First Responder Peer Support Programs
By Emily Cnapich, M.S., Samantha Rodriguez, M.S., Bailee Schuhmann, M.S., Judy Couwels, M.A., Vincent Van Hasselt, Ph.D., and Jessica Blalock, M.A.
There is an overwhelming need to manage the mental health and psychological well-being of emergency service workers, including police officers, firefighters, emergency medical technicians, correctional officers, and dispatchers. To address these concerns, peer support programs have garnered increased interest and support in the first responder community. Most of the work in this area has focused on qualitative feedback, such as self-reports concerning the perceived impacts of peer support programs. However, little attention has been directed to delineating the steps taken to design these programs, unique considerations for first responders, or methods for the empirical examination of the programs’ efficacy.
The authors will discuss the collaborative efforts between a university psychology department and a sheriff’s office to create an effective peer support program for the agency’s sworn and civilian personnel. They offer several considerations and strategies that may serve as guidelines for departments wishing to implement their own peer support programs.
Society relies on first responders to perform their duties effectively and make sound judgments in response to highly stressful, life-threatening situations. Due to frequent and ongoing exposure to traumatic events (e.g., motor vehicle crashes, domestic disputes, homicides, suicides), occupational stress (e.g., shift work, personnel shortages), and a pervasive stigmatized view of mental health in the emergency service culture, there is increased risk for behavioral and psychological problems among these workers.
Possible long-term effects of the physically and mentally demanding nature of a first responder’s job include alcohol abuse,1 depression,2 sleep disorders,3 marital discord and domestic violence,4 post-traumatic stress disorder (PTSD),5 and suicide.6 Consequently, first responder peer support programs that may help treat these mental health concerns are clearly needed.
Using peer support training as a strategy for identifying and intervening in behavioral and psychological issues is now widely recognized in the first responder community.7 Peer support is based on the notion that those who have overcome the impact of stressful and traumatic events are uniquely qualified to assist others dealing with similar experiences through increased awareness and vigilance, empathic responses, and personal validation.8 There are four main advantages of peer support programs.9
- Provide training in the identification of risk factors for behavioral and mental health problems
- Reduce stigma by encouraging conversation surrounding mental health and normalizing difficult experiences and adverse reactions to stressors of the job
- Create an environment where people feel comfortable approaching one another
- Link peers to outside professional resources for additional care when necessary
One study outlined guidelines for peer support in first responder agencies by utilizing a group of international practitioners and professionals to determine the main objectives of these programs. Identified as most significant were being compassionate, offering low-level psychological intervention (e.g., active listening and validating techniques), identifying peers that may be at risk to themselves or others, and acting as a liaison for professional help.10
While research concerning the efficacy of peer support programs is still new, there is preliminary evidence that they can improve an individual’s ability to deal with traumatic events.11 One study examined the effectiveness of peer support programs among 631 police officers in northern Colorado. Results revealed that 48.3% participated in peer support. Of that group, over half reported the support directly or indirectly helped them perform their duties and/or improved their home life.12
Some evidence indicates that peer support programs have higher participation rates than Employee Assistance Programs and outside mental health resources.13 These findings are consistent with the contention that consulting with a peer may reduce resistance and stigma associated with seeking professional help.
Similarly, research has found police officers view peer support training as beneficial. In an evaluation of a Peers as Law Enforcement Support (PALS) program, participants’ ratings of course content and instructor effectiveness indicated the training was practical, informative, relevant, and useful.14
This article will delineate useful strategies and considerations of implementing first responder peer support, using the authors’ PALS program as an illustration. Examples are based on the authors’ experience and numerous applications of this model. Certainly, there is variability across agencies on several factors, such as funding, geographic location, and department size. Therefore, the content of this article is intended to serve as a basic framework that can be modeled or modified depending on the needs and constraints of each agency.
