A Peer Support Service Integrated Into the 988 Lifeline
A peer support option should be integrated into the 988 Suicide and Crisis Lifeline so that 988 service users can choose to connect with specialists based on a shared lived experience. As people and communities become more siloed, the risk of mortality and morbidity increases. Social connectedness is a critical protective factor. A peer support service would allow individuals to receive support built on a lived experience that is common to both the service user and the specialist. It should be free and easily accessible through phone call and text messaging. This service is especially timely, following the 2020 rollout of the 988 Suicide and Crisis Lifeline, as well as recent peer support initiatives at the federal and state levels.
While the efficacy of peer support is most known with mental illness, it has successfully helped a range of individuals including cancer patients, people experiencing homelessness, racial minorities, veterans, and formerly incarcerated people. The peer support service should provide support for all kinds of lived experience, including experiences with: disability resulting from poor physical or mental health, substance use, suicidal ideation, veteran-connected disability, financial insecurity, homelessness, domestic violence and family court, nonnuclear family structures or living alone, former incarceration, and belonging to racial or ethnic minority groups. The service should be a preventative intervention as well as complimentary assistance for those in recovery or treatment.
Challenge and Opportunity
The United States faces an “epidemic of loneliness and isolation.” While individuals from all backgrounds are afflicted, the most vulnerable and underserved members of society have suffered the most. A range of challenging circumstances cause this suffering, including poor physical or mental health, nontraditional living conditions, and historic inequality. Not having anyone who shares one’s lived experience is isolating. These challenging life circumstances take an emotional toll, and they become risk factors for a slew of physical and mental health conditions that increase morbidity and decrease life expectancy.
In addition to the social costs, these outcomes have an increasingly devastating economic impact. Health care costs are projected to account for 20% of the U.S. economy by 2031. Psychiatric hospitalizations are steadily increasing, and a shortage of psychiatric inpatient beds is rampant.
Social connectedness alleviates physical and mental burdens. Peer support offers a cost-effective intervention for prevention and recovery. It reduces spending on both physical and mental illnesses, and it reduces psychiatric hospitalizations, saving an average of $4.76 for every $1 spent on peer support. In a New York City-based peer support program, service users saved about $2,000 per month in Medicaid costs and had 2.9 fewer hospitalizations per year.
Telephone-based peer support has life-saving outcomes, too. Over telephone, peer support led to a 15% increase in women’s mammography screening rates, with the highest increase among women of low-to-middle income. Telephone-based peer support increased breastfeeding rates by 14% and reduced breastfeeding dissatisfaction by 10% among first-time mothers, and it led to a 10% change in diet among patients with heart disease. While peer support would not solve national crises of homelessness or rising healthcare costs, it would ease them by fostering community empowerment and self-reliance and reducing federal intervention.
In 2023, SAMHSA rolled out “National Model Standards for Peer Support Certification”. This guide provides recommendations for how each state can integrate its own “peer mental health workforce across all elements of the healthcare system.” In its current form, SAMHSA’s strategy targets lived experiences with substance use and mental health. A broader scope would assist and empower more underserved members of the community. Following the momentum of SAMHSA’s initiative, now is the most optimal time to integrate a peer support service into the 988 Lifeline.
Peer support exists in the U.S., but services are spread thin across private and nonprofit sectors. The Restoring Hope for Mental Health and Well-Being Act of 2022 authorized $1.7 trillion in funding until FY2027 for various health initiatives, including peer support mental health services. This funding relies on organizations and institutions to independently implement peer support services based on community needs. However, a fragmented system can result in underuse, limited accessibility, and a varied quality of service, with pockets of the United States lacking any service at all. It also poses privacy concerns about how individuals’ data are stored and used, as well as cybersecurity vulnerabilities with smaller organizations that may lack a robust security infrastructure.
