C4 Innovations

Peer Support in Crisis Services

An episode of “Changing the Conversation” podcast

Cheryl Gagne and Steven Samra share tips and strategies for peer support workers in crisis services.

October 31, 2022


Steven Samra, Host (00:05): Hi everyone. Welcome to Changing the Conversation. I’m your host today, Steven Samra, senior associate with C4 Innovations. And today’s topic focuses on peer roles and crisis services. Too often people with mental illness do not receive a mental health response when experiencing a mental health crisis and often come into contact with law enforcement rather than a mental health professional. The lack of a robust mental health crisis system can lead to tragic results. For example, one in four fatal police shootings between 2015 and 2020 involved a person with a mental illness; and an estimated 44% of people incarcerated in jail, 37% of people incarcerated in prison have a mental health condition.

(00:53): Millions more end up in emergency departments that are often ill-equipped to address the mental health crisis, often waiting hours or days to access care. The new 988 Suicide and Crisis Lifeline provides immediate crisis intervention and support to help improve the crisis responsiveness for individuals who may be dealing with a mental health or a substance use crisis, or any other kind of emotional distress. People can also dial 988 if they are worried about a loved one who may need crisis support. Peer workers are uniquely qualified to provide services and supports for the 988 crisis line and to discuss this further, my guest today is Dr. Cheryl Gagne, senior associate at C4 Innovations. Welcome, Cheryl.

Cheryl Gagne, Guest (01:43): Thank you Steven.

Steven (01:44): Cheryl, I want to dive right in. Can you just share, what does it mean when we talk about crisis care?

Cheryl (01:53): Thank you, Steven. I think we can step back even further around what is a crisis? What constitutes a crisis kind of in our society? And often that happens when those around us feel concerned for our safety or the safety of others. And sometimes people initiate their own kind of outreach to get crisis support services. Other times, family members, teachers, other people in the community may call. Your very sobering introduction about the ills of the current system has really brought about a lot of changes in organizing crisis support services.

Steven (02:38): Cheryl, I know that this kind of work can be a fairly heavy lift. Can you talk about how peer workers might prepare for their roles in crisis care?

Cheryl (02:50): Sure. It really depends on which kind of crisis service environment they plan on working in. There are a whole kind of array, everything from the crisis call line. There are other kind of lighter services called peer warm lines that are very equipped to answer and respond to when connect people, when crises aren’t quite as hot, doesn’t really require a hotline. But often those sort of daily hassles or daily mini crises accumulate over time and can really lead people to experience a more kind of emergent crisis. And so we think about peer work as on the edges where we get to prevention of crises as well as kind of along the whole continuum of crisis services. Crisis services include the call lines, mobile crisis support teams. Steven, you had brought up the real challenges historically where there was an over reliance on law enforcement to respond to behavioral health crises.

(04:07): And this wasn’t just people with mental illnesses, they’re people who were living with autism, sometimes somebody experiencing dementia, but law enforcement not being prepared to intervene in an effective way, misinterpreting behaviors and escalating the violence. The idea of peer support involving peer support in a mobile crisis response is happening in many, many places in the country. And there are several different models from the harm reductionists who are accompanied by police to do door knocks the day after an overdose that someone survived, offering harm reduction equipment and education, Narcan, support for family, police stay at the curb just to kind of oversee things. To the models where a clinician and a peer support specialist go out together to respond without law enforcement at all. And this is, it might be a clinician and a youth peer support worker to support somebody in their adolescence or young adulthood.

(05:24): So there are a lot of different models. Preparation would very much depend on what environment you’re working on. And we think about mobile crisis support and then crisis stabilization units. And again, there are a lot of different models of that. Some are largely peer run, so one that’s very popular and there’s one here in Massachusetts, at least one that I know of that was developed by RI International and others has been disseminated pretty widely across the country. And this is peer run, the hospitality part of the crisis care stabilization. There is a lot of tea and cookies and support and someone to really listen. There are clinicians available if there’s a need for any specialized treatment or medication, but by a large, the milieu, as they call it, is run by peer support specialists. So again, there’s a lot of different models really moving away from both law enforcement and hospital emergency rooms where we’ve seen the phenomenon of psychiatric boarding. There being no services to send people and stories of adolescents who have spent days, multiple days in psychiatric emergency rooms and how that takes its toll.

(06:58): And so the many, many ills of the current system in its response to crisis has really, really pushed out this effort to have a separate crisis call line. Separate from law enforcement, can coordinate with law enforcement, absolutely if necessary. And there’s some great stories of where that is happening, but it’s not kind of run by law enforcement, and there are multiple peer roles within that kind of array of services. We do have to recognize though that, I mean crisis services sort of represents a failure of the mental health system to really meet its mission and mandate. The number and complexity and outcomes of the crises that people are experiencing is not the, result of it is often not that they’re engaged in services. And as you pointed out, many and up in jails and prisons. And again, so we can really think of a healthy or well-functioning mental health system. Crisis response would be minimal by demand. Things would be working well, right? Unfortunately that is not the case. And instead this massive crisis response system has been put into place to compensate for what is essentially a broken mental health system.