Recruiting plays an integral role in the engagement and longevity of peer support teams. To reduce preexisting reservations or perceived biases from within the department, PALS coordinators send a peer facilitator recruitment email via a nonagency email address. This message includes program information, followed by a request for employees to nominate up to five coworkers they feel would be ideal to serve as a facilitator for those dealing with significant stressors and crises in their personal or professional lives, help recognize and assess conflicts, listen and offer support to peers, and maintain confidentiality within the guidelines of the program. All employees also receive the option to nominate themselves. The email underscores that participation in the peer support team is strictly voluntary.
Requirements for inclusion depend on department standards and criteria. However, to ensure integrity of the program, guidelines regarding length of employment and history of internal affairs (IA) investigations should be established. In the authors’ PALS program, IA provides a written history for each prospective member. Nominees with integrity allegations, such as lying or altering reports, are notified by email that they will not be included in the program. Those who meet inclusion requirements are notified that they have been selected for the team. Because the program is voluntary, selected facilitators have the option to decline the invitation.
Content, Structure, and Delivery
Expectations of facilitators are clearly outlined prior to and over the course of the training. If any facilitators feel they cannot meet them, they have the option to decline further participation in the peer support team. Trainees are informed of the six objectives of the program.
- Serve as a resource for peers during times of crisis
- Foster peer emotional health
- Recognize and evaluate conflicts, use active listening skills, and offer support
- Demonstrate and provide encouragement and trust
- Identify problem signs and symptoms that may indicate the need for help
- Provide options and referrals for outside mental health resources when needed
PALS training modules focus on active listening skills, stress, depression, substance use, anxiety and PTSD, suicide, and resilience. Additionally, role-play scenarios are included at the end of each module to incorporate and practice newly acquired information and skills.15
“Peer support is based on the notion that those who have overcome the impact of stressful and traumatic events are uniquely qualified to assist others dealing with similar experiences. … ”
Active Listening Skills
This section covers active listening and empathy skills to facilitate establishing rapport with a peer in crisis. Trained skills include verbal and nonverbal communication and avoiding communication blockers.
Verbal communication encompasses skills such as:
- Voice tone/intonation: Maintaining an interested, authentic, and empathic tone of voice that reflects the peer’s pitch.
- Paraphrasing/summarizing: Repeating in one's own words the meaning of the peer’s message.
- Emotion labeling: Identifying and tentatively labeling the feelings expressed or implied by the peer’s words or actions.
- Reflecting/mirroring: Using statements indicating ability to take the peer’s perspective.
- Open-ended questioning: Asking questions that encourage the peer to talk and do not elicit short or one-word answers.
- Normalizing: Regarding peers’ behaviors, emotions, or motives for behavior as “normal.”
Examples of nonverbal communication are body language, eye contact, affect, and expressive and appropriate physical gestures.
Communication blockers, such as asking “why,” interrupting, and advising create barriers during peer interactions. They are not helpful because they may evoke defensiveness or shift the focus of the conversation away from the peer in need.
This module is presented early in the training because of the impact stress can have on physical and mental health. Participants discuss the potential internal and external stressors encountered in their profession and receive a list of indicators and warning signs of excessive stress.
This portion of the training discusses commonly held myths concerning depression (e.g., it is a sign of weakness) and reviews signs and symptoms of depression, such as loss of interest, low mood, and sleep disturbance.
Trainees learn and define the terminology related to substance use and abuse (e.g., dependence, tolerance, withdrawal, binge drinking). This module also covers indicators of alcohol and opioid abuse, steroid use, and gambling addiction.
Anxiety and PTSD
This module reviews the “fight or flight” response and its impact on health; signs and symptoms of anxiety disorders (e.g., panic disorder, generalized anxiety disorder); and diagnostic criteria for PTSD, as well as its prevalence and impact on emergency service workers.
This section initially examines reasons first responders do not seek help, such as denial, anger, pride, fear, and stigma. It then reviews suicidal risk and protective factors and provides a checklist of warning signs. The checklist includes verbal and behavioral indicators used to assess suicide risk.
Participants define the concept of resilience and learn resilience-building techniques, such as mindfulness, diaphragmatic breathing exercises, and guided imagery. These methods enable trainees to practice self-care and serve as models of healthy behaviors for peers.
