Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: http://www.tandfonline.com/loi/udst20

An Evidence- and Practice-Informed Approach

to Implementing Peer Suicide Grief Support
Systematically in the United States

Franklin James Cook, Linda Langford & Kim Ruocco

To cite this article: Franklin James Cook, Linda Langford & Kim Ruocco (2017): An Evidence-
and Practice-Informed Approach to Implementing Peer Suicide Grief Support Systematically in the
United States, Death Studies, DOI: 10.1080/07481187.2017.1335552

To link to this article: http://dx.doi.org/10.1080/07481187.2017.1335552

Accepted author version posted online: 30

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 An Evidence- and Practice-Informed Approach to

Implementing Peer Suicide Grief Support Systematically in

the United States

Franklin James Cook, MA

Unified Community Solutions, Watertown, MA, USA

Linda Langford, Sc.D.

Unified Community Solutions, Watertown, MA, USA

Kim Ruocco, MSW

Unified Community Solutions, Watertown, MA, USA

Address correspondence to Franklin J. Cook, MA, Unified Community Solutions, Watertown,

MA, USA. E-mail: [email protected]

Abstract

The landmark report, Responding to Grief, Trauma, and Distress After a Suicide: U. S. National

Guidelines, identifies the suicide bereaved as an underserved population and recommends

systematic development of peer grief support to help meet the needs of survivors of suicide loss

(Survivors of Suicide Loss Task Force, 2015). A widespread array of peer grief support after

suicide (PGSS) services exists nationally, but only as a decentralized network of autonomous

programs. Some research indicates that peer support is generally helpful to the suicide bereaved,

1
a finding that is reinforced by a large body of emerging research showing that peer support is

effective in mental illness and substance abuse recovery. The practice, study, growth, and

refinement of peer support in those fields has generated viable ideas about the elements and

principles of effective peer support—for individual practitioners and for programs and

organizations—that could be used to guide the systematic implementation of PGSS. In addition,

a comprehensive PGSS program (Tragedy Assistance Program for Survivors) that currently

serves a large population—survivors of suicide in the military—could be a model for national

PGSS systems development. Finally, there are several frameworks for systems development—

Zero Suicide, consumer-operated services, recovery-oriented systems of care, and the consumer

action research model—that could guide the expansion and increased effectiveness of PGSS in

keeping with the Guidelines’ recommendation.

Keywords: military suicide, postvention peer support, suicide bereavement programs, suicide

bereavement, suicide grief programs, suicide grief

INTRODUCTION

The landmark report Responding to Grief, Trauma, and Distress After a Suicide: U.S.

National Guidelines (Survivors of Suicide Loss Task Force, 2015) issued a call to action and

outlined goals and objectives to strengthen and expand the resources, services, infrastructure, and

systems available nationwide for responding effectively after a suicide death (called suicide

postvention). The Guidelines establish that anyone who is exposed to a suicide may experience

negative effects and that multiple levels and approaches of care and support are needed to assist

the full range of people who may be traumatized or otherwise affected by a suicide, from first

responders to the public at large (see Key Concepts in the National Guidelines: “Suicide

2
Exposure” and “Levels of Care” by Cook, this issue). The predominant focus of the Guidelines’

recommendations is on more widely and effectively meeting the needs of people who lose a

loved one to suicide (suicide loss survivors).

To that end, Objective 9.3 of the Guidelines calls for the development nationally of

systematic peer support for suicide bereavement (peer grief support for suicide or PGSS).

Objective 9.3 states:

Develop and maintain the infrastructure and capacity for peer-to-peer support—in face-

to-face mutual-help groups and one-on-one, through the telephone and Internet, and at

activities such as healing conferences, retreats, and memorial services—to help meet the

characteristic needs of people bereaved by suicide (Survivors of Suicide Loss Task Force,

2015, p. 34).

The number of people bereaved by suicide is not accurately known (Berman, 2011;

Cerel, Maple, Aldrich, & Van de Veene, 2013; Crosby & Sacks, 2002; Shneidman & Leenaars,

1999). However, the Guidelines introduce recent research showing that the number of people

personally affected by each suicide death is substantially higher than previously estimated. Cerel

and colleagues found that, for each fatality, 115 people were exposed, and of those exposed, 21

felt a very high degree of closeness to the deceased and 11 said the suicide had a devastating

effect on their lives (Cerel, 2015). In 2015, the most recent year for which data are available,

44,193 people died by suicide in the United States (Drapeau & McIntosh, 2016). Extrapolating

from those findings suggests that each year more than 900,000 people experience the suicide of

someone to whom they feel very close—and almost half a million people feel a devastating

effect from their experience of suicide loss.

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 Furthermore, research findings delineated in the Guidelines “present the cumulative

argument that the severity and duration of suicide’s damage [for loss survivors] ... is far worse

than is recognized, and that our society is not even close to responding adequately or effectively

to lessen this damage or to help people recover from the tragedy that has befallen them” (Cook,

2015, p. iii).

