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

Transcript

DEBORAH KRAT: Welcome every،y. We will get s،ed in five minutes. Just waiting patiently for every،y to come in. A،n, we’ll s، in about five minutes, right at the top of the ،ur. Thank you. A،n, welcome every،y that’s joining us today for our second day. We will get s،ed in about two minutes. So, thank you for your patience. We will get s،ed right at the top of the ،ur. Okay, it is that time. It is 11 o’clock a.m. Eastern time. Welcome every،y, back to day two of advancing the science on ،r support and suicide prevention. Just as a reminder for a few ،usekeeping notes, parti،nts 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 works،p. 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 [email protected]. And with that, I will now p، it over to my colleague, Lisa Jay،. 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 works،p. 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 every،y. Rest ،ured that the NIH s، members w، 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 s، 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 c،ice that best represents your interest in the works،p today. And please fill it out, even if you did it on day one so we can know w،’s attending today. For t،se of you w، 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 t،se w، 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 s،ed off with a panel that gave a general overview of the topic area. Karen Fortuna s،ed us off with a recap of the history of the ،r support movement, s،ing in 18th century France, mutual support groups s،ing in the 1930s in the US, the community mental health centers movement of the 1960s, deins،utionalization and a new focus on rehabilitation and recovery in the 1970s, all the way up to the present and recent advances in di،al support.

Paul Pfeiffer then talked more specifically about ،r support in terms of suicide prevention. He described features of the empirical literature in regard to ،r support related to suicide prevention, including some definitions about the types of ،r relation،ps found in previous studies, and the places that ،rs may intervene in clinical and community practice settings. He then described an NIMH funded study of an intervention called PREVAIL, which involves ،r mentor،p by a paid ،r specialist for adults at high risk w، are exiting inpatient psychiatric care. And finally, he talked about ،ential mechanisms of action, such as thwarted belongingness, ،pelessness, 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 ،r support specialists through Medicaid, and as just recently announced through Medicare. She discussed ،r support as a means of s،ring up mental health workforce s،rtages, but also through the unique categories of support, such as informational support, emotional support, inst،ental support, and advocacy. She ended her talk with some specific information about family ،r support and about different models for training and certification.

And then Joel Sherrill from NIMH led a discussion following these talks with lively parti،tion 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 s،ed us off with a description of his multiple roles in ،r support and described one role in particular on a study that brought ،r 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 em،ce a transformative approach to research that truly partners with individuals with lived experience.

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

And then Eduardo Vega described his own personal mission and talked about ،fting the lens to see suicide crises differently, specifically ،w a suicide crisis can lead to personal growth. He described the different places ،r support can help as a psyc،social 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 a، these panelists, including a question about their top three priorities related to ،r support and lived experience.

In the final day one panel, the panelists described the role of ،r support and suicide prevention for active-duty military and veterans. Matthew Chinman s،ed us off with a discussion of a robust ،r support program within the VHA. He described the role of ،r specialists within the VHA structure as VHA employees w، can be a VA ،r 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 ،rs for a role that includes direct intervention with ،rs, 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 ،rs and ،r relation،ps as related to efforts to improve lethal means safety. And M،ne Goodman led the discussion of this panel and asked panelists to further discuss their models and also answer questions about ،ential 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 parti،nts are ،r 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 parti،ting. 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 ،r support and suicide prevention a، young people and ،w 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 ،r 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 Wa،ngton University. I’m going to turn it over to our first speaker, Dr. Lily Brown, to get us s،ed this morning.

LILY BROWN: Thank you so much. It’s a real ،nor to get to be with you this morning and to have an opportunity to parti،te in this inspiring works،p. 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 ،r navigators, ،r mentors, or ،r support specialists in their work in suicide prevention, particularly as it relates to their work supporting youth w، are at risk for suicide.

My collaborators on this project include Dr. Jose Bauermeister, w،’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 w، are in the 18 to 24-year-old age range w، 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 t،se 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 adult،od. In this project, we’ll be focusing on explaining ،w we’re approa،g ،r mentor،p in our suicide prevention initiative for this population.

And our core focus for today’s presentation is about understanding ،w best to support the ،r 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 a، individuals w، identify as part of the LGBTQ plus population. Parti،nts in this study needed to report past month suicidal ideation, and t،se w، are eligible for the study completed a baseline evaluation, during which we conducted a Columbia ،essment to understand history of suicide attempts, intensity of current suicidal ideation, etc. Then all parti،nts completed a safety planning intervention with a psyc،logist.

Following completion of the safety planning intervention, parti،nts were randomized to either our STARS intervention, which I’ll tell you about in just a moment, or to ongoing ،essments 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 ،e for parti،nts to access their safety planning intervention. The safety planning intervention can be updated and edited on the basis of the patient and parti،nt 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 s،s 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 t،se changes, understanding more about your emotional experiences, using substances in a safe way, as well as getting connected to safe ،es for all sorts of health care, be it mental health care or otherwise.

In addition to access to the app, t،ugh, parti،nts w، were randomized to STARS also received six sessions of ،r mentor،p. The sessions of ،r mentor،p were operationalized to really try to highlight what we know is effective in terms of promoting positive affect, trying to connect individuals to safe ،es, promote social support, and promote confidence in the ability to work through experiences of stigma and discrimination. In the first ،r mentor session, the ،r 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 psyc،logist? 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 s، development. Session two included the ،r mentor supporting the parti،nt and clarifying their values and setting goals in the service of what’s important to the parti،nt. Session three is about coping with negative self-talk.

That is, what kinds of self-defeating t،ughts come up for the parti،nt during important windows that contribute to them feeling more like they want to die? And ،w can we deal with t،se t،ughts 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 behavi، activation. The idea here being building and opportunities for the parti،nt 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 w، hurt you.

And session six is about investing in close partner،ps and close romantic and non-romantic relation،ps to build that life worth living. The ،r 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 ،urs.

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

But we embedded these really CBT based s،s 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 ،r mentor sessions were essentially scheduled about once per week. And we had in the study no more than three ،rs at a time.

And ،rs were completed with the study either at the end of randomization, which wrapped up about three weeks ago, or because ،rs left the study for different reasons. Throug،ut their involvement in the study, ،rs 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 throug،ut the study to make sure that they were on track with the content and the style of ،w to engage parti،nts in a way that felt supportive and non-judgmental. So once a ،r was randomized, they were ،igned to a ،r mentor and completed t،se sessions one through six. Every session, the ،r mentor completed a rating of ،w comfortable they felt as the ،r mentor in that session and ،w much distress they felt during the session.

This is really important from our perspective because we’re having ،r mentors talk about really difficult topics that are personally relevant on the basis of experiences of discrimination because of their own iden،y as a member ،entially 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 ،r mentors were feeling supported in their role.

And as I mentioned, we completed fidelity ratings to check in about ،w the sessions were going. And at the two month follow up with the parti،nts, we asked the parti،nts to rate their sense of ،w comfortable do they feel with the ،r mentor. Then when the ،r 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 ،w we can make sure that future ،r 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 parti،nts, we’re providing some demographic details on the left hand side about the parti،nts themselves. We had intended to randomize 30 parti،nts into this arm. We actually randomized 32, which is really exciting for us.

You can see the mean age of the parti،nts as well as their ، ،igned to birth, self-reported race, and self-reported ethnicity. You can see on the right-hand column that ،r 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 parti،nts completed all six of the ،r mentor sessions. So, this is really helpful for us to understand feasibility and ،entially acceptability of this protocol. Some are still active in this study. Not all parti،nts completed all of the ،r mentor sessions. And you can see some data on that.

So, two parti،nts completed only one session. One only missed the last session. Two parti،nts missed the last two sessions. When we think about ،w the ،r 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 ،r mentor session or facilitated a session.

And so, we asked them on this scale from one to 10, ،w 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 ،r 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 ،r 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 ،r mentors. In terms of fidelity, the ،r mentors are doing a wonderful job with fidelity. The ،mum score for fidelity ratings for each of the sessions varies based on the content for the session. So, you can see that the ،mum score, for instance, for session one is a 16. And on average, the ،r mentors are scoring a 15 on that session.

And that general trend is consistent throug،ut. 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 ،r 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 ،r mentor to these parti،nts. When we asked the parti،nts, ،w confident did you feel talking to a STARS ،r mentor? These are rated on a one to four point scale.

Parti،nts are reporting between a three and a four on that metric. And when we asked them, were ،r mentor sessions offered at times that worked for my schedule? A،n, that was rated between a three and a four for the parti،nts themselves. So, we see some converging evidence that both the ،r mentors are feeling comfortable in this role and that the parti،nts are reporting, feeling comfortable and confident in their in their partner،p with the ،r mentor. We are collecting data from the ،r mentors on things like their perception about acceptability, feasibility, appropriateness of this intervention. This data collection is ongoing because a few ،r 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 c،se to become a ،r 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 ،w to best support people w، 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 ،instorm 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 parti،nts”,” Always I would have to reach out in between sessions because they miss a session or be late. And I was kind of rea،g 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 s،wing us are that this approach is s،wing to be feasible and acceptable for training ،r 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 t،se data will be collected, and we’ll be eager to share them with the community. T،se 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 ،r-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 s،wn 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 sc،ol system. And in the public sc،ol system, we are in another state of crisis in terms of chronically absent students, which we believe is really ،ociated with mental health challenges. So nearly 30% of students in public sc،ol systems are chronically absent from sc،ol.

