We’re All in This Together
While the psychological health and well-being of war-fighters can suffer at times for a number of reasons, social isolation puts service members at heightened risk. The research of psychologist and suicide expert Dr. Thomas Joiner suggests that two key variables are at play for those who consider suicide: a self-perception of being a burden to others and a feeling of not belonging. 3 Within the military culture those risk factors, e.g., limited engagement with new unit members or new recruits, may be systemic if left unaddressed by leadership at all levels—especially small-team leadership.
For those returning from deployment, the theme of not belonging is common, temporary, and a frequent focal point of treatment. It is commonplace for seasoned service members to report bonding with those with whom they have deployed, yet then limiting the intensity of bonding during subsequent deployments. That practice has an adaptive quality to it; it may buffer an individual from experiencing a significant sense of loss if the new relationship is terminated or otherwise compromised by the very nature of war. Yet it is also maladaptive: It limits one’s social-support network, which is a key component to developing resilience and a strong sense of belonging.
However, for new recruits who have not been deployed, suicide is also a tragic reality and a readiness issue. An often-shared theme in that group is the sense of not belonging and a subsequent feeling that one is a burden to the team. The recommended course in that situation is not to lower standards or expectations of new recruits, but to increase group cohesion and address deficiencies without alienating them. For example, it is often better to include a new recruit who is “feeling down” in a training exercise rather than “giving him a break” and leaving him in the barracks. Inclusive, shared group experience in overcoming adversity is more likely than ridicule or isolation to build esprit de corps, which as an expression of social support improves unit cohesion and readiness.
Adopting and successfully implementing Total Force Fitness—“a methodology for changing the way we understand, assess, and maintain our people’s wellbeing and sustaining our ability to carry out our missions”—is one way to address deficiencies. The Chairman of the Joint Chiefs Guidance for 2011 highlights the importance of improving “the Health-of-the-Force by caring for our people and their families and by restoring our readiness.” 4 That strategic emphasis on people—not machinery and platforms—serves as the primary driver for improving the readiness of the force. Peer-to-peer mentoring and counseling is another technique that organizations of high-stress and high-risk populations are turning to—with encouraging results.
Make no mistake, peer support is not new. The reinforcing “we’ll-get-through-this” whisper from one unit member to another on the battlefield, or an on-base confrontation about the need to cease engaging in an observed at-risk behavior (or the encouragement to find a more productive one)—those are examples of peer support, and they occur every day, in every unit. Great units already encourage that type of communication, and there is something that must be learned from it. Leaders who set the condition for positive social interaction in a unit both on and off the battlefield—and who themselves set the example—provide increased opportunities for members of the group to receive the help they need, when they need it. Increased peer support develops trust and respect among unit members, two elements crucial to readiness and mission sustainment.
Readiness requires more effective social support and networking capability to meet the challenges of today and tomorrow, and small-team leaders are essential to making it happen. The Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury recently analyzed these issues and laid out a specific set of recommendations.
The Benefits of Peer Support
As part of an ongoing mission, DCoE explored how to most effectively apply the model of peer support to the military environment. The military is a culture wherein members take care of one another. Peer support—defined as assistance provided by a person who shares commonalities with the target population—is based on the notion that shared experiences, especially combat, bind individuals in ways that foster trust and credibility. 5 Those two attributes, of course, are central to developing relationships in which individuals can open up and discuss their problems comfortably. Peer support—widely used in formal and informal programs—has been found to have a positive effect on individuals with shared diseases, conditions, and situations. 6
Peer-to-peer programs offer opportunities for individuals to talk with trained supporters, peers who can offer educational and social support and provide avenues for additional help if needed. In addition, the community—the military itself or an individual’s family or loved ones—benefits from the individual service member’s participation in peer support. Benefits include greater social networking, improved quality of life, enhanced wellness, improved coping skills, acceptance of illness or situations, improved medical compliance, reduced anxieties, and increased satisfaction of health status. Individuals who are better able to cope with their feelings and thus have healthier relationships are far more likely to be productive than they would be if distracted by stress, dealing with depression, or engaged in substance abuse. 7
The Way Forward
Based on reviews of more than 45 professional journal articles on peer support and 15 actual peer-support programs in the military and other government agencies, DCoE outlined ways for the military community to continue to offer—and expand—peer-support approaches to service members’ needs within three specific realms: combat and operational stress, suicide prevention, and recovery.
Combat and Operational Stress: The stressful nature of the tasks required, time away from loved ones while serving, and the environment in which service members operate can lead to enormous stress. Several peer-support programs have been created to help alleviate the effects of operational stress in military life. Model peer programs aimed at addressing operational stress entail carefully selecting a peer from within a unit and training him (or her) to provide stress-coping support throughout the deployment cycle, i.e., while in garrison and at home. Peer supporters are held accountable in the role of counselor, and maintain strong confidentiality agreements while serving as a liaison with chaplains, unit leadership, and the military health community. Peer supporters in model programs undergo training to:
• Identify and be aware of signs of stress
• Know when to reach out to others for assistance
• Facilitate referrals
• Follow through to monitor improvement
• Encourage unit members to use existing support programs
Suicide Prevention: Addressing the needs of operational stress can indirectly contribute to suicide prevention by providing ongoing support, encouraging assistance-seeking, and strengthening resilience. Several peer-support programs created to address suicide prevention also handle operational stress, and vice-versa. Additionally, some programs train peers to act as “gatekeepers”—those able to identify suicide warning signs effectively and direct at-risk service members to trained counselors.
