In this approach, we first identified gaps in current suicide prevention interventions and standards of care, including understanding the current state of the literature (as documented in the Introduction section), intervention development methodology among those with lived experience [30-32], and community-engaged research to inform intervention development [29,32]. Next, the principal investigator (PI, SAC) held a series of informal discussions with various VHA local and national peer support and mental health leaders, which highlighted encouraging support for VHA peer specialists to be involved in suicide prevention efforts while remaining inside their scope of practice. Simultaneously, the PI sought out and established relationships with scientific experts in suicide prevention, SMI, peer support services, and intervention design. These experts were identified as leaders in their fields by recommendations by others the PI spoke with and some were previously known to the PI. Experts in all areas echoed the same message as VHA leaders. SMI experts specifically emphasized considering cognition when tailoring interventions for individuals with SMI or anyone in an emotional or suicidal crisis. To date, compensatory cognitive strategies [33,34] have not been used to improve learning and recall in the context of suicide prevention interventions but may be crucial as cognitive impairments may limit the ability to recall and engage in preventive behaviors and intervention strategies.

Preliminary research, based on the new knowledge acquired, was then conducted. This research focused on further understanding the important role of safety planning (ie, a 6-step plan collaboratively completed with a provider and a veteran to identify when the veteran is becoming suicidal and what specifically the veteran can do next [35,36]) as a suicide prevention intervention standard of care given the calls for future research on safety planning [37] and that many trials with suicide-related outcomes exclude individuals on the basis of psychosis [5]. This preliminary research found that increased social support is needed during a suicidal crisis [38,39], that veterans welcome the use of peers in suicide prevention care [40,41], and that improved ability to remember and use one’s safety plan is needed [42-44]. Further conversations were needed to determine whether peers could enhance safety planning.

Valuing veteran peer specialists’ perspectives on their potential role in suicide prevention, the PI first met with a group of 5 veteran peer specialists across the country interested in providing input as identified by a community liaison expert. Then, the PI joined the monthly meeting of the 9 local VHA peer specialists via invitation from the local recovery coordinator. Across meetings, a major discussion point was “recovery planning,” the prime example being the Wellness Recovery Action Plan (WRAP) [45]. WRAP is a peer-delivered, evidence-based intervention for those with SMI. WRAP centers on identifying broad warning signs of mental illness, developing wellness or coping tools for functional independence, planning for day-to-day effective living within one’s community, and building a crisis and postcrisis plan. WRAP focuses broadly on mental health and shares aspects with suicide safety planning. Although no formal protocols have been tested to adapt recovery planning for suicidal crises, veteran peer specialists informally shared that they have successfully used WRAP with individuals who are suicidal. Given the added benefit of interventions that directly target suicidal ideation and behaviors [46,47], a suicide-focused, WRAP-inspired plan delivered by peer specialists would allow for a recovery-oriented approach to enhance safety planning for veterans with SMI.

Following these conversations, a preliminary intervention curriculum framework was designed. Core concepts included valuing recovery, using wellness tools broadly and when suicidal, setting recovery goals, daily planning development, and learning (ie, cognitive training) strategy identification. This first iteration was reviewed by a VHA peer specialist, and, with verbal consent, the VHA peer specialist then explored the core concepts with 3 veterans with SMI. Both the VHA peer specialist and the veterans with SMI shared that the core concepts were relevant and acceptable to discuss in a peer support appointment. Notably, the VHA peer specialist expressed increased comfort, competence, and confidence in suicide prevention care following review of this intervention framework. Local and national VHA leadership provided feedback on the intervention framework and study design in one-on-one meetings over the study planning period. Leadership feedback remained centered on keeping the service within a VHA peer specialist’s scope of practice.

Five of the 9 locally employed peer specialists approached agreed to formally participate on a peer specialist advisory board. These advisors were provided with an informational sheet and provided verbal consent for their participation. All advisors on this board were peer specialists employed by the VHA and provided peer support services in mental health–related clinics and outreach teams. Peer specialist advisors attended eight, 30- to 60-minute meetings via videoconferencing to discuss the 3 themes in aim 1.

