilot study. So, the first part component of that is developing partnerships and churches. And we had three partners. We initially were going to do pilot in four churches in four different communities in New York State. We made the decision to do three churches and then we revisited the first church, which is the church I'm going to describe here. Our first partner was First Corinthian Baptist Church in Harlem. The pastor is Reverend Michael Wallman Jr. And each church has a church we call a church champion. That person is the person who's the liaison between the research team and the church community. And in this case, the church champion was Dr. Lena Green, who's the executive director of the Hope Center. This is a well-resourced megachurch.

There's a strong presence of outreach in the community. And they have a center that's called the Hope Center, which they create mental health programs through that center. They actually had gotten some funding from Nike to do a program called Thrive. And Haven Connect was embedded in the Thrive program. Our second church partner was Rochester's First Genesis Missionary Baptist Church, where the Reverend Johnson, Reverend Frederick Johnson Sr. was the pastor. And I just said that each church implemented Haven Connect a little differently. The first church did it all virtually. We also did this in the middle of COVID. This church opted, even with COVID, using safety protocols associated with church protocols for COVID in churches, decided to do all of their sessions for Haven Connect in person.

And then our last partner, which was in Albany, New York, Macedonia Baptist Church, where the Reverend Michael Poindexter is the pastor and Deacon Greg Owens was the church champion, they did theirs as a hybrid. So, some of the sessions were done in person and some were done virtually. The other two people in this picture, this is Reverend Darrell McCullough, who is on the staff of Haven Connect. He's a pastor in his own right. This is Reverend Poindexter. This is Amita Joshua, who was the program coordinator for all of our sites. And this is Deacon Greg Owens. I also want to stress that although Haven Connect has a strong peer support component, it is not only peer support. We also have support from trusted adults and from church leaders.

We have young people who are exposed to support systems at multiple levels. The second component of Haven is faith-based curriculum. This is a curriculum that's developed based on a course I used to teach in a seminary on depression in the black church. And I took that semester-long course and condensed it to this faith-based curriculum, which is about 90 minutes long. It's an educational overview for pastors and youth leaders on mental health education, looking at risk and protective factors for suicide. They also look at the core factors from Youth Connect component of the program. And those four cores are kinship, guidance, purpose, and balance. I'll talk about those a little bit more detail in a minute. And then we basically provide this information and show pastors how to integrate this information into their sermons, their Bible study lessons.

Their schools, Sunday school lessons, and their youth programs. And so that's really important. We also have sample sermons for them to look at so they can get a sense of how you can put this information together into a sermon. So, these are examples of sermons. The first picture is a picture of me preaching a sermon called What We Failed to Notice. Interestingly, that comes from a quote from R.D. Lange, who's a psychiatrist, who said the range of what we think and do is limited by what we fail to notice. And because we fail to notice what we fail to notice, there's little we can do to change. And so, this sermon was basically about anxiety and how we often experience anxiety symptoms and are not aware of what we're going through. And so, what can happen when we have some information about particularly negativity bias and automatic thinking and how we can change that.

This is the second picture is the pastor from Albany and Reverend Poindexter. And he did a sermon entitled Big Help for Big Battles from Isaiah. And then the last person was Dr. Warren, who did a sermon called Notes from a Second Sight. And he did that from Second Kings 6, 11 through 17. The third component of Haven Youth Connect is the Youth Connect program. As I said earlier, my colleague, Dr. Peter Wyman at University of Rochester developed this program. So, Youth Connect is based on the Wingman Connect program. It's an RCT validated upstream suicide intervention that uses a strength-based approach to increase social connection, to increase adaptive coping skills, to foster a healthy, supportive social network and to engage and help to basically change norms about help seeking. And also about having mental health challenges.

I also want to say and should reiterate here that this is really a strength based universal approach. So, these are kids who participate into the Haven Connect program are not necessarily in crisis. And so, we present this to the churches is that we want to catch kids before they fall into the water or before there's a crisis. And so, this is a program that can be available to all of the youth in the program, not just those who are at high risk. Youth Connect itself is a really engaging, interactive training that focuses on group members learning and modeling for each other the skills to sustain the four cores. And these are research validated protective factors, kinship, which are healthy bonds, not just with family members, but also with the family that we create within the church environment.

And also, a particularly salient point for black youth is because black members of the black community often engage in and create fictive kin. And so, I look at my own life and my children's life. They have play aunts and uncles. They have play cousins, play siblings. And so, any bond that's a healthy bond that facilitates that sense of social connectedness is really important and is reinforced. Guidance and support for mentors and also having access to medical and mental health expertise. What I love about the guidance core is that it also teaches young people that they themselves can be mentors to others. And then our young people, these are teenagers. And so, they're definitely struggling with and thinking about their goals and their values and what they want to do when they grow up.

I think this was somewhat heightened because we were in the middle of COVID. And so, we were able, they were able not only to hear from other people, but to openly share what their own struggles around this issue. And to realize it was okay that they weren't completely sure about their purpose or what their immediate goals were. And then the importance of balance and self-care and support. So, the youth participate in three 90 minute highly engaging modules where they have specific learning objectives and activities. That include their reasons for engaging in the existing community group. Introducing the four cores as protective factors that promote resilience. Discussing ways to balance and strengthen each course. And each session the young people would go around in the circle and talk about which core they had and tried to strengthen during the past week.

How they felt that went. Or were there other cores that they could strengthen. Or what the ones, which ones were they already strong in. And it also really focuses on extending what they learn in the sessions into their natural environments. By inviting groups to work together to strengthen their course between sessions. And then we will also be having informational and motivational texts that we'll be sending to the young people after the training. We also have adult small group leaders who were recruited from the churches. They actually facilitate the small breakout groups that occur within the training. And they are trained for 10 and a half hours to engage in these, the young people. Then we also have other adults in the church who may not be able to commit the time to do the 10 and a half hours training and do the actual training with the young people. But are interested in being supportive. And they have a two-hour mini version of the youth training.

So, the youth have access again to support not just only from peers, but also with trusted adults. These are just some of the preliminary findings that we have with the pilot study. Just asking them what they thought about the program. And so, as you can see, there's overwhelmingly positive thoughts and views and beliefs about the program. People felt more prepared to handle challenges of life. Identifying with people who support them. Identifying what gave them purpose. Increasing their ability to benefit from the strengths of the program. And we also got qualitative information from the young people. One of my favorite ones was one of the young people said it taught me that I need to not be so mean and that I need to be nicer to people. So, these are just some of the results of the surveys that we asked them about what they thought of the program. We were really fortunate to take that pilot data and use that to leverage getting funding from the American Foundation for Suicide Prevention.

We got a focus grant. We'll be able to scale this program up to 12 churches. There'll be six churches in Rochester, New York, six churches in Harlem or in New York City. And as I'm speaking, we are beginning to do the first training and the first set of churches we just began last week. So, we're very excited about how this is all going to turn out. And before I say end, I want to thank my colleagues, Sidney Hankerson, the Icahn School of Medicine, Peter Wyman, they are the co- we have multiple PIs on this project. And I also really want to thank Jay Carruthers who gave us the seed money because I was telling him he was really brave because he gave us that money and allowed us to really focus on the process and not as much on outcomes. I think sometimes we're also we're so eager to get to outcomes and obviously outcomes are really important that we don't pay enough attention to the actual process of implementing these programs. These are, excuse me, I want to also acknowledge those who participate in the program, my colleagues who work with us diligently to put this program together and implement it. That's my contact information. Thank you very much. And I believe you. We have a little bit of time. Thank you.

CHRISTINA BORBA: Thank you. I would love to ask all of our presenters to turn on their cameras so that we can do some discussion and our Q&A is very lively. And so, I've tried to organize a little bit so that we can have a really fruitful discussion. I just wanted to thank all three of you again for such wonderful presentations and all the important work all three of you have been doing in this area. And what I found really interesting is how similar but also very different the three models are. There are some underlying themes for sure, but everyone is approaching it quite differently.

And so, one of the questions that has come up in the Q&A for some for some of our specific questions for our speakers, but in general, what was coming up is really about the characteristics of the peer mentor. And so, for example, Lily, some of the questions that were coming up were really about age and sexual and gender identity and how these different kind of demographic characteristics are important in terms of your program. But then also, Katrina, a lot of questions were coming up around the requirement of being college educated and really thinking about what is the value of that and the rationale for having that as a requirement. And then for Sherry, really also just thinking about you're looking at multilevel in terms of mentorship, both youth and adult. And what are some of those characteristics that you're all looking for? So, the general question is really around the characteristics of the peer mentor. And so, I'll start with Lily and thinking specifically of your program.

LILY BROWN: Sure. Yeah, there were some great questions coming into Q&A about, you know, who are these peer mentors? And I'll tell you a little bit about how we went about recruiting them, because I know as also came up in the conversation on Thursday, we paid the peer mentors. Obviously, you know, one should do that given their critical role to this project. But because we're paying them, they're technically employees. And as a result of that, we need to make sure we're following employment law and how to recruit peer mentors into this role in a way that allows for us to make sure that they have lived experience that's relevant to the participants. So, here's how we did that. What we did is we opened up an application for four peer mentors. And in addition to, you know, sending a cover letter and a CV, we asked for the applicants to provide in a paragraph an explanation about why it's important to them to work with the LGBTQ+ population, specifically around suicide prevention.

And so, this open ended paragraph description resulted in phenomenal responses that really made clear that the people that we ultimately were interviewing and able to select had outstanding lived experience to complement those of the participants. So, while we're not able to, you know, ask that information outright at the time of employment, it is perfectly allowable to ask individuals to share why this project is potentially important to you. And in so doing, all of the participants who ended up, all of the peer mentors, rather, who ended up partnering with us self-disclosed information that made it obvious how well suited they were to the role. And we've been very pleased. That strategy for recruitment was one that followed some of Dr. Jose Bauermeister's prior work and working with young MSM and peer mentors for that population. And so, we were delighted that it worked so well again.

CHRISTINA BORBA: Great. Thank you. Katrina, you had a lot of questions and really thinking about that college educated piece. And I was wondering if you could speak to that a little bit for our audience.

KATRINA ROUNDFIELD: Yeah, I think it's a great question. And I truly appreciate it. It's something that our company has really thought a lot about and is something that we would like to push, push for. So, one of the things that I think is a shaping factor in that decision is really our customers and our customers, our school systems, we pay, you know, they pay us to provide the services. I had saw a couple of questions I didn't get to yet that about the pay of this service. For the most part, we sell into school systems to our families and teenagers do not pay. And as a result of that, we really want to abide by a lot of the screening procedures, background check procedures and a lot of the requirements of our school customers. And so that is why, in part, why we have moved a little bit more towards college graduates who have some of those baseline requirements. However, I do want to point out that there's some really great points in there that I absolutely agree with, which, you know, a lot of our kids who really need help are coming from foster youth backgrounds, homeless backgrounds.

You know, parents who have been incarcerated backgrounds, you know, all kinds of different backgrounds that in a lot of ways really do require peers who have gone through those experiences. And as a result, not necessarily completely as a result, but many of those individuals may not have had a college background. And I think that is really important for us to really match those teens with people who may not have those requirements, but may be excellent, excellent peer mentors. So, I do agree with that point and it's something that I would love to continue to talk with our school partners about and really open and expand their thoughts on, you know, how we can approach this in a way that really is equitable and really supports the kids that need the help.

CHRISTINA BORBA: Great, wonderful. And Sherry, what are some of the characteristics, both for adults and your youth mentors? And some of the questions that have come up is really thinking about support for LGBTQ+ youth. And how does the program provide that support for our youth?

SHERRY MOLOCK: OK, I think those are both great questions. The first question is pretty easy. So, I always tell people this is church, so whoever wants to volunteer can. So, that's one thing that's very different about a church content is that it's a good thing in a way, I think, because the volunteerism is very highly valued in church and communities. And so, there is an expectation that people give back. We don't have a particular characteristic that we're looking for, but most of our adult mentors are schoolteachers, counselors or people who are retired and have grandchildren in a teenage age group and want to get back in that way. And some of the young adults have kind of struggled with depression or anxiety and part of their journey of giving back is also participating in this group. So, we have all age groups. We deliberately and intentionally did not limit the age group because we felt that because it's a trusted adult and you'd be surprised for some of these kids, the trusted adult is an older person.

And an example of that would be Deacon Greg. He's probably in his 60s or 70s, but the children love him. And then in other churches, you might see a young adult. So, we basically allowed the church to pick who's a trusted adult in this group, and the kids can also nominate people that they feel comfortable talking with and working with. So, it's not always a peer that's the person that you'd be most likely to confide in. I always get the LGBTQ question. And so, it's a little bit complex, but there are open and affirming churches in the DMV area. An open and affirming church is a gay affirming church. My church is a gay affirming church. Some churches started off that way. When we were created, we were created to be an open and affirming congregation. Some have evolved into that. So, the good news is that if you're in a major metropolitan area, you probably have open and affirming churches who are openly supporting gay youth and gay families. And in our case, we did that. We have a lot of outreach in our community, and we also have a pride flag outside of church to make sure people would know it's a safe space.

More commonly, though, I think, is some of the churches in our pilot study struggle with this. And so, there is information in the faith based curriculum about LGBTQ risk and about how the church impacts that. Some of them felt uncomfortable sharing that. So, they mentioned risk for LGBTQ youth, but didn't necessarily talk about how the church is implicated in that. And others did. I was very shocked. Yeah, I know. I was very shocked. Well, I will say, I think all of the churches that we are participating and we have lining churches up and recruiting churches right now are very acutely aware that young people are really having crises. And they are all acutely aware how important the church can play in the positive role in that. And so, I think people are opening up more about what's their responsibility and what are ways that we can be more supportive of young people. I do want to stress that I think one of the things that we tend to do in this field is we want a one size fits all intervention. I don't think that's true. I think the church is not going to work for everybody, but I think it can work for a lot of people. And one of the things we ask churches who are struggling with this issue is think about how you can take the positive and hopeful messages and then naturally embedded community supports that you have in your church and how you can utilize that, leverage that in a way that's natural to support you. And you can continue to struggle with the theology of being open and affirming, but make sure you're being supportive.

CHRISTINA BORBA: Great, thank you. And so a broad kind of set of questions that was really coming up was thinking about, you know, it's really using peers in that task sharing, task shifting model. A lot of you talked about, you know, aspects of cognitive behavioral therapy, motivational interview. And so, we're really thinking about having peers deliver some of these kind of clinical strategies. And so, some of the questions that were really coming up is really thinking about, first of all, mandated reporting and the protocol for that for our peer mentors. And then also that type of training that is provided to the mentors in some of these more clinical based applications. And so I'll start with Katrina this time.

KATRINA ROUNDFIELD: Sure, thank you. Love that question. So, I'll start first with mandated reporting. For mandated reporting, all of our mentors are mandated reporters, and they take a government provided mandated reporting training that certifies them as mandated reporters. And then the more meaty question around CBT skills and how that sort of scoped. One thing that I think is somewhat possibly different about our program is just that our program really scopes these mentors around supporting the implementation of the skills. And so, what that training actually looks like is we do provide the mentors with all of our content. So, they watch those videos themselves as part of our orientation and training.

So, they know, you know, the basics of what these videos are saying, but they are not necessarily required to teach it or regurgitate that information to the teens. The teens are watching those videos and they do ask the mentors questions and we tell the mentors, you know, use your lived experience to say, yep, I use that triangle sometimes too. Here's how I use it. You know, thoughts, feelings, and behaviors are connected for me in this way, or they may watch the video and say, I've tried that negative self-talk component and some of it works for me, some of it doesn't. And I think that's the piece that, you know, is how we really train our mentors to use their leverage their lived experience without requiring them to be experts in CBT.

CHRISTINA BORBA: Great. Lily?

LILY BROWN: Yeah, it's a great question. So, one of the reasons that our program is set up in the way that it is, is that a licensed clinician is doing the initial evaluation about both eligibility and safety, and then doing the safety planning intervention with all participants before they're randomized. And so, for the peer mentor sessions, you know, we know that risk within any of us can fluctuate dramatically from moment to moment. And so just because we have a sense about a person's risk at the time that we do the baseline evaluation tells us very little about what could change between now and the next six weeks when they're doing their peer mentoring sessions. We've attempted to set up the peer mentor sessions to not focus on conducting suicide risk assessments. So, the peer mentors are actually not asking, are you having any increased risks from last time?

Instead, what they're doing each time is saying, have you been using your safety plan? What's getting in the way of that? What could we change about your safety plan to make it more helpful for next time? What's going well about that? What's not going well about that? Before they dive into the plan content for that session after session one. That doesn't mean that, you know, in human conversation, you know, the peer mentors might learn about something that's concerning to them. And we have made it very clear that their role is not to implement emergency response planning beyond getting connected to one of us licensed clinicians, because we really have wanted to take the burden off the peer mentor. I'd love to hear feedback from people in the audience about whether this is the right decision or whether we should change this for the future.

But our thinking is, we really want as much as possible to preserve the rapport between the peer and the peer mentor. And to not have that be confused with a clinical hierarchical relationship. And as a result, what we do is for all the peer mentor sessions, one of our licensed clinicians is on call. In the event that the peer mentor has any sense that something's going on that they want a clinician to follow up with, they will let us know that. That hasn't yet happened for a single peer mentor session. That has from time to time happened for our check-in CSSRS assessments that we do at two, four, and six months after the baseline evaluation.

From time to time, we have needed to check in with folks. It hasn't yet happened for any of the peer mentor sessions, which we're delighted about. But one of the things that we proactively check in about during our weekly group supervision where the peer mentors chat with one another, really one of the only clinician directed parts of those conversations is, is there anything that people are concerned about in terms of risk? We always start there. So far, the answer has never been yes, but that will likely change as we think about deploying this at a much larger scale. So those are some of my thoughts about that. I'd love feedback from the group as well on that.

CHRISTINA BORBA: Great. And Sherry, for you as well, in thinking about the role of both the adult and the younger peers in terms of either supervision or reporting, how does that work within the church setting?

SHERRY MOLOCK: Ours is very similar to Lily's. We also don't want the nature of the supportive relationship between peers, particularly youth peers to change. I think for young people in particular, there's a whole don't snitch, don't tell kind of norm that goes on. We're actually trying to combat that. We don't want to inadvertently reinforce that. So, we also have clinicians on site. We do a screening when we're enrolling kids into the program. And kids who are flagged from that screening are contacted by a clinician within 24 hours. And then we, based on what that is, that clinician can either develop a safety plan with that young person and or refer them for further assessment slash treatment.

And same thing with trusted adults. To be honest with you, I think if we train, if we tried to train adults to be mandated reporters, we probably would be much less successful because I think that would also be scary for people in the church. And I think they would be really concerned with, are we going to have someone flagged and we miss it? And I think that would be almost self-defeating. So, we conceptualize ourselves as a team. The team has different roles. We have the kids as part of the team, trusted adults as part of the team, the licensed clinicians as part of the team. So different people on the team have different roles. And the kids and the trusted adults don't have the suicide risk assessor role.