A peer support service that is integrated into the 988 Lifeline would ensure that all Americans have equal access to a high-quality, confidential peer support network. The standardization of the 988 Lifeline is a prime example of successful implementation. Its transition from a 10-digit number to a three-digit dial led to a 33% average increase in in-state call volume over four months. Standardization shifted funding from primarily private and nonprofit initiatives and donations to stable public sector support. As a result, call pickup rates rose from 70% to 93%, and wait times dropped from 2 minutes 20 seconds to just 35 seconds.
The 988 Lifeline also adheres to privacy and confidentiality protocols in line with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. Under these protocols, the 988 Lifeline retains minimal information about callers and texters, and this information stays private and securely stored. A peer support service with similar safeguards would help both service users and peer support workers (PSWs) feel safe when sharing sensitive information.
Peer support for mental health has gained traction recently. The National Alliance for Mental Illness (NAMI) offers peer-to-peer courses, although these are currently limited in their duration and available locations. Last year, Congress expressed an interest in peer support mental health services: a “Supporting All Students Act” was proposed in the Senate for “peer and school-based mental health support.” This endeavor especially targets the escalating suicide crisis among youths in the form of a peer-to-peer suicide prevention. The Wisconsin Department of Public Instruction also recently introduced Peer-to-Peer Suicide Prevention Grants. The federal and state-level governments clearly recognize the value of peer support work. Still, they underutilize its potential.
Loneliness and isolation are at an all-time high in the United States. However, they stem from a multitude of causes. An empathic connection with a peer who has lived the same experience has immense potential for healing and recovery in both the PSW and the service user. The 988 Lifeline should include an integrated peer support service for both mental health and a broad range of lived experiences. While there exist some peer support services for conditions not related to mental health, these are not standardized or easily accessible to the entire American population. Many peer-operated warmlines (i.e., support lines) exist. However, they are spread across dozens of phone numbers and websites with varied and limited sources of funding. A single peer support service integrated into the 988 Lifeline would make peer support universally available. This service would address the emotional toll that accompanies a wide range of challenging life circumstances.
In short, a peer support service integrated into the 988 Lifeline would make the efforts of existing peer support organizations even more effective as it would:
- Standardize training, quality of care, and confidentiality,
- Expand the kinds of lived experience that are available for peer support, and
- Maximize the distribution of high-quality services across the U.S., with a focus on reaching high-risk populations.
Action Plan
The peer support service should begin by covering only a few kinds of lived experiences. After this implementation, the service should be expanded to cover a broader range of experiences.
Recommendation 1. Create a Peer Support Task Force (PSTF).
A PSTF should be established within SAMHSA. The secretary of the U.S. Department of Health and Human Services (HHS) should work with SAMHSA’s assistant secretary for mental health and substance use to establish this temporary task force.
The PSTF should lead the implementation of the peer support service, acting as an interagency task force that coordinates with partners across the public, private, and nonprofit sectors. This partnership will ensure that different lived experiences are accounted for and that existing resources are used effectively. The PSTF should collaborate with federal agencies, including the Department of Veterans Affairs (VA) and the Indian Health Service (IHS), as well as with advocacy organizations like NAMI and the American Cancer Society that champion the needs of people with specific lived experiences.
The PSTF should be charged with the following recommendations to start.
Recommendation 2. Integrate a peer support option into the 988 Lifeline.
Under the authority of the PSTF, integrating a peer support option into the 988 Lifeline could bypass additional Congressional action.
In the first pass, the integrated peer support option should cover only a few kinds of lived experiences (e.g., suicide and behavioral crises, veteran-connected disability).
- Before scaling the peer support service across the United States, the PSTF should implement a pilot program to test and refine protocols. The PSTF should select 988 Lifeline centers in states that already have a strong peer support program, and it should pilot peer support call and text services. The pilot program should select a few peer support needs to test first (e.g., suicide and behavioral crises, veteran-connected disability), as a narrow scope will be easier to assess for the first pass.
- The PSTF should then incorporate feedback from this pilot program as it scales up and integrates a peer support option into the nationwide 988 Lifeline.
- The PSTF should coordinate with the Federal Communications Commission (FCC) to add a caller menu option for peer support into the 988 Lifeline. (E.g., “Press 4 for peer support.”)