In other words, the suicide bereaved in the U.S. are a very large, under recognized, and

underserved population, a situation that could be ameliorated by the systematic expansion of

effective PGSS services.

This paper establishes a foundation for advancing Objective 9.3 by describing the range

of services that comprise PGSS; summarizing research to date on the benefits of peer support for

suicide loss survivors; identifying evidence- and practice-informed principles of effective peer

support programs in the mental health and substance abuse literature; and describing a case

example of a well-developed program that employs a systematic approach to PGSS.

PEER SUPPORT IN THE CONTEXT OF SUICIDE

BEREAVEMENT

Peer support is defined broadly as social, emotional, instrumental, and other assistance

that involves people with a shared condition or difficulty that is based on relational mutuality and

interpersonal connectedness (Solomon, 2004). PGSS refers to support of the suicide bereaved by

fellow suicide loss survivors who are further along in their grief. While informal peer support

from friends, family, and co-workers, is valuable (Dyregrov & Dyregrov, 2008), the term PGSS

as it is used here refers to formal, intentional peer support. Specialized peer support after suicide

is useful because the experience of suicide bereavement is seen as having particular qualities of

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its own, including shock and confusion over the deceased’s role in causing his or her death;

persistent and painful uncertainty about why the death occurred; deep feelings of shame, guilt,

and fear; struggles with troubling moral and spiritual questions; and being profoundly affected

by trauma and stigma (Survivors of Suicide Loss Task Force, 2015).

PGSS can be delivered in many ways, including face-to-face, by telephone, and online. It

occurs in a variety of settings, including individually, in groups small and large, in written

communications, through outreach teams, and at healing and memorial events (Barlow et al.,

2010; Beal, 2011; Campbell, 2002, 2006, 2011; Campbell, Cataldie, McIntosh, & Millet 2004;

Cerel & Campbell, 2008; Cerel, Padgett, & Reed, 2009; Dyregrov & Dyregrov, 2008; Dyregrov,

Plyhn, & Dieserud, 2012; Feigelman, Gorman, Beal, & Jordan, 2008; Jordan et al., 2011;

Feigelman, Jordan, McIntosh, & Feigelman, 2012; McMenamy, Jordan, & Mitchell, 2008).

PGSS efforts vary widely in their reach, from serving large numbers of people to helping one

bereaved family or individual. For example, tens of thousands of survivors attend the annual

International Survivors of Suicide Loss Day, a 90-minute program professionally produced by

the American Foundation for Suicide Prevention (AFSP) and broadcast to groups gathered at

hundreds of sites worldwide as well as online. At the other end of the continuum, in communities

across the country, pairs of volunteers on LOSS (Local Outreach to Suicide Survivors) teams

arrive almost immediately at the scene of a suicide to support the family, working alongside law

enforcement and emergency medical services personnel (Suicide Prevention Resource Center &

SPAN USA, 2010).

Suicide bereavement support groups are a form of PGSS services that has been operating

in the United States at least since the 1970s, and mutual-help groups are the most widely

available type of peer-to-peer assistance for suicide loss survivors (Barlow et al., 2010). No

5
organization offers centralized management or technical assistance nationally for such groups,

but AFSP maintains a directory where more than 800 independent groups voluntarily list

information about their meetings. AFSP also has offered support group facilitator training

nationally for almost 15 years, training approximately 1,500 people over that span of time. AFSP

records show that attendees of the training are primarily survivors of suicide loss and that the

majority of the groups in its directory are facilitated by a peer helper (D. Marshall, personal

communication, December 6, 2016). The steady growth in support groups is generally indicated

by comparing these numbers to those from a 2009 survey, which identified 417 groups for

suicide bereavement, with 78% of them led by survivors (Cerel et al., 2009).

Also, a number of AFSP chapters across the country operate Survivor Outreach

programs, through which two volunteer peer helpers visit suicide bereaved families—usually in

their home, within a few weeks or months of the death—to offer support and comfort and to link

them to resources. In the decade since the program began, more than 400 peers have been

trained; and there are now 48 chapters offering outreach to the newly bereaved (D. Marshall,

personal communication, December 6, 2016).

The Active Postvention Model (APM) is another example of an established PGSS

program. Also called the LOSS team model, it is a first-responder approach that has been in

existence for almost 20 years, offering immediate crisis support and connecting the newly

bereaved to community-based services (Cerel & Campbell, 2008). There are teams operating in

at least 10 states, with the degree of centralized management and support for the teams varying

widely from state to state. No data are available on the number of LOSS teams nationwide or the

number of families who have been served. There is an annual LOSS team conference, which in

2016 was attended by more than 200 participants. Implementation of APM in the U.S. has

6
influenced similar efforts in Australia, Ireland, Canada, and Singapore, and the APM has

informed the work of many programs not using the rubric “LOSS team.” It is estimated that as

many as 5,000 people—the majority of them survivors of suicide loss—have attended LOSS

team trainings worldwide. (F. Campbell, personal communication, November 28, 2016; S.