CHRISTINA BORBA: Great. So, Sherry, you end it and I'm going to start with you on the next question. Trying to bounce around. I noticed, especially given the COVID pandemic, some of you are fully virtual. I think Katrina, you are fully virtual. Sherry, you actually did talk about that even during COVID and putting in those safety protocols in place that you opted to be in person. And so, I wanted to hear from all three of you, and Sherry, we'll start with you first, about the pros and cons of in-person versus virtual, given the era of telemedicine and telehealth. And where do you think we're going and where should we be going with that?

SHERRY MOLOCK: That's a great question. And we are wrestling with this on our team. So, we initially designed Haven to be in person. But quickly when we started doing the pilot, we did a pilot before the pilot, it was all virtual. And that was because it was the beginning of the COVID pandemic. And the logistics of trying to figure out how we could get 90 kids together in one space with protocols and be safe, we just feasibly couldn't do it. So surprisingly, it went really well. And I think you can actually probably get more kids to participate if you do it virtually, because the transportation and some of the logistical issues go away with that. So that's the positive thing.

What we are wondering about is, are the group dynamics the same? And do the kids have not so much support, but your sense of social connectedness, is it the same? And I'll give you an example outside of the program. My youngest daughter is an East Asian Studies major. She lived in China for several years. She lived in Korea. And at the height of the pandemic just started, she came home. And she's also a member of the LGBTQ community. So, I'm thinking she's fine because she's a supportive parent, of course. And she has this wonderful peer group. But what I didn't recognize, though, was she lived more authentically overseas, because this is a process. So, when she came back, I kept saying to her, what's wrong?

And she kept saying, I feel really isolated. And I was saying to her, no, you're in Washington, D.C., and this is a very LGBTQ friendly place. But what I realized as we were helping her process this, I think when you're a member of a marginalized group, your tribe, this is what I call it, you need a visible tribe. It's not enough to say, I have these people who support me. You need to interact regularly with these people. And I think in a very physical way. And that's what I'm wondering about our project, is when you're doing it virtually, does that sense of tribe still exist? And that's an empirical question. I don't know. But I do think we should be trying to figure that out, because it may be that doing something virtually has some logistical benefit to it. But the sense of social connectedness and belongingness and not feeling marginalized may be hard to create in a virtual environment.

CHRISTINA BORBA: Thank you for that. Katrina, I'll go to you next. You have the opposite of fully virtual.

KATRINA ROUNDFIELD: Yeah, fully virtual. And I think when we first designed this program, we looked at the numbers of the teen mental health crisis and really looked at the statistics of who is serving those teens and who is being underserved. And so, we initially set out to really expand access. And so, what that looks like is a virtual platform. I will share that we have actually found that our access is particularly relevant for communities that are typically marginalized. So, 78% of our teenagers are Black, Indigenous, and people of color. And then 28% are LGBTQ+ teens who, you know, so many of them say that they don't have people who are supporting them who have shared their lived experience. And sometimes that means you have to connect a mentor in New York to a teen in Wisconsin who, you know, is the only LGBTQ kid in his rural community.

And so that is what we were solving for. However, as a community psychologist, I will absolutely say that yes, there is virtual community. I think that that is a phenomenon. However, I do believe that building those connections and relationships in their physical environment do matter. And so just as Dr. Brown and Dr. Molock have also spoken about it, I like Dr. Brown's kind of building relationships in their communities as part of the core component of the program. And it's something that, in fact, our school systems have really pushed us on saying, hey, that's great that they're having a great relationship with their mentor, but how is that translating into their community and the school? And so that's something that we're continuing to iterate on and really build into our curriculum around how do you find other people? You know, is there a way that the mentor and the trust that you built with that mentor can translate into other trusted individuals in your community? And how can you connect with those people? So that's something that I really appreciate the question on and something we're continuing to think about.

CHRISTINA BORBA: Great. Thank you. And Lily?

LILY BROWN: For our project. There was one In-person meeting, which was the baseline evaluation when we conducted the initial CSSRS, and then completed the safety planning intervention from there. All of the Peer Mentor sessions were completely virtual. Peers had the option participants had the option to complete those through a normal telehealth visit with video on and audio on. They had the option to turn off their video if they felt more comfortable that way. They also even have the option to just engage purely through the chat function if they prefer to do it that way, and we made that determination on the basis of some of Jose Baumeister’s foundational work through his IREACH program, where they were doing peer mentorship with Adolescent and MSM. And so based on his prior research, they found that there was a lot of heterogeneity, a preference for how to engage even virtually in our project, we're not finding so much variability.

There are some differences in how the Peer mentorship is set up between IREACH and our project, which might account for that specifically in our project that Peer Mentor sessions are scheduled at the time of randomization.  So, they say, Okay, here are the six sessions, let's make sure that they work for you. Where as in IREACH it was a little bit more on an as needed ad hoc kind of basis. My understanding and IREACH not having been involved is that is, that there was one peer mentor session that was expected really to build before and buy in that this was a useful thing, and then future sessions could have been engaged upon on an ad hoc as requested basis. And so, whether or not that accounted for the difference in our sessions.

The participants were keeping their videos on, even though they weren't required to. And so, the future implementation of this will be that everything will be completely virtual. Which to me makes a good deal of sense. Given that a part of the intervention is also a mobile health application. To have things completely virtual will be, I think, ultimately helpful, especially in response to some of the questions. I Jeff I believe in the chat with saying Jeff Coke saying, we're in Tennessee. We've got a real need world-based implementations, and we agree that's exactly what we'd like to do in the future, and keeping things completely virtual, will help us in that regard.

CHRISTINA BORBA: Great, thank you. One of the questions I have, and I had jotted it down, as you were all presenting, you know, we're really talking about, you know, thinking about mental health outcomes for our youth. But I think Lily, you might have touched on this a little bit in your presentation and really thinking about the support the peers are getting. And what happens when and if they are in crisis. And so, since you ended last, I'll start with you, Lily, in terms of where, especially with the fact that it's peer to peer, and what type in all of your three programs, what support systems do we have for the peers who are involved in this work? And Lily, I'll start with you.

LILY BROWN: Sure. So, our program has weekly supervision consultation, however you want to think of it. We have two clinicians in that meeting, but the meeting itself is facilitated and led by the peer mentors and providing feedback to one another. And this is an opportunity for everyone to model their humanity. And the clinicians try to take the lead on this as much as possible and sharing, you know, when we're hearing about certain stories, sharing our genuine human reactions to them in a way that we hope to be validating for the peer mentors to try to dismantle perceptions about needing to be, you know, I think anybody in a helping role, clinicians, peer mentors, no matter where their background is. We often start this role from a place of needing to be perceived in a competent way.

That's probably true for all jobs. But when we're thinking about mental health support, I think that that perception is amplified even more, this belief that I need to be strong, I need to be stable, I need to be a role model. And actually what we try to demonstrate is that to be the best kind of helper any of us can be is to be human and to be, to have permission to set your boundaries, to have permission to describe when things are difficult for you and an invitation openly to talk about support that they need, whether that's formal support and getting connected to therapy services, or just an opportunity to talk about what's been hard in their role. That's something that we really try to emphasize in the group supervision. And we, of course, also leave it open for the peer mentors to reach out to us one-on-one for that support, which some have taken us up on as well, not in a formal counseling role, to be clear, but just to brainstorm how some of these topics are affecting the peer mentors and what might be helpful for them in their journey as a peer mentor.

CHRISTINA BORBA: Great. Katrina?

KATRINA ROUNDFIELD: Yeah, really echoing what Dr. Brown was just saying, we have mentorship or mentorship in a consultation model specifically. So, every week we pay them and it is required to come, but we pay them to come to a consultation group that's very similar structure as was described where it's mentors leading mentors, but a licensed clinician is in the room as well for any kinds of really just listening for any kinds of other concerns that might be coming up that a clinician might have. A licensed clinician might be able to comment on, but that is how that session is led. And we, again, that modeling of support for one another of processing what they're hearing, because, you know, my workforce is mostly young adults.

So, they're, you know, they're still kind of going through their areas of life and growing themselves and learning about themselves. So, we really support them and really mentor them as well. And so, that is a good portion of how it looks. And I will mention, yes, there's a licensed clinician who manages that consultation, but also there's a mentor manager. So, we elevate one of our mentors who is in a kind of supervisory role as well to really model that you don't have to be a licensed clinician to do this work, to lead this group and to be a, you know, a great facilitator and team member to your other colleagues. So, I did want to make that point clear as well.

CHRISTINA BORBA: Great. Thank you. And Sherry.

SHERRY MOLOCK: I would say ditto to Drs. Brown and Roundfield. I think one of the things I do want to stress is that our program is really an upstream approach. So we aren't, while there may be children in crisis in our groups, we're not soliciting for that. And so, some of this is probably not going to come up as much as in the other programs. But having said that, the whole point of the program is for young people to learn how to support each other, both inside the church and outside the church. And we're not, we're not, compared to how the Youth Connect program has been done in other contexts with the Wingman Connect being a more boundary environment, the church is a little more fluid than that.

So, we also have kids who are members of the church in the program, but we also have kids who are not members of the church. And probably anywhere from 25 to a third of those kids are not members of the church. So, by definition, these kids have contact with each other outside of the church environment. And we actively encourage that. They also have access to the trusted adults. I also should say some of the trusted adults are not members of the church either. So, I think that's, I think that's a good thing. So, I think people are encouraged to use the, and strengthen the four cores, not just in the church service or context, but outside of it as well. And then we're sending the motivational text messages to foster that as well.

CHRISTINA BORBA: Right. I really appreciate this discussion. And it's come up in the Q&A a little bit about, you know, really not stigmatizing the role of the peer mentors, but really thinking about support. And so, I really appreciated this, this discussion. So, we have a few minutes left. And, you know, for me, what's really important is, you know, thinking about research and data and how do we make it scalable and sustainable. Right. And so, a few minutes left and a very big thesis question for all of you is, what is your thoughts about where do we go next? And how do we think about making this more sustainable and scalable for our future youth? And Katrina, I'll start with you this time.

KATRINA ROUNDFIELD: Sure. I really want to expand what we think are peer supporters. So, you know, we, I'll speak from a business perspective that we have talked to, because we want to make this program scalable across the nation. We want to get kids the support that they need. And we find that peer support has been really specific to SUD, to SMI, to OUD. And I think that that is incredible and important. I also think peers can be experts and have incredible value for the whole spectrum and continuum of care for young people. And, you know, on a suicide prevention panel, that is true prevention.

That looks like, you know, earlier stages that we can get involved and support these young people. That means that we can actually give them the support they need before they get to the place of crisis. And so we are, you know, really eager to push the research forward in this area so that we know what's safe, what works, how it works. And then also, you know, really make sure that our medical systems and healthcare systems and whoever those payers are, can support this work sustainably and also pay our peer mentors, because that's really valuable work and should be compensated fairly. So, I think those are the areas that are really exciting for me and what I think the future can look like. Great.

CHRISTINA BORBA: Sherry?

SHERRY MOLOCK: I think I feel like Katrina would like to say ditto. I think our next steps are hopefully going to be two things. One is I would really like us to implement this on a denominational level. I really feel that we need to make change at an institutional level, not just at the individual level. I think embedding this in the church is the beginning of that. But I just get, like, ecstatic when I think, what if we could do this, like an entire denomination would implement this program? And like Dr. Roundfield said, way before kids are in crisis, so that could we have that kind of effect, that kind of change for an entire system is really exciting for me. And then the other one is to implement this, or how do we adapt this in a non-religious setting?

I think that my colleague, Sydney Hankerson, just got some funding in New York to do this with Boys and Girls Clubs. Boys and Girls Clubs are great because a lot of youths do athletics, and then my kids did Boys and Girls Clubs until they were in high school. So, it's a way to reach younger kids, and it's a way to do it. They don't have to belong to a church. And again, it's not as boundary, but it's an example of where you can really change peer norms and peer support around an issue. And also, we don't have as many Black boys in church either, and that's another reason why we want to do some kind of recreational kind of system where kids and Black boys are more likely to participate.

CHRISTINA BORBA: Great. And Lily?

LILY BROWN: So Dr. Jose Bauermeister and I are working on our next steps for this now, and what we're thinking about is trying to develop a nationwide, what we call a Type 2 Hybrid Implementation Effectiveness Trial, where the idea is taking what we've learned in our pilot protocol, which is conducted specifically for youth in Philadelphia, and seeing how this works when we scale this up to availability for recruitment to youth nationwide. And one of the things that we're wanting to be particularly thoughtful about when we do that is attending to the value of a peer mentor, really getting what it's like to live where you live.

So, there are unique experiences for everybody on this call about what it's like to be in this year, in this place that you live at, that someone who's from a different city or a different, more rural area is not going to understand. And so how do we promote connection when we're really trying to scale this up? What does that look like in terms of our strategy for recruiting peer mentors from multiple locations across the country and helping to match them in a way that feels relevant to the participants and the peer mentors? So that's what we're working on now and hoping to get that off the ground in the next six months or so.

CHRISTINA BORBA: Great. Well, the Q&A is still very lively, so I encourage all three of you to, if time allows, to continue to answer some of the questions that our audience has. Some are very specific to each of your research and others are more broad. I wanted to thank all three of you again for just amazing presentations, a great discussion. It's clear that you have very much interested our audience as, like I said, the Q&A keeps going. And so, we really, really appreciate your time and hope that we can continue working together.

It is now my great, great pleasure to introduce our moderator for our next panel, Dr. Rajeev Ramchand. And I think you've just turned on your camera. Excellent. And so, I will hand it off to you now. Thank you very much.

RAJEEV RAMCHAND: Thanks, Dr. Borba. Hi, everyone. Thank you so much for this next session. We are going to get started right away without further ado. This session is called Peer Support in Crisis Services, Part One. And we have a great panelist of people who've been involved in peer support for crisis services.

As you see here, Brandon Wilcox from Rocky Mountain Crisis Partners, Craig Leets from YouthLine, and Charles Browning and Aaron Arrow, who goes by Arrow Foster, from RI International. And I just wanted to start this session noting that in many ways, I think crisis services has its root in peer support. So, we're in a very informal way if we think about the history of services like those provided by what's become D.D. Hirsch in California to where we are today. And so, I really think it's going to be interesting to talk about where we are now, perhaps the evolution from where we came and where we're going forward. So, without further ado, I'm going to hand it over to my colleague, Brandon Wilcox. Brandon, take it away.

BRANDON WILCOX: Thanks, friend. I appreciate the introduction. Can everyone hear me fine? I'm going to share my screen as well. So, my slides come up. I really appreciate that you started my introduction with talking about kind of the evolution of crisis services and where peer has been within that. As we talk today, during my presentation, I will talk about kind of this evolution of peer support within crisis services. When I started my career in peer support about 16 years ago, I feel like peer support specialists weren't always invited into this space and into this conversation. I feel like we've almost had to earn our right to be able to provide this, especially when we're talking about the perspective from behavioral health and community mental health settings. We know that a lot of regulatory sources and some of the funding sources that have evolved from community mental health and behavioral health settings have not necessarily involved peer support specialists. And when we talk about crisis, especially that of psychiatric crises that involve suicidality, that there has been a large emphasis at times on licensed providers providing that service just for risk management and for other things that regulatory sources require.

And so, I'm really excited to be here today because I get to talk about providing peer support services on a crisis hotline. And like I said, throughout my evolution of being a peer support provider, we haven't always been invited into these spaces due to regulatory sources, beliefs, misconceptions, and perceptions about peer support. And sometimes this theory of risk management that comes up when providing services to individuals in crisis. So, today we'll be talking about how we do that at Rocky Mountain Crisis Partners. And like I said, y'all, my name is Brandon Wilcox. You will see my title is Crisis Programs Director. That's my title on a business card. That's what they pay me to do. But that's not necessarily my identity that brings me to peer support. And so, I think it's really important to introduce myself within that identity. That kind of gives me a little bit of credibility and why I'm a peer support specialist. So, I am a suicide attempt survivor.

I am a loss survivor. I'm someone who lives with a relationship with depression. I'm in recovery from substance misuse. And I've had a series of traumas throughout my life. And so, I feel like it's really important as I present about peer support that I also step into that role of an individual who identifies as a peer, identifies as someone who has lived and living experience within this arena that we're going to be talking about today. So, team, I'm just going to start off by just doing a quick overview of Rocky Mountain Crisis Partners. That is the organization that I'm associated with and I'm a crisis programs director within. And that's where the associate or sorry, that's the organization in which we provide our peer services through. So, Rocky Mountain Crisis Partners is the Colorado state hotline provider, which means that we provide crisis counseling 24-7 by bachelors and masters level of clinicians. This also includes our text and chat line as well. So, individuals can text and chat into the Colorado crisis line and they can receive what is like a traditional counseling service provided by bachelor and masters level clinicians 24-7. An expansion of the Colorado crisis line is the support line.

And so that's the line that I directly oversee and participate within. And so, our peer support services are provided by peer specialists and we provide our services 17 hours a day, seven days a week. We do have a voicemail set up. So, if anyone calls outside of our hours, they're able to leave a voicemail and we will return that call the following business day or that call rolls over to our crisis line. So, no one is left in the queue, but we do not provide 24-hour peer support, but individuals can receive peer support during our open hours, which is 17 hours out of the day. When we speak about peer support at Rocky Mountain Crisis Partners, we are kind of this triad of models, if you will. There's these recognized models of peer support in the United States. And we have found this blend and what we train our peer support specialists on is an alternatives to suicide model, which has been talked about during this presentation. And I'm going to go over it a little bit more.

We do use the model that was created by Sherry Mead and her team, which is intentional peer support. And we have found a way to integrate that into our support line as well. And then Colorado has created their own competencies for what peer support is. This is largely associated to Medicaid reimbursement and what peer support specialists need to be competent in in order to be reimbursed by Medicaid. Our organization is not one that is associated with Medicaid reimbursements, but we do pursue the Colorado credential for peer support, which means that we also have to train our peer support specialists in the Colorado core competencies. And so, when we're talking about the peer support that we provide at Rocky Mountain Crisis Partners, it's a blend of these three models and competencies. Rocky Mountain Crisis Partners also answers 988 for the Colorado area codes. As many of you are probably familiar, 988 routes through area codes. And so Rocky Mountain Crisis Partners does answer 988 for Colorado.