Although peer support teams usually comprise members from the same job functions, the authors have had personnel from different positions within departments (police and correctional officers, dispatchers, and civilian staff) attend the same training. In these combined programs, participants can apply newly acquired information to shared experiences while considering each other’s diverse perspectives.
However, content is modified to be relevant to all attendees. For example, statistics concerning common mental health problems should reflect the group’s composition by presenting rates of substance abuse and depression in police and correctional officers as well as dispatchers. Further, role-play scenarios are constructed to apply to all trainees.
Instructors should be sensitive to the importance of delivery style in maintaining attention and facilitating discussion throughout training. Adopting a casual, relaxed approach, particularly when covering difficult topics, allows trainees to feel comfortable sharing their personal perspectives. In addition, the trainer can incorporate humor, such as funny videos (when appropriate), to increase comfort. Given the inherently stressful nature of working in emergency services, research has shown that levity relieves first responders from job-related stress and helps build group cohesion.16
Acting out a role is an essential component of peer support training. It gives trainees an opportunity to apply the skills they have learned and receive feedback. Role-play scenarios often cause some anxiety early in the training. However, after the first several repetitions, nearly all participants report feeling more comfortable. Also, rather than having trainees divide into pairs to practice the scenarios, the authors have found it more effective for trainers to act as the distressed “peer” and ask attendees to respond to the trainer. This method gives trainers the opportunity to evaluate the trainee’s skill level and provide more accurate performance feedback.
The way to provide feedback deserves mention. Feedback that sounds critical risks alienating the group and discouraging role-play participation. Consequently, feedback should be presented in a constructive and positive manner. A frequent occurrence in role-play scenarios with first responders is their inclination to immediately problem-solve rather than actively listen. Trainers should be vigilant of this tendency and encourage trainees to employ active listening first.
“[Peers as Law Enforcement Support] training modules focus on active listening skills, stress, depression, substance use, anxiety and PTSD, suicide, and resilience.”
Confidentiality is a fundamental component to the success of peer support programs. Given that anonymity is highly concerning to first responders, any breach of it may compromise program participation. The implementation of confidentiality is based on an agency’s standard operating procedures; it is important to establish guidelines for peer facilitators to follow.
Several states have enacted legislation protecting the privacy of peer communications. For instance, Florida delineates privileged communication, definitions, provisions, and exemptions to confidentiality in peer interactions.17 For states that may not be safeguarded by formal legislation, a privacy statement is recommended in peer support team policies to provide members with a degree of confidentiality.
When conducting peer support training, it is crucial to minimize distractions, such as cell phones and laptops. Asking trainees to turn these off, and redirecting if they do not comply, is usually sufficient. Further, interspersing relevant videos that are educational and entertaining throughout the modules has proven effective in maintaining group interest and attention. For example, movie or television clips are a good resource for finding such segments.
Refresher courses are important to ensure previous skill levels are maintained and interventions continue to be effective. Active listening is a focus of follow-up training. Engaging in role-play scenarios and receiving feedback enhances and reinforces a peer facilitator’s ability to employ these skills to create an environment that fosters trust and support. Refresher courses are also used to encourage trainees to be mindful of their own physical and psychological well-being to ensure effectiveness in their peer support roles.
Because self-care practices vary greatly across individuals, peer facilitators identify their own unique coping strategies. As needed, they review and demonstrate previously covered stress-reduction techniques, such as diaphragmatic breathing, guided imagery, and mindfulness. Follow-up training also offers an opportunity for peer facilitators to share concerns or barriers they have encountered. In sharing their experiences, they receive input from trainers and fellow team members.
The timeline for scheduling refresher courses varies, depending on each department’s specific resources, needs, and personnel availability. The authors have found it beneficial to meet quarterly with the peer support team to identify any problems or deficits and ensure maintenance of previously trained skills. Follow-up meetings are usually brief, lasting approximately one to two hours. However, an annual one-day refresher is recommended to provide a more comprehensive review of materials covered in the initial training.
