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The Fusion Model and Measuring Peer Inclusion in Behavioral Health Organizations

Peer Powered Scale Organizational Self-Assessment

When Dr. Charles T. Browning and Lisa St. George started developing The Fusion Model in 2019, they set out to combine seemingly resistant approaches by “fusing” best practices from the biomedical and recovery models. (St. George is Vice President of Peer Support and Empowerment at RI International, and Dr. Browning is the company’s Chief Medical Officer.) The Fusion Model aligns with SAMHSA’s National Guidelines for Behavioral Health Crisis Care, which lays out the essential components for a crisis system to function appropriately—regional or statewide crisis call centers that coordinate in real-time, centrally deployed 24/7 mobile crisis, and 23-hour crisis receiving and stabilization programs. The guidelines also integrate critical crisis care principles and practices such as not requiring medical clearance from an emergency medical facility before admission and “no wrong door,” an approach where facilities accept everyone who comes.

“No wrong door is essential to all layers of the crisis system,” says Dr. Browning. “Whether we’re talking about 988 call centers, mobile crisis support services, or crisis stabilization facilities, people need access to care.” 

In addition to the essential structural elements, the guidelines highlight that the following qualities must be “baked into” the crisis care system: 1. Trauma-informed care, significant use of peers, and addressing a person’s recovery needs, 2. Suicide Safer Care practices, 3. Safety and security for staff and people in crisis, and 4. Collaboration and partnership between the behavioral health and 911 crisis systems and first responders, such as law enforcement and emergency medical services. 

Dr. Browning notes that SAMHSA’s guidelines have garnered much attention from legislators and state leaders. However, while there’s been a widespread emphasis on the essential structural elements of a crisis system, the corresponding, equally vital, crisis care principles and practices have gotten less attention. In part, this might be because the latter’s benefits are sometimes perceived as seemingly intangible when, in fact, they’re evidence-based. That includes trauma-informed care and peer support services. For example, trauma-informed care can increase engagement, decrease the demand for hospitalization, and positively affect housing stability, one of the biggest hurdles for a person to attain mental health treatment. It also improves relationships between people and their providers and increases confidence and satisfaction among both staff and the people they serve. 

Researchers have found that people who engage in peer support programs have improved social functioning, quality of life, and recovery and experience fewer crisis events and hospitalization. In addition, peers themselves also benefit from the service—they have increased recovery-oriented gains and learn essential recovery skills, making them more confident and hopeful, and they experience a reduction in hospitalization.

However, as Jess Stohlmann-Rainey told #CrisisTalk last year, while there’s a growing understanding that peer support services are vital, there’s also a fundamental, nationwide misunderstanding of what peers do and the function they serve. She’s the director of program development at Rocky Mountain Crisis Partners in Colorado. As evidence rises on the efficacy of peer support, she pointed out that it’s increasingly showing up in legislation and funding but with nominal guidance or direction on implementation. “That’s because everyone seems to know peer support is good,” she said, “but they haven’t spent the time to learn what peer support is.”

Dr. Browning says many behavioral health organizations are scrambling to implement 988. While they might understand the need to incorporate peers better, they may not know where to begin. An effective diagnostic tool could help organizations determine how well they include peers. (Telecom companies had to begin directing the three-digit number for mental health, substance use, and suicide crises to the National Suicide Prevention Lifeline by July 16.)

RI International, a nonprofit, has long incorporated peers in their programming, but St. George and Dr. Browning wanted to find a way to see just how “peer-powered” they, in fact, were. He says the concept “peer-powered” goes far beyond peer support; it’s when services are person-centered, hopeful, and include peer support and lived experience as essential crisis care components. The aim is to create an environment that fuses biomedical and recovery model best practices and has the greatest potential for person-centered outcomes. However, joining the two is no easy feat: it means applying this philosophy to everyone who walks through the door—even those who come unwillingly. 

“Crisis facilities should have a ‘no wrong door’ approach and thereby be accessible,” says Dr. Browning. “But these facilities also need to be places where you or your loved one will feel cared for and get the level of services needed.”

Despite increasing awareness that communities should divert mental health, substance use, and quality of life crises from the criminal legal system, many don’t have well-connected crisis systems, making it difficult for 911 or first responders to do a warm handoff to behavioral health services. Additionally, crisis facilities often “cherry-pick,” deciding what patients they’ll accept and which are “too difficult.” Without that connectivity and a “no wrong door” approach—where facilities take everyone who comes—law enforcement has nowhere to take someone experiencing a behavioral health crisis but the emergency room or jail. 