I want to be really specific, though, that our peer support specialists are not associated with 988. We do not answer calls through 988. That doesn't mean that we don't have clinicians with lived experience on 988, as we absolutely do. But they are not providing a peer support service. And we're going to get into the difference between that identity of lived experience and peer support as a service in my next slide. Also, at Rocky Mountain Crisis Partners, we do have these specialized services, such as mobile dispatch and our hospital follow-up program. Our hospital follow-up program is this really unique service in which an individual who enters an emergency department for any psychiatric or substance use reason in Colorado can enroll in our hospital follow-up program, which means that upon discharge, they will receive a certain amount of calls, depending on the risk level or depending on the reason for admittance into that hospital. They'll receive a certain amount of calls from our clinicians providing a follow-up service. That follow-up service is traditionally to build connection, to check in on the safety plan, to see if the person has returned back to an emergency room, to see if they've also been connected into post care, and to ensure if any other needs need to be met, that we can provide a service to meet those needs.

What's awesome about this hospital follow-up program is that our peer support specialists are also engaged within this program. And so, when an individual is leaving a hospital, they can work with a peer support specialist as soon as the next day in order to like really feel supported as they integrate back into their community and back into their life. And our peer support specialist is actually growing in popularity through our enrollment and our hospital follow-up program. And we'll talk a little bit more about that as well. So, when we get into this, I think it's really important to talk about this definition. If you've been a part of this presentation over the last two days, you've heard different definitions of this term peer. And I think many organizations kind of define this differently and they look at this differently. And this is a big talking point in the peer community as well. And I know there's a lot of contention around this and some people have different belief systems around it.

But I'm just going to really define what we think of it at Rocky Mountain Crisis Partners. And so, when we think about peer support, we think about it as an intersection between identity and service delivery. And so, an identity being an individual with lived or living experience with a mental health condition, a substance use condition, and or a previous experience of trauma. And so, that's that identity piece that associated with peer. And I know when we think about peer, there's that place of identity. But when we think about a service delivery, I also think it's important to recognize that peer support in itself is a service that is offered. And so, when we talk about peer support at Rocky Mountain Crisis Partners, we do talk about that intersection between identity and delivery. And if you're wondering, what do you mean by delivery? I'm going to talk all about that in our next slide. The whole kind of point of my presentation today is talk about what is the goal, the target or the aim of peer support when working with people in crisis, especially through a hotline function. And so, I'm going to talk about what is peer support service delivery through our hotline and our next slide. I think it's really important and you've heard this many times.

I hope this doesn't sound like a broken record, but peer support is an alternative. I like to think about it as probably the originator of care. And then there became a more clinical practice. And now it's becoming a peer support again. But peer support is an alternative to traditional crisis counseling. We are not associated with diagnostic practices. We are not looking to assess. We don't run a suicide risk assessment. We don't screen for substance misuse. We don't do things that are traditionally connected to counseling services. Or to some of those services that many of our callers have engaged in throughout their behavioral health history or treatment history. I like to think of peer support as having a different flavor, a different technique, and it's a different art. And I really do explain that in the next slide. I also want to highlight that in the Colorado crisis line that we have an incredible increase in popularity when it comes to the support line. Just if we were to do a one-year snapshot, back in January of 2023, the support line received about 14,000 calls a month.

We are currently trending just over 19,000 calls a month. And that data was taken in January of 2024. So, over a course of a year, we have grown over 4,000 calls in a month. And so, I think the narrative that I hear within that is that Coloradoans want peer support, that they are gaining something from peer support, that the word is getting out there about this service of peer support, and so it's gaining in popularity. I talked to you about our hospital follow-up program earlier, and one of the things that we're also noting is that our new enrollees are choosing peer support at an almost two-to-one rate as they're choosing traditional crisis counseling. And so, I think one of the things that that is telling us is that when people are leaving clinical settings, especially acute hospital-like settings, that they want something different as a post-care follow-up, is that they are wanting to connect to people who have a sense of understanding of what this experience is like and how to make meaning of this experience. And that's what peer support does. This other kind of interesting stat that comes from our data is looking at the increase within our peer support services and our traditional crisis counseling services. So, our crisis counseling services has pretty much been receiving right around 20,000 to 22,000 calls per month.

And that has been steady for over the last year, year and a half, where our peer support is continuously increasing. And so I know we can't draw necessarily some conclusions from that data, but one of the things that when looking at this that I do start to believe is that individuals who have been a part of behavioral health systems, who have been part of traditional community mental health practices or have been in treatment for a substance use diagnosis or a mental health condition, are wanting something differently. And I think that different is peer support. It's that human connection. It's that understanding through lived experience. It's that being able to be with a person without a designed treatment plan or designed treatment practice. And it's really awesome to see this service really growing in popularity. And the citizens of Colorado continuously tell us, we want this, we need this, we benefit from this.

And we see that in our monthly numbers that people are continuously utilizing our line. So, I told you the meat and potatoes of my presentation is really all around on what is the goal of peer support on a crisis call. I kind of told you earlier that I feel like peer support hasn't always been invited into this space, that when I started my journey as a peer support specialist, that the word crisis was always associated with a service delivered by a licensed provider, someone who could possibly run a suicide risk assessment, or if the risk was so high, they could place them on an M1 hold or pursue hospitalization. And I feel for the longest time, the word crisis and suicide has always been associated with service delivered from someone with a licensed or a medical provider in that sense. And that peer support kind of pushes back against that in a way.

We offer an alternative. Our model is really around what we call VCVC. It's that validation, curiosity, vulnerability, and connection. We work to validate a human being's experience. We stay curious around the worldview and we stay curious in ways that we can explore how does this make meaning for you. We're vulnerable around our connection with them and vulnerable around our experience and working with them and explore their vulnerabilities. And then everything is working towards that sense of connection. Y'all, in our calls, crises are self-defined, so they can be anything from an acute situation that's going on to something that might be a little bit more existential. What does it mean for me? Right. And so, a lot of the times we are creating a sense of security. We are doing something about how do you stay safe now. But in other calls, we're working towards a sense of empowerment. How do you continue to move through this issue? How do you move through this problem?

How do you move through this concern of yours? In all of our calls, it is fundamental that we explore a sense of community. Where is their community? Where can they find hope? Where can they find connection? Where can they find others? We know that this feeling of siloing and isolation only prolongs a sense of crisis. And so, we're finding community. Lastly, all of this leads to autonomy and choice. We want to work with individuals in crisis where they have their highest sense of autonomy and choice within their crisis. We don't want to work towards hospitalization. We don't want law enforcement involvement. We don't want mobile dispatch out of their house if it's not necessary. And so, everything that we're doing with our caller is leading to the highest sense of autonomy to keep them connected within their community and keep their choice at the highest. And so, just to wrap up, I think it's really important. I know we have a lot of researchers in this call. We have people wanting to know what works and what doesn't work. And so, I think it's really important that I just highlight some common struggles and challenges that we have as peer support specialists managing a hotline.

First and foremost, and I've already talked about this, I don't want to go too much on a soapbox, is that there is still a lot of misperception and beliefs about peer support being a service that can be offered to an individual in a time of crisis. We have a lot of regulatory and funding sources that say certain things are required. You must use life-saving measures. You have to call the police. You need to do a welfare check. We know that some of those things don't necessarily align with peer support values and philosophies. And so that's a challenge of how can we integrate within the system without being a part of some of these things in the system that have traditionally caused some harm. Sometimes it's hard for us to define and measure outcomes. We talk to people over a phone call. We don't necessarily know the long-term impact of the phone call that we had with those individuals. That's different with our hospital follow-up program. We kind of have a pre- and post-survey where we can understand those.

But in our work as peer support specialists on the crisis line, it's really hard for us to define an outcome. And then last, and I think you're going to hear any peer support specialist and any leader in peer support tell you this, is that it's a struggle to always find how to measure and balance well-being of peer support specialists when there is this inherent risk of exposure to traumatic experiences. I think about this especially in our new world of being virtual and remote and how are we continuously putting peers within these spaces where they can continue to help others, but then also being able to really give the energy and the space it's need for those peers' well-being as well so they can continue to do that work to the best that they can. And so, these are common struggles and challenges that we hope to overcome and to evolve and to get better at within Rocky Mountain Crisis Partners and the whole peer continuum. But yeah, so that's the end of my presentation. I will be around for the panel discussion. I'm going to turn the time over to my colleague, Craig, and he's going to talk to you about YouthLine.

CRAIG LEETS: Thank you so much, Brandon. Good morning, everyone. My name is Craig Leets. I use he and him pronouns, and I am the deputy director for YouthLine at Lines for Life. Let me share my screen here. All right. Is everyone seeing my slides okay? I will assume we are. So, I just want to first start off by telling you about YouthLine. YouthLine has been in existence since 2000, so, almost 25 years we've been providing peer-to-peer support. Our parent organization is Lines for Life. Lines for Life is dedicated to preventing substance abuse and suicide through providing hope and help, and YouthLine does that same thing through a peer component. As Brandon did for you, I will also define to you what peer means to us. When I say peer, what we are talking about is youth supporting other youth. So, we are like a handful of other services across the country where we have teen and young adult volunteers and interns who are providing support and help to other youth.

We are headquartered in Oregon, but we are supporting youth across the United States, and we talk about our work as a three-legged stool. So, there are three essential components to YouthLine that allow us to support youth across the country. The first, which I will talk about, is our help, support, and crisis line where we are providing support 365 days a year. We also do education outreach locally. We want to make sure that we are doing that prevention component of the work to provide skills and resources to youth. And then additionally, youth development and workforce development is an essential component of our work. Because our youth volunteers are the heart of our program we need to make sure that our youth are prepared to support other youth, as well as ensuring that they have the skills and continuing education to do this important work. All right, so I'm going to jump in to tell you about our help, support, and crisis line. This picture that you see here is our call center headquartered in Oregon.

As you can see, there are some paper chains. There's a lot of light. It is a fun space. There's a really, you can't see it, but there's a picnic-sized Jenga tower that every time it falls, it crashes to the ground and startles me. But we are a youth development space. We are serving youth ages 10 to 24 across the United States. We do sometimes have youth younger than 10 who reach out to us, and we will support them as well. But we know that the best support for youth that young is really a trusted adult. So, our youth volunteers and interns, they are as young as 15 and go up through their early 20s, and they are the first responders on our help, support, and crisis line. What we know is that teens want to talk to other teens. Teens best understand what it's like to be a teen today. And so, our teens are those first responders supporting other teens across the country who are reaching out for help.

We have that peer-to-peer service 4 to 10 p.m. Pacific every day of the year. Obviously, outside of those hours, our youth are in school or they are sleeping. So, from 10 p.m. to 4 p.m. Pacific, we have specially trained adult crisis counselors who are providing that support to youth who call us. Unfortunately, we cannot currently provide that chat and text, which are the two ways in addition to phone calls that youth are able to reach out to us. So, when we don't have our peers on the line, we have an autoresponder on our chat as well as our text that encourages youth to either call us or reach out to 988 so they have the support that they need in that moment. Our youth are supervised by highly trained clinicians.

There is always at least one master's level clinician in the room, and those clinicians are supervising and overseeing every contact. They're on the phone with our youth. They are reading every text and chat that comes in to ensure that our youth have all the support that they need to do this work. All right, I will go on to the next slide. So, as I've mentioned, our help support and crisis line is one of our essential components of our work and is kind of the core of the YouthLine. What I want you to see here is that we have served tens of thousands of youth over the years. More recently, you can see in 2020 with the start of the COVID pandemic, youth reached out to us because they were lonely, they were feeling isolated. And so, that year we served just over 28,000 youth. We also had an influencer on TikTok with about 100,000 followers who posted our contact information on there, and that brought us a lot of response as well.

As you can see from this slide, it shows you some of the common reasons that youth reach out to us. So, our motto on youth line is no problem is too big or too small. We want youth to be reaching out for help when they need it. And so, you can see that they might be reaching out to us about academic pressures. They may have had a failed math exam. They may have had a fight with a parent. Or they might be experiencing thoughts of self-injury or suicide. So, we support youth in a range of crises with their mental health and want to make sure that they know it's okay to reach out and they can reach out to us whenever they need it. We currently are serving about 25,000 youth a year that has leveled out after that peak in 2020. And we are talking to youth not only across the country, but also across the world. So, the second component that is so essential to our work is education and outreach. This is the prevention component of our work.

We want to try and do that upstream work so youth know their resources, they have skills before they need to reach out to us, and they know that they can reach out for help if they need it. So, some of those intentions of our outreach and education work are to destigmatize mental health, are to encourage those help-seeking behaviors. We want youth to have skills and resources, as I mentioned. And we also hope that they can identify a trusted adult in their life. As one of the previous panelists mentioned, trusted adults are a core protective factor. And what we know and what we talk about with our youth is that that trusted adult might not be a parent. It might not be a guardian. It might be someone outside of their family. And so, we want to make sure that they are getting the support that they need. The four components of our outreach and education work are, one, social media. Follow us at the YouthLine on Instagram. We have regular posts that are informed by and created by our teen volunteers, our interns, and our young adult staff.

Again, keeping that peer-to-peer component running through all aspects of our work. We have our youth actively involved in our social media presence. Another component of our work is free promotional materials that we send to schools, community organizations, and youth-serving organizations across the country and across the state. We want to make sure that youth know about YouthLine. So, we have these complimentary materials where adults can order stickers, wallet cards, wristbands, brochures. We want to make sure that youth know about YouthLine when they need to reach out for help. Another way that we do that through our outreach work is being present in the community. We are at community events. We're talking about YouthLine. We're making sure youth know about us so they can reach out. Additionally, we also do volunteer recruitment because we need to recruit those teen volunteers to help serve other youth across the country. Finally, and most importantly, we have mental health lessons that we deliver in middle and high school classrooms across Oregon.

These lessons meet national standards for mental health, and they do all of those things that we mentioned before, right? We really want to promote mental health as a thing that we all have and that youth should reach out for help when they need it. Finally, the third component of our program, as I mentioned, are our volunteers, our youth development and workforce development program, that we are creating youth mental health ambassadors to go out into their communities. So, not only, obviously, are we providing them over 65 hours of classroom training, of role plays, of shadow shifts, to make sure that they have all of the skills and resources they need before they start on our help, support, and crisis line, but we also know that they're taking what they learn at YouthLine out into the community. At any given time, we have somewhere between 130 and 150 youth volunteers and interns who are providing that support. They receive ongoing education, professional development, and they are actively engaged, not only in their individual communities.

We know that a youth takes YouthLine and the skills they learn to their friends, to their sports teams, to their schools. But for example, tomorrow is a legislative advocacy day here in Oregon, and a handful of our youth volunteers are going to the state capitol to speak to our legislators about how mental health is so essential and how youth mental health needs to be prioritized on the policy level. And so, our youth are not only getting this essential training to provide the support to other youth, but they're also increasing mental health as a normal part of their communities. A lot of people have questions for us about what the training looks like, so I'm just going to leave this slide up for just a minute just to give you some examples of what are the topics that are included in our training for our volunteers. What you can see, kind of the last two check marks on the list, are youth mental health first aid and safe talk. So, we're providing these nationally certified trainings, suicide prevention trainings to our youth, as well as many of our youth also go through assist during their time volunteering with us.

And so, we want to make sure they have those skills, resources, and knowledge to be able to support other youth. This next slide, again, I won't spend too much time on, but if we were to provide a frequently asked question for you, one of the main questions that we have posed to us is, is this work safe for youth to do? Is it safe for youth to be supporting other youth with their mental health crises? And we emphatically say, yes, we know that youth are already having these conversations with their peers in their friend groups. So, to assume that they're not already talking about suicide and self-injury and depression and anxiety would be incorrect. And so, we have this structure that we've put in place that includes a variety of facets to ensure that youth have all of the support they need to do this work. It starts as early as when they start thinking about volunteering with YouthLine. They go through an orientation where we talk about those sorts of topics that they might see on the line. And then they are provided that support throughout the course of their tenure with our program.

So, today's YouthLine, we have call centers across the state of Oregon. As I told you, we are supporting approximately 25,000 youth a year. During 2022-2023, our fiscal year, we had 205 youth throughout that year, and they dedicated over 24,000 volunteer hours to the program. And then there are about 20 of us who are full-time staff who are supporting the youth in doing this important work. One thing I will mention is we do have a work study program that provides a monthly stipend to volunteers for whom there are financial barriers to participating in our program. We know that being able to volunteer can be a privilege. And so, this work study program provides that benefit, that financial benefit for youth who need it to be able to volunteer with us. And then finally, I just want to tell you about a program that we're really proud of called Safe Social Spaces, where we are aiming to intervene in crisis online, particularly in social media. So, we have specially trained young adult crisis intervention specialists who go out into social media sites and find posts from youth who are talking about self-injury and suicide and they reach out to them.

They say, hey, I see you're struggling. I'm here if you want to talk. And then they then proceed to engage in a crisis intervention conversation through direct message with that youth. Some of the sites that we're on, you may have never heard of. I didn't before I started Youthline, Talk Life, Wisdo, Amino. But those are sites where mental health is discussed that our youth told us we should be on. In the more recent past, we've added Vent and Discord. Discord is another place where our youth has said you've got to be there. There are youth online talking about their mental health. So, as you can see from the statistics, we've over the lifetime of the program served over 2000 youth. We have been able to support about a quarter of them through direct messaging. Everyone we message gets resources from us and we are continuing to grow this program.

Why we think this program is really special and innovative is that we as crisis interventionists are going out to find the youth in crisis. Whereas typically we know many crisis intervention models might wait for someone to come to us. We are going to them. We are going to find these youth whose help-seeking looks like posting about self-injury and suicide online. And we are giving them the support they might need. That is my last slide. So, I just hope, again, follow us at the Youthline on Instagram. Check us out at theyouthline.org. And really, if you have youth in your life who might need that extra support and want to talk to another teen, please let them know about us. And I'm going to pass it over to Chuck Browning and Arrow Foster.

AARON FOSTER: I have not abandoned you, Chuck. I'm just getting the PowerPoint ready.

CHUCK BROWNING: Thanks, Craig.

AARON FOSTER: So, Chuck, would you like to introduce yourself first and then I'll go and then we can move forward.

CHUCK BROWNING: Sure. I go by Chuck Browning. I'm the Chief Medical Officer at Recovery Innovations, also known as RI International, and also the Medical Director of Behavioral Health Link.

AARON FOSTER: And I'm Aaron Foster. I go by Arrow as announced. I'm the Vice President of Peer Crisis Program Development and Training. I am first and foremost a peer specialist, a person with lived experiences, substance use, and mental health challenges as well as youth crisis. And I'm also the chair of our Peer Leadership Council, which you'll be hearing about here, and an author in psychiatric rehabilitation. I think what ours, just like many of the people who presented before us, we're going to define how RI defines peer specialist because as we know, every state, every federal agency, every organization has their own definition. And during this, I'd like to say that I like to define, I like to separate peers from peer specialists. Peer specialists are trained to do this work. Peers, the way we describe it, are the people we work with. So, with that, I'll move forward. I'm not going to read this whole thing. As I was looking at it, I thought, well, I'll share this and read it.