McNally, personal communication, Dec. 20, 2016).

An online peer-to-peer support organization, the Alliance of Hope for Suicide Loss

Survivors (AOH), has helped the suicide bereaved since 2008 by maintaining an Internet

community for survivors. The forum is available 24/7 and uses “bulletin board” software, which

enables people to share with each other in writing about coping with their loss in ongoing

conversations that evolve over time. Since its inception, more than 11,000 survivors have

registered for the forum, and on average, six new loss survivors register daily—and thousands

more read the forum without registering or posting. The forum is moderated by about 25 trained

peer helpers under the supervision of a clinician who is also a survivor of suicide loss (see

Walker, R. After Suicide: Coming Together in Kindness and Support, this issue). Notably, the

forum structure and practices—and the large volume of participation, 5,000 posts per month,

1,800 private messages—provide an environment where organically unfolding mutual help is

taking place among suicide bereaved people around-the-clock (R. Walker, personal

communication, Apr. 15, 27). (Also see Beal, 2011, for an example of a PGSS program that

utilizes an email mailing list for ongoing discussions.)

No centralized organizational structure exists in the United States that is focused on

PGSS helpers as a unified, coherent community of service providers, and almost all current

PGSS services are delivered through autonomous programs that are not affiliated with a formal

network supporting the practice of PGSS (an assertion that is a key rationale for Objective 9.3 of

7
the Guidelines, see above). However, there are a number of small clusters of support groups

associated with each other, for instance the Safe Place groups of the Samaritans in Boston, MA

(Hurtig, Bullitt, & Kates, 2011), the HEARTBEAT groups founded in Colorado in 1980

(Archibald, 2011), and Friends for Survival founded in California in 1983 (Koenig, 2011). A

number of PGSS services are affiliated, supported by, and/or can be located through independent

crisis centers in the National Suicide Prevention Lifeline network. A 2011 survey responded to

by 122 Lifeline centers, for instance, showed 43% offer a suicide grief support group and an

additional 50% can refer callers to a group (National Suicide Prevention Lifeline, 2011).

Taken together, long-term efforts such as those exemplified by the PGSS services

highlighted above show generally that a de facto workforce of PGSS helpers exists nationwide—

and although there is no centralized national network supporting the practice of PGSS, a number

of organizations do provide training and institutional support for PGSS and promote it as a

service for the suicide bereaved. This workforce potentially represents a starting place to

“develop and maintain the infrastructure and capacity for peer-to-peer support,” and at issue is

whether PGSS as a field of practice has the potential to be effective in “meet[ing] the

characteristic needs of people bereaved by suicide” (Survivors of Suicide Loss Task Force, 2015,

p. 34). The next section argues that the potential for such effectiveness is supported by research

evidence.

HELPFULNESS OF PGSS TO LOSS SURVIVORS

A number of research studies and reviews conclude that peer support is helpful to suicide

bereaved people (Aguirre & Slater, 2010; Barlow et al., 2010; Harrington-LaMorie, 2011;

McMenamy et al., 2008). The findings of Feigelman and colleagues also show that PGSS is

8
generally beneficial to survivors (Feigelman et al., 2012) as well as that attendance at peer

suicide grief support groups is helpful. The researchers organized feedback from participants

around Shulman’s (2006) principles for mutual aid to show that group participation helps the

suicide bereaved by affirming that others have experienced a similar tragedy, permitting

discussion of taboos, assisting with problem solving, providing shared information, and

promoting the feeling of “strength in numbers” (Feigelman et al., 2012). Suicide grief support

groups have also been shown, for some loss survivors, to be as effective as individual counseling

(McMenamy et al., 2008).

Peer-to-peer assistance for suicide survivors has also been found to be helpful when

delivered by first-response teams, for instance in connecting the bereaved to other grief and

trauma support services relatively quickly (Campbell, 2011; Campbell et al., 2004; Cerel &

Campbell, 2008), as well as through Internet-based interactions (Beal, 2011; Feigelman et al.,

2008). A review focused on clinical interventions also noted the value to the suicide bereaved of

peer-to-peer sharing that features “mutual, nonjudgmental emotional support in a setting where

survivors can tell their stories and receive advice about coping from others with similar

experiences” (Jordan and McMenamy, 2004, p. 346).

The findings specific to suicide grief are consistent with the literature on the effectiveness

of peer support for people bereaved by other types of death. For example, a review that includes

outcomes for mutual help grief support groups showed a reduction in several symptoms of grief

as well as improvement in social functioning (Pistrang, Barker, & Humphreys, 2008). In a study

of an eight-week peer support program for people bereaved by a traumatic death, which included

suicide loss survivors, participants’ self-reported perceptions were that they had made substantial

progress in their grief journey (Walijarvi, Weiss, & Weinman, 2012).

