Implementing Peer Specialists in Suicide Prevention Efforts in the Veterans Health Administration

Abstract

Objective:

The Veterans Health Administration (VHA) recognizes peer support as an underused intervention in suicide prevention. PREVAIL is a peer-based suicide prevention intervention that was designed and piloted with non-veteran patients recently hospitalized for suicidal thoughts or behaviors. The purpose of this study was to elicit veteran and stakeholder feedback to inform the adaptation of PREVAIL for piloting with veterans flagged for high suicide risk.

Methods:

Semi-structured interviews were conducted with multiple stakeholders from a VHA medical center in the northeast. Interviews focused on the perceived benefits and concerns of peer specialists directly addressing suicide risk with veterans. Interviews were recorded, transcribed, and analyzed using rapid qualitative analysis.

Results:

Interviewees included clinical directors (n = 3), suicide prevention coordinators (n = 1), outpatient psychologists (n = 2), peer specialists (n = 1), and high-risk veterans (n = 2). Overall, peer specialists were viewed as possessing many distinct strengths in engaging and helping high-risk veterans as part of a team approach. Concerns included liability, adequate training, clinical supervision and support, and self-care for peer specialists.

Conclusions:

Findings indicated support and confidence that peer support specialists would be a valuable addition and could help fill existing gap in VHA’s suicide prevention efforts.

Introduction

Suicide rates in the U.S. have increased significantly since 2000 and the rate for veterans is roughly 1.5 times that of civilians [1]. Suicide prevention is a top clinical priority for the Veterans Health Administration (VHA), which has launched multiple programs focusing on earlier identification of at-risk veterans as well as establishing suicide prevention teams for stepped-up care for veterans flagged for acute high-risk of suicide (e.g., recent suicide attempt, preparatory behavior, or suicidal ideation with intent) [2]. Although suicide rates are extremely high among veterans with suicide high-risk flags, [3] recent research suggests that increased encounters with the suicide prevention team are associated with significant reductions in self-directed violence [4].

The VHA recognizes peer support as an underused intervention in suicide prevention and calls for the development of peer-to-peer services to help those at risk for suicide [5]. Peer Specialists (PSs), individuals with lived mental health experience who are trained and certified, are increasingly adopted in clinical settings [6] and associated with improved recoveryoriented outcomes in mental and physical health domains [7–9].

Hopelessness and social disconnectedness are suicide risk factors and key elements of the interpersonal theory of suicide [10]. PSs have been shown to improve hopefulness and social connectedness when utilized as an adjunct to care [8]. Although PSs often serve populations who are at-risk for suicide (e.g., serious mental illness, substance abuse), their involvement is generally confined to addressing risk indirectly. According to a recent meta-analysis, indirect care approaches that only address symptoms associated with suicide (e.g., hopelessness, depression, anxiety) can help decrease suicide risk over the long-term, but only direct interventions that specifically target suicidal thoughts and behaviors are associated with reduced risk in both the short- and long-term [11].

PREVAIL is a recently developed PS-delivered intervention based on the interpersonal theory of suicide that directly targets suicide risk in patients recently hospitalized for suicidal thoughts or behaviors [12]. Over the course of the 3-month intervention, PSs share their lived experience with suicidal crises [13] as well as offer supportive listening, validation, and semi-guided discussions to foster hopeful goal-setting, interpersonal connections, and coping skills[12]. Although PREVAIL shows promise, [14] it has only been piloted with non-veterans. Important differences exist between civilians and veterans with respect to certain suicide risk factors, [15–18] particularly regarding firearms which are used in 68.2% of veteran suicide deaths, compared to 48.2% among non-veterans [19]. Veterans may be more hesitant than civilians to discuss suicidal thoughts and behaviors and prefer to manage their depression without help [20, 21]. Also, some veterans hold negative views of VHA mental care and suicide screening, which may impose barriers to working with PSs [22–24]. Other research suggests that the addition of PSs can be perceived as burdensome by providers and veterans [25].

VHA employs about 1,200 PSs nationwide. To adapt PREVAIL to veterans and VHA PSs as part of a feasibility study, we conducted a series of qualitative interviews with diverse VHA stakeholders and veterans. In this paper, we summarize the themes identified via rapid qualitative analysis regarding benefits and concerns regarding PSs implementing PREVAIL for high-risk veterans in the VHA system.