Of the scientific experts who provided input in the knowledge development phase, 6 scientific advisors were approached based on the sustained relationship with the PI and the unique area of expertise they championed. They all agreed to participate on the scientific advisory board. The scientific advisors included experts in suicide prevention, SMI, VHA peer support services and implementation, and intervention design and development. The scientific advisors attended one-on-one meetings with the PI and met regularly in small breakout groups every 3-4 months via videoconferencing. Each meeting focused on questions pertaining to the scientific advisors’ expertise area to best use that expertise to enhance the intervention and subsequent implementation.

The PI moderated all advisory board meetings. Before each meeting, advisory board members reviewed the current intervention material. They could provide written feedback in addition to providing their verbal feedback during the meeting. Discussion questions were posed in the following predetermined key areas in each meeting: (1) scope of practice (eg, how would this intervention change or enhance a peer specialist’s duties?); (2) content (eg, what do you think about a person thinking about suicide setting long-term recovery goals?); (3) intervention design (eg, how many appointments should be provided to cover the material?); (4) suicide prevention interventions (eg, what role should safety planning play in the intervention?); (5) training (eg, how much background suicide prevention information should be provided?); and (6) study design (eg, what role do the peer specialists delivering the intervention play in relation to the research team?). Meetings were audio-recorded with verbal consent. Advisors were not given compensation due to the nature of funding available.

VHA Peer Specialist Advisory Board themes included (1) the desire for suicide prevention training for peer specialists, (2) determining the role of VHA peer specialists in suicide prevention, (3) integration of recovery themes in suicide prevention, and (4) difficulties using a suicide safety plan during a crisis.

Peer specialist advisors were unclear what they are “allowed” to do when working with an individual at high risk for suicide, specifically when that individual was already known to be at a higher risk; they desired training to address these uncertainties. The peer specialist advisors believed that they did not have the confidence and competence to work with someone who is at a high risk for suicide (eg, “I’m worried I won’t know what to do or say [when someone says they are suicidal].”).

The peer specialist advisors were unclear of the role of their direct clinical supervisor when a veteran is already identified to be at an increased risk of suicide (compared with whether the risk was newly identified by the peer specialist, eg, “I’ve been told to just bring my supervisor in at any mention of suicide.”). At the same time, peer specialist advisors indicated that they felt that they could do more for a veteran at an increased risk for suicide instead of immediately bringing in a licensed provider (eg, their clinical supervisor) to address the risk (eg, via a comprehensive suicide risk assessment [48]) if they had the necessary training (eg, “I feel like I can do more for suicidal veterans, but I’m not sure what I am allowed to do.”). Peer specialist advisors believed that they should have more autonomy when it comes to working with veterans at risk for suicide (eg, “We can adapt to what is needed in the moment … that’s what we’re best at.”). These advisors expressed interest in continued participation in future phases of study, including providing informed consent to deliver the intervention and to share their experiences.

Unique skills peer specialists bring to a suicidal crisis are discussions of recovery and recovery planning (eg, “…I’ve been there and, even if I don’t have the exact same experience, I can still share my story to show that recovery is possible…”). A suicide-focused recovery plan was welcomed by advisors (paired with the appropriate suicide prevention training) as it (1) is within their scope of practice to complete a recovery plan with a veteran and (2) would provide them an intervention that is focused on suicide when they encounter a veteran at an increased suicide risk. Advisors agreed that this type of plan would be useful for veterans before and after a suicidal crisis, suggesting that this intervention could be for veterans at varying risk levels. Establishing rapport at the beginning of the interaction with veterans, focusing on strengths (eg, “specifically, reasons for living”), and modeling effective communication of suicidal thoughts were desired components to include in this intervention.