9
 There is a dearth of studies on interventions specifically for suicide grief support, and

much of the existing research lacks rigor in its methodology and focus (see Recommendations for

Research on Suicide Loss: A Commentary by Neimeyer, Cerel, and Maple, this issue)—and this

is even more so for research focused particularly on peer support for the suicide bereaved. It is

helpful, therefore, to also consider research demonstrating the effectiveness of peer support for

people struggling with mental illness and substance abuse. For example, in the mental health

field, studies find that peer helpers are effective with clients in promoting hope and affirming

that recovery is possible—and that they positively influence empowerment, self-esteem, self-

management, and engagement in social networks (Repper & Carter, 2011). Evidence also shows

that peer services delivered in collaboration with traditional care can be as effective as similar

services delivered by professionals (Rogers, Kash-MacDonald, & Brucker, 2009). For people

with substance abuse disorders, peer-to-peer services result in clients having improved social

connections and relationships with providers, reduced rates of relapse, and increased treatment

retention (Reif et al., 2014). In addition, peer support contributes to positive substance use

outcomes across diverse types of interventions (Bassuk et al., 2016). In fact, the study and

practice of peer support in behavioral health care provides the basis for identifying the

components of peer-to-peer services that make them effective. The next section looks at research

focused on evidence- and practice-based elements and principles of effective peer support that

could provide a foundation for advancing efforts to achieve Objective 9.3 of the Guidelines.

EVIDENCE- AND PRACTICE-INFORMED PRINCIPLES OF

PEER SUPPORT

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 The emerging body of evidence for the effectiveness of peer support practices, especially

in mental health care and substance abuse treatment, has been used to guide the implementation

of a multitude of peer-to-peer services—and a number of studies, reviews, and analyses have

provided a starting place for describing the working components of effective peer support

(Substance Abuse and Mental Health Services Administration, 2011a). By identifying common

observations and themes in the results of several key efforts, described below (Campbell, 2006,

2013; Daniels et al., 2010; SAMHSA, 2012), it is possible to deduce a number of principles that

are likely to provide a foundation for identifying rudimentary best practices that could guide the

implementation of PGSS services in line with efforts to accomplish Objective 9.3.

 The Consumer-Operated Services (COS) Program Multi-Site Research Initiative, a large

study that began in 1998, is the basis for a report (Campbell, 2006) and training manual

(Campbell, 2013) that delineate 46 common ingredients for effective COS, which are

behavioral health services primarily managed and operated by consumers of the services

being delivered. The vast majority of support in COS is delivered through peer-based

programs, and most of the 46 ingredients are readily identifiable as components of peer-

to-peer services.

 Using a qualitative process initiated by peer helpers and peer-program stakeholders at the

2009 Pillars of Peer Support Summit, Daniels and colleagues assembled a list of 25

operational elements characteristic of peer-specialist programs across the country (2010).

Peer specialists are trained and certified peer helpers who formally serve on teams

delivering mental health support and treatment—and the elements identified are directly

related to the qualities of peer support practices.

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 A process with antecedents in the 2004 National Consensus Conference on Mental Health

Recovery and Mental Health Systems Transformation (SAMHSA, 2006) and the 2005

National Summit on Addiction Recovery (SAMHSA, 2007) —which included mixed

methods of review and input over the years, ranging from assessment of research

literature to opportunities for public comment—resulted in “SAMHSA’s Working

Definition of Recovery," which outlines 10 principles of recovery, a cornerstone of which

is the principle that “"recovery is supported by peers and allies" (SAMHSA, 2012, p. 6).

A number of principles of peer support derived from these sources—and focused on the

practices of individual peer helpers—are listed in Table 1.

In addition to principles for individual practitioners of peer support, a set of evidence-

based principles to guide program and organization development can be deduced from a related

systems framework, recovery-oriented systems of care (ROSC) (Sheedy & Whitter, 2009). A list

of principles derived from Sheedy & Whitter’s work is shown in Table 2.

The individual practice principles in Table 1 and the program- and organization-level

principles in Table 2, taken together, provide a foundational framework for developing PGSS

services based on existing best practices.

In addition to needing a starting place for the application and assessment of best practices

in PGSS, work on Objective 9.3 would benefit from having a model program to which to refer

for guidance. The next section presents a descriptive summary of such a program, which is

currently serving a large population of the suicide bereaved in a systematic way.