Let's just define what RI, let's take what RI looks at. And this is what we look at. We want people to be competently trained. Many people have lived experience, as some of the people who have spoken here already have said, even the clinicians. I myself am also a licensed counselor in the state of Arizona with lived experience. But this is people who have been trained to use their peer support skills, their lived experience in the most appropriate way. It's about walking alongside people, not leading them, not guiding them, not directing them. It's about empowering and we say empowering, not about us giving away power. It's about creating spaces for people to become empowered, find their power that maybe has been lost due to stigmatization.

You know, all the horrible events that may have happened in their lives and really have a safe place to find that power again. To use the things that they identify as services and tools and activities. And it's about mutuality, breaking down the hierarchical system and not having that, but actually being with the person mutually and recognizing that they're the experts on themselves and their lives and what they need. When we look at it in the world of peer support, what does recovery means? It means that people, the way we describe it, they're aware of the challenges and manage those challenges. It does not mean a total absence of challenge.

It means we've come to a point where we can handle the situations where we can move forward without that having a major disruption in our lives. And we do realize that people may experience relapse or manage symptoms or take medication their entire lives. But it means that we have found a way to use those tools, whether it's medication, whether it's wellness recovery tools, whether it's, you know, the domains as identified by SAMHSA and making sure that they're all in a line. We found a way to use that and be safe and secure in our recovery. And at times we may have exacerbation of symptoms. But we know how to address those quickly and effectively and reach out when we need support also. And then I'm going to let Chuck, you want to talk a little bit about the diversity in services and the importance of that.

CHUCK BROWNING: Thanks, Arrow. Yeah, as we start talking about peers in crisis services, especially as it relates to us at Recovery Innovations, separate from just the importance of driving forward that recovery focus, I think the diversity aspect of what peer support specialists bring to our team is so important to recognize. And when I think about the diversity, so many times peer support specialists in particular crisis centers where we're operating, they bring in part in our reflection of the makeup of the community, maybe more than any other group. The important piece of that is how much that impacts the inclusivity and engagement aspects of the services in the community. And so, it doesn't just bring diversity to those that we're serving. It also brings an enriched picture and feeling to the staff of all we're working with. So, I think it's an important mosaic. And it soon as we get to the panel, I'm sure we're going to be talking about this difference between peers being in crisis service versus their own lane because that's been a lot of the questions and things. We just feel like it creates an unbelievable complement to fuse those things together.

AARON FOSTER: Nicely said. And you're going to see as we talk about peers, we decided to look to name this slide. Peers can work in crisis center rather than the age old question of should peers work in crisis center because RI really is based on peers in crisis. In fact, our very first services were incorporating peers in crisis back in 2000, 2002. And so, as we talk, you're going to hear me talk a lot about the training pieces, the instructional design piece, because that's what I oversee around the world is our training in crisis and in peer certification. Whereas Chuck will talk more about the on ground uses and things that we're going to be discussing about here. So, Chuck, I'm going to turn over to you to talk about the warm lines, crisis lines, mobile and crisis centers.

CHUCK BROWNING: So, we're going to just do a quick walk through some of the different continuum of crisis and not get too deep into the details, but specifically focus on what we do at Recovery Innovations. But, you know, we say peers can work. It is part of SAMHSA's national guidelines that peer support and many what I would call peer power practices are a part of the essential care practices for the national guidelines and care. And so, you know, when you talk about different lanes of care, obviously, peer support, as it was discussed and shared by Brandon and Craig and some of our previous panelists, the importance of peer support in that warm line crisis line aspect. And so, I'm not going to go into depth of that, just that that is an important piece of some both in warm line supports. Some states are using folks with lived experience as trained volunteers on their actual 988 lines across the country.

Although that does get into a lane different of doing assessments and things of that nature, which I know we're going to be talking about, I'm sure, in the panel. Going to the next one is kind of that next layer up when people need someone to come to them thinking about mobile teams. And the current recommended model in SAMHSA is having peer support as one of the two members of a team, usually along with another licensed clinician. And that role of the peer support specialist being the person to help support with engagement, support voice of that person going through that lived experience and crisis within the assessment and the team. And so, you know, when you look at this, this is an example of one of the companies that operates in Phoenix, Arizona, separate from R.I., but definitely has a lot of interactions with our crisis receiving centers and look at the volume of people that they're supporting and working with, with an ability of stabilizing about 75% of those people in the community. So, it's from a standpoint of numbers and looking at impact, these teams have been shown to really help people avoid higher levels of care when not needed for safety reasons. And then finally Arrow, getting to talk about what we do at Recovery Innovations, which is our crisis response centers.

AARON FOSTER: Yeah, and I think it's just real important to note here that peer support has been an integral part of our crisis response centers since we opened. So, we are big believers that peer support really can be implemented in any part of the crisis continuum of care. And we call that fusion. We call it the R.I. way. Chuck is the originator of both those terms for us here. But it's really it's the best of clinical and best of peer support practices where each person utilizes their strengths in their roles and complements the others. Not co-scripted into another position, not going outside of our scope of work, but complementing each other. And so, it's at R.I. we look at lived experience in all of our roles. And it's valued in everything that we do, you know, in some of the stuff that I talk about nationally, I talk about, you know, peers have been an integral part of R.I. even within our non-clinical services. We create career pathways for peers. Currently, we have three pathways for peers without having to leave the peer realm and go into a different discipline, but stay within the peer realm. We believe in the peer first and peer last, which is the first person at the receiving center that the person meets is a peer.

Not a security guard. Not a clinician, but the peer and the last person that they see before they leave is the peer specialist. And those peer specialists are in that continuum of care all along the way. We co-design our services. As I stated, I'm the chair of the Peer Leadership Council and everything that we do within R.I., any policies that we enact, any changes that we make, all have to run by the Peer Leadership Council. This consists of peers in our organization around the country and different regions, reviewing that to make sure we stay peer focused. It's also run by the Medical Leadership Council with Dr. Chuck as the head of and our Diversity Council also. So, we make sure that peer services, everything that we do is co-designed with peers. We also have a strong belief in that we do with and not to or for. We are not there to enable people. We are there to support them in their journey. And we have a no force first policy in all of our settings. Force is never even on the table unless there is no other choice left available. Chuck, if you want to talk about that a little more as you go into what this looks like in this couple of slides, we're going to show how this really works.

CHUCK BROWNING: Yeah, and I think when you look at those keys, one of the things to understand that's so important about the layers of peer support in all the different levels of our company, whether it's on the board or in the executive team or at our site level, is how much that peer powered concept, those are tools and ways that we train our staff to be able to operate and connect with people. And that it's not just for a peer support specialist to be peer powered, it's for a doctor, a nurse, a licensed clinician that's working on that team to guide that. And you cannot have that without that cohesion and teamwork and fusion that we talked about. And yet, like fusion, it's really hard to pull those elements together and do it the right way. It's always a constant tension and things that we're working on. So, looking at how it works, these are just some examples of some typical things that a person coming to a crisis receiving center might need or might be a part of the process of things that work with as they go through there. And that could be people that come in voluntarily for help off the street. It could be people who are brought in, in some cases on a voluntary commitment or brought in by law enforcement. And so, one of the things that happens first is we look at what are the roles of different teammates and those different things. And so, as we talked about, and we've talked about before, and several other panelists have mentioned, the role of the peer support specialist is not for assessment. It is about engagement, connecting to the people that we're serving, helping them also be a champion for their voice, but also for the overall experiences being provided by all of our staff to be in the heart of being peer power. So, being recovery and being collaborative, no force first, working on strengths about what's strong with that person and empowering them instead of just focusing on what's wrong.

So, there's all these different things that are happening, and a peer support specialist may be actually participating in some of those steps, or they'd be there in whatever the role, like if a nurse is doing something with a guest, such as checking their vital signs or doing skin checks, the peer support specialist may be there in a supportive role if something is needed. And then as we go on to the next slide to just talk about some of the other things, within the milieu of a crisis receiving center, and again, in these centers, usually anywhere from 60 to 75% of people who come in that oftentimes without this system would be going to an emergency room, going to jail, or not having access to care, are able to return back to their community connected to care safely with follow-up in less than 24 hours. And so, a vital part of that is that trauma-informed care, trauma-informed environment, and the engagement, connection, classes, and groups that are done in these short-term crisis centers. And so many of them are led by peer support specialists using curriculum particularly designed in that level of expertise, focusing on empowerment, thinking about meaning and purpose, thinking about some of those key ingredients that make such an important part separate from just medication, and some of the other classical medical model things that make a difference in helping someone's crisis improve quickly and help them return to their community.

AARON FOSTER: Yeah, I want to add something that I think is often not discussed, but I think it's very important that you kind of touched on is the peers there through a lot of the process. And I think one of the roles that we as peers play, and I know I found beneficial when I was receiving services in a crisis center, was the peer was able to translate what I was saying to the clinician and translate what the clinician was saying to me. If I'm in crisis, I often don't speak well for myself. I speak in feelings. I speak in existential thought. I don't necessarily say what could be understandable to somebody who has not experienced it. And so oftentimes that peer can really be a good translator back and forth and really help bring that team together.

CHUCK BROWNING: And going back to teamwork, it's not just translator. I cannot tell you when I did this for years as the main provider in a rural North Carolina clinic, how important peer support specialists were to educating me as a psychiatrist about the things that were going on, and the way that I needed to handle myself that had an impact in my role and interactions. And so, if you have that shared collegiality and teamwork of being able to resonate in your own experience and expertise, I might have a good differential diagnosis of what's going on with a rash of someone that came in. But boy, I can learn a lot if I'm listening to what's going on from good peer support specialists doing that work.

AARON FOSTER: You echo exactly what it shows on this slide in just a moment that Sammy says as the MD. But we're giving some examples here of how this interdisciplinary team works, and some of the things that people have said that have worked there. So, Beverly said, you know, she was like, oh, no, now I have somebody else to take care of. And yet after working there a while, she's only got these are strong individuals. I don't need to take care of them. Peer support often said, you know, I'm hired here, but are they going to accept me? Are they going to listen to me? Is my voice going to be valued? What I found out with this fusion model, with this interdisciplinary, it's hard work. But you know what? It's working and it's helping others. And then Sammy spoke about exactly what you were talking about there, Chuck.

He was anxious about having people in recovery join the team and didn't think it was really a good place for people. And I'll say exactly what the quote doesn't show here is like that to, you know, work in this place. They're going to get triggered. They're not going to be able to work. And then what I found out was, you know, just like you said, learned a lot from working alongside peer support. They identify needs and concerns. I know as a clinician, when I have my clinician hat on and I'm doing assessment, that person tells the peer support a lot more than they would tell me. So, it's about communication. It's about sharing. It's about really working together. But none of this happens without continual improvement. You know, Chuck, you mentioned earlier that, you know, this is constantly, there's a tension, constantly making it work, constantly going back.

Well, how do we fix this? This isn't working. How do we test to see if this is working? Well, we have three instruments of continual improvement that we're going to go over. Chuck is going to start with the matrix model. And then we're both going to talk a little bit about the peer-powered skills very quickly. And then a new instrument that we created in relationship with another state that we are finding a lot of value in. And that's the work readiness gauge. So, Chuck, do you want to tell us a little bit about that?

CHUCK BROWNING: Do not worry about trying to dissect all the different details of this. The main point of this is this is a structure of quality improvement of leadership. And as you can see, the important piece of this is that there is a peer leader, just as there is a nursing leader and a provider leader, in their level of subject matter expertise, leading certain KPIs and certain operational quality improvement movements of the leadership of the site so that at the site level, there's a role to move up and be promoted and actually be a leader and a voice over not just the peer staff of the site, but overall peer-powered practices for all staff.

AARON FOSTER: And that's you're talking about the peer manager in that role.

CHUCK BROWNING: Yes

AARON FOSTER: Which means they sit at the table with the other SMEs and have a voice in all decisions, correct?

CHUCK BROWNING: Correct.

AARON FOSTER: The other thing we have, and Chuck can tell you more about, which is fairly new, but really has brought us a lot of good data. Chuck, you want to talk about the peer-powered skills?

CHUCK BROWNING: Yeah. So, Lisa St. George, our former vice president of peer support and recovery, and I really wanted to develop an internal tool that would help us be able to measure how peer-powered we were with some of these things that Arrow and I have been describing to you. And so, we worked together and modeled it very much after the Zero Suicide organizational self-assessment tool with three major categories of measuring peer voice and culture, the use of peer-powered practices, and then the tools and systems in place to execute that. And we've created this free access website for any organization that could use. We use it internally, but we've completed it as a tool for people to be able to use in their own organization to see where they are. And by the answers that you get, you get follow-up things by that. And I know we've got to wrap up for getting into our panel, but we've got one more tool.

AARON FOSTER: Okay. And the last tool I have is the newest one, and this was created by our training team and the instructional designers there because we kept getting asked, as we've heard here many times, are they trained to work in crisis? Are they ready to work in crisis? We believe the peers have a choice. If they want to work in crisis, they can. If they don't want to feel it's appropriate, they don't need to. But am I ready? So, this has three asynchronous modules for you to go through. It talks about what life is like as a peer support in crisis centers. It's been reviewed by all of our teams. It talks about ethics, workforce relationships, and then gives an overview of the day in their life. And it's currently being tested as an interview instrument. In this state that I talked about earlier. So, we're really excited about this. And I believe we made it close to time, didn't we?

RAJEEV RAMCHAND: You were great. Thank you. Thanks, Arrow. Thanks, Chuck. That was great. I'm going to invite all the panelists to come on screen so that we can have a dynamic discussion. And I'm going to lead with the question. So, thank you all. I think that this was a really great insights into part one of crisis services and peer support in crisis services. And I just want to thank you for sharing your experiences with us. I think they're really fascinating. I'm going to get to the first question. I think it's a really interesting one. And I think it's really interesting because the questioner said, this might be a semantic question, but I actually think it's really important. He's like, is there value in differentiating beyond, between concept of shared lived experience when we talk about peer? Or should we be, at the youth line, peer is identified by age group, right? By youth versus non-youth. But we could also think about peers with the same experiences, same diagnoses, if that's the same symptoms clusters. So, I'm curious how you all kind of approach this, these sub-differentiations within peers. I think it's really important when we think about, especially when we think about services for, when we start differentiating kind of the services that peers provide and kind of the people that they're providing them to. So, I don't know if somebody else, we'll start with Brandon.

BRANDON WILCOX: I was sitting there just praying in my mind, like start with someone else, start with someone else, start with someone else. Yeah, so I think this is really difficult. And I've actually struggled with this in my own personal philosophy to the point where I think the word peer is actually sometimes getting in our own way of being able to provide a human experience and a human service. But I think it helps categorically almost with the individual receiving the support from us. So, when we say peer and our definition of peer is someone who has a similar experience with a mental health or substance use challenge, it really does help our, like the receiver of the service know who they're kind of working with. Someone who has been in a similar mindset, someone who has been in a similar place. Maybe you have gone through similar treatment settings or have had similar experiences within treatment. And so, I guess I don't really know how to answer the question because I don't know if it helps sometimes or if it hurts sometimes. I think though, when it at least creates a category in which the person who's receiving the service has a better understanding of who they're getting it from.

RAJEEV RAMCHAND: Anyone else want to chime in?

AARON FOSTER: Well, I'd like to say, oh, I'm sorry. Do you want to go ahead? I'd like to say, and I'm always going to come from that training point of view that, you know, the first thing that we are as peers are engagement specialists and change agents. We know how to use what we have learned in our own lives to help others. And I find that if a person knows how to make that connection, it doesn't have to be exactly the same experience, but you can find the similar recovery experience. You know, Dr. Bill Anthony at Boston University back in the 90s said, I think it's the best definition of recovery I've ever heard. Recovery is a common human experience. And break it down to how it's an experience of substance use, it's an experience of mental health. It's a common human experience and finding that engagement and then train and use those skills to engage but it also doesn't mean that if you're not able to engage, that you can't pass off to somebody who may be able to. I think that communication with the individual, what would you like? Always asking first before doing anything. Is it okay if I share this? What would you like? Who would you like to speak to? It's so important right up front.

CHUCK BROWNING: And Arrow, I can echo in on that just to give some real life experiences of times in the years of being in that medical leadership role at our crisis centers is that sometimes I do think that it so matters that you have the ability to use that overall training. But if you are someone who is in recovery strictly from substance use, and then it's your first time on a crisis center and you're having folks who might be having a really tough day with being challenged with psychosis or mania, it can be a little bit of a different, you know, so I think the importance of training and giving some supportive understanding that and hopefully being able to have folks that have both experiences adds, again, just like that slide, it adds diversity to the support that you can give people and share with that. But I don't think it should be an exclusive that you have to have that in order to be able to be effective.

CRAIG LEETS: The only thing that I'll add is just for us, it's some education in the moment about what peer means. We don't want to say teen to teen, though we do in some contexts, because we're serving 10 to 24, and we don't want those young adult youth to not feel like they can reach out to us.

And so, in the moment, we might help folks understand what we can provide. I liked how in the model with Appa Health, like a youth is able to choose a mentor, a peer mentor, a support person who shares some of their identities. We will sometimes have youth who ask for more than just teen to teen, who will ask for a specific identity.

And if we rarely and probably would never kind of transfer to a volunteer who shares an identity or lived experience, what we will do is refer to other services, right? So, there's Black Line, there's Trevor, there's the Trans Lifeline, that if someone is looking for another crisis service with someone who shares their identity, then we'll refer them to that service because it might be a better fit than what we're able to provide.

RAJEEV RAMCHAND: Great. Thanks, Craig. Craig, I'm going to stay with you. There's a question, you answered it in the chat, but I think it is worth a discussion. It's about self-injury and self-injury on the line. And I'm just going to read this question verbatim. Although 988 police and other involuntary interventions are a big concern, I also find that people answering 988 are not well trained in good responses to self-injury. For example, they don't get overly focused needing to stop it, don't automatically link it to increased suicide risk, are able to explore what it means, how it's working or not working for someone, harm reduction approaches, et cetera. How does the youth line respond when someone talks about self-injury?

CRAIG LEETS: I think we need to do many of those things that were just named that other services don't provide, right? So, our main goal to anyone who reaches out to youth line about any of their concerns is to really validate those feelings to affirm that it's natural and normal that they are feeling those ways. De-escalation is something that is important to us. De-escalation for us means that we don't need to involve emergency services. And we do that about 97, 98% of the time. And what we do in crisis is we will just listen to them. We will ask them questions. We will explore with them, how are you feeling? What is leading to these thoughts of self-injury? And validate all those feelings and the background concerns and then just brainstorm with them, right? We rely on them to lead the conversation, but we might ask them to consider are there other activities in which you might engage to help? Obviously, it's not going to be one for one, right?

It's not going to be the exact same results. It’s not going to be the exact same feeling. Can they scream into a pillow? Can they hold an ice cube, right? There are other strategies that our clinicians and our youth are aware of that they will just brainstorm with the youth to see if that is an option. And harm reduction is also a component, right? That there may be a conversation with the youth about engaging in practices that make it safer to self-injure if that's something that a youth is really committed to doing in that moment. So most importantly, we are validating those feelings and trying to brainstorm a path forward with them for safety planning and self-care.

