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Peer specialists can prevent suicides: properly trained peers play a vital role in regional suicide prevention effort.

Peer specialists, or trained paraprofessionals who are current or former consumers of behavioral health services, are part of a paradigm shift in behavioral health: They embody the recovery model and, as they participate in greater numbers, act as the foot soldiers of system transformation, contributing to positive outcomes among those they serve. (1) Typically, peer specialists:

* Teach skills needed to facilitate self-advocacy and recovery;

* Explain available service options;

* Promote the use of natural supports in the community; and

* Encourage wellness and a sense of self-worth in consumers.


While widely accepted in many areas of behavioral health, peer specialists have not yet played a significant role in suicide prevention, postvention, or aftercare (for attempters), despite the fact that this area has been under-resourced and underserved. A growing body of research, opinion, and experience demonstrates that trained peer specialists, equipped with their own suicide-related experiences as well as learned recovery and support skills, can play a role in suicide prevention among consumers living with serious mental illnesses. It's time they did so.

Mental illness is a major risk factor for suicide. (2) According to the CDC, 45 percent of some 9,000 suicide victims in 16 states (2007) had a psychiatric diagnosis. (3) Mental illness can trigger or aggravate other risk factors including low self-esteem, poor coping or problem-solving skills, substance use, financial and employment problems, and more. At the same time, it weakens protective factors such as interpersonal relationships and adherence to treatment. Thus, it is no surprise that suicidality is more prevalent among those with serious mental illness than among the general population, with mental health consumers showing higher rates of suicidal ideation, attempts, and suicides. In fact, suicidality is a factor in most psychiatric hospitalizations and in many readmissions. (4)

The need for suicide prevention programs is clear, and there's a role for peer specialists in these efforts. In 2004, Kathryn Power, director of the Center for Mental Health Services, predicted this role: "In a transformed system, consumers ... will act as gatekeepers. They will recognize the warning signs of suicide and be able to encourage people at risk to seek treatment." (5)

However, this prediction remains unrealized. In 2009, when Montgomery County Emergency Service, Inc., a non-profit psychiatric hospital offering comprehensive crisis intervention services in Norristown, Pa., contacted a series of national, state, and local organizations for advice about peer specialist programs for suicide prevention, none were found.

How peer specialists can help

The National Strategy for Suicide Prevention stated that "to make suicide prevention efforts more effective and to leverage resources, suicide prevention must be integrated into programs and activities that already exist." (6)

Because peer specialists are already integral to many existing programs, they may be available to step into new suicide prevention efforts. They can work close to those at risk, offering skills and values that readily lend themselves to suicide prevention. Many also have personal experiences of recovery from serious suicidal behavior and suicide loss. They know how the shame and stigma linked to suicide can affect recovery and they are willing to offer their experiences to help other consumers.

Peer specialists have two roles in suicide prevention and postvention:

1. Identifying individuals who are potentially at risk of suicide and directing them to professional help.

2. Providing support to help initiate and sustain recovery from suicidal behavior or suicide loss.

These roles include showing empathy, caring, and concern; giving information and help in acquiring new life skills; and helping consumers feel connected to others.

The First National Conference for Survivors of Suicide Attempts in 2005 recommended several ways that peer specialists could participate in suicide prevention efforts:

* Validating and normalizing similar experiences;

* Increasing supportive community-based networks;

* Communicating suicide risk/prevention information to families at hospital discharge;

* Developing volunteer support systems; and

* Tracking patients to ensure follow-up and aftercare. (7)

In addition, peer specialists can support suicide prevention in provider or peer-led settings through activities that include:

* Developing self-help plans for consumers coping with persistent suicidality;

* Facilitating gatekeeper programs to recognize warning signs of suicide and interventions;

* Operating peer-run "warm" lines for consumers coping with suicidality-related concerns;

* Educating family members about risk factors and warning signs of suicide;

* Facilitating peer-led psycho-education groups on suicide prevention; and

* Organizing suicide bereavement support groups for consumers (led by peer suicide survivors).

