Suicide Prevention: Combating Suicide Through the Implementation of a Peer-to-Peer Prevention Program

By Sarah A. Burrage, Ph.D and Christi Garner, LMFT, RYT

Defining the Problem

Our nation is currently in a suicide crisis. Suicide rates are steadily increasing across the nation, while the rates of suicide for both veterans and active-duty personnel continue to outpace those of the general population. The increasing suicide trend has been a concern for military members and their families for nearly two decades, with suicide rates steadily rising across all services and components. The active-duty suicide rate per 100,000 population increased from 18.0 in 2011 to 24.8 in 2021.[1]

Suicide risk factors for military personnel are often due to the unique stressors and demands they face in their service.[2] High suicide rates coupled with the fact that suicide is rarely caused by a single issue, often leaves one searching for solutions to a complex trend, triggered by a mixture of emotional, psychological, physical, cultural, and environmental conditions. While mental health services are available to help the military population and their families, fewer than 25% of suicide decedents received outpatient mental health services or substance abuse services within the 90 days preceding their deaths.[3]  The military suicide crisis has been difficult to contain for mental health professionals alone and a growing body of scientific evidence has begun to point to the utility of community-based peer support approaches to interventions.

The Department of Defense (DoD) has attempted to identify, create, implement, and examine interventions with the hopes of reversing the suicide rate trend.[4]  Subsequent research has shown that military personnel facing mental health issues are more likely to seek help from a peer over a mental health professional, such as in the Air Force’s peer-to-peer suicide prevention project known as The Airman’s Edge, which applies injury prevention and safety principles rather than a more traditional mental health and psychological wellness approach.[5]

Bowersox et al. (2021) stated the “U.S. Surgeon General’s national suicide prevention strategy (2012) and other guidelines have included recommendations that peer support be integrated into the care of individuals at high risk for suicide (Hedegaard et al., 2020; National Action Alliance for Suicide Prevention, 2019; U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2012).”[6]  Research has shown that military personnel facing mental health issues are more likely to seek help from a peer over a mental health professional.[7] In the case of the military population—a small subset of the general population containing unique cultural symbols and behaviors not easily understood by professional caregivers not immersed in the culture—peers are better positioned to leverage unit camaraderie, esprit de corps (feeling of pride, fellowship, and common loyalty), and an innate understanding of the unique stressors and demands of military life.

These studies pave the way for much needed community-based peer approaches to military suicide. Loneliness and isolation are major factors in our current mental health crisis[8] and strongly associated with suicidal behavior.[9]  Meanwhile, having peer supports increases relationship protective factors, which decrease the feelings of loneliness and isolation.[10] Peer support programs enhance protective factors that protect against suicide risk. Participation in peer support programs has been associated with improved coping skills and increased resilience in addition to positive effects on physical health. Protective factors for suicide prevention include effective coping and problem-solving skills, strong sense of identity, support from friends, feeling connected to others and reduced access to lethal means of suicide among people at risk.[11]

Community-based peer support programs both enhance all these protective factors and mitigate risk factors that will improve suicide prevention. In the military community setting, a peer support program which normalizes suicide prevention behaviors as part of overall mental fitness, focused on unit readiness and mission success has potential to reverse the suicide rate trend. These volunteers must be themselves, supported through a well-structured program with clearly defined objectives and guidelines, supervision, and support from mental health professionals to guide, mentor, and consult with the peer volunteers.

A properly structured peer support program should include multiple delivery paths that can increase the touchpoints across support groups, peer mentoring, peer education, and the seamless transition to community health workers. Peer support programs are not intended to replace interactions with mental health professionals, but rather destigmatize the act of seeking help, triage the demand for peer support, and provide a seamless handoff of more serious cases to professionals for deeper intervention and follow up. This paper will propose a community-based peer support program for suicide prevention.

Peer Support

Peers have an important role to play in suicide prevention. Peer support is defined as “social emotional support, frequently coupled with instrumental support, that is mutually offered or provided by persons having a mental health condition to others sharing a similar mental health condition to bring about a desired social or personal change.”[12]  There are several types of suicide prevention services that use peer support and peer interactions. These types of services often include peers being gatekeepers, on demand crisis support, acute care crisis support, and crisis prevention/relapse prevention.[13]

Research into peer support for suicide prevention is on the rise and being evaluated.[14] [15] Both the Air Force and Army use peer support components within their suicide prevention programs. The Army’s Suicide Prevention Program “suggests the possibility of appointing a ‘lifeline’ buddy to oversee an individual in crisis until a referral is made or the crisis is over.”[16]  Additionally, the U.S. Department of Veterans Affairs (VA) explored a promising peer prevention evidence-based approach to suicide prevention set to serve military communities and family members in 2019.[17]  When assessing the outcome of this approach, cultural elements of military life and service, i.e., shared language, beliefs, and distinctive experiences, were deemed foundational to peer relationships and prevention.[18]

Research suggests that military peer support programs can effectively reduce the stigma associated with seeking help for mental health issues[19] by raising awareness among the military population and offering a vehicle for open dialogue.[20] Moreover, service members are often more willing to talk to their peers about their struggles, making it easier for them to seek support and access appropriate resources. Participating in peer support programs has been associated with improved coping skills[21] and increased resilience, allowing service members to better navigate the stressors and challenges of military life. Peer support programs are also more cost-effective compared to traditional mental health interventions, making them more feasible for implementation and sustainability within military organizations.