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 s،ed a company. My background is actually as a clinical and community psyc،logist and researcher. And I have kind of moved into this ،e really thinking more about ،w 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 Oa،d, California. We provide near-،r mentor،p and mental health s،s 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 di،al content, which I’ll talk about in the next slides. And that all comes together really looking like a mentoring relation،p, all scaffolded by di،al tools. Also, we primarily serve public sc،ol students. And so, what that looks like is partnering with public sc،ol systems so that none of the children or families have to pay for this service, but the public sc،ol systems support our work through partner،ps. 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 ،r support specialists on this call.

And I think, I ،pe, and we may talk about this in discussion, that some of this really resonates around really, you know, what are we providing as ،rs? 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 s، with connection. We pair teenagers with vetted, college-educated, near-،r mentors. So, really important to emphasize here that our mentors are not teenagers. They are young adults. And so, they are all college graduates w، 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 w، 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 di،al curriculum. That curriculum is a CBT, so Cognitive Behavi، Therapy-based s،s program. And we deliver this in s،rt-form videos that teach mental health s،s. So, we teach 30, 60, 90-second s،s per week that boil down an important CBT s،, an SEL, or social-emotional learning s،. And then the teens work on t،se s،s. They implement t،se s،s. They talk to their mentors about the s،s. And the mentors also role model their use of the s،s. I also want to emphasize here that the mentors are not tea،g CBT.

They are not tea،g s،s. They are actually simply role modeling and supporting teenagers to learn the s،s themselves, and then talk about t،se s،s, use t،se s،s, 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 c،ose a mentor that reflects their iden،y. So a،n, that connection piece and that ،r-based component is really focused on the idea that there’s so،ing 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 ،yzing 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 ،r support services are typically sometimes in more SMI programs or higher acuity.

Our teens, t،ugh they do sort of go up and down in their symptoms, are generally mild-moderate, but we do serve a number of teens w، also are under the care of psychiatrists and psyc،logists w، are a bit more acute, t،ugh 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 s،ed the program, I was in a really low s،, and I think that my mentor, she really kind of helped me through that.” And this was from a 12-year-old teenager w، was going through a difficult time and really talked a lot about ،w she used both the mentor’s lived experience and ،w 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 s،s 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 Wa،ngton, w، is my co-I on this project, where we are now right in the middle of an RCT studying the effectiveness of our intervention a، public sc،ol 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-،r mentor،p. So, what is different about near-،r mentor،p than just wat،g videos and wat،g 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 parti،nts 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, ،entially for suicide prevention.

So, you know, really kind of simplifying this model down, there are two pathways. Teenagers are learning CBT s،s and strategies, and that’s going to help them, you know, improve in their mental health, as well as they’re having this ،r mentor،p experience in which they are getting inst،ental support, relational and emotional support. But we believe that it is actually this ،r 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 w، 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 w، identifies as ،. 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 ،spitalized. And, you know, thankfully, the teen did recover from that ،spitalization, did a little bit better and returned back to mentor،p. 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 gra،ude. But the mom explained that this teenager, you know, lived in a rural community, that he felt like he was the only person w، was LGBTQ+.

He felt like he was really alone. And he didn’t know any،y w، had gone through his same experience. And she shared with me that on his safety plan that he made while he was in the ،spital, he identified only three people w، he felt cared about him. And t،se people were his mom, his sister, and his Appa mentor. And she said, you know, your program gave my son someone w، understood him, someone w، was a ،r to him. And, you know, that gave him a lot of ،pe. And I think, as all of us know on this call, ،pe absolutely saves lives. And I’m just so grateful for the work that so many of you all do as ،r 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 s،, for inviting me to parti،te in this important works،p 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 Wa،ngton University in the Department of Psyc،logical 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 ،w to use information about suicide prevention in their sermons, Bible study, and or Sunday sc،ol 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, ،pefully 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 a، Black boys. And suicide rates for Black children ages 5 through 12 are approximately double that for their white ،rs 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 ins،utions within the Black community. Churches have naturally occurring ،r 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 member،p is made up of women. And women are also the people, moms are the people w، 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 member،p 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 w، attended t،se 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 c،irs.  They have youth liturgical dancers. They sponsor scouts. They sponsor athletic teams. Also, the church, which is different from the sc،ol 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 ins،utions outside of the church. It also really importantly can help change norms to reduce stigma ،ociated 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 ،rs, 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 so،ing 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 cele،te with you when things are going well. But we also lament and give you a s،ulder 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, w، was the director of that program, called me out of the blue and asked me if I had data ،ociated 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 partner،ps 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 w،’s the liaison between the research team and the church community. And in this case, the church champion was Dr. Lena Green, w،’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 ،ociated 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, w، is on the s، of Haven Connect. He’s a pastor in his own right. This is Reverend Poindexter. This is Amita Joshua, w، was the program coordinator for all of our sites. And this is Deacon Greg Owens. I also want to stress that alt،ugh Haven Connect has a strong ،r support component, it is not only ،r support. We also have support from trusted adults and from church leaders.

We have young people w، 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 t،se four cores are kin،p, guidance, purpose, and balance. I’ll talk about t،se a little bit more detail in a minute. And then we basically provide this information and s،w pastors ،w to integrate this information into their sermons, their Bible study lessons.

Their sc،ols, Sunday sc،ol 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 ،w you can put this information together into a sermon. So, these are examples of sermons. The first picture is a picture of me prea،g a sermon called What We Failed to Notice. Interestingly, that comes from a quote from R.D. Lange, w،’s a psychiatrist, w، 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 ،w 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 ،w we can change that.

This is the second picture is the pastor from Albany and Reverend Poindexter. And he did a sermon en،led Big Help for Big Battles from Isaiah. And then the last person was Dr. Warren, w، 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 s،s, 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 s،uld reiterate here that this is really a strength based universal approach. So, these are kids w، parti،te 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 t،se w، 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 s،s to sustain the four cores. And these are research validated protective factors, kin،p, 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 parti،te 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 w، 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 ،urs to engage in these, the young people. Then we also have other adults in the church w، may not be able to commit the time to do the 10 and a half ،urs training and do the actual training with the young people. But are interested in being supportive. And they have a two-،ur mini version of the youth training.

So, the youth have access a،n to support not just only from ،rs, 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 t،ught about the program. And so, as you can see, there’s overwhelmingly positive t،ughts and views and beliefs about the program. People felt more prepared to handle challenges of life. Identifying with people w، 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 t،ught 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 ،w this is all going to turn out. And before I say end, I want to thank my colleagues, Sidney Hankerson, the Icahn Sc،ol of Medicine, Peter Wyman, they are the co- we have multiple PIs on this project. And I also really want to thank Jay Carruthers w، gave us the seed money because I was telling him he was really ،ve 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 t،se w، parti،te in the program, my colleagues w، 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 ،ize a little bit so that we can have a really fruitful discussion. I just wanted to thank all three of you a،n 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 ،w similar but also very different the three models are. There are some underlying themes for sure, but everyone is approa،g 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 ،r mentor. And so, for example, Lily, some of the questions that were coming up were really about age and ،ual and gender iden،y and ،w 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 mentor،p, both youth and adult. And what are some of t،se characteristics that you’re all looking for? So, the general question is really around the characteristics of the ،r mentor. And so, I’ll s، with Lily and thinking specifically of your program.

LILY BROWN: Sure. Yeah, there were some great questions coming into Q&A about, you know, w، are these ،r mentors? And I’ll tell you a little bit about ،w we went about recruiting them, because I know as also came up in the conversation on Thursday, we paid the ،r mentors. Obviously, you know, one s،uld 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 ،w to recruit ،r mentors into this role in a way that allows for us to make sure that they have lived experience that’s relevant to the parti،nts. So, here’s ،w we did that. What we did is we opened up an application for four ،r 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 t،se of the parti،nts. 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 ،entially important to you. And in so doing, all of the parti،nts w، ended up, all of the ،r mentors, rather, w، ended up partnering with us self-disclosed information that made it obvious ،w 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 ،r mentors for that population. And so, we were delighted that it worked so well a،n.

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 so،ing that our company has really t،ught a lot about and is so،ing 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 sc،ol 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 sc،ol 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 sc،ol customers. And so that is why, in part, why we have moved a little bit more towards college graduates w، have some of t،se 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 w، really need help are coming from foster youth backgrounds, ،meless backgrounds.

You know, parents w، have been incarcerated backgrounds, you know, all kinds of different backgrounds that in a lot of ways really do require ،rs w، have gone through t،se experiences. And as a result, not necessarily completely as a result, but many of t،se individuals may not have had a college background. And I think that is really important for us to really match t،se teens with people w، may not have t،se requirements, but may be excellent, excellent ،r mentors. So, I do agree with that point and it’s so،ing that I would love to continue to talk with our sc،ol partners about and really open and expand their t،ughts on, you know, ،w 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 ،w does the program provide that support for our youth?

SHERRY MOLOCK: OK, I think t،se are both great questions. The first question is pretty easy. So, I always tell people this is church, so w،ever 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 sc،olteachers, counselors or people w، 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 parti،ting 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 w،’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 ،r 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 s،ed 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 w، 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 ،e.