RAJEEV RAMCHAND: Anyone else want to add about self-injury before we go on to the next? All right, let's move on. This is the two-parter. I'm going to direct it first to Chuck, then to Brandon, and then we can, if anyone else has any comments. And this is based on a thread that I see coming in the Q&A. So, on the one hand, there is a participant who's saying we need a serious discussion about respect for team members. Peer specialists are professionals. I don't like the underlying theme of separate or alternative. But then at the same time, there was another question that says, let me just find it. All presenters are addressing the positives of having peer support and not talking about issues within patient care settings and agencies of having people meeting with patients that are not educated thoroughly and are trained at a higher level. I've had several boundary issues after hiring peers where peers believe they know things they don't and operate outside their scope of practice. How is this being handled? So, I feel like there's this tension between this integration, some calling for an elevation of peers, some kind of expressing concerns about perhaps even elevating that role. So, Chuck, I'll start with you, then we'll go over to Brandon.

CHUCK BROWNING: Yeah, I was just reading it over and over, that theme. It’s why I named that term the fusion model. It’s the best of medical-clinical meets the best of peer and recovery of support is I think both elements are so important to pull together. However, fusion for the energy of the sun or a star is bringing two atoms of hydrogen together. And it takes an unbelievable amount of energy, temperature, and pressure to make that happen. And so that likewise, sometimes as you can see, there's so many different opinions of how do you put these things together and make it work the right way without creating conflict, blurred boundaries, those kinds of things. I think, you know, so in my experience, I think you just, from someone who has worked in that environment for over a decade, you cannot understand the richness that involves when you get the teamwork going and everyone respects each other as teammates.

And so I think some of that is why we created that peer-powered organizational tool was so that organizations could really invest in thinking about how their culture and voice of that is built up throughout the whole organization so that everyone has much understanding of that role and how it works together with the as you do for a nurse's role and doing certain things or as you do for a licensed clinician and doing certain things. And so that's one piece of it. So, it takes that workplace and culture part to have it. And on the other hand, I think there's going to be a constant adjustment in figuring out the best balance of how to pull these things together to get the best out of it, but do it in a safe way and do it in an evidence-based practice way, which is why the research and what the NIMH is doing is so important to help drive this forward of saying, this is a best practice. This is what works.

RAJEEV RAMCHAND: Brandon?

BRANDON WILCOX: Yeah, Chuck, I really loved your slide about fusion. I was taking notes during it and I was like, I'm going to have to connect with Chuck and Arrow around this because I love this concept. I also think this is what moves the needle. And what I talk about as moving the needle is I think peer support as a scope has only grown in the sense of having more and more responsibility and opportunity to work within people, whether it's crisis and or any type of healthcare setting. I think the scope has grown and I think we have had a fight against stigma for that scope to grow. But I think when we do talk about fusion, I think that there is a separation in the sense from what I call traditional services and peer services because I do worry about some of the underlining and kind of foundational principles of peer support being lost within traditional services. I think about this opportunity around power differential. And we know like traditional crisis services, there is a power differential between the therapist and the client or what we would term client from time to time. And I don't want to see peer support move into a place where there is a power differential, where there is diagnostically driven practices where we're giving certain labels and things of that sort.

And so, I do think that there is a separation. Do I want to see more lived experience within that? Absolutely. And I do think that there is a ton of lived experience within people who provide services and Chuck and Arrow are both examples of that, myself included and Craig included. Like we provide services and have an identity within it. But I think that a degree of separation creates integrity around the service. And I think that that's important. As far as like scope issues, I think that this is a scary place around stigma too. And I'm going to sound a little bit soapboxy and I'm really sorry, but you gave me a platform so I'm going to take it. I feel like sometimes we do this thing that like peer support is working outside of their scope. And y'all, I think in any form of career development, especially in armed services, we've seen everyone work outside of a scope. We've seen a therapist work outside of a scope, a case manager work outside of a scope, a psychiatrist work outside of a scope.

And it's not necessarily an issue of the specialist as much as it might be an issue of how they were trained, how they are supervised, how they are performance managed and things of that sort. And so, I do know that we have scope issues within the work, but those are like, almost like performance management issues that I think are universal to any, to any job or any employment. And so, I just get worried that we say these things like that we kind of take this broad stroke that like it's a risk because peers may work out of the scope. And I think that risk is connected to any service that can't be delivered. It's all about how do we continue to work with that individual to know what their scope is and where their best practice can be engaged.

CHUCK BROWNING: Can I say just one follow-up? Because it's such a great point, Brandon, the way that you're bringing that up. And one of the things that Lisa St. George has always said to me when you talk about the separation, it's such a tough line in the sand of like, we have people that are, you know, throughout the country and it's a minority and we needed to make it even a smaller minority who at times for certain periods of time are on involuntary commitment or in a hospital against their will where there is a power differential.

And the question is, would you, how do, is it, do we want those people to not get access to really good peer support practices and peer support specialists in that role? But yet it's exactly true what you said, Brandon, too, is that it does blur, you know, there is a, there is something that's, when you mesh those two together, it's a really tough, it's a tough balancing act when you're talking about those things that don't have the answers. I'm just saying that's, I don't want them not to have the access to that in that situation either.

RAJEEV RAMCHAND: Well, I think that the point of these, when NIMH has these meetings, it's because there are unanswered. So, we need to explore all that. So, I appreciate everyone's kind of perspective, including those who asked the question. I have four other questions. We have around five minutes. We can go a little bit over, as I'm going to direct each question to one of you with others can kind of pipe in as needed. So, the first one, and this came up in the first session today, is this issue of pay and sustainability. So, the question in the comment was, how are your services funded? But I think it kind of opens up a larger issue, which is, you know, and this is something we talked in the preparatory call. Do you think that there is this expectation that these services, that these should be done kind of a more volunteer basis? They're being underpaid. Those with peer support specialists are being underpaid. And how can we both pay people adequately for the services they're provided, but also have a model that's sustained? How do we fund, how do we get the support to do that? So, I'm going to address that one to Brandon.

BRANDON WILCOX: I don't know. I don't, because this is something that, you know, in my experience, both working in community mental health settings and now on a hotline, it's a really difficult conversation to have. I think in community mental health work where we are largely Medicaid reimbursed, finding the right type of Medicaid codes that still work for peer support in order to receive the highest amount of reimbursed possible, so then you can justify a higher salary rate for peer support specialists, like that's a really difficult place. And I think that it, I think it's a really difficult thing.

I also like, I would challenge that some of these barriers are from an agency or organizational perspective as well. And, you know, any of us who have worked in peer support has probably worked for an organization where we've had to challenge some of these hiring models or some of these salary grades and saying, hey, we're paying two different people who are doing the same work, different money, just because of an educational requirement. And so, let's start to challenge some of that red tape and those requirements around that as well.

I think when it comes to like public funding, such as Medicaid and Medicare, it really comes down to like policy and legislation really proving that these services are invaluable, that they do reduce hospitalization, that they do improve outcomes, that they do reduce suicide, all of these things that unfortunately the insurances will save money over time, which then could lead to higher funding for the salary requirement itself. But I challenge that a lot of this actually sits at an agency or organizational level. I've worked for a lot of organizations who have like kind of a benefit to education rather than a benefit towards lived experience.

And how do we kind of challenge that concept to say that lived experience is equally as valuable as education and someone shouldn't be paid more just for having a bachelor's degree who is providing a similar service or a similar amount of work and kind of breaking down some of those concepts. As far as funding from like a state and or from an insurance level, I don't know how we move the needle on that. Hopefully more research and positive outcomes and things of that sort. But I think organizations and agencies also need to look at some of their funding and their own requirements and start to like make sense of the logic that kind of breaks down pay that way.

RAJEEV RAMCHAND: Craig, I'm going to turn to you. And this is a natural dovetail with respect to research. So, I think that a lot of this, there is a need to kind of demonstrate from a research perspective, the value that these models have that can then lead to research. I'm curious, you work with youth, you know, volunteers as well as participants. Do you seek out research collaborators? Do research collaborators come to you and what do you think is the most beneficial for researchers interested in working in peer support models?  What do you think is the most beneficial kind of model? You know, do you want them to be like, you know, with you kind of all the time and how close do you want that collaboration to be?

CRAIG LEETS: Yeah, I really appreciate that question. I think historically we have had researchers reach out to us. We are currently collaborating with a number of institutions on a number of projects around our youth development component as well as specifically on safe social spaces and great research collaborators, great faculty partners. And I think what is really important to understand and what I appreciate about the partners with whom we work is that we have some limitations on how to measure outcomes, right? That what would probably be ideal is if we could reach back out to any person who ever reached out to us to see how they're doing, right? To ask them how our service impacted them.

However, what we know is our role as a crisis intervention service is we are here to provide someone support in the moment. And our goal, success for us, is that they've committed to safety. If we get to the end of our interaction and they've committed to safety, we have done our job and that is success for us, right? And so really, it's important for those research collaborators to really understand our service, to understand what we determine is success, and then kind of partner and kind of be malleable in how we figure out a way to measure outcomes creatively. So, for example, with one of our projects with Safe Social Spaces, we are accessing public social media sites where people are publicly posting. And so, is there content there that we can engage with, right?

Where we don't have to reach out to an individual because we've done our job with them and we don't reach back out, but there's still meaning to be made. There's still science to advance. And that comes with those partners who really understand the work that we do and are flexible in how to achieve those measurements of our outcomes and success.

RAJEEV RAMCHAND: We're at time. Stephen, I'm going to go five minutes over just so we can get the next two questions, I hope that's okay. He gave me permission earlier in the chat. So, as long as it's okay with you all, we're going to make use of it. Aaron, Arrow, sorry. I want to ask; I just saw your name. I want to ask you, you brought up mobile crisis and I think that's a really interesting example of, and it's something that we haven't discussed much about, about having a peer support specialist go to an acute mobile crisis center. One person in the Q&A is a peer support specialist and says that that person does mostly post-scene kind of, they don't go to the acute kind of scene. And is that normal or is there a model for integrating peer support specialists into an acute kind of mobile crisis, acute scene?

AARON FOSTER: There is a model. It's the Crisis Now model. One of the authors is my partner here, Chuck Browning, which is the model that is being put forth for mobile crisis care and that is a clinician and a peer support. I think one of the things, this really ties in well to this whole discussion because one of the things that we see is around the country, each state has a different definition. Each state says peers can do this or peers cannot do this or the peer advocates within that state say we don't want peers doing this or we want peers doing this. So, each state is different.

I agree with the model that a peer support, if they're trained, if they feel that crisis work is for them and can do it, need to be a part of that team. I always say, people that we support, we don't want to look at like little china dolls like they're going to break if something goes wrong. I think we need to feel the same way about the peers that we work alongside. We're not going to break. You know, we may have some challenges given them, but with correct supervision, with correct support, with our own wellness, we're going to be able to do that. So, I think peers on a mobile team are very important.

I'd like to also say that one thing that will help that a lot is that the Senate right now has an initiative to get peer support, which has never existed on the Department of Labor, on that site, as a distinct job, put through and the House is creating theirs now. Because right now, peer support is viewed as community health worker or psych tech. And having our own Department of Labor code with our own competencies and tasks and everything would really help all these very disparate definitions around the country and in different states saying, yes, you can, no you can't, yes, you can, no you can't. And then a peer moves from one state to the next. And now I'm confused because I was able to do over here, but I can't over here. So, it's an ongoing, Chuck mentioned about that tension.

Just like that, it's an ongoing tension. But I think that, especially with the panelists I'm seeing here, very proud to discuss this beside Craig and Brandon, is if we get together and we continue to move this forward, we can't sit back and say, what is the state going to do? What is the legislator going to do? What is that person going to do? We need to get out there and do just like our predecessors and like some of my idols from the 90s and early 2000s did. It's time for us to stand up and do this and move it forward.

RAJEEV RAMCHAND: Great.

AARON FOSTER: Sorry, now I’m off my soapbox.

RAJEEV RAMCHAND: No, that's great. I'm going to have a last question. Chuck, I'm going to address it. I'm going to have you all chime in and also give you the opportunity for the last word, but we are running a little bit late. And that's a question that's related to what you say. And I realize all people who work in the mental health space, and this was made abundantly clear during COVID when we saw kind of a draining of the workforce for lack of a better term, are encounter stressors and they can experience burnout, things of that nature. But I'm curious, and Brandon, this is something you brought up in your presentation. How do you care for peers who might encounter a traumatic event in the course of crisis work when responding to a mobile crisis call when taking a very challenging phone call? How do you care for your peers? What are the processes in place? And you can't go into all of them with our limited time, but I'm just kind of, where does it fit on your priorities and what do you have in place? So, Chuck, I'll start with you and I'll go quickly down the road.

CHUCK BROWNING: I'll try to be very, very brief. And so, it's a topic we can talk about for a long time. Number one is like, just like Arrow talked about, we really don't feel that our peer support specialists need an extra layer of support protection than a nurse, a clinician, or a psychiatrist or a nurse practitioner in our teams. So, we do, however, think it's really important for all people doing crisis work because it is, it's got its own things that really lead to high levels of burnout, turnover, and things like that to work on self-care, have postvention after events within the team, as well as support by the overall organization. I think that's a really important piece. One other thing I'm going to say that I think is really important that I believe is truly driven by peer support's involvement in our teams when you feel like you're making a difference in crisis and you're seeing people happier, decreased in their crisis, engaged and connected to the work that you're doing and see those results, it makes a huge difference in burnout and making you feel like your work makes a difference every day. And I truly believe that that's something that peer support specially shines in helping make that happen for teams when it's done the right way.

RAJEEV RAMCHAND: Craig, I'm going to go to you. Do you want to answer it or do you want a final word? Whatever.

CRAIG LEETS: Yeah, I think I'll just, yeah, I think emphasize what I said again, that I think youth are already having these conversations among their friend groups. We do have adults in the room who are monitoring every contact and so can step in if a call becomes too acute. However, our youth work one shift a week for about three and a half hours. They're asked to commit to a year, but they're not getting a really serious contact every time they're on shift with us. And when they do, that's why we have a connection with guardians. We have adults do debriefing in the room. We do self-care planning with those individual youth so they're able to process through those challenging contacts that they might have. But our youth are super capable. They're super strong. And we believe that they're totally capable of doing this work.

RAJEEV RAMCHAND: Great. Brandon?

BRANDON WILCOX: Yeah, I ditto everything that was said. I think one of the things that we work to not do is be hypervigilant or overcritical of their work, right? Or of their well-being and their recovery process. We trust their recovery process. We trust all of the plans and all the techniques that they have that have got them to this point. So, I think what I would add is we are willing to have conversations in a supervision space about well-being, around how do you stay well in this work, how do you build safe enough plans to stay safe enough to continue to do this work. So, we make it an integrated part of supervision that we just talk about our well-being in general. We use that across the whole board. That's not just specific to peer support specialists.

We use that to anyone who answers the line at Rocky Mountain Crisis Partners. So again, we're not siloing and or stigmatizing individuals with lived experience. But I will add, I think it's our job as leaders. I am a director to challenge some of the concepts at an organization level that doesn't lead to staff well-being. So, if we don't have good PTO policies or if our bereavement policy is not DEI inclusive or just these things that sometimes doesn't lead to a healthy workforce, it's our job to challenge that. And I've noticed that there's a lot of barriers that prevent for people being well in this work. At an organizational level.

RAJEEV RAMCHAND: Wow, that's powerful. Great. Arrow, last word.

AARON FOSTER: I'm going to double ditto that, Brandon. Sorry to pick you back off of that, but I did what everybody has said here also. And I think also, and you may have mentioned this, Brandon, also that, you know, building in that self-care in the supervision. So, when we talk, we do consulting with organizations that are hiring peers for the first time. One of the first things we talk about is peer supervision isn't that much different than regular supervision. The content of what you talk about aligns with the tasks and the needs of that person. And so that needs to change a bit, but supervision is supervision. If you're given good supervision, you're always talking about wellness and self-care.

RAJEEV RAMCHAND: Great. Well, thank you. There's so many more questions in the Q&A. I'm sorry to those in the audience. I want to just thank Craig, Brandon, Arrow, Chuck for spending time with us today. I want to thank really dynamic discussion and also finally NIMH and specifically Becky and Brendan and Stephen, Lisa and Jane for inviting us all here today. So, look forward to the rest of the day and crisis services part two in a bit. So, thanks so much, everyone.

STEPHEN O’CONNOR: Yeah, thank you so much, Rajeev. So, we're going to take a five-minute break and we'll reconvene at two o'clock so that we stay on schedule with the time for the third and final session. See you soon.

STEPHEN O’CONNOR: Hey, welcome back. We're going to go ahead and start the final session for this workshop. So, I invite Matt Goldman to come on camera and we can pull up the slide.

MATTHEW GOLDMAN: Thank you, Stephen. And hello, everyone. Good morning to the West Coasters. Good afternoon to the East Coasters. And welcome to our final panel session of this fantastic workshop. I'm Matt Goldman. I use he, him pronouns and I'm with the King County Department of Community and Human Services, where I'm the medical director for the Crisis Care Center Levy Initiative here in the Seattle metro area. I am really excited for this final session, which is called Peer Support in Crisis Services Part Two as a follow-up to the session that just concluded. And I'm excited to hear from and then help moderate a discussion with three outstanding panelists. First, we're going to hear from Dr. Christina Labouliere. I hope I got that pronunciation right. With the New York Office of Mental Health. Then Dr. Michael Wilson with the University of Arkansas Medical Sciences. And then finally, Dr. Margie Balfour with Connections Health Solutions in University of Arizona. So, without further ado, I'll hand it over to Christa.

CHRISTA LABOULIERE: Great everybody. Can you see that, Matt?

MATTHEW GOLDMAN: Yes, we see your slides perfectly.

CHRISTA LABOULIERE: All right, awesome. Thank you so much. I'm very excited to be here today to talk about some of the work that we have been doing with RI International with Dr. Browning and Arrow, who presented earlier today on training peer specialists in the safety planning intervention for suicide prevention. We want to talk about feasibility and acceptability of doing this, but also the experience of the providers who were doing this. And so, as we've already talked about widely during the past couple of days, peer specialists have been successfully integrated into a lot of recovery-oriented services, but suicide prevention has been a little behind the curve in regards to that. And whenever we meet with peers, clinicians, administrators, there are always several contributors to why folks are a little leery to include peer supporters in suicide prevention, some of which have already been discussed, lots of fears of contagion or liability or that benign stigma of protecting the peers.