Steven (08:28): It’s clear that the 988 has a lot of benefits for a community and for the individual who is in crisis. What about benefits for peers that are in this role?

Cheryl (08:43): Yeah, I don’t know. I think it has some potential, and we’ll have to see how indeed it rolls out. No state, no county has sort of implemented its whole plan. And I have to acknowledge that most of the plans for integration of peer support services within crisis support services is still on the to-do list for most counties and states. So that’s happening now. There’s potential for wonderful opportunity to work. I know people who work in, again, living room crisis stabilization and report feeling a lot of real benefit to their work, just feeling so grateful for the opportunity. Working conditions are nice, and they feel good that they’ve helped people get started on a maybe somewhat different pathway. And they’ve prevented somebody from going to jail or unnecessary hospitalization. So people feel good about their work. It’s not perfect. Not every person does well with the lack of structure, and people may need more support for a time and maybe a more restrictive setting. Unfortunately, there are parts of the system that are still very coercive. And so it’s can become tricky when different programs can’t accommodate every person.

Steven (10:21): Well, we’ve talked a little bit about the potential benefits for peers, but I know that crisis response also brings a lot of exposure to trauma. And I wonder, do you have any insight on how peers might deal with the almost certain vicarious trauma that they’ll experience as they go through this job over the long term?

Cheryl (10:47): It’s a really important question, and I think it begins as people are kind of contemplating, considering choosing a work environment. Not everybody is really cut out to work in crisis environments. People really need to be able to become centered, to be able to keep calm amidst chaos, be able to tolerate the imperfections in the work. You may have colleagues that are not as respectful as you believe is right. And so it really is about really taking an assessment of what is my temperament? Is this a good environment for me? And it is for some people. Some people really thrive in fast-paced, lots of change environments. But really to know and make that sort of informed decision, what skills am I bringing to it? What is my kind of emotional self-management like? I can confess that mine isn’t great. So there are lots of places that I probably wouldn’t be a star worker.

(12:01): I’d have a lot of problems. So I think it really is important to know yourself and go into these work environments with open eyes. There are other services if you’re somebody who likes a little more predictability, a little more unity around our mission and culture. There are programs that employ peers to do navigation, peer support and navigation for people following a crisis. We know people are at super high risk for illness, accident, suicide, following a hospitalization.

(12:45): So helping people really be able to get their feet back under them, link them, and support them as they get services, provide some sense of community for them if that’s what they want. And that’s an opportunity open to peer workers who might not want to be in a fast-paced or work with so intimately with clinicians. So it’s really important to know yourself before stepping into those roles. And there is education. Absolutely. The skill set required is really intense. Interpersonal skills, not only with people experiencing crises, but being able to cool the heat, bring the people down to a stronger sense of calm. Helping people with that, having that skill set is really important. Being an excellent listener, really listening for understanding and being able to respond in a way that is empathetic and supportive. So those real core interpersonal skills are critical.

Steven (14:03): Yeah, I mean, think one of the reasons I did not become a licensed drug and alcohol counselor is because I recognized how stressful and how difficult that actually would be for me to do it over the long term. But it took a bit of thinking and self-reflection to actually get there. And I think this leads me to the final question for today. Given the challenges and stressors that occur when you’re working in crisis services, can you say a little bit about the importance of actual real self-care and true work life balance? Not the lip service that often gets thrown towards that. What are your thoughts, Cheryl?

Cheryl (14:51): So in my conversations with people who are actually working as a member peer worker within a team, and that’s both across the whole continuum, call centers, mobile crisis supports and crisis stabilization units, almost all mention the importance of the basic self-care of good sleep, good nutrition activity and community being important, connection, community. But those were the basics. And then different people had somewhat different avenues. There wasn’t really strong consensus, but what there was strong consensus around where the organizational structures that made work life balance, managing vicarious trauma all possible.

(15:43): And several of those, certainly supervision. Very high-quality supervision can really help people navigate that real kind of difficult relationships and boundaries and feelings about a person we’re supporting. And then the other thing was opportunities to really connect with team workers. And whether that was sort of a debriefing session that was so important after critical incident or a team meeting that really was strength-based and positive and encouraging all team members. So I think that those structures were really important and not every organization or every culture has those in place. So there’s a lot to learn about what portion of work life balance belongs to a worker and what portion or what pieces, what can organizations do to genuinely support it.

Steven (16:48): I know in our own organization, Cheryl, it’s basically baked in that you will take some time off. Your supervisors usually try to enforce that for you. And so there’s some organizational boundary setting that I think certainly in my early years of working was really important because I didn’t have a sense of, first the work life balance. And second, because I was new to the work, I wanted to show my commitment. How much I wanted to do that work. And I wouldn’t say no to anything at that time. And I found it certainly leads to a bit of compassion fatigue and potential burnout. So I think that that piece is really, really important. And Cheryl, thanks so much for your time today.

Cheryl (17:37): Well, you’re welcome, Steven. Thank you.

Steven (17:40): And to our listeners, join us next time on changing the conversation.

Erika Simon, Producer (17:44): Visit C4 innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on changing the conversation.


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