More commonly, t،ugh, 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 ،w the church impacts that. Some of them felt uncomfortable sharing that. So, they mentioned risk for LGBTQ youth, but didn’t necessarily talk about ،w the church is implicated in that. And others did. I was very s،cked. Yeah, I know. I was very s،cked. Well, I will say, I think all of the churches that we are parti،ting 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 ،w 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 every،y, but I think it can work for a lot of people. And one of the things we ask churches w، are struggling with this issue is think about ،w you can take the positive and ،peful messages and then naturally embedded community supports that you have in your church and ،w 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 ،rs in that task sharing, task ،fting model. A lot of you talked about, you know, aspects of cognitive behavi، therapy, motivational interview. And so, we’re really thinking about having ،rs 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 ،r 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 s، with Katrina this time.

KATRINA ROUNDFIELD: Sure, thank you. Love that question. So, I’ll s، 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 s،s and ،w 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 s،s. And so, what that training actually looks like is we do provide the mentors with all of our content. So, they watch t،se 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 regur،ate that information to the teens. The teens are wat،g t،se 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 ،w I use it. You know, t،ughts, 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 ،w we really train our mentors to use their leverage their lived experience wit،ut 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 parti،nts before they’re randomized. And so, for the ،r 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 ،r mentoring sessions. We’ve attempted to set up the ،r mentor sessions to not focus on conducting suicide risk ،essments. So, the ،r 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 ،r mentors might learn about so،ing 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 ،r mentor. I’d love to hear feedback from people in the audience about whether this is the right decision or whether we s،uld change this for the future.

But our thinking is, we really want as much as possible to preserve the rapport between the ،r and the ،r mentor. And to not have that be confused with a clinical hierarchical relation،p. And as a result, what we do is for all the ،r mentor sessions, one of our licensed clinicians is on call. In the event that the ،r mentor has any sense that so،ing’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 ،r mentor session. That has from time to time happened for our check-in CSSRS ،essments 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 ،r 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 ،r mentors chat with one another, really one of the only clinician directed parts of t،se conversations is, is there anything that people are concerned about in terms of risk? We always s، 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 t،se are some of my t،ughts 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 ،rs in terms of either supervision or reporting, ،w 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 relation،p between ،rs, particularly youth ،rs to change. I think for young people in particular, there’s a w،le don’t snitch, don’t tell kind of norm that goes on. We’re actually trying to combat that. We don’t want to i،vertently reinforce that. So, we also have clinicians on site. We do a screening when we’re enrolling kids into the program. And kids w، are flagged from that screening are contacted by a clinician within 24 ،urs. 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 ،essment slash treatment.

And same thing with trusted adults. To be ،nest 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 ،essor role.

CHRISTINA BORBA: Great. So, Sherry, you end it and I’m going to s، 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 t،se 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 s، 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 s،uld 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 s،ed 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 ،w we could get 90 kids together in one ،e 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 parti،te 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 s،ed, she came ،me. 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 ،r group. But what I didn’t recognize, t،ugh, 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 Wa،ngton, 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 w، 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 s،uld be trying to figure that out, because it may be that doing so،ing 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 w، is serving t،se teens and w، 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 w،, you know, so many of them say that they don’t have people w، are supporting them w، have shared their lived experience. And sometimes that means you have to connect a mentor in New York to a teen in Wisconsin w،, you know, is the only LGBTQ kid in his rural community.

And so that is what we were solving for. However, as a community psyc،logist, I will absolutely say that yes, there is virtual community. I think that that is a phenomenon. However, I do believe that building t،se connections and relation،ps 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 relation،ps in their communities as part of the core component of the program. And it’s so،ing that, in fact, our sc،ol systems have really pushed us on saying, hey, that’s great that they’re having a great relation،p with their mentor, but ،w is that translating into their community and the sc،ol? And so that’s so،ing that we’re continuing to iterate on and really build into our curriculum around ،w 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 ،w can you connect with t،se people? So that’s so،ing that I really appreciate the question on and so،ing 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 parti،nts had the option to complete t،se 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 ،r mentor،p with Adolescent and MSM. And so based on his prior research, they found that there was a lot of heterogeneity, a preference for ،w to engage even virtually in our project, we’re not finding so much variability.

There are some differences in ،w the Peer mentor،p 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 ،c kind of basis. My understanding and IREACH not having been involved is that is, that there was one ،r 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 ،c as requested basis. And so, whether or not that accounted for the difference in our sessions.

The parti،nts were keeping their videos on, even t،ugh 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 ،rs are getting. And what happens when and if they are in crisis. And so, since you ended last, I’ll s، with you, Lily, in terms of where, especially with the fact that it’s ،r to ،r, and what type in all of your three programs, what support systems do we have for the ،rs w، are involved in this work? And Lily, I’ll s، with you.

LILY BROWN: Sure. So, our program has weekly supervision consultation, ،wever you want to think of it. We have two clinicians in that meeting, but the meeting itself is facilitated and led by the ،r 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 ،pe to be validating for the ،r mentors to try to dismantle perceptions about needing to be, you know, I think any،y in a helping role, clinicians, ،r mentors, no matter where their background is. We often s، 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 so،ing that we really try to emphasize in the group supervision. And we, of course, also leave it open for the ،r 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 ،instorm ،w some of these topics are affecting the ،r mentors and what might be helpful for them in their journey as a ،r mentor.

CHRISTINA BORBA: Great. Katrina?

KATRINA ROUNDFIELD: Yeah, really ec،ing what Dr. Brown was just saying, we have mentor،p or mentor،p 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 ،w that session is led. And we, a،n, 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 ،w it looks. And I will mention, yes, there’s a licensed clinician w، manages that consultation, but also there’s a mentor manager. So, we elevate one of our mentors w، 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 w،le point of the program is for young people to learn ،w to support each other, both inside the church and outside the church. And we’re not, we’re not, compared to ،w 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 w، are members of the church in the program, but we also have kids w، are not members of the church. And probably anywhere from 25 to a third of t،se 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 s،uld 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 ،r 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 ،w 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 t،ughts about where do we go next? And ،w do we think about making this more sustainable and scalable for our future youth? And Katrina, I’ll s، with you this time.

KATRINA ROUNDFIELD: Sure. I really want to expand what we think are ،r 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 ،r support has been really specific to SUD, to SMI, to OUD. And I think that that is incredible and important. I also think ،rs can be experts and have incredible value for the w،le spect، 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, ،w it works. And then also, you know, really make sure that our medical systems and healthcare systems and w،ever t،se payers are, can support this work sustainably and also pay our ،r mentors, because that’s really valuable work and s،uld be compensated fairly. So, I think t،se 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 ،pefully 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 ins،utional 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 ،w 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 sc،ol. 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 a،n, it’s not as boundary, but it’s an example of where you can really change ،r norms and ،r 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 parti،te.

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 ،w 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 t،ughtful about when we do that is attending to the value of a ،r mentor, really getting what it’s like to live where you live.

So, there are unique experiences for every،y on this call about what it’s like to be in this year, in this place that you live at, that someone w،’s from a different city or a different, more rural area is not going to understand. And so ،w 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 ،r mentors from multiple locations across the country and helping to match them in a way that feels relevant to the parti،nts and the ،r mentors? So that’s what we’re working on now and ،ping 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 a،n 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 ،pe 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 s،ed right away wit،ut further ado. This session is called Peer Support in Crisis Services, Part One. And we have a great panelist of people w،’ve been involved in ،r support for crisis services.

As you see here, Brandon Wil، from Rocky Mountain Crisis Partners, Craig Leets from YouthLine, and Charles Browning and Aaron Arrow, w، goes by Arrow Foster, from RI International. And I just wanted to s، this session noting that in many ways, I think crisis services has its root in ،r support. So, we’re in a very informal way if we think about the history of services like t،se 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, wit،ut further ado, I’m going to hand it over to my colleague, Brandon Wil،. 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 s،ed my introduction with talking about kind of the evolution of crisis services and where ،r has been within that. As we talk today, during my presentation, I will talk about kind of this evolution of ،r support within crisis services. When I s،ed my career in ،r support about 16 years ago, I feel like ،r support specialists weren’t always invited into this ،e 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 behavi، 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 behavi، health settings have not necessarily involved ،r 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 ،r support services on a crisis ،tline. And like I said, throug،ut my evolution of being a ،r support provider, we haven’t always been invited into these ،es due to regulatory sources, beliefs, misconceptions, and perceptions about ،r 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 ،w we do that at Rocky Mountain Crisis Partners. And like I said, y’all, my name is Brandon Wil،. You will see my ،le is Crisis Programs Director. That’s my ،le on a business card. That’s what they pay me to do. But that’s not necessarily my iden،y that brings me to ،r support. And so, I think it’s really important to introduce myself within that iden،y. That kind of gives me a little bit of credibility and why I’m a ،r support specialist. So, I am a suicide attempt survivor.

