Silver Award: Reciprocal Peer Support for Addressing Mental Health Crises Among Police, Veterans, Mothers of Special Needs Children, and Others

Confiding in someone with similar experiences is often helpful during a time of personal crisis. That is the guiding principle behind Reciprocal Peer Support, a groundbreaking program that connects persons experiencing a mental health crisis with a peer from a similar background. Cops talk to cops, veterans talk to veterans, and mothers of children with special needs talk to each other.

Located in a large call center at Rutgers University Behavioral Health Care (RUBHC) in Piscataway, New Jersey, Reciprocal Peer Support oversees hotlines for 14 unique peer support programs, including COP2COP, Mom2Mom, Vets4Warriors, Vet2Vet, and Care2Caregivers. Callers are immediately put in touch with a trained peer supporter who gathers information while assessing suicide risk. If appropriate, peer supporters can pivot to a case management role, providing long-term support based on four structured tasks in order to secure services as clinically indicated. The Reciprocal Peer Support tasks include connection, information/risk assessment, case management, and resilience.

The “cultural connection” between callers and peer supporters is the key to the program’s success, said program director Cherie Castellano. Not only does it help overcome stigma, but it also forms the foundation on which to build a relationship. “These days, everyone can search the Web for referral options and access to information,” said Ms. Castellano. “Our callers are looking for something more,” she said. “They need to know that they are not alone and that seeking help is a viable option.”

In recognition of a reciprocal peer support program for addressing mental health crises among police, veterans, mothers of children with special needs, and other populations, Reciprocal Peer Support was selected to receive the 2018 Silver APA Psychiatric Services Achievement Award.

Pure presence

The connection between caller and peer supporter has been at the heart of Reciprocal Peer Support since the beginning, according to Ms. Castellano. The first program began in 2000, when the New Jersey Department of Personnel contracted with RUBHC to implement a crisis intervention services hotline for police. Since then, 14 hotlines for unique populations have employed 125 peer supporters over the past 18 years. The program’s budget has grown to over $5 million annually, funded by federal and state contracts and grants.

As the first program of its kind in the nation, COP2COP serves as the model for all of the Reciprocal Peer Support programs. Every effort is made to match a caller in crisis with a peer supporter with similar experiences, for example, service as a Marine. Shared experiences, such as trauma, self-medication, or caring for a family member with Alzheimer’s, can also serve as an effective secondary matching criterion.

To establish a connection with a caller, Ms. Castellano said, the peer supporter must provide a “pure presence.” The goal of the conversation is to engage the client without judgment—avoiding preaching or directing—and to experience moments of shared suffering and pain. Peer supporters are trained to collect information about the caller’s presenting problem and behavioral, medical, family, and work history while assessing for suicide risk and weapons availability.

The quality of the connection is largely dependent on the peer supporter’s ability to utilize empathy, active listening skills, and direct and indirect communication. Unless a peer is reporting behaviors that would indicate serious risk, the peer supporter maintains a conversational style and uses informal questioning as much as possible. This skill set is particularly important for callers who typically avoid sharing their feelings with others, such as first responders. At Cop2Cop, for example, retired police officers function as peer supporters and clinicians who offer a deep understanding of officers' concerns, problems, and family issues and sustain the “cultural connection.” At Mom2Mom, peer supporters remind callers that caregivers need support, too.

Although most encounters between peers and peer supporters take place by phone, the programs also provide face-to-face individual and group peer support, crisis intervention services, prevention and training, and advocacy for specific populations. Callers to the Mom2Mom hotline, for example, can also receive peer support through live chats, and clinical professionals are available to conduct telephone assessment of depression, anxiety, and family and marital issues.

In many cases, the relationship between the caller and the peer supporter is maintained over a significant period after the crisis subsides. However, sometimes peer supporters fail to establish a connection with the peer, ending the helping relationship. To avoid that outcome, peer supporters are taught to monitor for signs that a caller is wary of making a connection. In many cases, multiple efforts may be necessary to cement the relationship. In fact, peer supporters will often make three to five contacts for every initial contact they receive. Sometimes partnering clinicians will work with the program to find a better match.

When a match does not work out, Ms. Castellano works with the peer supporter to examine what went wrong. Sometimes, she said, peer supporters are unable to “truly hear the voice of the peer in need,” possibly because of their own personal experiences or biases. Although peer supporters are encouraged to be aware of their own strengths and vulnerabilities, the program acknowledges that some connections will fail.

Even for partners who manage to forge a strong connection, the relationship may be tested again by the pivot to case management. Peers tend to hold peer supporters responsible for undesirable clinical encounters, despite the fact that Reciprocal Peer Support is not formally associated with sources of treatment. Although Reciprocal Peer Support attempts to vet all the providers, doing so is not always possible.

A unified approach

Each year more than 183,000 incoming/outgoing calls serve approximately 8,000 unique clients on the peer lines at the RUBHC call facility. On average 70% of callers agree to Reciprocal Peer Support, which—because of its access to the call center—is able to provide a more unified approach than is typical for programs of its kind. For example, because of the center’s sophisticated automated call distribution capacity, each program has its own toll-free 800 number, giving callers immediate access to a peer with similar experiences.

In addition, the center’s integrated patient management system allows the program to take advantage of partnerships with clinicians at the RUBHC. Peer supporters are always ready to facilitate access to a higher level of care by working closely with an appropriately trained behavioral health care professional. With guidance from clinicians, peer supporters can link callers with a wide variety of behavioral health care services and housing, financial, and family-oriented services. If a referral or service offered is not ideal, the peer supporter tries again, linking the peer with other resources while maintaining the connection forged over repeated contacts. The sense that the peer supporter and peer are pursuing solutions “together” is key.

Building resilience

Although connection is at the heart of Reciprocal Peer Support, affirming resilience among peers and peer supporters could be considered its ultimate goal. Peer supporters are encouraged to engage in self-care and self-affirming activities as a way of strengthening their own resilience as a group. For example, Cop2Cop peers have walked for years in the American Foundation for Suicide Prevention suicide survivor walk and other events to memorialize officers lost to suicide. Peer supporters in Vet2Vet advocate for soldiers by volunteering to be present at dozens of events to welcome home returning service members.

Whenever possible, peer supporters are encouraged to acknowledge signs of resilience among the peers to whom they are assigned. These opportunities tend to arise later in the relationship, when the immediate crisis has passed, and may signal that the relationship is winding down.

Many peers who have accessed Reciprocal Peer Support will confidently return for additional support over time, but for others, the experience represents a single episode of support. However long the relationship, the essential elements are the same—risk assessment, care management, affirmation of resilience, and, above all, a duty to connect.