TAPS: A MODEL PROGRAM FOR COMPREHENSIVE PGSS

SERVICES

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 The PGSS program operated by TAPS (Tragedy Assistance Program for Survivors) is an

example of comprehensive, customized services being delivered to a substantial population of

people bereaved by suicide in keeping with the Guidelines’ call for the development of

systematic peer support for the suicide bereaved. This summary is intended to describe TAPS

services sufficiently to illustrate what it looks like to deliver systematic PGSS in a discreet

community (people who have been affected by the suicide of someone in the military) by

providing an array of interrelated services and resources with the requisite infrastructure and

capacity to support the programs being delivered.

TAPS was established as a nonprofit organization in 1994 to meet the needs of families

bereaved by the death, from any cause, of a U.S. military service member—using peer-based

services as its core approach (Harrington-LaMorie & Ruocco, 2011). Since 2009, TAPS has also

operated a program devoted to providing specialized peer-to-peer services to people bereaved by

suicide among military personnel, and it now has the capacity to systematically deliver support

to about 7,000 suicide loss survivors.

The TAPS network of services for suicide loss survivors—all developed, delivered, and

managed primarily by peers, both staff and volunteers—includes:

 24/7 telephone help line

 Access to all levels of professional care, including crisis assistance, trauma care, and grief

counseling

 Website, listserv, chat, and social media

 One-on-one mentors and grief support groups

 Annual national healing seminars and monthly regional healing seminars

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 Numerous annual recreational trips and retreats for subgroups of survivors (children,

spouses, men, siblings, etc.)

 Various programs to benefit children bereaved by suicide, including grief camps where

active duty service members mentor children one-on-one

 Print materials, a reading list, and a quarterly print and online magazine

 Case management, including liaison with programs for military benefits and health

services

 Individualized referral and follow-up, including help with access to mental health and

grief support resources, as well as to practical resources addressing a full range of

survivors’ needs

 Opportunities to formally honor and memorialize loved ones

 Volunteer opportunities beyond peer helping, ranging from administrative and event

support to fundraising activities

 Opportunities and training for survivors to become peer helpers themselves

Here are brief descriptions of three major components of TAPS services: its intake and

ongoing support process; its peer mentor program; and its annual Suicide Survivor Seminar and

Good Grief Camp.

TAPS Intake and Ongoing Support

TAPS’ outreach to suicide bereaved people whose loved ones die in the military is

routinely initiated by a contact made to TAPS by a casualty assistance officer (CAO), who is the

official liaison between the military and the deceased’s next of kin. This contact is guided by

formally agreed-upon policies and procedures that include, on the part of TAPS, educating

14
CAOs and other military personnel on the characteristics and challenges of suicide loss and, on

the part of the military, obtaining a release of information (ROI) from families to permit outreach

from TAPS.

Everything that happens between TAPS and survivors takes into account that the death

was a suicide, and—while a staff person may perform many duties and tackle various tasks—the

main role of staff is to provide peer grief support. Since each situation is different, the order and

timing of the actions TAPS takes to support each family differ, but the following occurs as

directly and as effectively as possible in every case:

 The situation is assessed by the manager of the staff specializing in suicide grief support

(all 13 of these staff, including the manager and the executive who oversee PGSS

services, are themselves suicide loss survivors).

 A staff person whose background, experience of loss, and other circumstances constitute

the closest “match” is assigned to reach out to the newly bereaved person.

 An initial contact is made, beginning a phase of outreach that involves a number of

contacts during the first days, weeks, or months after the loss.

 A Survivor Resource Kit is mailed to the family, which includes books and other

information especially matched to their situation, as well as personalized gifts.

 In addition to serving as a PGSS helper, the staff person fields questions about and

assesses a multitude of possible needs, ranging from mental health and trauma care to

support for children and from issues with the military to practical matters such as

finances.

TAPS has access to a wide variety of resources and methodically customizes resource

information for all survivors. For example, protocols for helping a bereaved person in crisis are

15
in place in every setting; there are staff who specialize in helping survivors deal with the military

bureaucracy; and a Community Based Care department provides local research for every kind of

assistance, performing individualized searches based on each survivor’s circumstances.

This arrangement—through which a staff person, who is first and foremost a peer helper,

provides the survivor with ongoing grief support and responsive case management—remains in

place for as long as is necessary to stabilize the situation.

From the beginning, survivors are familiarized with TAPS services and can take

advantage of the 24/7 telephone help line, website, children's programs, and magazine and other

psychoeducational material. They also have opportunities to take part in peer-to-peer interactions

with the larger TAPS survivor community (chat, listserv, social media, support groups, regional

and national healing conferences, and survivor retreats). Once the bereaved person’s situation is

relatively stable, he or she can be matched with a peer mentor.

TAPS Peer Mentor Program

TAPS has 176 trained peer mentors, and 140 of them are formally matched to individual

suicide loss survivors (TAPS calls them mentees). As many as 30 of the active peer mentors also

stay in touch informally with additional loss survivors, primarily the newly bereaved and people

who are struggling with especially difficult circumstances.