- The PSTF should coordinate with the FCC and U.S. Digital Service to implement a telephone triage, so the service user can submit a request for a specific kind of peer support and then be routed to a PSW on shift who has a lived experience that best matches the submitted request.
- The PSTF should facilitate the 988 Lifeline’s partnership with existing local and national peer support organizations and warmlines. Partnering with these existing organizations would bolster the 988 Lifeline’s capacity to provide peer support. Furthermore, states that already have a strong peer support certification in place could easily integrate their trained PSWs into the 988 Lifeline services using their existing infrastructure and expertise.
- The PSTF should coordinate with the FCC to incorporate a peer support text messaging option within the 988 Lifeline’s text and chat services. (For example, service users could text “PEER” to 9-8-8 and be routed to a PSW on shift.)
- The PSTF should implement a public campaign to the general public clarifying that the 988 Lifeline will remain as a suicide and crisis hotline, but it will also provide access to broader peer support services. The available peer support services should be clearly outlined on the 988 Lifeline website.
PSWs should work in call centers alongside 988 Lifeline phone and text specialists.
Recommendation 3. Develop an action plan to fund and sustain the integration of the peer support service.
The peer support service would need funding to become integrated into the 988 Lifeline. The government has recently approved funds for mental health initiatives, such as with the Restoring Hope for Mental Health and Well-Being Act of 2022. In 2023, HHS announced an additional $200 million in funding for the 988 Lifeline, but overall, HHS has granted almost $1.5 billion in total toward the 988 Lifeline. Similar avenues of funding should help jumpstart the integration of the peer support service.
For continued maintenance, fees for the peer support service should apply in a similar fashion to 9-1-1. That is, service users should not pay each time they access the 988 Lifeline or its integrated peer support service. Some U.S. states have already passed 9-8-8 implementation legislation that allows a monthly flat fee to be collected through telephone and wireless service providers, as permitted in the “National Suicide Hotline Designation Act of 2020”. The remaining states should be encouraged to pass similar legislation. The fee should remain in an account that is spent only for the maintenance of the 988 Lifeline and peer support services. If a fee is collected, then the FCC should provide an annual report on these fees and their usage.
Funding for the peer support service’s integration into the 988 Lifeline would entail the following:
- Maintenance of the peer support service
- Financial compensation for trainers who will train and mentor the PSWs
- Recruitment of trainers and PSWs
- The development of training resources for PSWs
Recommendation 4. Establish state-level standardized peer support training and certification.
PSWs should learn skills that are commonly taught to 988 Lifeline specialists, including active listening and recovery-oriented language. They should learn how to share their own stories, navigate challenging conversations, maintain boundaries, and self-care. Their training should be standardized at the state level, and it should be based on the “National Model Standards for Peer Support Certification” established by SAMHSA.
While most U.S. states have some version of peer support certification for mental health and/or substance use recovery, the PSTF should work with advocacy organizations to ensure that the state-level standardized training accounts for the peer support needs and demographics of each state. The peer support training should address the needs of people with a diverse range of lived experiences. Peer support needs can also be studied using caller outcome data that are recorded by 988 Lifeline specialists.
The PSTF should recruit trainers who will train and mentor the PSWs. To start, the PSTF should liaise within SAMHSA and with existing peer support organizations to coordinate this recruitment.
Recommendation 5. Establish a nation-wide system for the recruitment and training of PSWs.
Recruit individuals who would like to use their own lived experience to help other community members. Recruitment should occur through hospitals, clinics, as well as peer-run and community-based organizations to maximize recruitment pathways.
Current 988 Lifeline phone and text specialists could also be good candidates for the peer support service. Many are motivated by their own lived experiences and are already trained to handle calls across multiple helplines. 988 Lifeline specialists are instructed to focus on the service user seeking help and not share about themselves. However, specialists’ own lived experiences––if they are comfortable sharing them––represent untapped potential.
Once recruited, individuals who are training to become PSWs should attend live training sessions online with a peer cohort.
Recommendation 6. Expand the peer support service to cover a diverse range of lived experiences.