Methods

This analysis emerged from a two-year feasibility project using Intervention Mapping [26] to adapt and pilot PREVAIL among veterans flagged for suicide risk. Intervention Mapping is a systematic approach that draws on systems-based and participatory models to understand a health problem and its causes. As part of the needs assessment to assess organizational capacity (e.g., readiness to adopt a new program) and to identify potential changes to elements of PREVAIL, semi-structured qualitative interviews were conducted with directors, suicide prevention coordinators, clinicians, PSs, and high-risk veterans to gain a better understanding of this group’s: (1) attitudes toward PSs involvement in suicide prevention efforts, (2) current involvement of PSs in clinical care and safety planning, and (3) beliefs about how PSs can improve suicide prevention efforts.

This study was approved by the VHA Central and site-specific Institutional Review Boards.

Sample

Nine interviewees from a VHA medical center in the U.S. northeast participated in this study. Participants included veterans (n = 2) with current or recent suicide risk flags, suicide prevention coordinator (n = 1), clinicians including outpatient psychologists (n = 2) and PSs (n = 1), and directors of inpatient psychiatry, psychiatric emergency department, and rehabilitation services (n = 3).

Data Collection

Participants completed a semi-structured interview that lasted 30–60 min. Interview guides were created based on our past qualitative research experience and informed by other research using Intervention Mapping or rapid qualitative analyses [27, 28]. Questions for directors, suicide prevention coordinators, and clinicians focused on the perceived benefits and concerns about PSs being part of suicide prevention efforts; the ideal role of the PS on the suicide prevention team; and the types of policies or trainings that would be helpful to PSs serving in this role. Example questions included “What do you think about peer specialists being trained in suicide prevention efforts?”, “What concerns, if any, would you have about peer specialists playing such a role within the VA?”, and “What kinds of policies, structures, or practices might need to be in place to support peer specialists in this work?”. For veterans, questions focused on their perceptions of the care received from the suicide prevention team (e.g., what was helpful, what might have been improved) and their thoughts about working with PSs. Examples of veteran questions included “Did the services and supports meet your needs or expectations at the time you needed care?”, “What did you find most helpful? Most unhelpful?”, “What do you wish had been different or had been available to you during this time?”, and “What would you think about having a Peer Specialist be part of the larger suicide prevention team?”

Data Analysis

All interviews were audio recorded and professionally transcribed verbatim. Transcripts were independently analyzed by two researchers (LD and LK) using a rapid qualitative analysis developed for health services and quicker implementation research [29]. This approach was designed to be more efficient in regard to time while balancing rigor with practicality to produce results that are comparable to traditional qualitative methods [30, 31]. Transcripts from all interviews were first summarized in a template based on interview question followed by identification of similarities and differences in key themes. Identified themes (headings in the Results section) and sub-themes (italicized text in the Results section) from interviews with directors, suicide prevention coordinators, clinicians, and veterans were triangulated and paired with direct quotations and narrative summaries to ensure alignment and representation. Any discrepancies were resolved through discussion, with audio files and transcripts consulted as needed to reach consensus in the identification and description of themes.

Results

Peer Specialists’ Unique Potential in Suicide Prevention

When asked about PSs being included in suicide prevention teams, directors, coordinators, and clinicians were uniformly positive that this would be a welcome addition (Table 1). Directors and clinicians discussed how veterans with high suicide risk often benefit from “non-traditional treatment options,” and that PSs can be “a great asset” providing social support to veterans, particularly those who are vulnerable to social isolation. Clinicians also noted that PSs often have less administrative responsibilities than clinicians, allowing for more flexible time to listen to veterans’ needs so they feel adequately “seen and heard.” As one suicide prevention coordinator explained about veterans with high suicide risk, the ability to connect with a trusted peer is “sometimes the only way they’ll allow themselves to access help.”

Table 1.