Also, there's been some concern from peers about lack of clarity about their role, not “clinicianizing” peer supporters. We don't have a ton of empirical evidence to validate these concerns, but they keep coming up. And so, we really wanted to do a study to see how acceptable, feasible, and safe was it for us to train peer specialists in an adapted version of the safety planning intervention that could be delivered by peers in crisis settings at RI International. And so, we started out with peers, introducing them to the safety planning intervention. This was something that they were already often doing in their crisis settings, but they hadn't received particular training in it up to this point. RI International provides a lot of training in regards to how to be a good peer, but not as much in regards to the safety planning intervention specifically.

So, me and my team met with folks, this was during COVID, so we did it virtually, to introduce them to what the safety planning intervention is, when it's appropriate to use, and really the goal is to reduce risk during suicidal crises for folks who are presenting in crisis settings. We also really wanted to give folks the orientation that the safety planning intervention is a clinical intervention. So not just orienting peers to filling out the form, but also orienting them to the broader perspective on what the safety planning intervention is, because we really thought this was places that peers would shine. Building a relationship with people, making sure that they're really connecting with them and helping them to problem solve are things that we know that peers do very well. And so, we were hoping that from this orientation, the broader safety planning intervention, not just checking the box and filling that form, would be something that peers would feel could fit within their role.

And so, we had two phases in our study. The first one was really training development. We have trained thousands and thousands of clinicians in the safety planning intervention, but this was really our first time doing a lot of work training peers, training folks with lived experience specifically. And so, we really wanted to go to them and say, what do you need? What's appropriate for your population? What's appropriate within your view of your role? Does this work for you? So, we started out by giving a standard version of the SPI training that we typically give to mental health providers, and then got extensive feedback from the peers who participated. And so, we were very lucky to have 11 peers, as well as the vice president for peer support and empowerment, Lisa St. George, participate in this feedback session. And really, it was similar to what we typically would do with clinicians, but then made sure that we put particular emphasis on are there components of this that you consider to be appropriate?

What would be safe for peers to implement? What aspects would need to be changed or emphasized or de-emphasized to really make this appropriate so that we could adapt the intervention for peers? Now, the nice news was that the training was very well received. Everybody felt that the content was appropriate for delivery for peers, that it was relevant to their role, would be helpful in their work in crisis centers. There was some general feedback, though, on things that we really needed to adapt to make this more appropriate. And so, there was a greater emphasis put on making connection with the individual at risk. One of the things that really came up from a lot of peers was that when they had received safety plans as a consumer in the past, there really wasn't a whole lot of connection or humanity in the room sometimes with clinicians who are rushed or stressed. And so, really taking that time to forge a connection was very important to the peers and thought that it would be a better setting for engaging in safety planning. They also had a lot of recommendations on how to best balance self-disclosure with focus on the individual.

So, knowing when to share their personal experiences to help form that connection or to help flesh out some strategies on the safety plan without taking that emphasis from the individual in need to the peers themselves. They also provided great information on really what peers do best, how instilling hope based on one's own recovery can be a vital part of safety planning that may be unique to the peer experience. Peers were very adamant that handling triggers is already a very important part of being a peer specialist. And so, dealing with suicidality is no different. Peers were quick to reference that many clinicians have lived experience. And so, this view that maybe peers weren't capable or needed to be protected from doing this work wasn't necessarily appropriate, especially for folks who were already working in crisis settings as part of their employment.

They also felt that there was certain language and jargon, things that were included, that they really wanted to change to make this more appropriate to their role so that it didn't sound clinician-y. And we were very open to that kind of feedback. And ultimately, we were able to make adaptations to the training materials, develop a manual for peers, and provide peer-focused training that we administered to a bunch of folks in phase two. So, here's some examples of some recommendations that were made by peers to simplify some of the concepts that are used in safety planning, making them a little bit more user-friendly and peer-friendly. And so, then we rolled out this new training. We delivered it over five virtual training sessions to 76 peer specialists from RI International.

Again, this was during the pandemic, so all the trainings were held virtually, and evaluation materials were collected remotely. And these were all done in like the last couple of years, so data is hot off the presses. What we found, you know, we had a nice, diverse sample of peers who participated in terms of race, ethnicity, gender, wide ranges of experience, with some being very new to the field, some being in the field for longer and having a lot of experience with suicidality. But importantly, all reported a history of serious suicidal ideation or attempt that was at least two years in the past. So, everybody felt like they were stable to do this work, but had this lived experience in their past. We administered a bunch of measures, basically looking at feasibility, their own symptoms of suicidality, if any presented during the training or after, and their positive and negative affect from participating.

And what we found was that although we had a very vulnerable sample historically, where, you know, everybody had suicidal ideation or behavior in their past, rates of ideation did not increase from pre to post training and did not elicit suicidal behavior. More importantly, peers liked it. Positive affect was stable from pre to post training, pretty high. And there were actually increases in some types of positive affect that we weren't expecting. You know, folks were expressing that they felt more interested or more strong after participating in training. While instances of negative affect were low at pre-training, they actually mostly decreased to post-training and significant decreases were found for several emotions, showing that training, you know, was not iatrogenic in any way.

You know, training wasn't eliciting negative affect. And when it came to feasibility and acceptability, you know, folks were very satisfied with the training. They really liked it. And they felt that it was going to be effective for the work that they were doing in crisis settings at RI International. You know, they didn't think that this was unreasonable for peers to do, and they were kind of excited to get out there and try it out. And so ultimately, the take-home message was that, you know, SPI training was not harmful to peers relative to their suicide or their negative affect. If anything, many peers expressed a lot of positive affect and enjoyed participating in the training. Certainly, these were a special level of well-trained peers who were already working in crisis settings, so that may not necessarily generalize to every peer supporter in the world. But within our sample of folks who were already working in crisis settings, they really felt that this was well within their role and that they enjoyed the training with no ill effects.

Participants reported high satisfaction with the training and really felt that they thought it would be effective, appropriate, and suitable for them to conduct with suicidal individuals presenting in their setting. So, ultimately, what I would say is, you know, from the peers' perspective, with quality training, with quality supervision, peer specialists can be safely integrated into these types of suicide prevention efforts in crisis settings. They view their inclusion positively. There wasn't a ton of negative stuff going on. You know, they were really quite pleased to participate, and for the most part, the data showed that there was no negative effects. And they also felt that SPI was in line with their role, that they could potentially bring something to the delivery of safety planning that was unique to peers.

And so, our future directions now are piloting this with folks. You know, as I said, they were already doing safety planning. We're hoping to see, you know, did this training enhance their ability to provide safety planning? And we're following up with them now, you know, a couple of months later to find out how it's going and to also look at the quality and completeness of their safety plans. So I want to give a shout out to my amazing team, you know, certainly the co-developers of the safety planning intervention, Drs. Barbara Stanley and Gregory Brown, who were also co-trainers on this project, as well as our colleagues, my SP-TIE team at Columbia, the New York State Suicide Prevention Center, and our amazing colleagues at RI International, especially the peers who were willing to help us in the development and really co-develop this training. And those are my slides. I will hand the floor to our next presenter.

MICHAEL WILSON: So hello, everyone, and thank you, Dr. Labouliere. That was a fabulous talk. And I kind of like to dovetail right into this or to a lot of the themes that you mentioned. So, for those of you I haven't met yet, my name is Mike Wilson. I am an emergency physician, and I always feel a little bit like I have to apologize for that because I tend to speak way too quickly, tend to use way too many slides, and tend to use lots of pictures. So please bear with me. If there are any questions, I'll try to answer those at the end. Please don't hold that against many of the wonderful organizations that I represent, including the Coalition on Psychiatric Emergencies, which did a lot of work on the stuff that I'm about to tell you about. All right. So, with that, I think we all know why this is important, but it bears repeating anyway. This is some research that actually came out of some collaborators at the NIH, including our friend Michael Schoenbaum. And this study looked at all California data.

This was by Goldman-Mellor. And they found that if you show up in an emergency department with thoughts of self-harm, you are 57 times more likely to die by suicide and 14 times more likely to die from any other cause within one year after visiting the ED. I think we all know this data, but it's worth repeating. This is a huge problem. And so, the question really becomes, I get this a lot whenever I go out to conferences, why aren't you people in the emergency department doing more? And this has oftentimes taken the debate over screening or turned into a debate over screening. And in fact, this was such a controversial question, and the Washington Post got interested in this a couple of years ago. And they interviewed a scientist who I have a tremendous amount of respect for, Dr. Ed Boudreaux. There he is standing in the trauma bay with the bright light shining. Just honestly, just like my last shift, like 12 hours ago, our trauma bays look exactly the same, except theirs look a little bit cleaner.

Anyway, so Dr. Boudreaux said, look, it should be a no brainer. You can save hundreds of lives doing this. And by this, he meant screening. But the amount of pushback has been frustrating. And if this is you, then I'm talking directly to you. Now, a little bit later, if you kind of read through this article, they interviewed a impertinent person at the University of Arkansas who happened to be an assistant professor at the time. I'm kidding, that was me. And I said, look, I happen to be a fan of screening, but the question is, how do you treat folks once they find out or once you find out that they want to hurt themselves, you can't just screen and send them out the door. And then added this phrase, which unfortunately was a little too quotable. Focusing on screening is a little bit like worrying about the lawn catching on fire when the house is burning down. And I think many emergency physicians tend to believe that the emergency departments nationwide are a house on fire.

So, we realized pretty quickly we were not going to be able to make any headway in our suicide prevention efforts in the ED without getting emergency department physicians the data. And this ICARE2 tool, for those of you who have seen it, was a collaborative effort between the American Foundation for Suicide Prevention and the American College of Emergency Physicians. And it was a mnemonic based on a systematic review designed to help emergency physicians know kind of what the steps are. And the mnemonic stands for the different steps. Notice that the first one is identification or screening. And the important point here is that ICARE2 was built on the largest systematic review of ED trials only. It did all of the things I think right in this regard. It got a professional methodologist, got input from key stakeholders, including many of the folks on this call, before publication. And more importantly, it adhered to the Institute of Medicine criteria for creating clinical practice guidelines.

I think for those of you who remain frustrated at emergency departments for not doing more for suicide prevention, have to... I would counter that by saying, look, emergency departments are not going to change based on expert opinions of how they can run their emergency departments better, nor should they. You really have to get emergency department physicians the data. And in this case, a well-done systematic review. So not surprisingly, what we found in ICARE2 was that safety planning, and again, this is ED trials only, is an evidence-based method of reducing suicide risk, exactly as our last speaker just said. Now, no offense to the good Dr. Boudreaux. This is a copy of the Stanley Brown safety plan, which we happen to use at the University of Arkansas. There it is. It's a one pager. Again, I think most people on this call are familiar with that safety plan. But there are a lot of barriers to safety planning. And the first is the feasibility of doing a 20-to-45-minute intervention when we have level one traumas, strokes, MIs.

Last night, for instance, I had a patient who was about to lose a limb from an arterial embolism. Those folks are always, unfortunately, going to get pulled. Our resources are going to get pulled to those folks. But there are other barriers as well, and that is the acceptability by patients and also the time and staffing that goes a little bit to the feasibility as well. Now, not surprisingly, and again, Dr. Labouliere mentioned this, peers may be an innovative solution. And the earliest mention, of course, in literature dates from the late 18th century. Generally, however, the peer movement is attributed to a 1970s resurgence of interest. And of course, the fact that I'm even here at all with these other amazing speakers points to the fact that NIMH in 2024 has taken real interest in this.

So, we decided to do our own randomized control trial to find out if peers could help with safety planning in the emergency department. What we did, we took patients, and we're just, I mean, we're, I think, representative of most EDs in the country. We are a level one trauma center. We see adult pediatrics. We just happen to be in a less resourced, more rural state. So, we took patients who came into the emergency department with thoughts of self-harm, and we randomly assigned them to either peer-delivered safety planning after we did some appropriate training with them along the lines that our last speaker mentioned, or we randomized them to mental health provider-delivered safety planning, which is mostly our psychiatric nurse and or social worker. Now, our sample size was very limited, and we asked for more, but our IRB was quite nervous about us doing a clinical intervention, as you might expect, in folks that were there on one of the worst days of their life. So, we were severely limited to 30 folks. We later convinced them because we had some data loss that I'll show you in a second. We convinced them to let us have a few more, but not many more, and we had to do a lot of justification and interim data analysis to show them that folks were actually doing okay.

So, what did we measure? We measured the feasibility of doing this, and in the ED, that's going to be length of stay, length of stay, length of stay, because, again, we don't have enough beds. No ED does. Last night during my shift, there were approximately 20 folks in the waiting room almost my entire shift, a different 20, of course, but always folks waiting to be seen, but we also measured safety plan completeness, safety plan quality. We measured the acceptability of this to patients, and we measured the preliminary effects, which are mostly going to be ED returns within three months after the ED visit, and, of course, deaths. This is what our flow diagram looked like. We assessed a little under 96 folks for eligibility, and for those of you who are wondering why EDs don't do more safety planning, the number that we excluded was not because our inclusion criteria were too narrow, but because the folks that we approached were, in general, too ill or too intoxicated to participate. The staff objection there usually had to do with the safety for our peers. So, we randomized 37 folks, and we allocated them roughly into 50-50 to either the peer-delivered safety planning or the provider-delivered.

So, what did we find? This slide is busy. I'll draw your attention to the parts I want you to see, and the first is completeness. Folks who got the peer-delivered safety plan had a more complete safety plan than the providers, higher quality, and, again, if you're interested in the methodologic details, I'm happy to tell you how we did it, but we did it using the stuff in the literature, and you'll notice that although it took our peers longer in terms of time to make the plan, the total ED length of stay was not different. That's not too surprising because our peers didn't have any other clinical duties. Now, here's the interesting part. There was no difference in the number of ED visits, no statistically significant difference in the number of ED visits before the intervention, but after the intervention, the folks in the provider group made slightly more visits while folks in the peer group made slightly fewer, so when you analyze the difference, it'll turn out significant, and I'll show you that in a second, and then finally what you see below that box is that our patients liked making the safety plan equally well between groups.

That wasn't statistically significant. There may have been a trend to liking a little bit more with the peers. So, as I mentioned, ED return visits, there was no significant difference between the groups, but there was a significant decrease from three months before to three months after, but that was for peer safety planning only, not for provider safety planning. And there were no deaths in either group, but again, it was a very small sample by design of the IRB. If you are interested in the longer detail of this, it is published. This came out in Psychiatric Services. Here is the reference down at the bottom, and I'm proud to announce that we actually won the American Foundation for Suicide Prevention Award for this. I promise that's me under the text there. For some reason, they didn't cover up my collaborators, but they did cover up me, but I promise that's me underneath. And I'll sum up here, and that is safety planning may help reduce suicide risk. That's the experimental evidence is a lot less strong than you would think, particularly in the ED setting. However, based on ED trials, it does appear that safety planning will help reduce that risk if patients are able to cooperate with it, and remember I showed you that flow diagram that a significant number of the folks we approached simply weren't able to.

Now, even though this is an evidence-based practice, it's often difficult to do in the emergency department setting, but it is feasible and acceptable for peers to help with safety planning and may be associated with fewer ED returns, and I'm going to put a big asterisk on maybe because our sample size was so small. Of course, if you have any questions, my email address is there, and I am happy to either answer questions if we have a little bit of time left over or wait until the panel.  All right, I have two minutes before I turn it over to Dr. Balfour for your next, so I'll at least answer the first question, which is, is safety planning the same as advanced directives, and no, it is not. Safety planning is a cognitive intervention. It's a clinical intervention, as Dr. Labouliere mentioned, and its sole purpose is to help the patient or the individual come up with strategies to help manage, if you will, suicidal crises in the future, and then one last question, what were youth or pediatric age people included in this study? The answer is no, unfortunately, so with that, I'd like to turn over to my colleague, Dr. Balfour, also from the Coalition on Psych Emergencies.

MARGIE BALFOUR: Hi, and thanks for having me, and so my name is Margie Balfour. I'm a psychiatrist with Connections Health Solutions. We operate crisis centers in Arizona with others underway in other states, and when I first met with Stephen talking about, you know, what do we want to talk about in this session, I started kind of running through our crisis system and all of the places that peers work and said, well, which one do you want me to talk about? He said, I want you to talk about that, so, you know, we have peers all woven throughout our crisis system, and those of you who are kind of steeped in crisis services may have seen versions of this graphic. It's been borrowed for a lot of PowerPoints and white papers and things, but it's actually based on the Southern Arizona crisis system. Those are real numbers from our regional behavioral health authority, and it kind of shows how when you look at a crisis system, it's not just a program here or there.

It's really a system, a coordinated system with multiple parts and multiple partners, and they're all aligned towards this common goal, or should be, of getting people the care they need in the least restrictive setting or the most community-integrated setting, and so if you think about it, you can organize the crisis services along this continuum of least restrictive to most restrictive, so first you've got your crisis lines, then mobile crisis, then crisis facilities, and then after the crisis, post-crisis wraparound and crisis residential respite for some folks, and then also at every point along here, you want easy access for law enforcement because people with behavioral health emergencies, they have a lot of potentially bad outcomes. A quarter of officers involved in shootings involve a mental health emergency. People with behavioral health issues and diagnoses are way overrepresented in our jails and prisons, so we also want to have easy access for law enforcement or they can divert those people into this care pathway instead.

And so I'm going to kind of talk about throughout this system where different peers and programs work, and also the way our system is organized is we have a single behavioral health, a regional behavioral health authority that gets all the Medicaid funds, the SAMHSA funds, state and local funds, and then they subcontract with all of us providers, and we all together work towards these goals with the behavioral health authority coordinating things. And so, I'm going to be talking about some things that we do but many things that it's our partners doing this, and so, they've graciously loaned me some slides to be able to do that, And first with our crisis line, so back to this slide, we've had a crisis line established in Arizona for a very long time, 988 now points to it, but in addition to that, and we heard some detail about how operationally a warm line like this might operate. But there is an organization called Hope Incorporated that's a peer-run organization. And they run a warm line on the hours, or it's not 24 hours, but it's a lot of hours. And so that's for anyone who can call and just they need someone to talk to, need some support, when looking at our whole system.

And we've got some various groups that work on high utilizers, frequent callers, things like that. One way to help those people who continuously call the crisis line or come to the crisis facilities, sometimes connecting them to this warm line was the thing that they needed where they actually started reaching out to the warm line and getting peer support instead of needing some higher-level crisis services. So, they do great work. And then mobile crisis, so we've got in our county, Pima County, which is about a million people. We've got about 16 mobile crisis teams, they operate 24-7, they're two-person teams, they have performance measures on there about how fast they have to respond, and they are able to resolve most of the crises out in the field, about 70%, if they see someone in the field and do an intervention, they can get that person connected to what they need without needing to bring them to an ER or a crisis center.