Peer mentors are supervised by a full-time staff person who is a suicide loss survivor and

whose only role with TAPS is developing and maintaining the TAPS peer mentor workforce—

including delivering peer mentor training. All training is based on best practices. It begins with

an online workshop, followed by a full day of classroom training, then ongoing in-service and

16
specialized training (on topics such as trauma-informed care, working with a survivor in crisis,

etc.).

Being formally matched with a mentee involves:

 Careful assessment of the mentee’s readiness for working with a peer mentor

 Detailed consideration of the situation shared in common by the mentor and the mentee,

including the deceased’s branch of service and relationship to the survivor (child, spouse,

sibling, etc.); circumstances of the suicide (while deployed or not, means used, etc.); and

geographic proximity

 Ongoing monitoring, coaching, and debriefing to ensure that the mentor-mentee

relationship is working well for both parties and is meeting the needs of the mentee

Peer mentors have ready access to assistance from the clinically trained staff who are also

survivors of suicide loss, which includes both master’s- and doctoral-level counselors. Mentors

document their interactions with mentees in order to ensure effective staff communications and

continuity of care for the survivors. All TAPS program elements—seminars, retreats, magazine,

psychoeducational material, website, online community, etc.—purposefully include components

or “tracks” that are specially designed to strengthen peer mentors and to support them as

individual caregivers and as a peer helper learning community.

Overall, the peer mentor community is managed as a unified volunteer workforce, with

ongoing recruitment, training, quality assurance, supervision, support, and recognition.

TAPS Annual National Military Suicide Survivor Seminar and Good Grief

Camp

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 The first three-day seminar for suicide loss survivors, held in 2009, was attended by 200

suicide bereaved adults and staffed by 7 TAPS employees, 2 expert consultants, and a handful of

volunteers. The grief camp that year was attended by 60 children. The 2016 grief camp was

attended by 600 suicide bereaved adults and 200 children—and staffed by 28 TAPS employees,

some 20 consultants and presenters, a dozen Family Care Team members (civilian counselors

who work with military families), about 50 event volunteers, and 200 volunteer mentors for the

children. In addition, 100 experienced peer mentors were among the attendees.

For the Good Grief Camp, TAPS recruits and trains a mentor for each child, who

accompanies the child throughout the weekend as they participate together in a structured series

of activities involving social interactions, recreation, grief education, emotional support, and

community building. The mentors arrive on Thursday night, receive a full day of orientation and

training on Friday, and spend the next two days immersed in the activities designed for the

children, all under the supervision of TAPS staff—many of whom are parents of bereaved

children.

The consultants, presenters, and other professional support staff include experts in suicide

grief support, trauma recovery, and a number of special topics (spiritual care, art therapy, yoga,

storytelling, health communications, service animals, etc.). Among these experts are pioneers

who began working as peers with suicide survivors in the 1970s; founders of innovative

programs especially for the suicide bereaved; and authors, clinicians, spiritual advisors, and

advocates. TAPS’ use of best practices has been strengthened by its longtime affiliation with

these leading practitioners and researchers in PGSS, who are involved in strategic planning,

program development, staff training, and direct services and support delivered at the seminar.

18
 The logistics provided for the seminar include TAPS supporting travel from door-to-door

(i.e., from participants’ homes to the host hotel); providing 100% of the meals; and making sure

that everyone receives a photo button with their loved one’s picture on it and a TAPS T-shirt.

The physical space is attended to in an intentional way that creates the tone and feeling of a

family reunion. Participants can find special help of every kind, from crisis assistance (24/7) to

one-on-one consultation with a counselor, staff person, mentor, or one of the experts in

attendance.

Every aspect of the seminar—from transportation to mealtime and from structured

sessions to open-ended activities—is designed to put survivors in touch with other suicide

bereaved people with whom they have something in common, positioning even the newest

survivors not only to receive help from someone they can relate to but also to help another

survivor if someone reaches out to them.

In recent years, between one-fourth and one-third of those in attendance have been

relatively newly bereaved survivors. That means there are hundreds of people present whose

emotions at least some of the time are likely to be intense, raw, and painful—so the event is

structured so every element of the experience contributes to their sense of being in a safe place.

All along the way, the first circle of help available to survivors is from others who have lost a

loved one to suicide—and beyond that, professional help of every kind can be summoned if it is

needed.

The above summary of TAPS’ PGSS programs does not sufficiently highlight a

paramount feature of the services provided, which is that the interplay among all of the

“separate” elements has created within TAPS a powerful sense of community among survivors

of military suicide. Relationships among them are animated by the very strong shared feeling

19
that, together, they have survived a life-altering (and even life-threatening) experience. Survivors

of suicide loss affiliated with TAPS see themselves as a family; and as people’s connectedness

within the community extends over time, it becomes increasingly clear to them that everyone

who engages in the process both receives help from and gives help to the other “TAPS family”

members.