Peer-to Peer Suicide Prevention Program

Program Goals

The peer-to-peer suicide prevention program’s main goals are:
(1) reducing suicide rates;
(2) increasing awareness around prevention; and
(3) providing support for those experiencing difficulties coping with daily stressors.

Reducing Suicide Rates

A peer-to-peer suicide prevention program leverages a peer’s relatability and ability to empathize, which increases awareness and support. This relatability can lead to more open and honest conversations, reducing stigma and encouraging help-seeking behaviors. Peer-to-peer programs increase accessibility to care, thereby reducing suicide rates. According to Bowersox et al.’s (2021) study:

Peer support has the potential to address suicide risk through multiple mechanisms. Peers providing emotional support and sharing their experience of recovery could increase perceived connectedness and reduce hopelessness among support recipients, two key factors for preventing suicidal ideation according to the interpersonal theory of suicide (Van Orden et al., 2010). Peer support may also reduce suicide risk by decreasing stigmas, increasing orientation to personal growth and recovery, and encouraging active care engagement (Salvatore, 2010; Holmes et al., 2013; Suicide Prevention Resource Center, 2018).[22] (p. 2)

Increasing Awareness Around Prevention

A peer-to-peer suicide prevention program can be easily integrated into workplaces and communities, increasing awareness about the role of prevention, destigmatizing the desire to get help, and highlighting an alternative for those who might not access formal mental health services. Peers reduce stigma and judgment by creating a safe environment that normalizes the experience for those with suicidal thoughts. Peers can assist with early intervention and increased awareness because they are part of the same social circles as those they assist, may detect warning signs of distress early on, and can prevent crises from escalating by providing referrals and assistance in a timely manner.

Providing Support

Peer support programs can be more sustainable and cost effective compared to traditional mental health services and can use a tailored approach to fit the specific needs and preferences of the targeted population. By providing positive support and role modeling, peers can inspire hope and demonstrate recovery is possible. In 2011, Money et al. states that:

For the individual, peer support increases the number of social relationships and provides education to support positive coping behaviors as well as information on resources available beyond the immediate peer supporter. Peer supporters, in turn, can experience a sense of empowerment by helping a peer, while at the same time building their own self-confidence and strength.[23] (p. 5)

When peer support is integrated with professional services, they complement existing resources and contribute to a more comprehensive and sustainable health support system.

Program Structure

The peer-to-peer suicide prevention program structure is an approach that includes support groups, peer mentors, community health workers and peer educators, mimicking the structure of many non-medical counseling programs.

Figure 2: Program Structure Breakdown

Adapted from Money et al. (2011) list of peer-to-peer program models (See Appendix B for details).[24]

This approach allows for flexibility to meet the needs of the military population, as well as the individual needs of a given component or installation. Each component of the program provides versatility and structure to create more opportunities to receive peer support that otherwise would not be possible.

Peer Supporters

Selecting peer supporters in a military environment is a crucial process to ensure the effectiveness and safety of the program. Peer supporters will have opportunities to offer ongoing regular one-on-one check-ins and follow-ups with their contacts to facilitate, encourage, support and ensure continuity of care. Here are some key criteria to consider when selecting peer supporters:

• Voluntary Participation: Peer support should be a voluntary role, and individuals who express a genuine interest in helping their fellow service members should be encouraged to participate. Forcing or pressuring individuals into this role would hinder the effectiveness of the program.
• Emotional Resilience and Stability: Potential peer supporters should demonstrate emotional resilience and stability. They should have the capacity to handle their own emotions while providing support to others and not be at high risk for suicidal ideation themselves.
• Trustworthiness and Reliability: It is essential to select individuals who are trusted and respected within their military community. Reliability and a commitment to confidentiality are crucial for maintaining a safe and supportive environment.
• Communication Skills: Peer supporters should possess strong communication skills to establish rapport and foster a sense of trust with their peers. They should be able to convey empathy and understanding effectively, while communicating in a tactful manner.
• Cultural Sensitivity: The selected peer supporters should be sensitive to the diverse backgrounds, experiences, and cultures within the military community. This sensitivity ensures that they can provide support in a non-judgmental and inclusive manner.[25]

Peer supporters should receive ongoing support and supervision from mental health professionals and should be provided with training on topics like self-care and nervous system regulation strategies. Continued support helps ensure their well-being and effectiveness in their role. Additionally, regular evaluation and feedback mechanisms should be in place to assess the peer supporters’ performance and to identify any areas for improvement.