And then as of, I think, last year, there's a new state requirement that says that 25% of these teams must have a peer on them. So, we've got peers working in that setting for the last year, and it's been going well. And then when you talk about mobile crisis teams, it was brought up, I think, in the last session, right now, with crisis services, a lot of this stuff is still in evolution and still in development, and this graph is a slide borrowed from our esteemed moderator, Dr. Matt Goldman, where they did a survey of mobile crisis teams around the country. And one of the things they asked is who are on your mobile crisis teams, and so you can see there's this broad mix of different types of professions, but peers are the third most common team member. And right now, we're talking about research questions, what combination is best and for which populations and for which situations, and I think those are some research questions that we need some studies to start to ferret that out.

One thing that's been recommended, these are links to a couple of white papers from Fountain House and the Vera Institute for Justice that is very much in favor of having peers as being part of a mobile crisis response. And one of those is when we talk about equity and having the people who are providing services look like and be part of the community that they're serving, just sort of the facts of who tends to be master's level clinicians, it's mostly younger white women, and that's not the whole world. And so having peers on mobile crisis teams is one way to start to have a workforce that is more similar to the environment that you're serving. And then when we talk about crisis stabilization centers, right now, there's a huge variability in crisis stabilization centers. I mean, almost so that I kind of sometimes say that the term crisis stabilization unit is pretty much meaningless because if you ask 50 different states what is a crisis stabilization unit, you're going to get 50 different answers right now. And there's a lot of work going on at SAMHSA to start to create some definitions and standards, but this was my attempt to try to put some things into some buckets as to what exists currently. And you've got some, on the right end over here, you've got the crisis facilities that are really meant for low-acuity people and living rooms and peer respites and crisis respites that are mostly peer-staffed would kind of fit over here. And so by definition, there's a lot of peers in those settings. And then on the other end of the spectrum, you've got really high-acuity centers, so people who are danger to self, danger to others, acutely psychotic, agitated, potentially violent, in need of withdrawal management, like medically managed withdrawal management. So those settings, you can have peers in those settings as well, and I think when you are talking about crisis systems and designing a system, you want to have a continuum of these sorts of facilities. No one is better than the other. They serve different roles, and one thing I do get kind of concerned about as people are starting to stand up crisis systems is that they sometimes want to leave out this high-acuity group, saying, oh, well, those are too acute.

They need to go to the emergency room, or involuntary people still need to go to the emergency room. And I think those people are most in need of a specialized mental health setting, and so we need to have facilities that can serve those folks as well, but you can totally have peer support in those settings. This is data from our crisis center in Tucson, and one of the things that you also hear in the crisis world is you need a no-wrong-door approach. And what that means in practice is that you need to be able to take everyone. Sometimes mental health facilities have a reputation for being easier to have than to get into a mental health facility because of all these exclusionary criteria, too intoxicated, too violent, et cetera. And we want those folks, and we want law enforcement to use these crisis centers so that it's easier to drop someone off with us rather than to book them into jail, but it also means we can never turn the police away, and we need to get them out, get the officer back on the street as quick as possible.

And then we want to provide engaging and recovery-oriented services to even this high-acuity group. So, we don't use security. We have staff that are specially trained to be able to help manage de-escalate and things like that. And so this is kind of an example of how even with this really high-acuity population that peers can make a substantial difference. So, this is seclusion rates compared to what the national average is for inpatient units, and a crisis center is actually more acute than an inpatient unit because if you think about it, no one gets to an inpatient unit without having been stabilized in an emergency room first. Whereas these folks are coming directly from the street, often intoxicated with methamphetamine and other substances. And so we were looking at our rates of using seclusion restraint, which we don't like to do, but we do have it as a last resort because if you can't do that, then you turn away everyone who might need seclusion or restraint, and then they end up in the ER where they're more likely to be seclusion, being a secluded restraint. So, we created a new intake process to try to decrease this because we noticed that most of our seclusion restraints were happening in that first 30 minutes when the person first got there. And so, adding a peer to that intake process, we helped bring that down so that we're below inpatient national averages even though our population is more acute. As far as what else peers are doing, they're doing a ton.

This is a brochure that some of our peers created a while back that talks about the sorts of groups that they do and the interactions that they do and the things they focus on. They're also circulating all around. As was mentioned in the last session, sometimes if I'm seeing someone who's had, say someone's struggling with their kids being taken by DCS, and I know of a peer who's had that experience, you can say, oh, well, let's have you talk to Jane because she's had that happen before. And it really changes the culture, and this was sort of alluded to in that last session too, and we have people who started off working for us as peers, but now they've moved on into other roles in the organization, but it's not like that peer part of their brain turns off, so I think it adds a lot to the culture. I also wonder, I would love for someone to research this. I think that it makes other staff who have lived experience but aren't officially peer specialists be more open about disclosing their own experience, and I think that's a really good thing.

We are working on, we're collaborating with Dr. Pisani, Dr. Lockman, who are doing the THRIVE study that is a group intervention that involves peer support. It's a safety planning type intervention. And what I love about this study is it wasn't just, okay, here's this thing we want you to do, and just do it, and no matter how much it disrupts your workflow or whether it's feasible. The first aim was actually to come in and study the process of how it works in a high-acuity crisis setting and then figure out how best to adapt the intervention to fit in the existing workflow. And then so we've just finished that now, and so now we're just about to start aim two, which sort of tests whether it's feasible, and then aim three is a randomized controlled trial.

Just in the interest of time, just going to go through this quickly, but this is some information about what the actual group focuses on. And then afterwards there will be a component where peers are doing follow-up phone calls and follow-up outreach to help post-crisis to give them additional coaching post-discharge. This is a schematic that kind of shows in our crisis system kind of the interaction that we have with law enforcement. And there's opportunity, and peers are working in these settings also, so most of what we talked about today is focusing on this orange part, which is the acute crisis where there's a high sense of urgency and there needs to be some kind of intervention. And so, if there's no safety issue, that should be completely the role of the mental health system. So, that's that bottom right quadrant where we've got our crisis lines and mobile teams and facilities. And then when there is a safety issue, our law enforcement may respond, but they may call the mobile crisis to assist with them. And there may be peers involved in that process. But for the blue part is a part that we don't focus on quite as much, but after the crisis, as the crisis is resolving, there's opportunity for outreach and continued navigation and engagement so that it doesn't escalate and evolve into another crisis.

And so, again, if there's no safety issue, then that should be completely the responsibility of the behavioral health system. So that's that bottom left quadrant where we heard, you know, one of the presenters from before talked about some post-hospitalization follow-up, and, you know, we have a clinic up in Phoenix that does a similar thing. But then if there is a safety issue, that's where we've got in our system, peers who are working with the law enforcement. So, this is some data from a peer-run organization, that same one that runs the Warm Line, that does post-crisis follow-up for people coming out of our center and others that shows the reduction, it's a pilot that they did that shows the reduction in service utilization before, during, and after when they did their navigation with them. And it shows it can make a significant impact, and that's definitely something that needs to be studied more. And then with law enforcement, there's multiple teams where there are co-responders of these specialized mental health teams that are plain clothes, unmarked cars, that are doing outreach and follow-up for special populations. So, the mental health support team is focused on when there may be a threat to public safety. And when they added mobile crisis clinicians, they were able to bring the percent that they needed to take somewhere to hospitalize down from 60 to 20%, because they were able to get them connected to care as outpatients. That program went away during COVID.

We've recently gotten a DOJ grant to bring it back, but we're going to do it with peers, and it'll be peers from our organization working with that special team. There's a substance use deflection program where law enforcement can, has the discretion to not arrest people for certain amounts of substances. There was a grant that was through SAMHSA for another organization called Kodak to have a peer go with them and do outreach and follow-ups centered around most of the opiate crisis, but other, other substances too. And there was an evaluation of that that showed that they really were connecting people to treatment rather than arrest. And then there's a homeless outreach team where there's peers who have lived experience of homelessness that work with an agency called Old Pueblo, where they go out with law enforcement and do outreach there. So, there's lots of opportunity for peers.

And then for people coming out of jail, you can think of jail as similar to when we talk about post-hospital, the need for navigation coming out of the hospital, where you need that probably even more coming out of jail. Where your benefits have been turned off and you're at high risk of, of ending up back in jail if you don't meet all of your, go to every single appointment and all those things. And so that same organization Hope Incorporated does really great work where they go into the jails and meet with people and help follow them and navigate afterwards. So, there's a, you know, the before someone said, you know, we need to stop asking, you know, should peers work in crisis settings and more ask, can they work? And they are working in crisis settings. And so, I think, you know, more of it's a question of, you know, start to define, well, what should they be, you know, what are they best matched at which programs you know, which programs work best for which populations in which situations, just like any other intervention. I think, you know, they're, they're already interwoven in the fabric of crisis services. And if you're more interested in thinking about crisis is from a, from a systems perspective, there's a link in a QR code for a report called the roadmap to the ideal crisis system that kind of talks how, talks about how you look at a crisis system kind of comprehensively. So, with that, I'm looking forward to the panel discussion.

MATTHEW GOLDMAN: Fantastic. That was an awesome set of presentations. So, thank you so much everyone for your participation and for sharing. We have quite a few really good questions in the Q&A, which we'll get to in a moment. And I also have a couple additional questions for follow-up. But I just wanted to share first as sort of in the moderator role, a few reactions, a few themes that I heard, and also to describe a bit about what we're doing here in King County and the Seattle metro area because peer specialists are a big part of our initiative as well. And so just sort of as a, as an extra example of a program that's really, you know, leaning into this space. So, first just a summary of some of the points that I heard that resonated really across the presentations. So, first I think that there is a forming consensus that peers should really be a part of crisis response. That seems like, you know, it's clear in the evidence that we've heard from, as well as many of these thought piece sort of reports that are being released by various important institutions.

So, just wanted to say that out loud. Sometimes the obvious thing gets buried, but that is clear here. Some really important pieces that I heard that I wanted to amplify one that peer specialists are not unique in having lived experience. Other clinicians also have lived experience in mental health and substance use. And so, for that reason, sort of concerns about additional sensitivities around peers are often misplaced. Of course, we need to support our workforce in all of our different components of our workforce and peers should not be an exception to that. There was, I think an important point around peers being partners in developing new initiatives to make materials more accessible. So, sort of, you know, digesting materials around safety planning, for example, and asking for feedback about language. I thought that was a great example to, you know, really highlight, you know, how do we make these kinds of interventions make sense and, and ensure accessibility.

You know, I think just to put some of what we heard in context, the idea of having peers play an important role in safety planning is partially the idea of task shifting. So, you know, we are in a workforce crisis in behavioral health we are at large. And there's a lot of different ideas around team-based care and task shifting, meaning how do we make sure that there are, you know, more readily available workforces to help with some of these key functions that the current workforce is just totally not able to keep up with. And I think, you know, the idea of having peers play an important role in that has clearly come up here and I think is, is important food for thought. Another thing that was clear was around peers being a workforce. Speaking of workforce that can help address the need for a representative workforce, meaning having behavioral health workforce that really represents the people that we're trying to serve. And given that peers often are a more diverse group than clinical providers that that's, it's, you know, an important pathway for increasing the representativeness of the behavioral health workforce.

And, and also just to add, that's not only because, you know, I think that intrinsically is an important thing and a good idea. There is also an evidence base for culturally congruent care and evidence demonstrating that people who are seeking care often feel more comfortable seeking that care from providers who do have a race slash ethnicity match to their own personal identities. And so, this is not just a nice to have, this is a, you know, a critical factor for treatment outcomes. And, and again, peers being sort of a pathway to making that more possible. I think the last thing to say is there's absolutely a need for more research in this area that was called out at various different points. And that's not necessarily a clear path. I think some of what we heard from Dr. Wilson was that the IRB had concerns about some of the research that was being done. And, and there are some, I think, structural factors for us to consider in terms of our institutions, as we're actually trying to implement some research studies that, that there, you know, we need to work towards normalizing some of this work, given the clear opportunities and the importance of, of peers in suicide prevention activities, including in crisis services. So just some reflections there.

I think that with all of that said, I do want to share a little bit about what we're doing here in King County. And also, to say, we're, we're going to go until the half hour. So, we've got like 37 minutes more to go here. So, we should have robust time for discussion. And so, I hope it's okay to take a few minutes. This is also Stephen O'Connor prompting me to share a little bit about, about what we're doing here in King County. So, I'm happy to. So, the voters of King County in April of last year approved a property tax levy to fund the creation of five crisis care centers across the County. This will provide robust funding to the tune of over $1 billion to support the creation of five crisis care centers, as well as expanding and restoring to historic levels, our residential treatment facility capacity, as well as investing deeply in our behavioral health workforce for some of the workforce reasons that I was describing a moment ago. And what this opportunity includes, I mean, there's a lot to it, and I'm not going to get into all the details, but I do want to emphasize that these crisis care centers are really meant to be a place for people to go when they're in a mental health or substance use related crisis.

Currently King County does not have a front door to care. And so, if anybody rich or poor, you know, whatever scope needs they needed were to look for a place to physically go, you know, anytime, day or night, the only real front door is the emergency room where of course many people might end up in the jails. If you know, there was a chargeable offense, or many people just don't access any help at all. And so, the, the creation of these crisis care centers is, I think really a demonstration of the, you know, urgency of creating that somewhere safe to go in the crisis continuum. And the crisis care centers as we're developing them here in King County include behavioral health urgent care, that's open 24-7. They'll include a 23-hour observation unit. That's at that higher acuity end of care from that excellent slide that Margie shared about sort of what are the different flavors of a crisis stabilization unit. And then there's also going to be a 14-day crisis stabilization unit for those who need more than just that 23-hour stay. And so really multiple options. And then importantly, there's also a follow-up program, a post-crisis follow-up program. Peer specialists are going to play an essential role in every component of this program.

So there's going to be peers who are at the front door of the program, sort of part of that peer first philosophy, where one of the first people to greet somebody as, as somebody comes into the crisis care center will be a person with lived experience to immediately initiate that engagement and really helping somebody, you know, feel comfortable and seen in what otherwise might be a very intimidating and scary space to enter into of one's own volition. There's going to be peers in that acute care setting. So, this is, I think, highly aligned with what Margie described in terms of, you know, in these, in these higher, you know, acuity settings, having peers play an important role in supporting folks, you know, helping again, focus on engagement and identifying needs, helping support people in what might be a very intense experience. And then also having peers be in that 14-day unit. But then also I think just as importantly, if not the most important in some clinical sense, this is my bias showing here that post-crisis follow-up program will include peers, which this is meant to be a model that includes care coordination and peer support, really with the focus on continuously engaging people in the aftermath of a crisis and helping people navigate to referrals and services that they might need. You know, we know that there are major challenges and engaging people in the aftermath of a crisis access to behavioral health care can be quite challenging and complicated.

And so having the peers who have that ability to connect with people who are in need at that time of great vulnerability is, you know, I think we're, we're very excited to launch that component of our program as well. So, I'm excited to share that and I've learned a lot today and in this workshop overall. So, thank you to our panelists and to the other workshops for helping inform how I'm thinking about helping design this program here in King County. But hopefully that's of interest to you all. So, with that, let's pivot to some of the questions. I'll start with the ones in the Q&A and then pending time, if we've still got time for it, I've got a few additional ones that we can add. And I invite my co-panelists to come back on camera here if you want to participate in the conversation. So, our first question that came from Peggy Garcia, I see Margie, you were typing an answer, but you might have a chance here to, to share with your, your words as well. So, in the mobile crisis intervention team through the Pima County prosecutors, is that a program through Pima County prosecutor's office still running? And if they are, are they connected to the behavioral health and peer supporter crisis teams?

MARGIE BALFOUR: Yeah, I don't think so. But the County is doing a ton of cool stuff around the reducing justice involvement. And a lot of it does involve peers as well, which I didn't have a chance to get into. So, in addition to that post-crisis follow-up where the peers go into jail and then help them navigate and make sure they make all their appearances and things like that. There's also a program that started with the SAMHSA grant called INVEST, which is an acronym and I can't remember what it stands for, but they have folks who go into the jail that focus on people who are potentially high risk for future misdemeanors. And then the newest thing that is really cool that should be opening soon is what they call their transition center. So, they've done so much work on trying to divert people with behavioral health needs out of being booked into jail that it's almost like too fast. And they're still kind of, you know, especially people who are intoxicated are still, they're kind of not, it's not enough time to really engage them. And so, they have this new transition center where on your way out of the jail, there will be various agencies there as well as a lot, a big peer presence and there'll be the ability for them to spend more time there and, you know, be engaged and hopefully get connected to services they need that are going to keep them from cycling through.

So not that program, I don't think anymore, mostly acute crisis response all goes to the behavioral health system, but they're doing some really cool, innovative things. Also, the city has a civilian and you're seeing this more, more and more, especially with all the emphasis on trying to get law enforcement away from responding to these mental health issues that can result in these tragic outcomes. They are creating a civilian kind of response team and how that works with what already exists.

You know, that's, I think communities around the country are kind of going to need to grapple with this kind of stuff is, well, what's part of the behavioral health system? What is part of the law enforcement system and, you know, how do those two interact?

MATTHEW GOLDMAN: Thank you, Margie. There's another question, which the question is, are the crisis response teams always male and female? And I think reading into that a little bit more if anybody has any thoughts on the gender matching versus ensuring that there's sort of opportunity for gender match with both male and female options. Also, I would add thinking about gender diverse populations as, you know, a key audience who of course has super high risk of suicidality and how gender sort of more broadly is approached in crisis response. I'm curious on any thoughts from the panelists. And I think we Stephen also added that we could also open this up to other previous sessions panelists as well. If anybody has anything to add in there.

MARGIE BALFOUR: Yeah, I know the team that I showed, I think that maybe that came up because I showed a very photogenic crisis team that was male and female. I think that would be great, but I think the realities of staffing because I mean, there's so much staffing strain that I don't know how feasible that is given the current workforce, but when there's situations where having a specific type of mobile team or a specific composition of mobile team for a specific response, I think there's opportunity to try to do that. Well, which team is available and who can go, that's known about that particular situation. But I think most of the mental health crisis world, most of the mental health world, I think like many industries is having staffing challenges that make some of those things difficult to do in practice. If anyone wants to chime in.

MATTHEW GOLDMAN: Thoughts from others on that one? Yeah, no, I agree with you Margie. I think it's in an ideal world, yes. And there are limitations there just based on the reality of workforce. But I think certainly that can and should be a factor when thinking about staffing decisions in sort of the day-to-day basis. There was another sort of comment that I'll frame up as a question. A participant described a program that they've been involved in and this is related to a respite. And they said that they'll accept people at their respite who are talking quite actively about suicide, have a plan or self-injuring, hearing distress voices. And so, they felt that they were worried that it's not an accurate statement to suggest that peer respite fits only in the low acuity segment. And so, I think Margie, that was in response to your types of settings slide, I'm curious.