Themes Related to Direct Utilization of Peer Specialists in Suicide Prevention

Theme	Key Provider Quotes	Key Veteran Quotes
Peer Specialists’ Unique Potential in Suicide Prevention Subtheme: Peer Specialists are fundamentally more relatable	“There S a sense I think among veterans that there is something unique about their experience, in particular if there has been a sort of a combat component or even certain kinds of injuries […] and so the sense of having another veteran is […] often one of the few places that our patients feel that they belong, that there’s an identity, […] a socially viable identity. ” “Peers can ‘get’ what veterans are going through in ways clinicians can’t always.” “I have found that when there are veterans who are hesitant to engage with some of the clinicians, pulling in a Peer Specialist, and often times a Peer Specialist closer to their age, is really helpful.”	“In a way it was easier to talk to them than anyone else. Cause, I don’t know, they’re real mellow about it and not pushing you, but more like asking you questions on what you wanted, what you want.” “I don’t know why, but like I said, they just come at it differently. You look at it differently. They talk to you differently. And sometimes it’s really what you need… It’s sure a lot safer, I don’t know why. A little bit more comfortable, definitely. ”
Concerns about Peer Specialists in Suicide Prevention Subtheme: Peer Specialists need adequate training, support, and supervision	“if they’re not licensed independent clinicians there could be a liability risk. if a patient who’s in crisis and the Peer Specialist is the only person that the patient speaks to and if there’s a bad outcome, it could leave the hospital or the Peer Specialist open to risk.” “Peer Specialists need to know when to triage someone who may be increasing their level of risk […] and not think they can manage on their own.” “Carrying around and listening to some people’s stories, not everybody can do that […] you kind of need to have the right stuff to be able to swim in some pretty despairing waters.” “.the only concern would be that somebody would sort of think they could manage something that they may not, not be able to.”
Multi-Stakeholder Endorsement for Peer Specialists on Suicide Prevention Teams Subtheme: Peer Specialists can offer veterans hopeful connection	“Being able to validate the Veteran’s feelings and trying to meet them where they’re at, at the moment, and not try to push and get them to a place too fast. But to be willing to spend the time and let them […] talk to you and hopefully explain […] what’s actually going on with them, and then you can guide them in the right direction.” “A Peer Specialist who’s doing well can be a walking testimony of ‘you can get better, and I can help you ‘ […] with the goal to engage in care so that they can make the strides that they deserve to make clinically. ”	“It’s more like, outside of the main doctors and stuff like that, was [where] I got to feel comfortable. The doctors didn’t make me feel uncomfortable, it’s just, I didn’t feel quite as comfortable as with a Peer Specialist.” “It helps you to believe that it doesn’t have to be that way, it [suicide attempt] doesn’t have to happen over and over again/’

Regarding the specific qualities a PS might bring to suicide prevention efforts, one key sub-theme was that PSs are fundamentally more relatable. By being veterans themselves, PSs can better understand what veterans are going through in ways that other non-veterans might not. Directors and clinicians highlighted how the “relatability and authenticity” of the peer relationship creates a sense of shared identity, one which is uniquely important to veterans, and described how this personal quality brings an authenticity to veterans’ care that allows for a deeper sense of social belonging grounded in the veteran experience. Multiple respondents stressed the ability of PSs to bring reluctant veterans into treatment because of their shared experiences and mental health struggles. Veterans shared similar experiences of feeling like they had an easy rapport with a PS and that they felt more comfortable talking with a PS than other service providers.

When asked what the focus of PSs joining suicide prevention teams should be, directors and clinicians reiterated the ability of PSs to connect with high-risk veterans on a personal level beyond what clinicians can usually offer. The veterans also shared that speaking with a PS, specifically about their own recovery story and prior suicidal thoughts, gave them hope that things could improve (Table 1).

Concerns about Peer Specialists in Suicide Prevention

Liability was a prominent theme with providers underscoring that PSs should be “a supplement to care,” operating as part of a team rather than working independently (Table 1). A A sub-theme was the need for adequate training, support, and supervision not just regarding caring for the veteran, but also self-care. Directors, suicide prevention coordinators, clinicians, and PSs recognized the negative impact of “carrying around” the psychological stress that often comes with working closely with high-risk veterans. In this context, respondents emphasized the importance of both regular individual and group supervision for PSs to share their experiences with the larger suicide prevention team and to discuss handling difficult situations as they arise.

With respect to training that would be essential or helpful to PSs, respondents mentioned topics specific to suicide prevention (e.g., risk assessment, safety planning, and lethal means counseling) as well as more general clinical approaches (e.g., sharing of personal recovery story and Motivational Interviewing). Recognizing that PSs “could definitely be instrumental in using a whole health approach to overall wellness,” training them in areas such as self-care would help prevent compassion fatigue as well as equip them with information to share in their work with veterans.