After successfully establishing the peer support service, it should be expanded upon to provide support for a broad and diverse range of lived experiences. The available peer support services should continue to be updated and outlined on the 988 Lifeline website.
Conclusion
A peer support service should be integrated into the 988 Lifeline. A service that caters to all kinds of lived experience paves way for a more empowered and self-reliant community. It fosters a societal mindset of helping each other based on shared lived experience in an empathic and healthy way. Peer support empowers both the PSW and the service user. While the service user finds empathy and understanding, the PSW finds a renewed sense of purpose and confidence. In this way, peer support would alleviate loneliness and isolation that result from a variety of causes while instilling longer-term resilience into the community.
This action-ready policy memo is part of Day One 2025 — our effort to bring forward bold policy ideas, grounded in science and evidence, that can tackle the country’s biggest challenges and bring us closer to the prosperous, equitable and safe future that we all hope for whoever takes office in 2025 and beyond.
A service user refers to any individual who uses the peer support service for assistance.
Peer support work can be empowering and healing for those in recovery. However, as with any emotionally challenging work, PSWs benefit from ongoing support and supervision. Some interactions can be draining, especially if they hit too close to home. It is common for 988 Lifeline call centers to have a trained staff member, such as a psychologist or therapist, on call for such situations. A PSW could use this resource to debrief or process as needed. Additionally, during recruitment, PSW candidates should be screened to ensure they are comfortable speaking about their own lived experience and helping others who are going through the same experience.
Most PSWs would be compensated in the same way as their 988 Lifeline call and text specialist counterparts. They would be compensated with rigorous ongoing training, support, and resources for recovery and self-care in return for their time. They would also benefit from a social support system of fellow PSWs. Some individuals who may be ideal candidates for peer support work may struggle to find employment and health insurance. They will be less likely to volunteer if they do not have a living wage. To maximize the range of lived experiences available, certain individuals should be eligible for financial compensation.
A service user’s phone call or text should be routed to a 988 Lifeline peer support operator or telephone triage, where the service user is asked to say aloud (or type) what kind of support they are searching for (e.g., “I want to speak with someone who has been in prison.”) Then, the service user’s call (or text) would be routed to a PSW (under an alias) anywhere in the United States who 1) is currently on shift and 2) has a lived experience that is closest to the service user’s request. Each PSW would have associated keywords, such as “former incarceration,” “PTSD,” or “living alone,” which means that they are trained to connect with any service user about those lived experiences. The PSW would follow the service user’s lead in the conversation, and the PSW could share parts of their own lived experience when appropriate.
Text messaging can be more accessible than a phone line for youths and people with disabilities. The 988 Lifeline includes a text messaging option for this same reason.
It is true that both the regular 988 Lifeline and peer support service would provide resources and emotional support. By incorporating peer support into the 988 Lifeline, existing local and national peer support organizations would be eligible to partner with the 988 Lifeline and bolster its capacity to provide peer support. This endeavor will help with some staffing concerns. Furthermore, the peer support service would cover a diverse range of lived experiences extending beyond mental health. Therefore, more individuals may be motivated to join the 988 Lifeline staff to share their unique lived experience and help others who feel the same way.
Integrating a versatile peer support service into the 988 Lifeline transforms the latter into a service that every single American can use. (Every American has some unique lived experience.) The service’s versatility may help incentivize the remaining states to pass legislation to collect a 988 Lifeline fee through telephone and wireless service providers.
Finally, peer support is a cost-effective, preventative intervention. It should help remove the burden on other federal services, thereby reducing overall spending in time.
After implementing the action plan outlined in this memo, a subsequent memo should outline how to integrate peer support work into the community in person and on a large scale. Incorporating peer support into the 988 Lifeline would show its effectiveness to the public, policymakers, and healthcare professionals. This credibility would bolster endeavors to integrate peer support work into community settings throughout the country (e.g., behavioral health centers, hospitals and emergency rooms, and community clinics). These endeavors could also lead to professionalizing peer support, so PSWs can be reimbursed through Medicaid programs and health insurance.
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