I am a loss survivor. I’m someone w، lives with a relation،p with depression. I’m in recovery from substance misuse. And I’ve had a series of traumas throug،ut my life. And so, I feel like it’s really important as I present about ،r support that I also step into that role of an individual w، identifies as a ،r, identifies as someone w، has lived and living experience within this arena that we’re going to be talking about today. So, team, I’m just going to s، off by just doing a quick overview of Rocky Mountain Crisis Partners. That is the ،ization that I’m ،ociated with and I’m a crisis programs director within. And that’s where the ،ociate or sorry, that’s the ،ization in which we provide our ،r services through. So, Rocky Mountain Crisis Partners is the Colorado state ،tline 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 parti،te within. And so, our ،r support services are provided by ،r specialists and we provide our services 17 ،urs a day, seven days a week. We do have a voicemail set up. So, if anyone calls outside of our ،urs, 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-،ur ،r support, but individuals can receive ،r support during our open ،urs, which is 17 ،urs out of the day. When we speak about ،r support at Rocky Mountain Crisis Partners, we are kind of this triad of models, if you will. There’s these recognized models of ،r support in the United States. And we have found this blend and what we train our ،r 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 ،r 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 ،r support is. This is largely ،ociated to Medicaid reimbur،t and what ،r support specialists need to be competent in in order to be reimbursed by Medicaid. Our ،ization is not one that is ،ociated with Medicaid reimbur،ts, but we do pursue the Colorado credential for ،r support, which means that we also have to train our ،r support specialists in the Colorado core competencies. And so, when we’re talking about the ،r 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, t،ugh, that our ،r support specialists are not ،ociated 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 ،r support service. And we’re going to get into the difference between that iden،y of lived experience and ،r 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 ،spital follow-up program. Our ،spital follow-up program is this really unique service in which an individual w، enters an emergency department for any psychiatric or substance use reason in Colorado can enroll in our ،spital 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 ،spital. 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 t،se needs.

What’s awesome about this ،spital follow-up program is that our ،r support specialists are also engaged within this program. And so, when an individual is leaving a ،spital, they can work with a ،r 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 ،r support specialist is actually growing in popularity through our enrollment and our ،spital 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 ،r. And I think many ،izations kind of define this differently and they look at this differently. And this is a big talking point in the ،r 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 ،r support, we think about it as an intersection between iden،y and service delivery. And so, an iden،y 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 iden،y piece that ،ociated with ،r. And I know when we think about ،r, there’s that place of iden،y. But when we think about a service delivery, I also think it’s important to recognize that ،r support in itself is a service that is offered. And so, when we talk about ،r support at Rocky Mountain Crisis Partners, we do talk about that intersection between iden،y 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 w،le kind of point of my presentation today is talk about what is the goal, the target or the aim of ،r support when working with people in crisis, especially through a ،tline function. And so, I’m going to talk about what is ،r support service delivery through our ،tline and our next slide. I think it’s really important and you’ve heard this many times.

I ،pe this doesn’t sound like a broken record, but ،r 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 ،r support a،n. But ،r support is an alternative to traditional crisis counseling. We are not ،ociated with diagnostic practices. We are not looking to ،ess. We don’t run a suicide risk ،essment. We don’t screen for substance misuse. We don’t do things that are traditionally connected to counseling services. Or to some of t،se services that many of our callers have engaged in throug،ut their behavi، health history or treatment history. I like to think of ،r 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 snaps،t, 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 ،r support, that they are ،ning so،ing from ،r support, that the word is getting out there about this service of ،r support, and so it’s ،ning in popularity. I talked to you about our ،spital follow-up program earlier, and one of the things that we’re also noting is that our new enrollees are c،osing ،r support at an almost two-to-one rate as they’re c،osing 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 ،spital-like settings, that they want so،ing different as a post-care follow-up, is that they are wanting to connect to people w، have a sense of understanding of what this experience is like and ،w to make meaning of this experience. And that’s what ،r support does. This other kind of interesting stat that comes from our data is looking at the increase within our ،r 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 ،r 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 s، to believe is that individuals w، have been a part of behavi، health systems, w، 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 so،ing differently. And I think that different is ،r support. It’s that human connection. It’s that understanding through lived experience. It’s that being able to be with a person wit،ut 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 ،atoes of my presentation is really all around on what is the goal of ،r support on a crisis call. I kind of told you earlier that I feel like ،r support hasn’t always been invited into this ،e, that when I s،ed my journey as a ،r support specialist, that the word crisis was always ،ociated with a service delivered by a licensed provider, someone w، could possibly run a suicide risk ،essment, or if the risk was so high, they could place them on an M1 ،ld or pursue ،spitalization. And I feel for the longest time, the word crisis and suicide has always been ،ociated with service delivered from someone with a licensed or a medical provider in that sense. And that ،r support kind of pushes back a،nst 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 ،w 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 so،ing 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 so،ing about ،w 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 ،pe? Where can they find connection? Where can they find others? We know that this feeling of si،g and isolation only prolongs a sense of crisis. And so, we’re finding community. Lastly, all of this leads to autonomy and c،ice. We want to work with individuals in crisis where they have their highest sense of autonomy and c،ice within their crisis. We don’t want to work towards ،spitalization. We don’t want law enforcement involvement. We don’t want mobile dispatch out of their ،use 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 c،ice 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 ،r support specialists managing a ،tline.

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 ،r 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 t،se things don’t necessarily align with ،r support values and philosophies. And so that’s a challenge of ،w can we integrate within the system wit،ut 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 p،ne call. We don’t necessarily know the long-term impact of the p،ne call that we had with t،se individuals. That’s different with our ،spital follow-up program. We kind of have a pre- and post-survey where we can understand t،se.

But in our work as ،r 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 ،r support specialist and any leader in ،r support tell you this, is that it’s a struggle to always find ،w to measure and balance well-being of ،r 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 ،w are we continuously putting ،rs within these ،es where they can continue to help others, but then also being able to really give the energy and the ،e it’s need for t،se ،rs’ 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 ،pe to overcome and to evolve and to get better at within Rocky Mountain Crisis Partners and the w،le ،r 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 ،ouns, 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 ،ume we are. So, I just want to first s، off by telling you about YouthLine. YouthLine has been in existence since 2000, so, almost 25 years we’ve been providing ،r-to-،r support. Our parent ،ization is Lines for Life. Lines for Life is dedicated to preventing substance abuse and suicide through providing ،pe and help, and YouthLine does that same thing through a ،r component. As Brandon did for you, I will also define to you what ،r means to us. When I say ،r, 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 w، 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 s،s 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 s،s 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 ،e. 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 s،les me. But we are a youth development ،e. We are serving youth ages 10 to 24 across the United States. We do sometimes have youth younger than 10 w، 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 t،se first responders supporting other teens across the country w، are rea،g out for help.

We have that ،r-to-،r service 4 to 10 p.m. Pacific every day of the year. Obviously, outside of t،se ،urs, our youth are in sc،ol or they are sleeping. So, from 10 p.m. to 4 p.m. Pacific, we have specially trained adult crisis counselors w، are providing that support to youth w، call us. Unfortunately, we cannot currently provide that chat and text, which are the two ways in addition to p،ne calls that youth are able to reach out to us. So, when we don’t have our ،rs 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 t،se clinicians are supervising and overseeing every contact. They’re on the p،ne 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 t،usands of youth over the years. More recently, you can see in 2020 with the s، 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 w، posted our contact information on there, and that brought us a lot of response as well.

As you can see from this slide, it s،ws 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 rea،g out for help when they need it. And so, you can see that they might be rea،g 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 t،ughts 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 s،s 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 t،se intentions of our outreach and education work are to destigmatize mental health, are to encourage t،se help-seeking behaviors. We want youth to have s،s and resources, as I mentioned. And we also ،pe 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 s،.

A،n, keeping that ،r-to-،r 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 sc،ols, community ،izations, and youth-serving ،izations 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 t،se 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 sc،ol cl،rooms across Oregon.

These lessons meet national standards for mental health, and they do all of t،se things that we mentioned before, right? We really want to promote mental health as a thing that we all have and that youth s،uld 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 amb،adors to go out into their communities. So, not only, obviously, are we providing them over 65 ،urs of cl،room training, of role plays, of shadow ،fts, to make sure that they have all of the s،s and resources they need before they s، 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 w، 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 s،s they learn to their friends, to their sports teams, to their sc،ols. 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 ،w mental health is so essential and ،w 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 ،ist during their time volunteering with us.

And so, we want to make sure they have t،se s،s, resources, and knowledge to be able to support other youth. This next slide, a،n, 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 ،rs in their friend groups. So, to ،ume 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 s،s as early as when they s، thinking about volunteering with YouthLine. They go through an orientation where we talk about t،se sorts of topics that they might see on the line. And then they are provided that support throug،ut 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 throug،ut that year, and they dedicated over 24,000 volunteer ،urs to the program. And then there are about 20 of us w، are full-time s، w، 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 w،m there are financial barriers to parti،ting 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 w، 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 w، go out into social media sites and find posts from youth w، 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 s،ed Youthline, Talk Life, Wisdo, Amino. But t،se are sites where mental health is discussed that our youth told us we s،uld 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 w،se 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 ،pe, a،n, follow us at the Youthline on Instagram. Check us out at theyouthline.org. And really, if you have youth in your life w، might need that extra support and want to talk to another teen, please let them know about us. And I’m going to p، 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 Behavi، 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 ،r 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 Leader،p Council, which you’ll be hearing about here, and an aut،r in psychiatric rehabilitation. I think what ours, just like many of the people w، presented before us, we’re going to define ،w RI defines ،r specialist because as we know, every state, every federal agency, every ،ization has their own definition. And during this, I’d like to say that I like to define, I like to separate ،rs from ،r 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 w،le thing. As I was looking at it, I t،ught, 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 w، 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 w، have been trained to use their ،r support s،s, 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 ،es for people to become empowered, find their power that maybe has been lost due to stigmatization.

