The peer specialist: possibilities for the recovery of
suicidal care consumers

Following the initiative of care consumers who felt that their voice regarding
their care was not heard by mental health services, a peer specialist movement
started in the United states in the 90s and has since expanded to Europe
(Doughty & Tse, 2010). The peer specialist movement proposes a holistic view of
care consumers (e.g., clients or patients) instead of a *narrow* (psychiatric
or medical) view of symptoms; it advocates a person-centered, integrated mental
healthcare delivery model, in which the consumer*s voice is taken seriously
(Cabral, 2014; Clossey, 2015).
The emergence and availability of peer specialists with a history of
suicidality (i.e., suicide attempts and/or suicidal ideation) who work with
suicidal care consumers is a more recent phenomenon in this context. In the
United states, the Suicide Attempt Survivor Movement was launched within the
America Association of Suicidology, aimed at the improvement of care provided
to suicidal care consumers (2014). The reason for this movement was that care
consumers are frequently dissatisfied with their treatment (Peterson & Collins,
2015); for instance, health care staff is perceived as unempathetic and
sometimes as judgmental, and care consumers* needs are not fully met (Cerel,
Curier, & Conwell, 2006; Lindgren, 2004). Furthermore, healthcare staff often
appear to focus exclusively on suicide risk assessment (Segal-Engelchin et al.,
2015), while care consumers appreciate a caring conversation (Ross, Kelly &
Jorm, 2014). Suicidal care consumers also observe discomfort, taboo, and fear
around healthcare staff discussing suicidality (Lindren, 2004).
The rationale behind the suicide survivor moment, having peer specialists
involved in suicide prevention (Thomas, 2011) is their anticipated unique value
in helping fellow care consumers with their recovery from suicidality. The
unique contribution of peer specialists in suicide prevention is expected to
emerge as a result of shared experiences with suicidality and shared
adversities in life, mutual recognitions of stigma, and shared challenges of
communicating with healthcare staff and/or family and friends about
suicidality. Due to their own recovery process, peer specialists can be a
source of inspiration or role models for suicidal care consumers (Salvatore,
2010).
Despite this potential of peer specialists, the employment of this group in
mental healthcare services in the Netherlands is still in its early stages.
However, due to recent developments, an increase of the number of peer
specialists can be expected shortly. Further professionalization of peer
specialists is supported by the Dutch Association of Mental Health Care that
requested the addition of peer specialists to the list of official mental
health professions (VZA), which emphasizes this conviction. Therefore, the role
of the peer specialist is increasingly important.
A general professional profile of the peer specialist (Van Bakel et al., 2014)
has been outlined recently in the Netherlands, yet it has no reference to
suicidality or suicide intervention skills. However, stakeholders with whom we
consulted (see project team and collaboration partners) acknowledge the
importance of peer specialists in suicide prevention. For instance, during
several consumer-led recovery training sessions (e.g., WRAP), trainers
acknowledged their difficulty in addressing suicidality when this topic
emerged. In a similar vein, students enrolled in the degree of peer specialist
who discussed their (previous)
9
suicidality in class, experienced that many educators lacked expertise and
knowledge concerning this topic. Suicide prevention is not part of the
curriculum for peer specialists, although suicidality and self-harm is
frequently a topic of discussion in working with suicidal care consumers. Risks
may exist when peer specialists work with suicidal consumers without adequate
training, supervision, or aftercare, as working with suicidal care consumers
can be burdensome. It also requires explicit knowledge about (juridical)
responsibilities and collaboration with other mental healthcare professionals.
The core foundations of the general peer specialist model (i.e., recovery
assisted by peers, Clossey et al., 2016; Johnson et al., 2014) is applicable to
suicide peer specialists and connects well with effective approaches to suicide
prevention (Van Hemert et al., 2012). We propose that peer specialists who have
recovered from suicidality can offer hope, support, and an opportunity for
re-connection to care consumers who are struggling with suicidality*aspects
that are proven to be crucial in suicide prevention (Alexander et al., 2007;
Herringstad & Biong, 2010, Oliffe et al. 2010). Peer specialists are well
equipped to suggest care improvements for suicidal individuals, and hereby
prevent suicide. However, further professionalization in this context is
needed.

The role of peer specialists in suicide prevention is promising, but the
professionalization of this field currently is underdeveloped. To achieve its
potential regarding suicide prevention, it is imperative that peer specialists*
role and professionalization in mental health services are strengthened.

Research questions

How can the unique value of peer specialists with a history of suicidality who
(intend to) work within mental health services be utilized to reduce
suicidality among care consumers?

How can the professionalization of peer specialists be strengthened and
potential pitfalls be addressed in relation to suicide prevention in mental
health services?

By professionalization, we refer to:
* training (e.g., understanding the suicidal process and recovery)
* curriculum development on suicidality
* resources for peer specialists in suicide prevention
* role development and role clarity
* supervision and aftercare

The professionalization of the peer specialists* role in suicide prevention
needs to be strengthened at two levels:
Level 1. Peer-to-peer support
Level 2. The institutional level, including staff and policies

Subquestion A:
What need do stakeholders perceive for initiatives from peer specialists with a
history of suicidality in relation to mental health services, and which
initiatives already exist in the Netherlands and internationally?

Subquestion B:
What unique value for the recovery process of suicidal care consumers can be
derived from current initiatives and the (future) integration of peer
specialists on the one hand? What potential risks could emerge on the other
hand, and how could these risks be successfully addressed? The unique value of
peer specialists refers to their experiential knowledge of suicidality, and if
their role is strengthened, benefits in suicide prevention include recovery,
peer support, the consumer perspective on care for suicidal people, suicide
intervention skills, and psycho-education. Next, the risk analysis is focused
on risks that emerge for suicidal consumers, peer specialists, and mental
health institutes and their managers. These risks include (a) the mental burden
of supporting suicidal peers; (b) issues of confidentiality, particularly in
relation to suicide risk taxation; (c) the complexity of dual relationships
between staff and peer specialists and those they attend to (consumers); (d)
resistance among traditional professionals against suicide prevention by peer
specialists.

Due to the early stage of involving peer specialists with a history of
suicidality in Dutch mental healthcare, we have chosen an exploratory and
qualitative research approach that interconnects stakeholders in the field. Two
research methods are applied: a review of international and national *grey*
literature and media, and focus group- and individual interviews.

The current research burden exists of a qualitative interview of approximately
one hour. Participants will be thoroughly informed about the purpose and nature
of this interview in advance. Although we will inquire after the suicidality of
the participant for contextual and descriptive purposes, the main focus of the
interview will be on the persons expectations, needs and experiences of peer
specialists and how they can help in the recovery process of suicidality.
Previous research has shown that discussing suicidality with vulnerable groups
and suicidal persons has no iatrogenic effects and can even alleviate stress
associated with suicidal ideation (Biddle et al., 2013, Dazzi et al., 2014;
Huisman & Kerkhof, 2017). Therefore, the burden of participating in the current
research is considered to be minimal and risks are negligible. Participants can
terminate the interview at any time without explanation; the researchers are
thoroughly trained in discussing the sensitive topic of suicidality, assess
suicide risk and are able to make referrals to further help if necessary.
Potential benefit of participating for participants is that they can contribute
to the further professionalization of peer specialists and can voice their
needs regarding the mental health care they are offered.