Moreover, many suicide-prevention programs employ 24-hour telephone hotlines staffed with volunteer peers to provide instant credible help and to encourage an individual to open up and obtain support. The effectiveness of that approach to reducing rates of suicide and mental illness, however, requires further study and assessment.
Recovery: Following a visible or invisible combat-related injury, service members may have difficulty with the healing and rehabilitation process. Peers who have gone through a similar injury and successfully rehabilitated can draw on that to provide experience-based knowledge and support.
An option for a peer-to-peer program in recovery-related issues is to develop a program directly within the medical treatment facilities where service members are receiving care. Peer volunteers in that setting can be made aware of available resources (both military and civilian) to help service members obtain optimal care, and/or to transition to civilian care, if that is needed. Benefits also can accrue to the peer supporter in such a relationship, reinforcing their own progress and recovery through helping someone else. Finally, a recovery-based peer-to-peer program can provide stability in a transitional period, such as a return to active duty status or reintegrating into civilian life. The social connections of the network may be the only peer contacts injured service members have when they first transition out of service.
A Cornerstone to Strength
Effective peer support driven by leadership at all levels is an excellent way to identify and reach out to service members who may be struggling. Formalization of peer- support programs can help enhance service members’ ability to function better as unit members and members of a family. Peer support serves as the cornerstone for readiness; sometimes just talking with a peer is all that is needed to make it through a difficult time. Other times, a peer supporter can get the help that a buddy may need. Regardless, effective peer support builds stronger teams, families, units, and military communities.
Peer mentors and peer counselors will always be in demand. Volunteer opportunities can be found within a specific branch of the armed services. All across the country, veteran medical centers and suicide-prevention hotlines targeting active duty personnel (and their families) are seeking volunteers. Additional information about some of those opportunities, as well as more in-depth discussions on peer support, is available in DCoE’s January 2011 review of peer-to-peer practices at www.dcoe.health.mil  .
2. David Brown, From Pejoration to Resilience: Integrative Hermeneutics on Anxiety, Fear, Uncertainty, and Preserving Self-Esteem in a Cross Cultural Milieu , (Honolulu, HI: Neurobehavioral Research Institute Press, 2004).
3. Thomas Joiner, Why People Die by Suicide, (Cambridge, MA: Harvard University Press, 2005).
4. ADM Mike Mullen, CJSC Guidance for 2011, http://www.jcs.mil//content/files/2011-01/011011165132_CJCS_Annual_Guida... 
5. Peer Support Programs in Diabetes, World Health Organization, 2007. Retrieved from http://who.int/diabetes/publications/Diabetes_final_13_6.pdf  .
6. Phyllis Solomon, “Peer support/peer provided services: Underlying processes, benefits, and critical ingredients,” Psychiatric Rehabilitation Journal , 27 (4), pp. 392–401.
7. Jean Campbell and Judy Leaver, “Emerging New Practices in Organized Peer Support,” Report from NTAC’s National Experts Meeting on Emerging New Practices in Organized Peer Support, March 2003. Retrieved from http://www.consumerstar.org/pubs/Emerging%20New%20Practices%20in%20Oraga...  .
Dr. Brown, a former Army NCO, is chief of the Integrative Health Division (Provisional) for Resilience and Prevention at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. He previously served as the lead psychologist over seven bases in Bavaria, Germany.
Using Peers in Suicide Prevention
• The U.S. Air Force uses peers as part of its Trauma Response Teams, a component of the USAF Suicide Prevention Program.
• The U.S. Army Suicide Prevention Program suggests the possibility of appointing a “life-line” buddy to oversee an individual in crisis until a referral is made or the crisis is over.
• Massachusetts’ Statewide Advocacy for Veterans’ Empowerment (SAVE) program has regional coordinators who travel directly to a veteran’s door to provide support and/or bring them into a VA medical center.
Using Peers in Combating Operational Stress
• Under the Centers for Disease Control’s Deployment, Safety and Resiliency Team program, an individual from each unit is trained in psychological first aid so that they can monitor and assess the state of their peers during deployment.
• In the California National Guard’s Peer Support Program, trained individuals are available to meet with fellow service members at drill and during deployment.
• The United Kingdom’s Trauma Risk Management program uses peers to screen individuals who may need additional testing or services following a traumatic incident.
Using Peers in Suicide Helplines
• VA’s “Veterans Chat” enables veterans to anonymously chat online 24/7 with a trained VA counselor. If the counselors determine there is a crisis, they can immediately transfer the caller to the VA Suicide Prevention Hotline.
• New Jersey’s Cop 2 Cop hotline has a phone bank with retired police officers and counselors who provide 24/7 live phone coverage.
• Police Organization Providing Peer Assistance responds within 15 minutes to calls received 24/7 and arranges to meet face to face with officers in need.
Using Peers in Recovery
• On-treatment team – VA hires veterans as peer support technicians to be a part of the case management team for veterans with psychological health issues.
• Education – Vet to Vet is a consumer/provider partnership in which trained veterans lead educational group sessions at facilities that offer VA mental health services.
• Social support through transition – The Canadian Operational Stress Injury Social Support (OSISS) Peer Support Network is a joint program that serves active duty and veteran service members. The OSISS Peer Support Coordinator is often the only constant for service members who change doctors, counselors and sometimes medications and treatment plans through the recovery process.