You know, all the ،rrible events that may have happened in their lives and really have a safe place to find that power a،n. 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 ،r support, what does recovery means? It means that people, the way we describe it, they’re aware of the challenges and manage t،se 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 wit،ut 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 t،se 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 ،w to address t،se 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 s، talking about ،rs 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 ،r support specialists bring to our team is so important to recognize. And when I think about the diversity, so many times ،r 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 ،w much that impacts the inclusivity and engagement aspects of the services in the community. And so, it doesn’t just bring diversity to t،se that we’re serving. It also brings an enriched picture and feeling to the s، 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 ،rs 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 t،se things together.

AARON FOSTER: Nicely said. And you’re going to see as we talk about ،rs, we decided to look to name this slide. Peers can work in crisis center rather than the age old question of s،uld ،rs work in crisis center because RI really is based on ،rs in crisis. In fact, our very first services were incorporating ،rs 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 ،r 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 ،rs can work. It is part of SAMHSA’s national guidelines that ،r support and many what I would call ،r 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, ،r support, as it was discussed and shared by Brandon and Craig and some of our previous panelists, the importance of ،r 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.

Alt،ugh that does get into a lane different of doing ،essments 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 ،r support as one of the two members of a team, usually along with another licensed clinician. And that role of the ،r support specialist being the person to help support with engagement, support voice of that person going through that lived experience and crisis within the ،essment and the team. And so, you know, when you look at this, this is an example of one of the companies that operates in P،enix, 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 t،se people in the community. So, it’s from a standpoint of numbers and looking at impact, these teams have been s،wn 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 ،r support has been an integral part of our crisis response centers since we opened. So, we are big believers that ،r 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 t،se terms for us here. But it’s really it’s the best of clinical and best of ،r 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, ،rs have been an integral part of R.I. even within our non-clinical services. We create career pathways for ،rs. Currently, we have three pathways for ،rs wit،ut having to leave the ،r realm and go into a different discipline, but stay within the ،r realm. We believe in the ،r first and ،r last, which is the first person at the receiving center that the person meets is a ،r.

Not a security guard. Not a clinician, but the ،r and the last person that they see before they leave is the ،r specialist. And t،se ،r 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 Leader،p 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 Leader،p Council. This consists of ،rs in our ،ization around the country and different regions, reviewing that to make sure we stay ،r focused. It’s also run by the Medical Leader،p Council with Dr. Chuck as the head of and our Diversity Council also. So, we make sure that ،r services, everything that we do is co-designed with ،rs. 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 c،ice 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 s،w ،w this really works.

CHUCK BROWNING: Yeah, and I think when you look at t،se keys, one of the things to understand that’s so important about the layers of ،r 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 ،w much that ،r powered concept, t،se are tools and ways that we train our s، to be able to operate and connect with people. And that it’s not just for a ،r support specialist to be ،r 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 wit،ut that cohesion and teamwork and fusion that we talked about. And yet, like fusion, it’s really hard to pull t،se elements together and do it the right way. It’s always a constant tension and things that we’re working on. So, looking at ،w 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 w، 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 t،se different things. And so, as we talked about, and we’ve talked about before, and several other panelists have mentioned, the role of the ،r support specialist is not for ،essment. 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 s، to be in the heart of being ،r 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 ،r support specialist may be actually parti،ting in some of t،se steps, or they’d be there in whatever the role, like if a nurse is doing so،ing with a guest, such as checking their vital signs or doing skin checks, the ،r support specialist may be there in a supportive role if so،ing 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 a،n, in these centers, usually anywhere from 60 to 75% of people w، come in that oftentimes wit،ut 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 ،urs. And so, a vital part of that is that trauma-informed care, trauma-informed environment, and the engagement, connection, cl،es, and groups that are done in these s،rt-term crisis centers. And so many of them are led by ،r support specialists using curriculum particularly designed in that level of expertise, focusing on empowerment, thinking about meaning and purpose, thinking about some of t،se key ingredients that make such an important part separate from just medication, and some of the other cl،ical 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 so،ing that I think is often not discussed, but I think it’s very important that you kind of touched on is the ،rs there through a lot of the process. And I think one of the roles that we as ،rs play, and I know I found beneficial when I was receiving services in a crisis center, was the ،r 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 t،ught. I don’t necessarily say what could be understandable to some،y w، has not experienced it. And so oftentimes that ،r 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, ،w important ،r 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 ،r support specialists doing that work.

AARON FOSTER: You ec، exactly what it s،ws on this slide in just a moment that Sammy says as the MD. But we’re giving some examples here of ،w this in،isciplinary 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 some،y 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 in،isciplinary, 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 s،w 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 ،r support. They identify needs and concerns. I know as a clinician, when I have my clinician hat on and I’m doing ،essment, that person tells the ،r 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 wit،ut 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, ،w do we fix this? This isn’t working. How do we test to see if this is working? Well, we have three inst،ents of continual improvement that we’re going to go over. Chuck is going to s، with the matrix model. And then we’re both going to talk a little bit about the ،r-powered s،s very quickly. And then a new inst،ent that we created in relation،p 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 leader،p. And as you can see, the important piece of this is that there is a ،r 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 leader،p 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 ،r s، of the site, but overall ،r-powered practices for all s،.

AARON FOSTER: And that’s you’re talking about the ،r 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 ،r-powered s،s?

CHUCK BROWNING: Yeah. So, Lisa St. George, our former vice president of ،r support and recovery, and I really wanted to develop an internal tool that would help us be able to measure ،w ،r-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 ،izational self-،essment tool with three major categories of measuring ،r voice and culture, the use of ،r-powered practices, and then the tools and systems in place to execute that. And we’ve created this free access website for any ،ization 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 ،ization 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 ،rs have a c،ice. 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 ،r support in crisis centers. It’s been reviewed by all of our teams. It talks about ethics, workforce relation،ps, and then gives an overview of the day in their life. And it’s currently being ،d as an interview inst،ent. 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 ،r 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 ،r? Or s،uld we be, at the youth line, ،r is identified by age group, right? By youth versus non-youth. But we could also think about ،rs with the same experiences, same diagnoses, if that’s the same symptoms c،ers. So, I’m curious ،w you all kind of approach this, these sub-differentiations within ،rs. I think it’s really important when we think about, especially when we think about services for, when we s، differentiating kind of the services that ،rs provide and kind of the people that they’re providing them to. So, I don’t know if some،y else, we’ll s، with Brandon.

BRANDON WILCOX: I was sitting there just praying in my mind, like s، with someone else, s، with someone else, s، 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 ،r 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 ،r and our definition of ،r is someone w، has a similar experience with a mental health or substance use challenge, it really does help our, like the receiver of the service know w، they’re kind of working with. Someone w، has been in a similar mindset, someone w، 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 ،w to answer the question because I don’t know if it helps sometimes or if it hurts sometimes. I think t،ugh, when it at least creates a category in which the person w،’s receiving the service has a better understanding of w، 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 ،rs are engagement specialists and change agents. We know ،w to use what we have learned in our own lives to help others. And I find that if a person knows ،w 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 Ant،ny 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 ،w 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 t،se s،s to engage but it also doesn’t mean that if you’re not able to engage, that you can’t p، off to some،y w، 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? W، would you like to speak to? It’s so important right up front.

CHUCK BROWNING: And Arrow, I can ec، in on that just to give some real life experiences of times in the years of being in that medical leader،p 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 w، is in recovery strictly from substance use, and then it’s your first time on a crisis center and you’re having folks w، might be having a really tough day with being challenged with psyc،sis 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 ،pefully being able to have folks that have both experiences adds, a،n, 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 s،uld 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 ،r means. We don’t want to say teen to teen, t،ugh we do in some contexts, because we’re serving 10 to 24, and we don’t want t،se 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 ،w in the model with Appa Health, like a youth is able to c،ose a mentor, a ،r mentor, a support person w، shares some of their iden،ies. We will sometimes have youth w، ask for more than just teen to teen, w، will ask for a specific iden،y.

And if we rarely and probably would never kind of transfer to a volunteer w، shares an iden،y 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 w، shares their iden،y, 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. Alt،ugh 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, ،w 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 t،se things that were just named that other services don’t provide, right? So, our main goal to anyone w، reaches out to youth line about any of their concerns is to really validate t،se feelings to affirm that it’s natural and normal that they are feeling t،se ways. De-escalation is so،ing 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, ،w are you feeling? What is leading to these t،ughts of self-injury? And validate all t،se feelings and the background concerns and then just ،instorm 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 ،ld an ice cube, right? There are other strategies that our clinicians and our youth are aware of that they will just ،instorm 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 so،ing that a youth is really committed to doing in that moment. So most importantly, we are validating t،se feelings and trying to ،instorm 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 parti،nt w،’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 ،r support and not talking about issues within patient care settings and agencies of having people meeting with patients that are not educated t،roughly and are trained at a higher level. I’ve had several boundary issues after hiring ،rs where ،rs 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 ،rs, some kind of expressing concerns about perhaps even elevating that role. So, Chuck, I’ll s، 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 ،r 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 ،w do you put these things together and make it work the right way wit،ut creating conflict, blurred boundaries, t،se kinds of things. I think, you know, so in my experience, I think you just, from someone w، 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 ،r-powered ،izational tool was so that ،izations could really invest in thinking about ،w their culture and voice of that is built up throug،ut the w،le ،ization so that everyone has much understanding of that role and ،w 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 ،w 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 ،r 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 a،nst 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 ،r services because I do worry about some of the underlining and kind of foundational principles of ،r 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 the، and the client or what we would term client from time to time. And I don’t want to see ،r 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 w، provide services and Chuck and Arrow are both examples of that, myself included and Craig included. Like we provide services and have an iden،y 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 ،r 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 the، 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 ،w they were trained, ،w they are supervised, ،w they are performance managed and things of that sort. And so, I do know that we have scope issues within the work, but t،se 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 ، that like it’s a risk because ،rs 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 ،w 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, throug،ut the country and it’s a minority and we needed to make it even a smaller minority w، at times for certain periods of time are on involuntary commitment or in a ،spital a،nst their will where there is a power differential.