MARGIE BALFOUR: Yeah. And that's like a slide that's still, you know, like a model in my brain, I guess, that's still like in development. I used to have it say lower acuity and I probably should put it back that way because to your point, you know, they're not necessarily low acuity people. But there are a population of people that could not be served in that situation and would, you know, if there's nothing else there, you know, they would end up in an emergency room. So, I think it's important to distinguish that all crisis facilities are not the same. I think it's great. I think you want a full continuum because I think the thing about what we do in our crisis centers, if you didn't need that level of intervention that might be overkill and maybe not the best experience. And so, I certainly don't mean to discount what other, you know, the other different levels of acuity for crisis centers, but I think we do need to clearly distinguish kind of like you've got level one trauma center, level two, you know, for, for traumas.

You know, there's, there needs to be a clear understanding of the population that can and can't be served at each facility so that one, you can plan a crisis system just like communities plan their trauma system to make sure that there's a level one trauma center, but then there's closer, you know, other ones. But also then, so you can figure out how to reimburse and pay because they may be staffed differently. And so, I think, and then for safety, if you want to make sure that you've got the population matched to the service intensity, but, but yes, I mean, more like peer run respite type places, you know, certainly do take people who are actively hearing voices and actively suicidal. I just think it's important that that a community have the full range of options so that no one has to go to the emergency room because they're behaviorally too acute, medically too acute. Yeah, that makes sense. But if it's because they are behaviorally too acute or because of their involuntary legal status, that shouldn't necessitate a visit to the emergency room because the mental health system can't handle it.

MICHAEL WILSON: I'll just, I'll just respond to that. And, and, and Margie and I know have known each other for years and have great respect for, and we've had this conversation as well. People are going to come to the emergency department anyway, right? It doesn't matter how many correct, what wealth of crisis services you, you build, we're still going to get some section of folks who, who come in. So I pushed back on the, you know, have to, it would be nice if folks didn't feel like they needed to be in an emergency department to be able to seek treatment somewhere else, but there's, there's still going to come, especially in lower resourced areas like the one I work in where we will, the, the need will always outstrip the supply.  But Margie, you can feel free as in past occasions to tell me I'm wrong.

MARGIE BALFOUR: So, no, you're absolutely right. And that's another thing too. I think when we're talking about crisis facilities and all this money and resources are being pulled, poured in to building out a crisis continuum, some of these crisis facilities should be attached to EDS. Like if you, there's a term empath unit that it's kind of meant to, it talks, it describes kind of what I described, what we do as a freestanding unit. But in this case, it's attached to the hospital under a hospital license. And I worry sometimes about that getting left out because it's traditionally not been under SAMHSA's purview to, you know, talk about you.

It's mostly, it's community-based, but if you, especially in a rural area, if you don't have the, the resources to, it's not sustainable to have a freestanding high acuity crisis center. It should be attached to the ED for economies of scale. And like, and to Mike's point, people are going to go to the ER regardless. And they may need to be there because they have a medical issue, but that doesn't mean like those people need a specialized behavioral health setting as well. Not just a holding area to hold them while they get shipped off to a psych hospital across town to actually provide engagement and treatment. And that absolutely should be the same type of interdisciplinary care that we're talking about in the freestanding units where, where peers are very much involved.

MATTHEW GOLDMAN: Great. Thank you. Another good question, I think for everyone here unless Christa, I saw you just come off mute if you want to add something.

CHRISTA LABOULIERE: Yeah. I just wanted to add in that context of the prior question that like we have to be careful of just thinking of this as task shifting, you know, like, because I don't actually think of it as task shifting, you know, like to some extent in, in some of the things, you know, especially the things I'm describing, you know, a lot of times in these settings, this is something a clinician traditionally would do and now peers are doing. But I don't know that that is the same experience.

And I think that that's something that we're gathering data on, but I think especially if we're talking about, you know, adjunctives to the emergency department or diverting folks from the emergency department.  I think we have an opportunity here for these peer-based services to be a different thing, even if they are utilizing some of the same skillset. And so, I just wanted to put that out there that like, when we're talking about things like staffing shortages and, you know, diverting from the ED, these are very real concerns. And also, I think there is a role for peers to do a job that otherwise could not be fulfilled necessarily by physicians and mental health professionals, both because of the limitations of the workforce and also because of something special that peers can bring to the table.

MATTHEW GOLDMAN: Thanks for that, Christa. And it's, it's a point well taken, and I think very important consideration. I'm going to ask my own question here, because that's sort of teed up with something that I was really wondering, both hearing your presentation and also Dr. Wilson's is there was a SAMHSA report that came out a little while ago, which basically describes, you know, the role for peers in crisis settings. I don't know if this is on your radar. I'll share the link in the chat, although I don't know if that's just for us internally or if this would go to everyone. But if there's a way for it to go to everyone, that's it. It's an excellent report that I think is very relevant to hear. And there's a significant discussion in this report on the role for peers in crisis services that SAMHSA put out around this concept of peer drift. And it describes both organizational peer drift and individual peer drift.

This might be familiar, including sort of the role for peers, I think in both directions, there's some, you know, I think plenty of experience where peers working in clinical settings have found that they end up not actually getting to serve a meaningful peer role and end up being stuck with sort of menial tasks in a way that's not realizing the full value of their role. And then there's also sort of the flip side where peers end up sort of aligning in their roles more with others in the team, like clinicians and end up taking on clinical roles that might actually be out of scope for what they would feel comfortable with or prefer doing. And so, I've been sort of trying to understand that and balance that hearing, you know, of course, safety planning is absolutely a clinical intervention. I agree with that statement. And so how, did you hear any feedback from peers in both of your initiatives, or is this, how did you sort of navigate that tension with the idea of peer drift into these more clinical roles when that's not, per se, at least historically been sort of squarely within the peer role as it's been defined in resources like the SAMHSA document?

CHRISTA LABOULIERE:  I mean, I think Arrow and Chuck might actually have the best answer to this given that they know RI International so well. But at least for the teams that we were working with, these were folks that were already doing this. It was part of their employment in their role as peer supporters. That was what they were doing. They were just kind of doing it on the fly without a ton of training. And so, we were not coming in with the idea of giving a clinician-based task to peers.

We were meeting with a group of people that were already doing this task and wanted to try to make it, you know, certainly provide them with some more skills for how to do a good job with safety planning, but also to see how we could make this task more peer like and how that would fit better within their role. So, I think that's a unique situation. You know, in a lot of places peers are not already doing safety planning and that may be outside of the scope of what they feel comfortable doing. But certainly, what we were hearing from folks at RI International is that they were really grateful to get the chance to learn how to do this well and to weigh in on how to do it more like a peer than, you know, just kind of being like thrown into a crisis setting and having to do this on their own.

MICHAEL WILSON: Matt, I'm sorry, I got a little lost in the question. Do I understand correctly? You were asking how did we keep peers doing the thing that we wanted them to do i.e. safety planning during the trial? Was that the essence of your question?

MATTHEW GOLDMAN: It was a little different. It was more like safety planning, I think, because it's a clinical intervention there. I think historically peer specialists have not played such an explicitly clinical role in suicide prevention and in crisis response. And so this is, this could be perceived as a deviation from that to have peers directly involved in this clinical intervention of safety planning. And I'm wondering if that was an issue there, or if, you know, if you got any feedback from the peers who were working in the emergency departments about feeling comfortable or uncomfortable doing this kind of intervention.

MICHAEL WILSON: Yes. Did you want me to expand on that? So, we got a ton of feedback.

MATTHEW GOLDMAN: Should have been open-ended.

MICHAEL WILSON: Yes. Is the short answer to your question. So, we got a ton of feedback before we did the trial, both from folks who were knowledgeable about safety planning, that perhaps we should really be reconsidering doing this with peers. And we got some feedback from some of the peers that like, why are you asking us to do a clinical intervention? We are nonclinical folks. And so, there were so many people telling us we shouldn't be doing this trial, that we didn't really attempt to fight the small sample size by the IRB all that much, because we're like, we may be the only ones who think that peers can do this successfully. So, yeah, I mean, I think it, it reconceptualize, you have to reconceptualize. And if you're going to use words like clinical intervention, that could mean anything from intubation to a central line, to a cardioversion, to a physical exam. But if we're going to use a word like collaborative intervention, which I arguably think safety planning is a lot more like than a central line, then that is well within the peer scope of practice.

MATTHEW GOLDMAN: Thanks for that, Mike. And I think your real experience of actually implementing this program is, is good support of that. Christa, I thought you'd come off mute and Chuck also just raised a hand.

CHRISTA LABOULIERE:  I mean, part of the, I feel like part of the collaboration that developed between Dr. Browning, Aaron, RI International and our team came from some of the resistance that we had faced in incorporating peers in our other suicide prevention. And then we met at a conference, and they came up to us and were like, oh yeah, we're already doing this. And we were like, oh wow. Because so many people here in New York state were concerned about the peers about whether this was congruent with their role. Clinicians were concerned, you know, we faced a lot of concerns both from our IRB and from clinical partners. And then we met somebody who was already doing it and they were doing it very well. And I think like part of why we decided to partner was that we wanted to see like, okay, in this, in this setting where you're already doing this, where folks have agreed to do this, how do they feel about doing it? And really it was very, very eye-opening to just hear from peers how this completely changed their conceptualization of safety planning, like what they had experienced before, what they thought of safety planning was actually very, very different than their experience of participating in this training and how they hope to approach safety planning with folks going forward. And I think that's really important.

You know, that qualitative piece, you know, there is a “peerization”, you know, of this process where, you know, like a good clinician should already be making this process collaborative, should already be listening to their clients and letting them inform. But sometimes that goes to the wayside. And I think these are places where peers really shine. And if they can also bring their own experience of how this has worked for them. You know, these are unique things that are not necessarily part of the clinical intervention but may be critical components of the collaborative intervention.

MATTHEW GOLDMAN: Really appreciate that. I think we've got 12 minutes left, Dr. Chuck, why don't you close us out on this topic and then we'll take a few of the other questions. We've got a lot of great stuff coming in.

CHUCK BROWNING: I did not mean to jump back in on the second panel, but there was a lot of discussion.

MATTHEW GOLDMAN: No, no, no, please. You're invited. We'd love to hear from you.

CHUCK BROWNING: So, you know, in the, in the grand scheme of things that are crisis services, the majority of our safety planning is done by licensed clinicians, but in our, in our discussion from our peer leadership on our executive team and in the training departments, a big thought process of that and where it was being done in some of our services was that it was aligned very similarly to working on a wrap plan with people. The steps were so fine and so similar that their job was not that appear support specialist job was not to do an assessment of anyone's safety. It was to do the collaborative work and using those same principles and things in the excellent way that they do that in helping collaborate with a person on the elements of their warning signs and those types of structures that they would do to react to that in a very similar manner. And so, when this was being presented and talking about the concepts of peers doing this at a AAS meeting way, way back years ago, we approached Barbara to talk about is it, does it make sense to us to take a look at it and study it and see what would be the pros and cons and evaluating that. So that was a, that's my memory about that that went through and I've actually, we've been really pleased with the impact of, of, of that. And in working specifically on like Christa said on shaping it to be very peer support specialist training driven in the way that you would do safety planning.

MATTHEW GOLDMAN: Thanks. There is a robust discussion in the chat, some really good points and thoughts and reactions to this conversation. So, I encourage people to look at the Q&A for some additional ideas from, from Brenda, from Doug and an additional attendee. Thank you for those comments. Okay. To change gears a little bit, clearly there's a lot to say about that one, but I do want to get to a couple of the other comments. So, one question was how would you speakers see the role of peer supporters in crisis services? So, helplines, emergency departments, crisis centers to support longer term needs is the goal on specialty care linkage, which are currently limited in supply. So, any thoughts on sort of linking what happens next role for peers there, especially given limited referral options that anybody has some thoughts on.

MARGIE BALFOUR: Yeah. I mean, our in our Phoenix facility, we started what we call our transitions program kind of for that reason. Because, you know, you have crisis programs and they have all their rules and regs and how they operate. And, you know, your crisis doesn't flip off at 23 hours and 59 minutes, because that's what is Medicaid billing for 23-hour ops, right? Yet people are told to go interact with the healthcare system, just like they weren't immediately in crisis, you know, a few hours ago. And so, just giving someone an appointment with a piece of paper on it was, you know, on a piece of paper was not sufficient for a lot of folks. And we see them coming back, but to the point made in the chat, other times people are coming back because those services aren't accessible yet, or people who just come into our urgent care, which is not the higher acuity ops it's, you know, its urgent care, but they need a bridging function because the services aren't there for them. And so, we created this program to fill that need. It's very, it's an interdisciplinary team. So, it has a provider. I used to be the psychiatrist on it. That was fun.

You know, it has licensed clinicians and then it has a strong peer component because peers are good at, you know, so good at all of that navigation and navigating the systems and helping with social determinants of health barriers, helping them learn how to use their Medicaid transportation benefit to get to appointments, for example. But and people stay in that program anywhere between like a couple of weeks to a couple of months, depending on that need. We also looked at primary care linkage too because, you know, pretty much everyone in that, when we did the initial pilot, they all had a PCP assigned to them because it was through their Medicaid plan. But it was like less than half of them had even knew that person's name or had been to see an appointment, had an appointment. And by the end, we had 70% of them had actually seen their PCP. So, not only helping bridge because there aren't resources, but helping people access the resources that they may not been able to access before, I think is an important part of that post-crisis aftercare.

MICHAEL WILSON: Look, I'll just sort of add briefly to that. I agree with everything Margie just said. We'll put it bluntly. Peers in the ED, nobody was really questioning whether they would be good after the ED, right? For patients. Nobody. We have tons of literature from lots of other conditions that post-discharge caring contacts works, right? Substance use navigators work. Nobody was questioning that piece. The real question is can they be helpful in an ED? And I won't say task shifting so that Christa doesn't have to repeat her excellent comment in that regard. And look, we've proposed that model. We would really like to take what we did in the ED and turn it into not just that safety planning intervention, but that safety planning intervention plus, again, that Christa mentioned where we follow folks out. And if, you know, we're hopeful that we can convince some NIMH reviewers on this point, that that's a worthy thing to do.

MATTHEW GOLDMAN: Thank you. That's great. And totally agree with that. We only have a few minutes left. And so, if it's okay, I'm going to do one closing question. I just got the blessing from Stephen to do that. Let's talk about kids for a second. So, there's two questions that I'm going to link together. One is we talk about the need to respond to the needs of parents when their child and teen is in crisis. And then another question that asked any thoughts about training families of, and those close to people with mental health challenges and peer support. And this is something that we've thought a lot about here at King County. One of the five crisis care centers that we're opening is going to be dedicated to serving youth.

And we already have plans in place where, or at least conceptually, that the peer role at this youth crisis care center will both include youth themselves with lived experience of mental health and substance use, but also what are also called caregiver advocates. So basically, families and caregivers, other members of a young person's family who have experience of navigating systems on behalf of, or in partnership with their child or family member. And so, I'm curious if that was touched on by any of the panelists in your work and any other thoughts on engaging families around serving youth in crisis.

MARGIE BALFOUR: Yeah. I mean, our Tucson facility has a youth unit, as well as youth urgent care. Some of our new facilities will as well. And peers play a huge role on that unit. You know, and a lot of the peers there have their own, you know, some of them have their own, like their family members have, you know, have lived experience, not only their own lived experience, but of their family of being a parent as well. I do think that is something that we should probably study better. It's definitely a research question. I mean, I know we've met just anecdotally, when we've had kids on the unit and some, another one of our recovery support specialists had a kid with similar, you know, presentation that having, especially with IDD, having that peer was really helpful on being able to help that youth be on the unit. But I don't think we've really formally studied it. I think, you know, and then of course our peers are involved when there's family meetings and things like that, but we haven't rigorously studied it. And I think that it would be a great area for research and study.

MATTHEW GOLDMAN: Christa or Michael, did either of your programs touch on serving youth or any experience that came at least anecdotally from, from your work?

CHRISTA LABOULIERE: Occasionally older teenagers are served in the settings where we trained, but it's a predominantly adult-focused service. I would say, you know, to, to echo Margie, we need to know more. We definitely, you know, I think there's great use for peer support, both for the youth themselves and for family members that need help navigating what's going on and supporting their youth in the best way possible. It was enough of a bear to get this through with adults through our IRB and various organizations. So, I think as some of the supportive data comes through, folks may be more willing to approach this with minors. I think certainly it's, you know, the data from earlier in the day supports that it's useful. Just it's, you know, it can be challenging to sell people on it.

MARGIE BALFOUR: Yeah. And as far as like the research questions, you know, and hearing some of the struggles that have been had with IRBs and doing stuff, whereas, you know, us in crisis unit, like Chuck would say, we're already doing it. And, you know, we're already doing it. Peers are already doing this work and I don't know how to get that message across to IRBs and things like that, but it's like, it's already happening. So, we should study it rather than go, oh no, we're concerned about the ethics of studying that. And then that being a barrier to doing the studies, like the trains left the station and crisis services are exploding and everyone is implementing these things, and the field is evolving rapidly. And, you know, we're trying to, you know, it's not something where we need to study it so we can implement it like five years later, it's happening now. So.

MATTHEW GOLDMAN: Well, thank you for those closing words, Margie. I think we are at the end of our time for this panel. So, I'm going to hand it back to the NIMH folks, but thank you all so much for a wonderful discussion. Really appreciate it.

STEPHEN O’CONNOR: Yeah. Thank you all very much. Thank you, Dr. Goldman. So, I just want to close out here by thanking you for attending this two-day workshop on Advancing the Science on Peer Support and Suicide Prevention. I would like to thank all the presenters and moderators who shared their good work with us and engaged in stimulating and thoughtful discussions. I would also like to thank our attendees for remaining engaged throughout the day, sharing their thoughts, imposing questions for the discussion.

The video recordings for both days of the workshop will be posted in approximately one month. With this workshop, we sought to characterize the state of the science on a topic of particular importance in regard to mental health. Today we expanded into the topics of suicide prevention and peer support for youth and crisis services.

We intentionally chose presenters who work in a variety of clinical and community practice settings. However, there are certainly programs that were not highlighted that are making important impacts in the field. NIMH has invested in peer support, suicide prevention research and intends to continue to do so.

Potential applicants are encouraged to review the NIMH strategic plan that's located on the NIMH website, and it's updated constantly and the Division of Services and Intervention Research landing page to learn more about our funding opportunities and priorities and expectations for applications. Of note, our effectiveness funding opportunities emphasize a deployment focused approach to effectiveness and services research that emphasizes the importance of including end user perspectives, including the youth, adults and families to access and support services throughout the intervention development and testing process. We've heard about the importance of including peer support specialist subject matter experts in leadership roles so that they can be more instrumental in their impact and research projects.

As a program officer at NIMH, you can always contact me. I'm happy to set up a time to discuss your research concept and help you think about those priorities in our funding opportunity announcements and that of our division. So, with that, I will close the workshop.

Thank you again for everyone involved. This has been a really great experience and I'm wishing you all the very best as you continue your good work. Please stay in touch and be well.