Program Evaluation Methods
While the need for peer support programs has been underscored for several years, research concerning their efficacy is limited. Thus, when implementing these approaches, program evaluation methods warrant consideration.
The PALS program efficacy is evaluated by assessing four criteria in a pre- and post-training assessment.
- Content knowledge and skill acquisition
- Active listening
- Consumer satisfaction
- Utilization of peer support services
Approximately one week before the training, a 20-question, true-or-false test is administered to evaluate how much the participants already know before the training. Questions pertain to topics covered in the training: active listening skills, stress, depression, substance use, anxiety and PTSD, and suicide. Examples of true-or-false statements are: “Symptoms of PTSD appear immediately after a traumatic event” and “Giving away possessions is a warning sign for suicide.”
To evaluate active listening skills prior to training, participants complete a role-play test that is videotaped and consists of eight scenarios simulating peer interactions. Each scenario includes four prearranged prompts provided by a role-playing peer to facilitate an extended interaction and mimic real-life encounters. Also, each prompt is sufficiently neutral in content to be appropriate and facilitative, regardless of the participant’s responses. Role-play responses are then retrospectively rated for the occurrence of active listening skills. An example of a role-play scenario is provided in the table below.
Examples of Pre- and Post-Training Assessment Role-Play Scenarios
“Engaging in role-play scenarios and receiving feedback enhances and reinforces a peer facilitator’s ability to employ these skills to create an environment that fosters trust and support.”
You see a colleague noticeably upset prior to starting his shift. He discloses he is having financial problems because he has been on light duty and unable to work overtime or details. This has placed an increased strain on his marriage. He mentions his wife has filed for divorce. What do you do?
Prompt 1: “I’m not letting her take my kids away.”
Prompt 2: “I’ve tried to talk to her, but she said the relationship is over.”
Prompt 3: “I just want to be with my kids.”
Prompt 4: “I don’t think I can live without them.”
You arrive to work and notice a colleague who appears to be intoxicated. What do you do?
Prompt 1: “I’ll just have a cup of coffee and shake it off.”
Prompt 2: “I must have had too much to drink last night.”
Prompt 3: “Not like anything important is going to happen today.”
Prompt 4: “Maybe you should have a drink to take the edge off.”
Immediately upon completion of the training, participants are provided a course and instructor evaluation to assess consumer satisfaction. This measure has eight statements regarding the participants’ opinions of the training and instructors. Examples of these statements are: “This course included practical application of the subject material” and “The instructor was knowledgeable about the subject matter.” Ratings are made on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). A comments section allows for qualitative feedback.
Additionally, trainees are asked to track utilization of peer support services. Interactions and peer encounters are tabulated using a contact tracking sheet that captures information such as the nature of the referral or problem, frequency of encounters, and outcome. Identifying information is not recorded to maintain anonymity.
A post-training assessment is implemented one to two weeks following program completion. Participants are again administered the same eight role-play scenarios and asked to complete the same 20-item knowledge test used in the pre-training assessment. This test evaluates participants’ retention with content areas covered in training. Post-training role-play scenarios are again recorded and retroactively coded by independent raters (i.e., research assistants not involved in role-play or training administration).
Pre- and post-training videos are coded on specific verbal communication skills targeted in the training (i.e., intonation, paraphrasing, emotion labeling, reflecting, open-ended questioning, and normalizing). The recorded scenarios are presented in randomized fashion to control for the effects of administration and order, and to keep the raters blind to whether they are observing a pre- or post-training assessment.
First responders are frequently exposed to stressors and traumatic events throughout their careers, often leading to the manifestation of various behavioral and psychological problems. Because the characteristically stressful nature of these professions will not likely change, departmental responses to managing employee stress and promoting well-being are of the utmost importance.