Relatedly, in developing the design of this intervention, advisors made a series of requests based on the recovery model. First, they asked for the intervention to follow a similar order as other recovery-oriented interventions they deliver in VHA, such as Whole Health. They stated that the general format should start with psychoeducation, move into inspiring hope, and then focus on recovery goals and social connection through daily action planning. Advisors noted that they liked “the option to have multiple versions” of certain materials. For example, the veteran could choose what format they prefer to use for their learning strategies (eg, post-it notes and mobile phone calendar). Finally, the advisors recommended a “triage approach” of what intervention material to focus on first (ie, asking about suicide) and then a hierarchy of recovery topics to target next in each appointment.

In discussing the current standards of care for suicide prevention, the advisors reported potential difficulties with using suicide safety plans during a crisis based on their own lived experience of using a safety plan. Advisors expressed needing something shorter (eg, “a reminder of just my main reason for living and whom I am going to call”), instead of a 1-page or longer document when in a crisis. Advisors also suggested that this shorter plan should be recovery- and strengths-focused as well as “pocket-sized.” Wallet-sized hard copies and digital phone backgrounds with the pertinent information were discussed to have options to meet the needs of varying veteran preferences. Advisors expressed that while veteran patient treatment manuals are helpful for some, the option of translating any curriculum to memorable subelements may be beneficial especially when in a suicidal crisis. Relatedly, they suggested strategies for reminding a veteran to engage with their plan (eg, “Have you ever thought about the use of cell phones or alarms to help people with their daily goals? It’s something I try to use because I’m really good at getting lost in my mind.”). Ultimately, they requested to not have safety planning play a direct role in the intervention except for reviewing the veteran’s safety plan with them if they indicated that they were at higher suicide risk following VHA mandates.

Based on the input from both advisory boards, we developed Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT). The aims of SUPPORT are two-fold: (1) increase competence and confidence of peer specialists in suicide prevention and (2) assist veterans with SMI at increased suicide risk through the recovery process.

The request for suicide prevention training by advisors led to the development of a training manual tailored to VHA peer specialists including two main sections: (1) a general suicide prevention training that can be a stand-alone training for any peer and (2) a training for VHA peer specialists in how to deliver a recovery-oriented, evidence-informed intervention for veterans with SMI at an increased suicide risk (Multimedia Appendix 1). The complete SUPPORT training includes two 4-hour training days. Adapting from other suicide prevention models for peer specialists [49], Figure 2 demonstrates the procedure in which peer specialists can ask directly about suicidal thoughts and an algorithm for when to incorporate intervention by a licensed provider.

As part of ongoing training, a study consultation group is also provided biweekly (timing based on the peer specialists’ request) after the complete SUPPORT training. The consultation group, comprising the peer specialists delivering SUPPORT, research staff, and a licensed clinical psychologist, serves as a dedicated time to discuss immediate concerns; receive feedback on SUPPORT appointments; discuss and process general concerns, fears, and questions; and discuss implementation or other administrative topics.

The SUPPORT intervention is designed to promote enhanced personal recovery, quality of life, and connectedness to foster effective management of veterans’ suicidal thoughts and behaviors (Figure 3). As is typical with other peer support services, the SUPPORT intervention augments and complements ongoing care (eg, case management, individual therapy, and psychiatric medication appointments).

After completing a comprehensive mental health evaluation with a licensed VHA provider, the veteran will meet with their peer specialist for approximately four 50-minute appointments to discuss and mutually share elements of value-based living, recovery and action planning, and compensatory cognitive (ie, learning) strategies. Including learning strategies as part of the SUPPORT intervention may improve learning of concepts, memory for intervention elements, prospective memory for symptom self-evaluations, review of intervention material, and promote general functional and social recovery. The final result is pocket-sized hard copy or digital set of 4 reminders for living (ie, the veteran’s main reason for living, what the veteran is most hopeful about, the veteran’s recovery goal, and who the veteran is going to call in a suicidal crisis).