Suicide prevention skills for peer specialists

Before peer specialists can undertake a meaningful role in suicide prevention, they must learn certain fundamentals, including:

* Basic concepts of suicide prevention and suicide loss;

* Knowing when to contact a crisis center or 9-1-1;

* Applying recovery concepts to coping after an attempt, suicide loss, or suicidal behavior;

* Developing "personal safety plans" for avoiding suicidal behavior;

* Understanding myths and stigma associated with suicide;

* Appreciating cultural/ethnic perspectives on suicide and methods of dealing with suicide loss;

* Facilitating peer-led suicide prevention/postvention groups; and

* Familiarity with appropriate community resources.

As peer-specialist learning makes clear the value of this role, it must also explain its boundaries and limitations relative to other roles. Specifically, it must clarify the circumstances when a potentially suicidal consumer requires the support of clinical professionals who offer crisis intervention, risk assessment, and therapy. While peer specialists can support consumers who are working with specialists like these, they must be careful to not take on any of these more specialized roles.

A provider's experience

In 2008, Montgomery County Emergency Service, Inc. added suicide prevention to the duties of two part-time peer specialists. The hospital had initiated a suicide prevention program for patients, families, and community members and sought to strengthen its efforts for current patients and those recently discharged. (8) To date, our peer specialists have:

* Facilitated a weekly inpatient suicide prevention support group;

* Provided one-to-one suicide prevention counseling to inpatients;

* Led regional suicide prevention training for other peer specialists and workshops at statewide consumer conferences;

* Participated in suicide prevention training for providers and police officers; and

* Developed a self-help, personal suicide prevention plan for consumers.

The peer specialists use their peer support and recovery training that they brought with them to the hospital, the suicide prevention education provided by the hospital, and their willingness to share their own past experiences with suicide to deliver an effective suicide prevention program. (9)


(1.) Schwenk E, Brusilovskiy E, and Salzer M. "Results from a National Survey of Certified Peer Specialist Job Titles and Job Descriptions: Evidence of a Versatile Behavioral Health Workforce." Philadelphia, PA: University of Pennsylvania Collaborative on Community Integration, 2009.

(2.) Ruter T and Davis M. "Suicide Prevention Efforts for Individuals with Serious Mental Illness: Roles for the State Mental Health Authority." Alexandria, VA: National Association of State Mental Health Program Directors, 2008.

(3.) Karch D, et al. "Surveillance for Violent Death--National Violent Death Reporting System, 16 States, 2007." Morbidity and Mortality Weekly Report. May 14, 2010; 59; SS04; 1-50.

(4.) Mellesdal L, et al. "Suicide Risk and Acute Psychiatric Readmissions: A Prospective Cohort Study." Psychiatric Services, 2010; 61; 25-31.

(5.) Power AK. "The Importance of Suicide Prevention in Mental Health Transformation." Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2004.

(6.) Public Health Service. "National Strategy for Suicide Prevention: Goals and Objectives for Action." Rockville, MD: U.S. Department of Health and Human Services, 2001; 53.

(7.) Litts D. "First National Conference for Survivors of Suicide Attempts--Summary of Workgroup Reports." New York, NY: Suicide Prevention Resource Center, 2008.

(8.) "Give patients crisis information before discharge to lower risk." Inside the Joint Commission. October 8, 2007; 4-6.

(9.) Salvatore T. "Suicide Prevention for Peer Specialists." Norristown, PA: Montgomery County Emergency Service, Inc.; 2009.


Tony Salvatore, MA, is the suicide prevention specialist for Montgomery County Emergency Service, Inc., a non-profit acute psychiatric hospital and crisis intervention service in Norristown, Pa. E-mail Tony at

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Title Annotation:PERSPECTIVES
Author:Salvatore, Tony
Publication:Behavioral Healthcare
Geographic Code:1USA
Date:Oct 1, 2010
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