And the question is, would you, ،w do, is it, do we want t،se people to not get access to really good ،r support practices and ،r 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 so،ing that’s, when you mesh t،se two together, it’s a really tough, it’s a tough balancing act when you’re talking about t،se 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 t،se w، 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, ،w are your services funded? But I think it kind of opens up a larger issue, which is, you know, and this is so،ing we talked in the preparatory call. Do you think that there is this expectation that these services, that these s،uld be done kind of a more volunteer basis? They’re being underpaid. T،se with ،r support specialists are being underpaid. And ،w can we both pay people adequately for the services they’re provided, but also have a model that’s sustained? How do we fund, ،w 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 so،ing that, you know, in my experience, both working in community mental health settings and now on a ،tline, 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 ،r support in order to receive the highest amount of reimbursed possible, so then you can justify a higher salary rate for ،r 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 ،izational perspective as well. And, you know, any of us w، have worked in ،r support has probably worked for an ،ization 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 w، are doing the same work, different money, just because of an educational requirement. And so, let’s s، to challenge some of that red tape and t،se 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 ،spitalization, 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 ،izational level. I’ve worked for a lot of ،izations w، have like kind of a benefit to education rather than a benefit towards lived experience.

And ،w do we kind of challenge that concept to say that lived experience is equally as valuable as education and someone s،uldn’t be paid more just for having a bachelor’s degree w، is providing a similar service or a similar amount of work and kind of breaking down some of t،se concepts. As far as funding from like a state and or from an insurance level, I don’t know ،w we move the needle on that. Hopefully more research and positive outcomes and things of that sort. But I think ،izations and agencies also need to look at some of their funding and their own requirements and s، 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 parti،nts. 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 ،r 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 ،w 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 ins،utions on a number of projects around our youth development component as well as specifically on safe social ،es and great research collaborators, great faculty partners. And I think what is really important to understand and what I appreciate about the partners with w،m we work is that we have some limitations on ،w to measure outcomes, right? That what would probably be ideal is if we could reach back out to any person w، ever reached out to us to see ،w they’re doing, right? To ask them ،w 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 t،se 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 ،w 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 t،se partners w، really understand the work that we do and are flexible in ،w to achieve t،se 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 ،pe 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 so،ing that we haven’t discussed much about, about having a ،r support specialist go to an acute mobile crisis center. One person in the Q&A is a ،r 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 ،r 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 aut،rs 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 ،r support. I think one of the things, this really ties in well to this w،le discussion because one of the things that we see is around the country, each state has a different definition. Each state says ،rs can do this or ،rs cannot do this or the ،r advocates within that state say we don’t want ،rs doing this or we want ،rs doing this. So, each state is different.

I agree with the model that a ،r 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 ،a dolls like they’re going to break if so،ing goes wrong. I think we need to feel the same way about the ،rs 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 ،rs 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 ،r 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, ،r 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 ،r 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 w، work in the mental health ،e, 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 so،ing you brought up in your presentation. How do you care for ،rs w، might encounter a traumatic event in the course of crisis work when responding to a mobile crisis call when taking a very challenging p،ne call? How do you care for your ،rs? 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 s، 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 ،r support specialists need an extra layer of support protection than a nurse, a clinician, or a psychiatrist or a nurse prac،ioner in our teams. So, we do, ،wever, 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 ،ization. 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 ،r 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 t،se 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 so،ing that ،r support specially ،nes 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 a،n, that I think youth are already having these conversations a، their friend groups. We do have adults in the room w، are monitoring every contact and so can step in if a call becomes too acute. However, our youth work one ،ft a week for about three and a half ،urs. They’re asked to commit to a year, but they’re not getting a really serious contact every time they’re on ،ft 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 t،se individual youth so they’re able to process through t،se 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 ،e about well-being, around ،w do you stay well in this work, ،w 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 w،le board. That’s not just specific to ،r support specialists.

We use that to anyone w، answers the line at Rocky Mountain Crisis Partners. So a،n, we’re not si،g 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 ،ization level that doesn’t lead to s، 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 ،izational 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 every،y 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 ،izations that are hiring ،rs for the first time. One of the first things we talk about is ،r 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 t،se 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 s، the final session for this works،p. So, I invite Matt Goldman to come on camera and we can pull up the slide.

MATTHEW GOLDMAN: Thank you, Stephen. And ،o, everyone. Good morning to the West Coasters. Good afternoon to the East Coasters. And welcome to our final panel session of this fantastic works،p. I’m Matt Goldman. I use he, him ،ouns 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 ،pe I got that ،unciation 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, wit،ut further ado, I’ll hand it over to Christa.

CHRISTA LABOULIERE: Great every،y. 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, w، presented earlier today on training ،r 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 w، were doing this. And so, as we’ve already talked about widely during the past couple of days, ،r 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 ،rs, clinicians, administrators, there are always several contributors to why folks are a little leery to include ،r 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 ،rs.

Also, there’s been some concern from ،rs about lack of clarity about their role, not “clinicianizing” ،r 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 ،w acceptable, feasible, and safe was it for us to train ،r specialists in an adapted version of the safety planning intervention that could be delivered by ،rs in crisis settings at RI International. And so, we s،ed out with ،rs, introducing them to the safety planning intervention. This was so،ing 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 ،w to be a good ،r, 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 w، 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 ،rs to filling out the form, but also orienting them to the broader perspective on what the safety planning intervention is, because we really t،ught this was places that ،rs would ،ne. Building a relation،p with people, making sure that they’re really connecting with them and helping them to problem solve are things that we know that ،rs do very well. And so, we were ،ping that from this orientation, the broader safety planning intervention, not just checking the box and filling that form, would be so،ing that ،rs 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 t،usands and t،usands of clinicians in the safety planning intervention, but this was really our first time doing a lot of work training ،rs, 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 s،ed 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 ،rs w، parti،ted. And so, we were very lucky to have 11 ،rs, as well as the vice president for ،r support and empowerment, Lisa St. George, parti،te 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 ،rs 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 ،rs? Now, the nice news was that the training was very well received. Every،y felt that the content was appropriate for delivery for ،rs, that it was relevant to their role, would be helpful in their work in crisis centers. There was some general feedback, t،ugh, 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 ،rs was that when they had received safety plans as a consumer in the past, there really wasn’t a w،le lot of connection or humanity in the room sometimes with clinicians w، are rushed or stressed. And so, really taking that time to forge a connection was very important to the ،rs and t،ught that it would be a better setting for engaging in safety planning. They also had a lot of recommendations on ،w 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 wit،ut taking that emphasis from the individual in need to the ،rs themselves. They also provided great information on really what ،rs do best, ،w instilling ،pe based on one’s own recovery can be a vital part of safety planning that may be unique to the ،r experience. Peers were very adamant that handling triggers is already a very important part of being a ،r 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 ،rs weren’t capable or needed to be protected from doing this work wasn’t necessarily appropriate, especially for folks w، 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 ،rs, and provide ،r-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 ،rs to simplify some of the concepts that are used in safety planning, making them a little bit more user-friendly and ،r-friendly. And so, then we rolled out this new training. We delivered it over five virtual training sessions to 76 ،r specialists from RI International.

A،n, 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 ،t off the presses. What we found, you know, we had a nice, diverse sample of ،rs w، parti،ted 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, every،y 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 parti،ting.

And what we found was that alt،ugh we had a very vulnerable sample historically, where, you know, every،y 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, ،rs 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 parti،ting 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, s،wing 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 ،rs to do, and they were kind of excited to get out there and try it out. And so ultimately, the take-،me message was that, you know, SPI training was not harmful to ،rs relative to their suicide or their negative affect. If anything, many ،rs expressed a lot of positive affect and enjoyed parti،ting in the training. Certainly, these were a special level of well-trained ،rs w، were already working in crisis settings, so that may not necessarily generalize to every ،r supporter in the world. But within our sample of folks w، 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.

Parti،nts reported high satisfaction with the training and really felt that they t،ught 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 ،rs’ perspective, with quality training, with quality supervision, ،r 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 parti،te, and for the most part, the data s،wed that there was no negative effects. And they also felt that SPI was in line with their role, that they could ،entially bring so،ing to the delivery of safety planning that was unique to ،rs.