Peer support programs have become a widely accepted standard of care for many agencies. They serve as effective resources by reducing stigma surrounding mental health concerns and creating an avenue for first responders to feel comfortable approaching one another for support.18
While much of the research on peer support programs is qualitative, there is still a need to address the considerations and strategies implemented when creating and evaluating these efforts. By using the approaches delineated in this article, agencies will have a framework to reference when implementing their own peer support programs.
Training considerations have been generated through the authors’ successful experience in applying the Peers as Law Enforcement Support model across many different agencies. The proposed method of program evaluation will provide a robust source of empirical evidence to determine its efficacy. Most important, the application of suggested strategies in newly developed peer support programs will ensure first responders receive quality training to capably support their peers in need.
“[T]he application of suggested strategies in newly developed peer support programs will ensure first responders receive quality training to capably support their peers in need.”
Emily Cnapich, M.S., a clinical psychology doctoral student focusing on first responder psychology at Nova Southeastern University in Fort Lauderdale, Florida, can be reached at email@example.com.
Samantha Rodriguez, M.S., a clinical psychology doctoral student focusing on police psychology at Nova Southeastern University in Fort Lauderdale, Florida, can be reached at firstname.lastname@example.org.
Bailee Schuhmann, M.S., a clinical psychology doctoral candidate at Nova Southeastern University in Fort Lauderdale, Florida, can be reached at email@example.com.
Judy Couwels, M.A., a licensed marriage and family therapist and Employee Assistant Program manager at the Broward County, Florida, Sheriff’s Office, can be reached at firstname.lastname@example.org.
Vincent Van Hasselt, Ph.D., a psychology professor and director of the First Responder Research and Training Program at Nova Southeastern University in Fort Lauderdale, Florida, and certified law enforcement officer, can be reached at email@example.com.
Jessica Blalock, M.A., a clinical psychology doctoral student and member of the First Responder Research and Training Program at Nova Southeastern University in Fort Lauderdale, Florida, can be reached at firstname.lastname@example.org.
1 James F. Ballenger et al., “Patterns and Predictors of Alcohol Use in Male and Female Urban Police Officers,” American Journal on Addictions 20, no. 1 (2011): 21-29, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3592498; and Kim Ménard and Michael Arter, “Police Officer Alcohol Use and Trauma Symptoms: Associations with Critical Incidents, Coping, and Social Stressors,” International Journal of Stress Management 20, no. 1 (2013): 37-56, https://psycnet.apa.org/record/2013-01911-001.
2 Tara Hartley et al., “Health Disparities in Police Officers: Comparisons to the U.S. General Population,” International Journal of Emergency Mental Health 13, no. 4 (2011): 211-220, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734372/; and John Violanti, “Police Suicide: A National Comparison with Fire‐Fighter and Military Personnel,” Policing: An International Journal of Police Strategies and Management 33, no. 2 (June 2010): 270-286, https://www.researchgate.net/publication/235259517_Police_suicide_A_national_comparison_with_fire-fighter_and_military_personnel.
3 Beth Pearsall, “Sleep Disorders, Work Shifts, and Officer Wellness,” National Institute of Justice Journal, June 14, 2012, https://nij.ojp.gov/topics/articles/sleep-disorders-work-shifts-and-officer-wellness#citation--0.
4 Ellen Kirschman, Mark Kamena, and Joel Fay, Counseling Cops: What Clinicians Need to Know (New York: Guilford Publications, 2014); and Egbert Zavala, “Testing the Link Between Child Maltreatment and Family Violence Among Police Officers,” Crime & Delinquency 59, no. 3 (2013): 468-483, https://journals.sagepub.com/doi/10.1177/0011128710389584.
5 Kristin Klimley, Vincent Van Hasselt, and Ashley Stripling, “Posttraumatic Stress Disorder in Police, Firefighters, and Emergency Dispatchers,” Aggression and Violent Behavior 43 (2018): 33-44, https://www.sciencedirect.com/science/article/abs/pii/S1359178918302416.