CONCLUSION AND NEXT STEPS

The 2015 Guidelines pave the way for advancing comprehensive postvention efforts

across the U.S. and recommend that the nation increase its infrastructure and capacity for peer-

to-peer services as a key component of suicide bereavement care. Some evidence suggests that

peer support programs help the suicide bereaved, and even though much more-focused research

is needed in this area, there is a robust literature on the effectiveness of peer support practices

and programs in mental illness and substance abuse recovery that can inform the expansion of

PGSS efforts in the U.S. The work in developing peer-to-peer services in those fields has

resulted in the ability to identify elements and principles that constitute the beginnings of best

practices for peer support. In addition, the suicide grief program of TAPS serves as an example

of a systematic effort to implement PGSS to serve a large, discreet population of people bereaved

by suicide (i.e., people who have lost someone in the military).

This paper’s exploration of these ideas provides a foundation for taking action to

accomplish Objective 9.3 of the Guidelines, and it concludes, below, by describing several

frameworks for systems development in areas related to suicide postvention and/or to peer

support that could be strategically valuable in developing next steps for such an endeavor:

 Zero Suicide

20
 Consumer-operated services and recovery-oriented systems of care

 The consumer action research model

Zero Suicide

Zero Suicide (ZS) is an innovative philosophy and approach recently embraced by the

suicide prevention field that can inform efforts to facilitate broad expansion of postvention

services in general—and PGSS specifically. ZS is both an aspirational goal and an approach to

transforming boundaried health care systems to reduce the likelihood that suicidal individuals

will fall through the cracks of fragmented care systems (National Action Alliance for Suicide

Prevention, Zero Suicide Advisory Group, n.d.). ZS includes seven essential elements of suicide

care for health and behavioral health systems to adopt in order to create an integrated system:

leadership, screening and assessment, care management, workforce development, effective

treatment, care transitions, and ongoing quality improvement. The goal is to create a culture of

“suicide safety” and shared responsibility throughout the system that enables consistent and

appropriate responses to suicide risk with adequate, effective, and integrated care (Grumet &

Hogan, 2014).

ZS already has adopted elements of care for people at risk of suicide that are aligned with

principles important to PGSS, for example, trauma-informed care and peer support for people

experiencing suicidal thoughts and behaviors. Because ZS is a systematic approach that attends

to the diverse needs of people in the care system, health care organizations that have adopted ZS

are well-positioned to expand their services to include caring for people who are bereaved by

suicide—and specifically in offering PGSS to suicide loss survivors. In addition, community

organizations who serve individuals bereaved by suicide could learn from the philosophy

outlined by ZS, which emphasizes systems of care rather than fragmented services.

21
 Consumer-Operated Services and Recovery-Oriented Systems of Care

Consumer-operated services (COS) are programs or organizations that are substantially

managed and operated by recipients (i.e., consumers) of the services being delivered (SAMHSA,

2011a), and recovery-oriented systems of care (ROSC) use an approach to healing (i.e.,

recovery) that emphasizes nonprofessional support as much as professional services and focuses

on building a person’s long-term, overall health as much as on treating a severe episode of illness

(White & Evans, 2015). A defining practice for both models is peer-to-peer services, and both

view the medical model as a complementary not preeminent component of their approach (and

these features are clearly compatible with PGSS). COS are recommended as evidence-based

practices by the Substance Abuse and Mental Health Services Administration (2011b), and,

similarly, ROSC is recognized as “an integral part of the new health care environment”

(Substance Abuse and Mental Health Services Administration, 2010, p. 1).

From a practical point of view, using the COS and ROSC models to guide foundational

work on developing PGSS services would provide peer grief helpers and their allies and

stakeholders with what amounts to a template—“Consumer-operated services: How to use the

evidence-based practices KITs” (SAMHSA, 2011c)—for strategically tackling Objective 9.3 of

the Guidelines. Several other sources of authoritative guidance are available, such as

“Operationalizing Recovery-Oriented Systems,” which assembles expert consensus on topics

related to long-term implementation of ROSC, such as operational requirements, effective

policy, workforce development, research, cross-system collaboration, and peer leadership

(Stengel, Schwartz, & Mathai, 2012).

22
 Perhaps most importantly, using COS and ROSC approaches would emphasize engaging

survivors of suicide loss—especially peer helpers—in developing and implementing a systems-

level response to suicide bereavement driven by the concept of long-term healing for loss

survivors (SAMHSA, 2012; White, 2008).

Consumer Action Research Model

Finally, a research element could be applied from the beginning of efforts to address

Objective 9.3 by using the consumer action research model (CARM), an approach that a

foundational researcher in COS believes is essential to developing effective peer-based programs

(Campbell, 2006). Next steps based on CARM would include strategically organizing research

from the bottom up by involving survivors and peer helpers as partners in the design, execution,

interpretation, and dissemination of research studies (Campbell, 2013). The potential value of

such an approach cannot be understated, for not only would it contribute to sorely needed

research in suicide grief support (see Neimeyer, Cerel, and Maple, Recommendations for

Research on Suicide Loss: A Commentary, this issue), it also would bring together for the first

time PGSS helpers—from various communities who deliver services in diverse settings using an

array of approaches—to purposefully focus on developing best practices in their field.