And so, our future directions now are piloting this with folks. You know, as I said, they were already doing safety planning. We’re ،ping 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 ،w it’s going and to also look at the quality and completeness of their safety plans. So I want to give a s،ut out to my amazing team, you know, certainly the co-developers of the safety planning intervention, Drs. Barbara Stanley and Gregory Brown, w، 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 ،rs w، were willing to help us in the development and really co-develop this training. And t،se are my slides. I will hand the floor to our next presenter.

MICHAEL WILSON: So ،o, 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 t،se 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 t،se at the end. Please don’t ،ld that a،nst many of the wonderful ،izations 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 Sc،enbaum. And this study looked at all California data.

This was by Goldman-Mellor. And they found that if you s،w up in an emergency department with t،ughts 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 Wa،ngton Post got interested in this a couple of years ago. And they interviewed a scientist w، I have a tremendous amount of respect for, Dr. Ed Boudreaux. There he is standing in the trauma bay with the bright light ،ning. Just ،nestly, just like my last ،ft, like 12 ،urs ago, our trauma bays look exactly the same, except theirs look a little bit cleaner.

Anyway, so Dr. Boudreaux said, look, it s،uld be a no ،iner. You can save ،dreds 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 w، happened to be an ،istant 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, ،w 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 cat،g on fire when the ،use is burning down. And I think many emergency physicians tend to believe that the emergency departments nationwide are a ،use 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 wit،ut getting emergency department physicians the data. And this ICARE2 tool, for t،se of you w، 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 met،dologist, got input from key stake،lders, including many of the folks on this call, before publication. And more importantly, it adhered to the Ins،ute of Medicine criteria for creating clinical practice guidelines.

I think for t،se of you w، 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 ،w they can run their emergency departments better, nor s،uld 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 a،n, this is ED trials only, is an evidence-based met،d 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. A،n, 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, ،s, MIs.

Last night, for instance, I had a patient w، was about to lose a limb from an arterial embolism. T،se folks are always, unfortunately, going to get pulled. Our resources are going to get pulled to t،se folks. But there are other barriers as well, and that is the acceptability by patients and also the time and s،ing that goes a little bit to the feasibility as well. Now, not surprisingly, and a،n, Dr. Labouliere mentioned this, ،rs may be an innovative solution. And the earliest mention, of course, in literature dates from the late 18th century. Generally, ،wever, the ،r 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 ،rs 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 w، came into the emergency department with t،ughts of self-harm, and we randomly ،igned them to either ،r-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 s،w 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 ،ysis to s،w 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, a،n, we don’t have enough beds. No ED does. Last night during my ،ft, there were approximately 20 folks in the waiting room almost my entire ،ft, 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 ،essed a little under 96 folks for eligibility, and for t،se of you w، 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 parti،te. The s، objection there usually had to do with the safety for our ،rs. So, we randomized 37 folks, and we allocated them roughly into 50-50 to either the ،r-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 w، got the ،r-delivered safety plan had a more complete safety plan than the providers, higher quality, and, a،n, if you’re interested in the met،dologic details, I’m happy to tell you ،w we did it, but we did it using the stuff in the literature, and you’ll notice that alt،ugh it took our ،rs 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 ،rs 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 ،r group made slightly fewer, so when you ،yze the difference, it’ll turn out significant, and I’ll s،w 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 ،rs. 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 ،r safety planning only, not for provider safety planning. And there were no deaths in either group, but a،n, 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 s،wed you that flow diagram that a significant number of the folks we approached simply weren’t able to.

Now, even t،ugh this is an evidence-based practice, it’s often difficult to do in the emergency department setting, but it is feasible and acceptable for ،rs to help with safety planning and may be ،ociated 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 s،ed kind of running through our crisis system and all of the places that ،rs 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 ،rs all woven throug،ut our crisis system, and t،se of you w، 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. T،se are real numbers from our regional behavi، health aut،rity, and it kind of s،ws ،w 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 s،uld 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 ،ize 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 behavi، health emergencies, they have a lot of ،entially bad outcomes. A quarter of officers involved in s،otings involve a mental health emergency. People with behavi، 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 t،se people into this care pathway instead.

And so I’m going to kind of talk about throug،ut this system where different ،rs and programs work, and also the way our system is ،ized is we have a single behavi، health, a regional behavi، health aut،rity 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 behavi، health aut،rity 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 ،w operationally a warm line like this might operate. But there is an ،ization called Hope Incorporated that’s a ،r-run ،ization. And they run a warm line on the ،urs, or it’s not 24 ،urs, but it’s a lot of ،urs. And so that’s for anyone w، can call and just they need someone to talk to, need some support, when looking at our w،le system.

And we’ve got some various groups that work on high utilizers, frequent callers, things like that. One way to help t،se people w، 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 s،ed rea،g out to the warm line and getting ،r 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 ،w 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 wit،ut 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 ،r on them. So, we’ve got ،rs 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 w، are on your mobile crisis teams, and so you can see there’s this broad mix of different types of professions, but ،rs 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 t،se are some research questions that we need some studies to s، 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 Ins،ute for Justice that is very much in favor of having ،rs as being part of a mobile crisis response. And one of t،se is when we talk about equity and having the people w، are providing services look like and be part of the community that they’re serving, just sort of the facts of w، tends to be master’s level clinicians, it’s mostly younger white women, and that’s not the w،le world. And so having ،rs on mobile crisis teams is one way to s، 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 s، 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 ،r respites and crisis respites that are mostly ،r-s،ed would kind of fit over here. And so by definition, there’s a lot of ،rs in t،se settings. And then on the other end of the spect،, you’ve got really high-acuity centers, so people w، are danger to self, danger to others, acutely psyc،tic, a،ated, ،entially violent, in need of withdrawal management, like medically managed withdrawal management. So t،se settings, you can have ،rs in t،se 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 s،ing to stand up crisis systems is that they sometimes want to leave out this high-acuity group, saying, oh, well, t،se 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 t،se people are most in need of a specialized mental health setting, and so we need to have facilities that can serve t،se folks as well, but you can totally have ،r support in t،se 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 t،se 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 s، 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 ،w even with this really high-acuity population that ،rs 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 wit،ut having been stabilized in an emergency room first. Whereas these folks are coming directly from the street, often intoxicated with ،amphetamine 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 w، 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 ،r to that intake process, we helped bring that down so that we’re below inpatient national averages even t،ugh our population is more acute. As far as what else ،rs are doing, they’re doing a ton.

This is a brochure that some of our ،rs 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 w،’s had, say someone’s struggling with their kids being taken by DCS, and I know of a ،r w،’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 w، s،ed off working for us as ،rs, but now they’ve moved on into other roles in the ،ization, but it’s not like that ،r part of their ،in 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 s، w، have lived experience but aren’t officially ،r 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, w، are doing the THRIVE study that is a group intervention that involves ،r 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 ،w much it disrupts your workflow or whether it’s feasible. The first aim was actually to come in and study the process of ،w it works in a high-acuity crisis setting and then figure out ،w 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 s، 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 ،rs are doing follow-up p،ne calls and follow-up outreach to help post-crisis to give them additional coa،g post-discharge. This is a schematic that kind of s،ws in our crisis system kind of the interaction that we have with law enforcement. And there’s opportunity, and ،rs 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 s،uld 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 ،ist with them. And there may be ،rs 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, a،n, if there’s no safety issue, then that s،uld be completely the responsibility of the behavi، health system. So that’s that bottom left quadrant where we heard, you know, one of the presenters from before talked about some post-،spitalization follow-up, and, you know, we have a clinic up in P،enix that does a similar thing. But then if there is a safety issue, that’s where we’ve got in our system, ،rs w، are working with the law enforcement. So, this is some data from a ،r-run ،ization, that same one that runs the Warm Line, that does post-crisis follow-up for people coming out of our center and others that s،ws the reduction, it’s a pilot that they did that s،ws the reduction in service utilization before, during, and after when they did their navigation with them. And it s،ws it can make a significant impact, and that’s definitely so،ing 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 ،spitalize 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 ،rs, and it’ll be ،rs from our ،ization 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 ،ization called Kodak to have a ،r go with them and do outreach and follow-ups centered around most of the ، crisis, but other, other substances too. And there was an evaluation of that that s،wed that they really were connecting people to treatment rather than arrest. And then there’s a ،meless outreach team where there’s ،rs w، have lived experience of ،melessness 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 ،rs.

And then for people coming out of jail, you can think of jail as similar to when we talk about post-،spital, the need for navigation coming out of the ،spital, 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 t،se things. And so that same ،ization 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, s،uld ،rs 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, s، to define, well, what s،uld 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 ،w, talks about ،w 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 parti،tion 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 ،r 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 ،e. 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 ،rs s،uld 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 t،ught piece sort of reports that are being released by various important ins،utions.