Nearly three years ago, retired Phoenix police officer Nick Margiotta told #CrisisTalk that crisis services must have a no-refusal, “no wrong door” drop-off policy for people in need. He shared that when he was newly trained in CIT and eager to do his first drop-off, he was sent away by every facility. The person in crisis had dialed 911, sharing that she was depressed, had been drinking, and threatened to take 100 Advils. Margiotta took her to a crisis stabilization facility when staff told him they couldn’t accept her because she’d been drinking. Then, the detox facility rejected her because she was suicidal.

Shifting to a no-refusal policy, says Dr. Browning, means crisis stabilization facilities might quickly find themselves treating a large number of people who don’t want to be there. In fact, of people at the observation unit at the non-profit’s Recovery Response Center in Peoria, Arizona, 82% arrive in the back of a police car, and 60% are there involuntarily. “It takes thoughtful intention for an organization to create a culture and practice where people who don’t want to be there feel cared for,” he says. The analogy Dr. Browning uses is atomic fusion, which joins two or more lighter atoms into a larger one. The process is difficult to sustain because it requires tremendous heat and pressure. “Just like atomic fusion, it can be immensely challenging to have a crisis system that says yes all the time and provides care in a welcoming, warm, and caring way.”

As he and St. George endeavored to determine the ethos alignment at RI, they realized they needed an organizational tool to do so. So together, along with feedback from the Diversity, Equity, and Inclusion Leadership Council and Peer Leadership Council, they developed the “Peer Powered Scale Organizational Self-Assessment.” The survey takes roughly 60 minutes to complete and can be done every six months or annually. Dr. Browning says the assessment allowed the company to self-evaluate and discuss quality improvement. “It also highlights what’s missing,” he says. When St. George and Dr. Browning began developing the tool, they quickly discovered programming inconsistencies. For example, one of the sites didn’t adhere to the company’s “peer-first, peer-last” approach, ensuring that a peer bookends a person’s experience at the facility. “The assessment tool,” he notes, “helped us standardize our practices at all of our sites.”

The peer-powered assessment tool is still in the pilot phase. However, Dr. Browning hopes to soon make it publicly accessible. The objective isn’t just to get a score but to use the assessment to foster dialogue, identify gaps, and develop action items. As he and St. George experienced, organizations doing the survey might find glaring but easy-to-fix inconsistencies. “They can then do an immediate reassessment,” he says, “instead of waiting six months.”

Instead of peer tokenism, the peer-powered survey examines whether peers are fully woven into an organization and its culture and if they’re in leadership positions. “We know that multidisciplinary teams, at every level of an organization, are essential for bridging the gap between recovery and biomedical models,” says Dr. Browning. Additionally, people with lived experience have navigated the crisis system and are best suited to identify organizational policies and practice pitfalls that contradict an agency or company’s own ethos, such as peer employment barriers and seclusion and restraint policies. 

St. George, who co-designed the assessment, has been instrumental in developing initiatives to abolish seclusion and restraint at the Recovery Response Center. She herself experienced seclusion and restraint by four men in a psychiatric hospital in the 1980s. “I didn’t have the strength to resist, verbally or physically,” she told #CrisisTalk in 2020. “There was no attempt at conversation. Their aim was only to control and punish.” She has made it one of her life goals to ensure no one experiences what she did in the name of care. 

Including peers, said St. George, helps dissolve the all too frequent “us vs. them” mindset among crisis facility staff, a dichotomy that contributes to the otherization of patients, making it easier to seclude and restrain them. “No matter when we use restraint,” she said, “it’s always a trauma and a treatment failure.”

The organizational assessment survey hits on what Dr. Browning calls the five peer-powered tenets: collaboration (“to do with, not to”); trauma-informed care; no force first; whole-person wellness; and strength-focused. “Even in a crisis, services should focus on a person’s strengths,” he says. “Unfortunately, my medical school experience was focused on understanding a diagnosis and figuring out what was wrong, but it’s critical to help people feel empowered and use their strengths during a crisis.” The assessment also presses an organization to examine how it values peers, not just in terms of wages and recognition, but also whether they’re part of program planning and development. 

While the peer-powered assessment tool is still in the pilot phase, Dr. Browning says it’s already been a vital vehicle to propel company-wide fusion initiatives at RI. With 988 now “live,” he points out it’s dire that organizations regularly assess how well they’re including and valuing their peer workforce. That said, Dr. Browning acknowledges that culture change is hard, making people and organizations hesitant to self-examine. “It’s like starting therapy,” he says. “It’s terrifying to make yourself vulnerable and self-evaluate, but sometimes the first step is the willingness to say, ‘This matters.’”