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Table 1. Practitioner-Level

EVIDENCE- and PRACTICE-INFORMED PRINCIPLES OF PEER SUPPORT

Based on research reported or reviewed in a number of sources, the effective practice of peer

support by individual peer helpers is guided by the following principles (Campbell, 2006, 2013;

Daniels et al., 2010; del Vecchio, 2012; International Association of Peer Supporters, n.d.;

SAMHSA, 2012):

 Takes place in the context of a relationship that is egalitarian and collaborative

 Is guided by the experiences, needs, choices, goals, and aspirations of the person being

helped

 Validates, utilizes, and builds upon the person’s:

 Present condition (where the person “is at”)

 Learning and communication style

 Available and accessible resources

 Personal strengths

 Respects and welcomes the person’s individuality, differences, culture, and unique

contributions

 Attempts to strengthen the person’s autonomy, self-efficacy, accountability, and

empowerment

 Recognizes and validates the person’s difficulties and suffering—and asserts ultimate

hopefulness

 Addresses all domains of well being: physical, mental, emotional, spiritual, relational,

and social

28
  Allows for many paths to recovery

 Asks the helper:

 To serve as an example

 To share his or her story effectively

 To embrace outcomes that also benefit the helper

 Emphasizes in the helper:

 Skills such as listening intently, speaking supportively, and asking open-ended questions

 Practices such as being kind, patient, empathetic, and compassionate

 Attitudes such as open-mindedness, respect, and tolerance

 Values such as dignity, inclusiveness, equality, and acceptance

 Is delivered in a way that:

 Does not employ diagnostic assessments or labels

 Is not intrusive or coercive

 Is not directive or prescriptive

 Does not arbitrarily sanction nonconforming or erratic behavior that is not dangerous

 Involves the helper being an advocate and encouraging the person’s self-advocacy

 Can include teaching knowledge and skills, such as self-care, storytelling,

communications, problem-solving, coping with emotions, etc.

 Addresses difficulties and crises forthrightly, judiciously (e.g., regarding confidentiality),

safely, and effectively

 Protects people’s safety by:

29
  Addressing abuse, neglect, and trauma

 Countering injustice and stigma

 Linking to higher levels of care

 Does not attempt to clinically treat or cure a medical or psychological condition (but can

complement clinical treatment)

30
Table 2 . Program- and Organization-Level

EVIDENCE- and PRACTICE-INFORMED PRINCIPLES OF PEER SUPPORT:

Based on Sheedy & Whitter’s review of sources (2009), the effective practice of peer support at

the program- or organization-level is guided by the following principles:

 Peer support: Programs are centered on and built around suicide loss survivors delivering

social, emotional, instrumental, and other assistance based on relational mutuality and

interpersonal connectedness. (Adapted from Solomon, 2004)

 Person-centered: Programs offer options that are responsive to individuals’ needs.

 Engaged with family and allies: Programs include members of a person’s support and

social systems as potential resources and/or to be served or otherwise engaged by the program.

 Comprehensive: Multiple approaches apply a variety of methods that address people’s

various circumstances and different learning and communication styles, etc.

 Anchored in community: Programs are connected to and integrated with elements of the

communities they serve.

 Connected to a continuum of care: Programs offer or link to all stages of a person’s

experience, from crisis to long-term recovery, across the lifespan.

 Based on partnership-consultant relationships: Programs empower those receiving

services to be full partners with those delivering services.

 Strength-based: Programs focus on individual assets and strengths.

 Culturally responsive: Programs welcome and accommodate people from different

backgrounds who are accustomed to various cultures.

 Respectful of personal belief systems: Programs honor and accommodate various

31
 spiritual, religious, secular, or cultural beliefs.

 Inclusive of stakeholders: Programs provide meaningful roles for consumers and

stakeholders, including leadership roles, in all aspects of program development and

implementation.

 Integrated with other systems: Programs are connected to all manner of resources and

services through direct relationships and referral networks.

 Supported by effective education and training: Programs build workforce competency

and meet participant needs through educational and training opportunities.

 Adept at monitoring and outreach: Programs engage people meaningfully and

progressively, including, as appropriate, beyond the boundaries of particular services being

delivered.

 Outcome driven: Programs are designed and implemented in collaboration with those

served to effect positive change in their lives.

 Research based: Programs are assessed by a variety of reliable methods that are linked to

quality improvements.

 Sustainably financed: Programs are financed sufficiently to meet the needs of the

community and to be responsive to new challenges.

32