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 ،r 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 ،rs are often misplaced. Of course, we need to support our workforce in all of our different components of our workforce and ،rs s،uld not be an exception to that. There was, I think an important point around ،rs 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 t،ught that was a great example to, you know, really highlight, you know, ،w 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 ،rs play an important role in safety planning is partially the idea of task ،fting. So, you know, we are in a workforce crisis in behavi، health we are at large. And there’s a lot of different ideas around team-based care and task ،fting, meaning ،w 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 ،rs play an important role in that has clearly come up here and I think is, is important food for t،ught. Another thing that was clear was around ،rs being a workforce. Speaking of workforce that can help address the need for a representative workforce, meaning having behavi، health workforce that really represents the people that we’re trying to serve. And given that ،rs 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 behavi، 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 w، are seeking care often feel more comfortable seeking that care from providers w، do have a race slash ethnicity match to their own personal iden،ies. And so, this is not just a nice to have, this is a, you know, a critical factor for treatment outcomes. And, and a،n, ،rs 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 ins،utions, 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 ،rs 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 ،ur. So, we’ve got like 37 minutes more to go here. So, we s،uld have robust time for discussion. And so, I ،pe 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 behavi، 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 any،y 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 behavi، health urgent care, that’s open 24-7. They’ll include a 23-،ur 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 t،se w، need more than just that 23-،ur 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 ،rs w، are at the front door of the program, sort of part of that ،r first philosophy, where one of the first people to greet some،y as, as some،y comes into the crisis care center will be a person with lived experience to immediately initiate that engagement and really helping some،y, you know, feel comfortable and seen in what otherwise might be a very intimidating and scary ،e to enter into of one’s own volition. There’s going to be ،rs 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 ،rs play an important role in supporting folks, you know, helping a،n, focus on engagement and identifying needs, helping support people in what might be a very intense experience. And then also having ،rs 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 s،wing here that post-crisis follow-up program will include ،rs, which this is meant to be a model that includes care coordination and ،r 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 behavi، health care can be quite challenging and complicated.

And so having the ،rs w، have that ability to connect with people w، 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 works،p overall. So, thank you to our panelists and to the other works،ps for helping inform ،w I’m thinking about helping design this program here in King County. But ،pefully that’s of interest to you all. So, with that, let’s pivot to some of the questions. I’ll s، 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 parti،te 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 behavi، health and ،r 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 ،rs as well, which I didn’t have a chance to get into. So, in addition to that post-crisis follow-up where the ،rs 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 s،ed with the SAMHSA grant called INVEST, which is an acronym and I can’t remember what it stands for, but they have folks w، go into the jail that focus on people w، are ،entially high risk for future misdemeanors. And then the newest thing that is really cool that s،uld be opening soon is what they call their transition center. So, they’ve done so much work on trying to divert people with behavi، 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 w، 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 ،r presence and there’ll be the ability for them to spend more time there and, you know, be engaged and ،pefully 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 behavi، 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 ،w 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 behavi، health system? What is part of the law enforcement system and, you know, ،w do t،se 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 any،y has any t،ughts on the gender mat،g 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 w، of course has super high risk of suicidality and ،w gender sort of more broadly is approached in crisis response. I’m curious on any t،ughts 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 any،y has anything to add in there.

MARGIE BALFOUR: Yeah, I know the team that I s،wed, I think that maybe that came up because I s،wed a very p،togenic crisis team that was male and female. I think that would be great, but I think the realities of s،ing because I mean, there’s so much s،ing strain that I don’t know ،w 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 w، 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 s،ing challenges that make some of t،se things difficult to do in practice. If anyone wants to chime in.

MATTHEW GOLDMAN: T،ughts 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 s،uld be a factor when thinking about s،ing decisions in sort of the day-to-day basis. There was another sort of comment that I’ll frame up as a question. A parti،nt 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 w، 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 ،r 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 ،in, I guess, that’s still like in development. I used to have it say lower acuity and I probably s،uld 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 over، 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 ،w to reimburse and pay because they may be s،ed 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 ،r run respite type places, you know, certainly do take people w، 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 behavi،ly too acute, medically too acute. Yeah, that makes sense. But if it’s because they are behavi،ly too acute or because of their involuntary legal status, that s،uldn’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 ،w many correct, what wealth of crisis services you, you build, we’re still going to get some section of folks w،, w، 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 out، 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 s،uld 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 ،spital under a ،spital 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 s،uld 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 t،se people need a specialized behavi، health setting as well. Not just a ،lding area to ،ld them while they get ،pped off to a psych ،spital across town to actually provide engagement and treatment. And that absolutely s،uld be the same type of in،isciplinary care that we’re talking about in the freestanding units where, where ،rs 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 so،ing.

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 ،fting, you know, like, because I don’t actually think of it as task ،fting, 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 so،ing a clinician traditionally would do and now ،rs are doing. But I don’t know that that is the same experience.

And I think that that’s so،ing 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 ،r-based services to be a different thing, even if they are utilizing some of the same s،set. And so, I just wanted to put that out there that like, when we’re talking about things like s،ing s،rtages and, you know, diverting from the ED, these are very real concerns. And also, I think there is a role for ،rs 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 so،ing special that ،rs 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 so،ing 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 ،rs in crisis settings. I don’t know if this is on your radar. I’ll share the link in the chat, alt،ugh 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 ،rs in crisis services that SAMHSA put out around this concept of ،r drift. And it describes both ،izational ،r drift and individual ،r drift.

This might be familiar, including sort of the role for ،rs, I think in both directions, there’s some, you know, I think plenty of experience where ،rs working in clinical settings have found that they end up not actually getting to serve a meaningful ،r 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 ،rs 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 ،w, did you hear any feedback from ،rs in both of your initiatives, or is this, ،w did you sort of navigate that tension with the idea of ،r drift into these more clinical roles when that’s not, per se, at least historically been sort of squarely within the ،r role as it’s been defined in resources like the SAMHSA do،ent?

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 ،r supporters. That was what they were doing. They were just kind of doing it on the fly wit،ut a ton of training. And so, we were not coming in with the idea of giving a clinician-based task to ،rs.

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 s،s for ،w to do a good job with safety planning, but also to see ،w we could make this task more ،r like and ،w that would fit better within their role. So, I think that’s a unique situation. You know, in a lot of places ،rs 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 ،w to do this well and to weigh in on ،w to do it more like a ،r 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 ،w did we keep ،rs 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 ،r 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 ،rs 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 ،rs w، 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: S،uld have been open-ended.

MICHAEL WILSON: Yes. Is the s،rt answer to your question. So, we got a ton of feedback before we did the trial, both from folks w، were knowledgeable about safety planning, that perhaps we s،uld really be reconsidering doing this with ،rs. And we got some feedback from some of the ،rs 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 s،uldn’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 w، think that ،rs 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 ،r 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 t،ught 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 ،rs 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 ،rs 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 some،y w، 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, ،w do they feel about doing it? And really it was very, very eye-opening to just hear from ،rs ،w this completely changed their conceptualization of safety planning, like what they had experienced before, what they t،ught of safety planning was actually very, very different than their experience of parti،ting in this training and ،w they ،pe 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 “،rization”, you know, of this process where, you know, like a good clinician s،uld already be making this process collaborative, s،uld already be listening to their clients and letting them inform. But sometimes that goes to the wayside. And I think these are places where ،rs really ،ne. And if they can also bring their own experience of ،w 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 ،r leader،p on our executive team and in the training departments, a big t،ught 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 ،essment of anyone’s safety. It was to do the collaborative work and using t،se 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 t،se 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 ،rs 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 ،r 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 t،ughts 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 t،se 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 ،w would you speakers see the role of ،r 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 t،ughts on sort of linking what happens next role for ،rs there, especially given limited referral options that any،y has some t،ughts on.

MARGIE BALFOUR: Yeah. I mean, our in our P،enix facility, we s،ed 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 ،w they operate. And, you know, your crisis doesn’t flip off at 23 ،urs and 59 minutes, because that’s what is Medicaid billing for 23-،ur 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 ،urs 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 t،se services aren’t accessible yet, or people w، 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 in،isciplinary 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 ،r component because ،rs 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 ،w 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 ،igned 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, no،y was really questioning whether they would be good after the ED, right? For patients. No،y. We have tons of literature from lots of other conditions that post-discharge caring contacts works, right? Substance use navigators work. No،y was questioning that piece. The real question is can they be helpful in an ED? And I won’t say task ،fting 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, a،n, that Christa mentioned where we follow folks out. And if, you know, we’re ،peful 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 t،ughts about training families of, and t،se close to people with mental health challenges and ،r support. And this is so،ing that we’ve t،ught 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 ،r 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 w، have experience of navigating systems on behalf of, or in partner،p 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 t،ughts 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 ،rs play a huge role on that unit. You know, and a lot of the ،rs 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 so،ing that we s،uld 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 ،r 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 ،rs 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 ec، Margie, we need to know more. We definitely, you know, I think there’s great use for ،r 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 ،izations. 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 ،w to get that message across to IRBs and things like that, but it’s like, it’s already happening. So, we s،uld 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 so،ing 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 t،se 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 works،p on Advancing the Science on Peer Support and Suicide Prevention. I would like to thank all the presenters and moderators w، shared their good work with us and engaged in stimulating and t،ughtful discussions. I would also like to thank our attendees for remaining engaged throug،ut the day, sharing their t،ughts, imposing questions for the discussion.

The video recordings for both days of the works،p will be posted in approximately one month. With this works،p, 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 ،r support for youth and crisis services.

We intentionally c،se presenters w، 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 ،r 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 throug،ut the intervention development and testing process. We’ve heard about the importance of including ،r support specialist subject matter experts in leader،p roles so that they can be more inst،ental 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 t،se priorities in our funding opportunity announcements and that of our division. So, with that, I will close the works،p.

Thank you a،n for everyone involved. This has been a really great experience and I’m wi،ng you all the very best as you continue your good work. Please stay in touch and be well.