6 Mark H. Chae and Douglas Boyle, “Police Suicide: Prevalence, Risk, and Protective Factors,” Policing: An International Journal of Police Strategies and Management 36, no. 1 (March 2013): 91-118, https://www.researchgate.net/publication/251236553_Police_suicide_Prevalence_risk_and_protective_factors; and John Violanti, Cynthia Robinson, and Rui Shen, “Law Enforcement Suicide: A National Analysis,” International Journal of Emergency Mental Health and Human Resilience 15, no. 4 (2013): 289-298, https://destination-zero.s3.amazonaws.com/Law%20Enforcement%20Suicide%20A%20National%20Analysis.pdf.
7 Sarah Henderson et al., “FIRST Response: The Firefighter Intervention and Response Support Team,” Fire Engineering, September 2018, https://digital.fireengineering.com/fireengineering/201809/MobilePagedArticle.action?articleId=1423594#articleId1423594; James Jeannette and Alan Scoboria, “Firefighter Preferences Regarding Post-Incident Intervention,” Work & Stress 22, no. 4 (2008): 314-326, https://ovc.ojp.gov/sites/g/files/xyckuh226/files/media/document/ci_preferences_for_intervention-508.pdf; and Police Executive Research Forum, An Occupational Risk: What Every Police Agency Should Do to Prevent Suicide Among its Officers (Washington, DC: Police Executive Research Forum, 2019), https://www.policeforum.org/assets/PreventOfficerSuicide.pdf.
8 Julie Repper and Tim Carter, “A Review of the Literature on Peer Support in Mental Health Services,” Journal of Mental Health 20, no. 4 (August 2011): 392-411, https://pubmed.ncbi.nlm.nih.gov/21770786/.
9 Vincent Van Hasselt et al., “Peers as Law Enforcement Support (PALS): An Early Prevention Program,” Aggression and Violent Behavior 48 (2019): 1-5, https://www.sciencedirect.com/science/article/abs/pii/S1359178919301156.
10 Mark C. Creamer et al., “Guidelines for Peer Support in High‐Risk Organizations: An International Consensus Study Using the Delphi Method,” Journal of Traumatic Stress 25, no. 2 (April 2012): 134-141, https://pubmed.ncbi.nlm.nih.gov/22522726/.
11 Anne Eyre, “The Value of Peer Support Groups Following Disaster: From Aberfan to Manchester,” Bereavement Care 38, no. 2-3 (2019): 115-121, https://www.tandfonline.com/doi/abs/10.1080/02682621.2019.1679453; and Fran Norris and Susan Stevens, “Community Resilience and the Principles of Mass Trauma Intervention,” Psychiatry: Interpersonal and Biological Processes 70, no. 4 (2007): 320-328, https://psycnet.apa.org/record/2008-00602-003.
12 Jack Digliani, “Police Peer Support: Does it Work?” Law Enforcement Today, March 15, 2018, https://www.lawenforcementtoday.com/police-peer-support-work/.
13 Cynthia Goss, “Utilizing the Brotherhood of Law Enforcement Personnel: The Need for a Statewide Peer Officer Support Model” (master’s thesis, State University of New York, Empire State College, 2013), https://www.proquest.com/openview/cb4c3b7d1247947c8c1f915cc7fa4c46/1.pdf?pq-origsite=gscholar&cbl=18750&diss=y.
14 Van Hasselt et al.
15 For a more detailed description of modules, see Van Hasselt et al.
16 Sarah Craun and Michael Bourke, “The Use of Humor to Cope with Secondary Traumatic Stress,” Journal of Child Sexual Abuse 23, no. 7 (August 2014): 840-852, https://pubmed.ncbi.nlm.nih.gov/25085244/; and Annette Folwell and Trevor Kauer, “‘You See a Baby Die and You’re Not Fine’: A Case Study of Stress and Coping Strategies in Volunteer Emergency Medical Technicians,” Journal of Applied Communication Research 46, no. 6 (November 2018): 723-743, https://www.tandfonline.com/doi/abs/10.1080/00909882.2018.1549745.
17 Peer Support for First Responders, FLA. STAT. § 111.09 (2020).
18 Van Hasselt et al.