Training Peer Supporters

Peers can be trained on a variety of techniques that help them to connect with those who are struggling, provide resources and referrals, guidance on seeking professional help, share simple coping strategies, and help those struggling feel less alone, making services more accessible to their communities. Peer supporters should have ongoing access to professional development opportunities. These opportunities can be both formal and informal. Peer supporters should receive comprehensive training and refresher training in:

• Active Listening
• Motivational Interviewing
• Crisis Mitigation and Access to Lethal Means Counseling
• Suicide Prevention
• Suicidal Behaviors
• Mental Health First Aid

Additional skills, abilities, and knowledge essential to being an effective peer supporter include:

• providing appropriate referrals to professional services when needed
• maintaining clear boundaries
• understanding confidentiality and mandated reporting protocols
• understanding when to involve professional help
• demonstrating leadership ability or potential
• possessing the ability to stay calm under pressure

Program Fidelity and Integrity

Program fidelity (delivering a program as intended) and integrity (delivering a program while adapting it as needed to obtain the desired, integrated effects) is key to maintaining its effectiveness and credibility. Measures to promote program fidelity and integrity include:

• Establishing clear and comprehensive guidelines outlining the program’s objectives, roles and responsibilities, boundaries, and confidentiality requirements. Then, effectively communicating these guidelines to all participants.[26]
• Ensuring supporters have access to and a comprehensive understanding of available resources.
• Implementing regular supervision and support from a mental health professional and evaluators to guide, mentor, and offer consultations.
• Implementing regular evaluations of the program and the peer supporters.
• Ensuring all training is current and based on the latest relevant research.

Confidentiality and Ethics

Confidentiality and ethics are essential to having peers in the program feel safe and able to speak openly while still following statutory and regulatory requirements put in place by governments and mental health organizations. If peer supporters share information learned about an individual outside of the service setting, it could weaken trust in the system. The violation of trust by a peer supporter could discredit the whole peer support program.[27] However, these protections are not limitless. Peer support programs must have conditions under which the peer’s right to confidentiality must be broken and the peer supporter has a duty to report what is said or done (i.e., instances of Duty to Warn and Mandated Reporting). These situations occur when the individuals pose a threat to themselves or someone else.[28]

Best practices for confidentiality and ethics include:

• Having confidentiality policies in place and discussed frequently with all personnel and participants.
• Having detailed policies in writing for all involved in the peer support program.
• Having protection in place for the peer supporter as well as the individual participant.
• Having policies that align with the DOD and state regulations for mandated reporting.
• Having a procedure in place for warm handoffs to Military Treatment Facilities in case of emergent needs.

Evaluation and Continuous Improvement

Evaluation is a key component to the continuous, incremental improvement of any program and in ensuring it meets its objectives. These evaluations are also important to delivering feedback on both whether peer support is working, and how it is working, thereby demonstrating program impact through quality of life and health outcomes. The method behind these evaluation components directly impacts program sustainability. Therefore, it is important to identify reliable measures, key performance indicators, and measurement tools/instruments that are reliable and relevant to the peer support programs’ objectives.

When gathering data, it is important to keep in mind that stigmas with mental health and cultural barriers can make gathering metrics of success risky. In 2011, Money, et al., cautioned that:

The limits of research and metrics is that although valuable for assessing the efficacy of a program or intervention, the use of survey instruments and other measures in peer support programs may, in some cases, run the risk of damaging the trust that is essential for success, and could even drive away individuals by adding to their fears about evaluation and loss of confidentiality. Especially in voluntary programs, such measures may be counter-productive vis-à-vis the primary goals of the program.[29] (p. 14)

However, quantifiable metrics of success can be collected that do not pose a risk to the integrity of the program. These include tracking the number of visits, number of repeat visits/follow-ups, and number of referrals to outside services while still protecting privacy and the trust placed in the program and its people.

Conclusion and Recommendations

The military suicide crisis has been difficult to contain for mental health professionals alone, despite multiple awareness campaigns, numerous suicide prevention initiatives, and improved access to counseling services. A growing body of scientific evidence points to the utility of community-based peer support approaches to intervention. In the case of the military population- a small subset of the general population containing unique cultural symbols, behaviors, and unique stressors – peers are better positioned to leverage unit camaraderie, esprit de corps, and an innate understanding of the unique challenges and demands of military life. In the military community setting, a peer support program which normalizes suicide prevention behaviors as part of overall mental fitness, focused on unit readiness and mission success has the potential to reverse the suicide rate trend.