Directors, suicide prevention coordinators, and clinicians also stressed the importance of ensuring that PSs receive appropriate supervision to help them maintain appropriate boundaries with veterans. As one PS explained, PSs can sometimes be prone to over-identifying with other veterans, so much so that it adversely impacts their own health and wellbeing. Underscoring the need for support and supervision, PSs should “not try to be a hero” and think they can undertake something that they may not be able to handle. In these cases, directors and clinicians conceded that much of this depends upon the individual PS, highlighting again the need for consistent training as some PSs do “a phenomenal job at this, and I can see others where it would be a disaster.”

Multi-Stakeholder Endorsement for Peer Specialists on Suicide Prevention Teams

Respondents were also positive in expressing how integrating PSs into suicide prevention would fill an existing gap in the VHA. Directors, clinicians, and veterans felt strongly that PSs have a unique ability to connect with and validate the distinct needs of high-risk veterans. A sub-theme was PSs can offer veterans a hopeful connection. Directors reported that when veterans connect with PSs in emergency or other acute care settings, they often follow these individuals through different levels of care and act as “a better bridge” for care continuity. With consistent supervision and training, PSs can also identify suicide risk and conduct “warm handoffs” to clinicians when a veteran needs additional care. The veterans that we interviewed also shared similar perspectives on PSs acknowledging them for who they are while having the ability to lead by example, which provided a sense of hope, trust, and support that is distinct from clinicians. The presence of and engagement with a PS was compared to a “walking testimony” for hope in recovery.

Discussion

PSs are increasingly being deployed beyond traditional behavioral health within the VHA, including primary care [32]. Although peer support is recognized as an underused intervention in suicide prevention, incorporating PSs on suicide prevention teams is seen as a promising approach that warrants further investigation [5]. The current results show support and confidence among VHA clinicians, directors, suicide prevention coordinators, and high-risk veterans that PSs would be a valuable addition to suicide prevention teams by working directly with veterans flagged for suicide risk.

PSs were seen as possessing distinct strengths in engaging high-risk veterans and engendering hope because of their recovery from and lived experience with suicidal crises. Many of the commonly recognized core competencies and key components of effective of PSs (e.g., promoting hope, supporting collaboration and shared-decision making, fostering natural supports) [33] were explicitly described by participants as applicable to addressing suicide risk. According to the interpersonal theory of suicide, the ability of PSs to empathize and connect directly with veterans may reduce feelings of hopelessness and social disconnection, which is supported by results from the PREVAIL feasibility study [14].

Directors, suicide prevention coordinators, clinicians, and PSs highlighted a number of considerations to help ensure the well-being and functioning of PSs in their work with high-risk veterans, including sufficient individual and group supervision for PSs and adoption of a team-based approach to care. Additionally, training in topics specific to suicide (e.g., safety planning and lethal means counseling) were viewed as being essential, while other training topics (e.g., self-care) would be helpful for PSs with maintaining their recovery.

This study has several potential limitations. First, the VHA is a unique healthcare system that focuses on the unique needs of veterans in ways that differ from other community-based systems that primarily serve non-veterans. All participants were from a single northeast VHA medical center which has a broad and longstanding PS program. As such, the current findings may not be transferable to other VHA settings which may differ in workplace culture or have limited experience with PS programs. All participants were volunteers who are familiar with PSs and may not reflect the views of other clinicians on the inclusion of PSs in assisting veterans. Given the small sample, these findings represent preliminary data with potential saturation among the sample of clinicians and directors (Table 1), but not for high-risk veteran due to insufficient participants. Additionally, because all stakeholders were from a healthcare system with a well-established peer program, this study may not directly reflect the experiences of other VHA programs lacking PSs or providers who an unfamiliar with the services that the PSs can provide within a VHA setting.

Additional research is needed to establish the feasibility and acceptability of an adapted version of PREVAIL with veterans. Moreover, the degree to which adding PSs to the existing care of veterans flagged for suicide risk is associated with reduced suicidal ideation needs to be evaluated in a fully powered controlled trial. Nonetheless, the current results suggest that activating the PS workforce to assist high-risk veterans warrants further examination.