• A properly structured peer support program should include multiple delivery routes that can increase the touchpoints across support groups, peer mentoring, peer education, and the seamless transition to community health workers.
• Peer support programs are not intended to replace interactions with mental health professionals, but rather destigmatize the act of seeking help, triage the demand for peer support, and provide a seamless handoff of more serious cases to professionals for deeper intervention and follow up.
• Due to program complexity, the right peer volunteers are key to a successful program. They must be resilient, trustworthy, discreet, and sensitive volunteers who are effective and tactful communicators.
• These volunteers must be themselves supported through a well-structured program that has clearly defined objectives and guidelines, supervision, and support from mental health professions to guide, mentor, and consult with the peer volunteers, and regular evaluations that feed into a continuous improvement cycle.

 

[1] Department of Defense (DoD). (2022). Department of Defense Annual Report on Suicide in the Military: Calendar Year 2021.

[2] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[3] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[4] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[5] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[6] Bowersox, N. W., Jagusch, J., Garlick, J., Chen, J. I., & Pfeiffer, P. N. (2021). Peer-based interventions targeting suicide prevention: A scoping review. American Journal of Community Psychology, 68(1-2), 232–248. doi:10.1002/ajcp.12510

[7] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[8] National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Health and Medicine Division; Board on Behavioral, Cognitive, and Sensory Sciences; Board on Health Sciences Policy; Committee on the Heal. (2020). Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington (DC): National Academies Press.

[9] World Health Organization. (2021). Suicide Fact Sheet. Retrieved from WHO: https://www.who.int/news-room/fact-sheets/detail/suicide.

[10] Holt-Lunstad, J., Smith, T., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: a metanalytic review. Perspectives on Psychological Science.  10(2), 227-237

[11] Centers for Disease Control and Prevention. (2022). Risk and Protective Factors | Suicide. Retrieved August 12, 2023, from CDC.gov: https://www.cdc.gov/suicide/factors/index.html

[12] Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392–401. doi:10.2975/27.2004.392.401

[13] Bowersox, N. W., Jagusch, J., Garlick, J., Chen, J. I., & Pfeiffer, P. N. (2021). Peer-based interventions targeting suicide prevention: A scoping review. American Journal of Community Psychology, 68(1-2), 232–248. doi:10.1002/ajcp.12510

[14] Huisman, A., & Van Bergen, D. D. (2019). Peer specialists in suicide prevention: Possibilities and pitfalls. Psychological Services, 16(3), 372–380. doi:10.1037/ser0000255

[15] Pfeiffer, P. N., King, C., Ilgen, M., Ganoczy, D., Clive, R., Garlick, J., . . . Valenstein, M. (2019). Development and pilot study of a suicide prevention intervention delivered by peer support specialists. Psychological Services, 16(3), 360–371. doi:10.1037/ser0000257

[16] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf

[17] Beehler, S., LoFaro, C., Kreisel, C., Dorsey Holliman, B., & Mohatt, N. V. (2021). Veteran peer suicide prevention: A community‐based peer prevention model. Suicide and Life-Threatening Behavior, 51(2), 358-367. doi:10.1111/sltb.12712

[18] Beehler, S., LoFaro, C., Kreisel, C., Dorsey Holliman, B., & Mohatt, N. V. (2021). Veteran peer suicide prevention: A community‐based peer prevention model. Suicide and Life-Threatening Behavior, 51(2), 358-367. doi:10.1111/sltb.12712

[19] Webel, A., Okonsky, J., Trompeta, J., & Holzemer, W. (2010). A systematic review of the effectiveness of peer-based interventions on health-related behaviors in adults. Am. J. Public Health, 100, 247–253

[20] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf

[21] Ramchand, R., Ahluwalia, S., Xenakis, L., Apaydin, E., Raaen, L., & Grimm, G. (2017). A systematic review of peer-supported interventions for health promotion and disease prevention. Prev. Med, 101, 156–170

[22] Bowersox, N. W., Jagusch, J., Garlick, J., Chen, J. I., & Pfeiffer, P. N. (2021). Peer-based interventions targeting suicide prevention: A scoping review. American Journal of Community Psychology, 68(1-2), 232–248. doi:10.1002/ajcp.12510

[23] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf

[24] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf

[25] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[26] Baker, J. C., Bryan, C. J., Bryan, A. O., & Button, C. J. (2021). The Airman’s Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide. International Journal of Environmental Research and Public Health, 18(6), 3153. doi:10.3390/ijerph18063153

[27] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf

[28] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf

[29] Money, N., Moore, M., Kasper, K., Roeder, J., Bartone, P., & Bates, M. (2011). Best practices identified for Peer Support Programs. Defense Centers of Excellence. Retrieved from https://staging.mhanational.org/sites/default/files/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf