Peer navigation intervention for individuals with serious mental illness reentering the community after jail incarceration: a qualitative case study

Abstract

Background

Criminal legal system-involved individuals with serious mental illness (SMI) experience more challenges accessing mental health and other community services than those without a history of criminal legal system involvement. A formative qualitative study was conducted to explore feasibility and acceptability and inform the adaptation of a mental health peer navigation intervention for individuals with SMI reentering the community after jail incarceration.

Methods

In-depth qualitative interviews and focus-group discussions were conducted with mental health peer navigators (i.e., certified mental health peer support specialists, peer recovery coaches) and individuals with lived experience of SMI and criminal legal system involvement (N = 20 total). Data were analyzed using applied thematic analysis.

Results

Four major themes emerged: (1) Feasibility and acceptability of peer-provided services: all participants reported that peer navigation services would be feasible and acceptable for individuals with SMI reentering the community after jail incarceration; (2) roles of peer navigators in addressing barriers to care: peers can address barriers to care experienced during community reentry and contribute towards service linkage/engagement; (3) shared identity and combating stigma: having a shared identity with peer navigators may minimize the impact of stigma and make it easier for clients with multiple marginalized identities to seek support; and (4) peer navigator skills and recommendations for the planned program: essential peer navigation skills include authenticity, reliability, active listening, advocacy, trauma-informed care, motivational interviewing, and empathy. Recommendations for the planned program include initiating services while clients are in custody, emphasizing the voluntary nature of peer support, knowing the limits of a peer navigation intervention, and offering support for peer navigators while on the job.

Conclusion

Participants saw peer navigation services for individuals with SMI with criminal legal system involvement as potentially feasible and acceptable. Such programs may enhance their impact by offering supportive supervision, emphasizing the voluntary nature of the service, and acknowledging recovery as a self-directed endeavor.

Key messages regarding feasibility

• Peer-provided services have gained popularity in the past few decades, but their feasibility for individuals with serious mental illness (SMI) in the criminal legal systems remains unclear.

• Individuals with history of criminal legal system involvement are typically prohibited from interacting with others with similar backgrounds; however, allowing them to interact could be useful for connecting individuals with SMI with services and resources in the community for successful reentry.

• Recommendations from this pilot study, including initiating services while clients are in custody, emphasizing the voluntary nature of peer support, and knowing the limits of peer navigation, will be used for the design and implementation of the planned peer navigation program.

Background

Individuals with serious mental illness (SMI) are overrepresented in the criminal legal system (which includes 911 calls, law enforcement contact, pretrial jail detention, courts, jail sentences, probation, and parole). Criminal legal system-involved individuals with SMI experience more challenges accessing mental health and other community services than those without a history of criminal legal system involvement [1]. Moreover, many individuals with SMI also navigate multiple systems of care because of the high prevalence of comorbid physical health and substance use disorders in this population [2, 3].

Reentry to the community after jail release is a vulnerable time for many individuals with SMI. This transition involves undertaking many activities before they are prepared to meaningfully engage in life in the community. During this period, individuals with SMI may need to initiate their Medicaid enrollment or reestablish their eligibility which was terminated during incarceration [4], identify a community mental health and medical provider, manage possible co-occurring addiction, and find housing, among other things [5]. Many individuals with SMI reentering the community after jail incarceration find it challenging to navigate these difficult administrative terrains. These tasks are made more difficult by often debilitating mental health symptoms, inability to afford services, inadequate discharge planning, perceived or experienced stigma of mental illness and criminal legal system involvement, and discriminatory social policies (e.g., policies that restrict access to housing/homeless shelters) [3].

In recent years, peer navigation services have gained prominence in mental health care, particularly interventions aimed at improving engagement with mental health and other services. Peer navigators, as defined in this study, are individuals with SMI and criminal legal system involvement, who have successfully overcome their challenges and are using their lived experiences and formal trainings [6], to support, encourage, and inspire others in similar situations [7]. There is strong evidence that navigation interventions provided by peer navigators have the potential to improve mental health, physical health, and substance use service-related outcomes among individuals with SMI [8, 9]. Peer navigation may also address barriers to service engagement in individuals with SMI who also have criminal legal system involvement. However, the evidence around their contributions in improving mental health and other outcomes among individuals who are involved in the criminal legal systems is still developing [10]. Potential barriers to use of peer navigators for individuals with SMI leaving jail may include traditional criminal legal policies that prohibit individuals with history of criminal legal involvement from being associated with others with criminal record [11]. Shortage of peer navigators may also cause potentially eligible individuals with SMI to wait until they are released to meet with their peer navigators [12, 13].

The current study was conducted as formative work for a pilot randomized trial [14] aimed at developing a peer navigation program for individuals with SMI reentering the community after jail incarceration. The current analysis reports on a qualitative study conducted to develop and tailor the Mentoring and Peer Support (MAPS) peer navigation intervention for individuals with SMI who have criminal legal system involvement. MAPS was designed to expand a peer navigation program which was previously developed for homeless African Americans with SMI [15]. Data collected for this qualitative study were aimed at tailoring and expanding an existing peer navigation program, specifically by including a criminal legal systems dimension. The focus-group discussions and individual in-depth interviews were conducted with mental health peer navigators (i.e., certified mental health peer support specialists, peer recovery coaches—who were trained to work with individuals with comorbid substance use disorder) and individuals with lived experience of SMI and criminal legal system involvement. The goal was to explore the potential feasibility and acceptability of the proposed intervention, ways peer navigators can reduce the barriers to care experienced by individuals with SMI with criminal legal system involvement, and intervention development/adaptation suggestions. Participating mental health peer navigators had relevant lived experience of SMI and/or criminal legal system involvement which provided insight from the perspectives of both a service user and a peer professional. This is a strength because perspectives of individuals with SMI and criminal legal system involvement are essential for understanding the needs and assets of prospective clients and peer navigators.

Methods

Study setting

The study team was located in Flint, Michigan. Two virtual focus-group discussions were conducted (with five participants in each group) with mental health peer navigators from Michigan who regularly work with individuals with mental illness reentering the community after jail incarceration. Four virtual in-depth interviews with peer navigators from Pennsylvania were also conducted. Six in-person in-depth interviews were conducted with individuals with SMI incarcerated at the Genesee County Jail in Flint, Michigan, where we have an ongoing research partnership.

Sampling and recruitment

Participants represented mental health peer navigators (i.e., certified mental health peer support specialists, peer recovery coaches) and individuals with lived experience of SMI and criminal legal system involvement. A combination of purposive and snowball sampling techniques was used to recruit peer navigators and individuals with SMI with criminal legal involvement.

Peer navigators (N = 14)

Inclusion criterion for peer navigators was having worked in a professional peer-based capacity for SMI or substance use disorders. We identified potential peer navigators who met our study eligibility criteria through our network of community partners. We contacted nearly all Community Mental Health Authorities in the state of Michigan, inviting them to forward our request to their peer-based programs. Once we identified the intial few, we asked each participant to recommend a potential participant for the study. All were either certified peer support specialists or peer recovery coaches. We conducted two focus-group discussions with five peer navigators in each group. One group included participants from Genesee County, and the second focus group involved participants recruited from the state of Michigan (out of Genesee County). We also contacted a peer-based program out of state (in Pennsylvania) to add external perspectives and learn about best practices and conducted four individual interviews with their peer navigators.

Individuals with SMI and criminal legal system involvement (N = 6)

Inclusion criteria for participants with SMI with criminal legal system involvement were the following: (1) being 18 years of age or older, (2) having a history of serious mental illness (i.e., bipolar disorder, psychotic disorder, or major depression with psychotic features), and (3) having lived experience with criminal legal systems (eg., incarceration, community supervision, mental health courts). We identified these individuals through the Genesee County Jail social worker via permission-to-contact forms to contact people while in jail. Our sample was gender and racially inclusive (see Table 1).

Table 1 Sociodemographic profile of participants

Informed consent was obtained from all participants verbally. Written signatures were waived to minimize contact due to the ongoing COVID19 pandemic.

Study design

To understand how a mental health peer navigation program works in a real-world context, we followed a qualitative case study design. Case study design was chosen because it facilitates a deeper understanding of a concept where there is limited preliminary work [16]. Results from this study were reported using the consolidated criteria for reporting qualitative research (COREQ) checklist [17].

Data collection

Data were collected from May 2020 to September 2021. Two experienced qualitative researchers (MH-female researcher—holds PhD in mental health epidemiology and BT-male researcher—with an MSW) conducted focus group discussions and in-depth interviews together. Open-ended topic guides were developed by the first author. Focus-group discussions with potential peer navigtors covered the most essential peer navigation skills, relevant lessons learned to date, services for individuals with SMI reentering the community after jail incarceration and how to initiate and maintain a culturally competent peer navigation service. We used the same topic guides for in-depth interviews with peer navigators from Pennsylvania. In-depth interviews with potential clients (individuals with SMI and criminal legal system involvement) explored (1) how peer navigators can best gain their trust, (2) their greatest needs in overcoming barriers to treatment engagement, (3) what they consider to be key for successful treatment engagement and how peer navigators could help with that, and (4) feedback on the proposed MAPS intervention. Both topic guides explored perceived feasibility, acceptability, and potential effectiveness of the planned peer navigation intervention. Data were collected by using a combination of in-person interviews (n = 6) and HIPAA-compliant Zoom-based approaches (two focus-group discussions and four individual in-depth interviews). Notes were taken by one of the interviwers during the interviews/focus-group discussions. Interviews and focus-group discussions lasted between 45 and 90 min. A digital or Zoom-based recording was used during data collection. Our sample size was determined by the principle of data saturation whereby no new concepts emerged during the interviews and the focus-group discussions.

Data analysis

Audio files were transcribed using verbatim and standard language capture (i.e., removal of filler words, false starts, repetitions, stutters). Each transcript was assigned a code. Personal identifiers (i.e., names, phone numbers) were removed. A document with the sociodemographic data linking participants to their data was stored separately. De-identified transcripts were imported to NVivo qualitative analysis software version 12 [18] for coding and analysis. The initial a priori coding structure was created based on the interview guide (deductive codes). Additional inductive codes were added to the coding structure based on recurring themes from interviews and review of transcripts. Analysis used applied thematic approach in which researchers identified and labeled patterns/codes within the data [19]. Two experienced qualitative researchers (M. H. and B. T.) conducted the qualitative coding using NVivo qualitative analysis software. All transcripts were double-coded. Where there were discrepancies in coding, the coders discussed and resolved the differences. Once coding was finalized, the researchers created summaries of each of the codes.

Results

Twenty individuals participated in the study. Eight of the 20 participants were women. Ages of participants ranged from 23 to 70 years. See Table 1 below.

Four major themes emerged:

• (1) Feasibility and acceptability of peer-provided services: All participants reported that peer navigation services would be feasible and acceptable for individuals with SMI reentering the community after jail incarceration.

• (2) Roles of peer navigators in addressing barriers to care: Peers can address barriers to care experienced during community reentry and contribute towards service linkage/engagement.

• (3) Shared identity and combating stigma: Having a shared identity with peer navigators may minimize the impact of stigma and make it easier for individuals with multiple marginalized identities to seek support.

• (4) Peer navigator skills and recommendations for the planned program: Essential peer navigation skills include advocacy, reliability, active listening, authenticity, trauma-informed care, motivational interviewing, and empathy. Recommendations for the new program include initiating the navigation service while clients are in custody, emphasizing the voluntary nature of peer support, knowing the limits of a peer navigation intervention, and offering support for peer navigators while on the job.

Feasibility and acceptability of peer-provided services

All participants said that mental health peer navigators can provide navigation support for other individuals with SMI who are reentering the community after jail incarceration. Participants agreed that peer navigators can identify a need and offer links to resources and services in the community. Peer professionals stated that a peer navigation program designed to engage clients after incarceration would be helpful because there is a lack of direction to resources that can facilitate community reentry. Beyond navigation and linkages to resources and services, potential clients also spoke highly of the critical value of the emotional support and unconditional acceptance.

Once again, someone to talk to. Everybody needs someone to talk to. Just someone to hear ’em out and listen to ’em and stuff means a big difference.

– Potential client interview- ID07

Peer navigator participants also shared potential barriers to the program based on their current experiences working with individuals in the criminal legal systems. Some of these challenges were related to laws that restrict individuals with criminal legal history from being around others currently in the system, including those on parole and probation. Another possible challenge was clients not engaging with a peer navigator after release even when the relationship was established while they are in custody:

I had people that I worked with that, of course, everybody’s got the “Oh, I’m done with this. I’m not doing it anymore. … and then, uh, give ’em my card, and they’re, “I’m gonna come see you as soon as I get out,”—and then-then they don’t show up. …they just disappear back into their life again. And then two or three months later, boom, they’re back again. That doesn’t mean it’s ineffective. What it does mean, it’s one more step that they’ve taken to say, yes, they wanna get help, but that one day when they do that again and then again, and then at that point—six, seven times later, whatever it is—yes, it becomes effective because it finally clicks, and it-it’s real.

– Peer navigator focus group 2-ID07

Participants also stated the importance of continued follow-up and patience from peer navigators when a potential client disengages. They specified that disengagement does not reflect on the overall program effectiveness, rather, it is part of the recovery process.

Roles of peer navigators in addressing barriers

Results suggested that peers can address barriers to care experienced during community reentry and contribute towards service linkage/engagement. All participants endorsed that reentry can be an overwhelming period for individuals with SMI as it requires transitioning back to the community while also working to identify mental health services and other providers in the community. However, they also expressed their enthusiasm about the potential of peer navigators to address some of the barriers experienced during community reentry. They emphasized the importance of prompt linkages to services in the community, specifically its great potential to prevent reentering individuals from resorting to old habits or service discontinuation. Moreover, participants in all groups (potential local peer navigators, out-of-state peer navigators, and potential clients) were enthusiastic about the contribution of a mental health peer navigator to minimizing the negative impacts of incarceration. They suggested that peer navigation services can address barriers to care by connecting them with services and resources in the community as stated below:

We’re the individuals with the resources. We know where to go here, where to go there. And the things that we don’t know, we know who to ask.

– Peer navigator focus group discussion- ID05

Participants mentioned that peer navigators’ knowledge of resources and services is critical for facilitating effective service engagement during reentry. This is important because another key barrier experienced by reentering individuals with SMI was lack of knowledge of services and resources in the community.

A big barrier for them, knowing where to go. It’s a very big barrier, you know? So we try to have that information for them. We don’t go for them. We don’t fill out the application. We may support them in doing things like that, but it’s their responsibility to go, our responsibility to find out where they need to go.

– Out of State Peer navigator- ID08

Peer professionals are often equipped with resources and connections that are beneficial to individuals reentering the community from jail.

Well, say you have a referral, and at that point, within 24 hours of receiving a referral—we will make contact with the client. Within 48 hours of receiving the referral, we will go out and see the client in person.

– Out of State Peer navigator- ID09

Peer navigators in our focus-group discussions and those we interviewed from out of state also expressed the importance of conducting assessments and coming up with a “game plan” to help them during the transition back to the community:

We basically do interview asking questions of how they feel and what they think they need and they lack in or what they’re strong in, and kinda come together with our own personal opinion of their statement to come up with a game plan of how we’re going to walk this out. You know, accomplish these goals, whether they be short term or long term.

– Out of state peer navigator-ID01

Another out-of-state peer navigator shared insights about the roles played by peer navigators as advocates and brokers connecting newly released individuals to community-based resources and services:

…It’s very hard to interact with other people ’cause you don’t know how to say the things that you need to say to get the services that you need. You know, some people—they don’t take other people very well, you know, especially if they got—they deal with trauma, or any type of, you know, like, mental illness …. Those things contribute to not being able to get the services because they don’t know how to even take a personal look at ’em. So, we as peers, help them, by calming them down and - try to say what you really feel, so we can distinguish what it is that you need.

– Out of state peer navigator- ID07

Potential peer navigator participants also indicated their role in ensuring easier transition back to the community, particularly the ways they can assist the reentering individual with paperwork and other practical needs:

If they just comin’ out of prison, we can get them on food stamps automatic, insurance automatic, you know—we can help them get their licenses back or find out what’s goin’ on with their license and tell ‘em what they need to do to get their licenses back… they have trainin’ classes…. like, for resumes and to learn how to resumes and just, I mean, pretty much anything that somebody, you know, wants to try to do, you know, we have programs for ‘em.

– Out of state peer navigator- ID10

Another participant also supported the above with the following:

Felonies are still, barriers for people to try to establish themselves back in the community—and don’t get me wrong. I think it’s very important that you have, you know, your recovery supports, whether it’s mental health, whether it’s co-occurring. But if I don’t have a place to live—one of the requirements of my parole is I gotta get a job and generate some income. I have no Social Security benefits. Not everybody’s on disability, or they’re waiting to see if they qualify. Those are some of the disparities in the community that are a struggle for people.

– Peer navigator focus group discussion- ID02

A potential client emphasized the importance of peer navigation by stating their potential to give reentering individuals a direction while seeking services:

Somebody that’s willin’ to help. Somebody that’s got my best interests, point me in the right direction.

– Potential client interview- ID03

All of the peer navigator participants endorsed that their services make a difference and are widely accepted by individuals and county-level agencies. They emphasized that their services have implications for long-term wellbeing of clients and their service use:

What we have found, and one of the reasons that [name] County is happy to fund us continuously is the service we provide keeps people out of hospitals, keeps people out of jail, keeps people generally focused on wellness and recovery.

– Out of state peer navigator-ID09

Shared identity, peerness, and combating stigma

Results suggested that having a shared identity with peer navigators may minimize the impact of internalized and experienced stigma and make it easier for clients with multiple marginalized identities to seek support. All categories of participants endorsed the importance of comfort and familiarity that is found in a shared identity. Some participants said that there is shame and guilt associated with mental health service use and incarceration, making it difficult for reentering individuals with SMI to reach out and seek support from people in their social circles. Navigation services provided by people with similar experiences offer a potential solution.

Matching identities of peer navigators and their clients was repeatedly mentioned by majority of the participants. This was said to benefit individuals with multiple marginalized identities. Specifically, they mentioned clients from minoritized backgrounds (i.e., Black, low income, LGBTQIA + , disabled) may find it easier to reach out to a peer navigator who shares their identity and lived experience. For example, an African American male participant discussed that having peer navigators of a shared demographic is important in initiating a dialogue to develop a comfortable and trusting relationship with clients.

Participants also added that peer navigators can communicate with clients from their own experience that bumps, relapses, and mistakes happen, and that they are not failures. Peers can encourage their clients by letting them see the possibility of new opportunities to try something different or to start again. They said that helping clients understand that staying well and striving for goals is a continuous task and should be a priority.

… Somebody has to carry the baton here…going in and bein’ a part of this ongoing promotion, education of, hey, I’ve been there. My story may look a little bit different, but there is hope and possibility. And, you know, I’d like to build a relationship with you, once you get out, that I could help you avoid some of the pitfalls and find some of the connections that are so valuable to be successful.

– Peer navigator focus group discussion- ID05

You know, nobody can tell ’em what to do. That’s not what we’re there for. We’re there to help them make better decisions and choices… but we can speak on experience, ’cause that’s the one thing that was— that’s a fact is our experience, you know, so. But we can’t tell them what to do, you know. All we can do is - if they fall, help ’em get back up. You know, if they fall short tell ’em it’s okay. You know- it’s okay. We all fall short. We are not perfect people.

– Out of state peer navigator- ID07

The emotional support found in peerness was also mentioned as a key factor in helping reentering individuals with SMI navigate difficult administrative and bureaucratic processes in the community. Participants in all categories acknowledged the challenge posed by having a history of criminal legal involvement, especially when they try to access services in the community.

… Understanding that you may have to go through four or five no’s because —of your past. It doesn’t mean you have to give up on your journey. It just means that sometimes—the road may be a little rougher for you because of your past. You know, you may have to push that extra mile. It’s important because, basically, most peers have already been through that, so while they’re speaking that, they’ve already lived that, so you can kinda see the proof right there…

– Out of state peer navigator-ID08

As indicated in the above excerpt, the fact that peer navigators are individuals who have walked those difficult paths and have successfully overcome these challenges can help other individuals draw strength and inspiration from their journey.

A potential client mentioned that a peer navigator’s knowledge of mental health challenges and recovery can help other people understand the challenges experienced by individuals with SMI.

A lot of people think mental health is just a joke. They don’t take it serious, so I think people need to really be more educated on the types of mental health conditions that are out here and to know that there’s help available.

– Potential client -ID03

Peer navigator skills and recommendations for the planned program

Participants described key skills a successful peer navigator must possess. Skills mentioned included advocacy, reliability, active listening, authenticity, trauma-informed care, motivational interviewing, and empathy/validating feelings. Among those, authenticity in sharing one’s own struggles and coping mechanisms was mentioned by majority of the participants.

Speaking about what skills are needed from a successful peer navigator, a potential client emphasized reliability as an important quality of a peer navigator.

Be reliable. You gotta just be reliable. Just followin’ through, just me followin’ through. I know that I got resources before, so it’s just the programs that’s just out there. If this program say they’re gonna be helpful, then you gotta stick to they word and trust in your gut feelin’ and then hope that everything fall in place.

– Potential client- ID08

Recommendations for the new program include initiating the navigation service while clients are still in custody, emphasizing the voluntary nature of peer support, knowing the limits of a peer navigation intervention, and offering support for peer navigators while on the job.

A key aspect of peer navigation as discussed in all the interviews and focus-group discussions was the need for creating linkages between peer navigators and potential clients before release from custody. The interviewed peer navigators indicated that connecting with and developing a relationship with individuals while incarcerated facilitates access to resources and support. This early engagement also creates a relationship that allows clients to reach out to their peer navigator once released as opposed to trying to gain a reliable audience and build a relationship with individuals after release. However, they also discussed that there are practical challenges to getting this relationship started while in jail:

So sometimes—the jails don’t want to let you come in and talk to ’em because they think— maybe they think that the person in jail’s gonna say, yeah, they wanna get help because that’s just free time. They don’t have to go do their other stuff, and so it becomes an excuse for them…a way for them to get out of their —responsibilities in the jail, but the reality of it is once the barrier’s down and then they see the effectiveness of it, they begin to look for us to come and ask us to come.

– Peer navigator focus group -ID07

To address the above challenge, they suggested that a panel of peer navigators offer a presentation about the importance of peer navigation and their role so the jail staff and clients can understand the service. Participants also expressed the need for periodic peer navigator gatherings to discuss needs, resources, strengths, and challenges they witnessed in their work. Participants said that meeting clients while incarcerated would allow pairs build trusting relationships. The importance of developing a trusting relationship between a peer navigator and a client was endorsed by all of the participants. Ability to connect with and nurture a trusting relationship with individuals while incarcerated was said to support familiarity which makes clients more likely to reach out to their peer navigator once released as opposed to trying to gain a reliable support and build a relationship with individuals after release.

Participants in the potential client in-depth interviews stressed the importance of being supported early on, having a listening ear, and being offered suggestions that would allow them to live a “normal” life upon reentry, underscoring the need for early initiation of the navigation service.

I just wanna find a job. I’m a licensed cosmetologist, too, so I just wanna find employment so I won’t have to live off SSI [supplemental security income] for the rest of my life. I just wanna be a part of the community and be normal. Even though I take meds, I still wanna feel normal, so I just need the peer support to listen to me, hear me out, give me their suggestions on helping me just be normal.

– Potential client -ID07

Another potential client participant also agreed that potential clients must drive their own recovery as peer navigators cannot lead someone’s recovery journey. He acknowledged the limits of what a peer navigator can do. However, the participant also suggested that peer navigators should have the ability/skills to help clients prioritize their needs and address challenges accordingly.

You don't have to be overwhelmed …. I'm not saying do something for the person 'cause everybody got to do stuff for themselves, but I'm just saying like, help him figure out things and stuff like that to where he doesn't have to sit there and think so hard about this problem when he has five other and six other problems that he has to think about that's also running around in his head at the same time. I would say a person—someone or a program to help with that to where he doesn't have to think about so much at once.

– Potential client-ID05

Despite the great support provided by peer navigators, some of the participants in the peer navigators’ focus-group discussions underlined the need for understanding the limits of the peer navigation relationship. Although they endorse their services can make a difference, they also admitted that some cases may require prompt referral to other providers as described below.

I was asked by a case manager to work with a person that was doin’ heroin, and I was talkin’ to the person—we were talkin’ about residential places to go, and finally he just threw his arms up in the air and says, “Why are we talkin’ about residentials and rehabs? I have a mental problem. I only do drugs to medicate because of my mental problem.” And I had to then say, “Okay, well, then maybe you need to go back to your case manager and discuss this. I had to defer him back, and I think that’s what we need to learn to do as I couldn’t save him beyond that point. I could only help him if he wanted it, so I had to defer him back to the case manager. And then three weeks later, I saw the case manager in the elevator, and I said, “How’s our friend doing?” and she said, “Oh, you didn’t hear? He overdosed on heroin.

– Peer navigator Focus group discussion- ID09

The fact that mental health recovery and access to services are mostly self-directed endeavors was also shared by another potential peer navigator.

You know, a person recognizes that they - need help. You know, because a person isn’t gonna get it till they want it anyway. They’re not gonna receive support until they’re ready to receive support.

-- Out of state peer navigator- ID07

There was a strong recommendation that peer navigation services should be open to those interested, and enrollement should be voluntary. Participants in the potential peer navigator focus group suggested that the voluntary nature of the service should be emphasized while introducing the new service.

I was just gonna say that it should always, always, always be a voluntary option. When people come across you and act like you have this peer support specialist assigned to you—like, it’s an assignment. This is what you get. You get what you get. You don’t throw a fit kinda thing. It’s not very attractive and—I don’t think that’s what we’re trying to do… when you force a person into somethin’, they do not put their all-in-all into it..

– Peer navigator focus group discussion- ID05

Surrounding peer navigators with support in their roles was one of the important topics mentioned by potential peer navigators. Ability to receive support while on the job was said to contribute to greater program success. The types of supports mentioned included allowing time and resources for self-care when tragedy happens to clients, creating opportunities for clients to connect with navigators, and allowing frequent access with to clients in institutional settings. These supports were said to reduce burnout among peer navigators.

Discussion

This qualitative study explored the feasibility and acceptability of mental health peer navigation for individuals with SMI with criminal legal system involvement. The study was conducted as part of a formative work for a randomized trial which aimed to develop a peer navigation program to improve service linkage for individuals with SMI who are reentering the community after jail incarceration [14]. Our findings from potential peer navigators and incarcerated individuals with SMI showed that peer-provided navigation services are likely to be feasible and acceptable. Moreover, findings from this study support that peer navigators can facilitate service linkage and reduce the impact of mental health stigma and incarceration.

Consistent with previous studies, our data demonstrated the promise of peer navigation in improving access to mental health and other community-based services for individuals with SMI [20, 21]. The idea of peer navigation is relatively new for this population (individuals with SMI and criminal legal system involvement). Nevertheless, as stated in other studies [22], our data suggests the strong potential of peer navigation in this population. Considering the high rates of comorbidities in this group, early initiation of navigation will encourage prompt service linkage and coordination of services as indicated in other studies [10]. However, our participants also stressed the self-directed nature of mental health recovery.

Participants recommended diverse areas where peer navigation services can make a difference for individuals with SMI who have criminal legal system involvement. Peer navigation services can make a difference in several areas of life, particularly during community reentry for individuals with SMI. These include housing, employment, tracking and renewing important identification documents, and identifying providers in the community. Our data also suggests peer navigators can play a key role by providing support for service initiation in the community and help people engage in care once providers are identified.

The power of shared experience was another recurrent theme in this study. For individuals navigating multiple stigmatized identities such as criminal legal involvement and having a history of SMI, shared experience (including having had contact with mental health and criminal legal systems) can serve as a powerful tool in mitigating the negative impact of the dual stigma they experience. Having had a shared experience also facilitates the creation of a trusting relationship among underserved populations. The closeness found in the peer navigation experience and the accessibility were said to foster trust [23, 24]. This was also consistent with what was reported in another qualitative study of ethnic minorities with SMI [25].

Participants also noted the importance of supportive supervision in peer navigation roles. Similarly, another study of peer navigation also reported the importance of providing formal and informal support, ensuring role clarity and promptly addressing challenges [26]. Supportive supervision provided by non-peer providers such as nurses was reported to help peer navigators work effectively in a system that is not in alignment with peer values [27, 28].

Nevertheless, one of the key concerns raised as a barrier to peer relationship in our study and also in other literature was the issue of some policies [10]. Our participants were concerned about policies that restricted individuals with history of criminal legal systems involvement from interacting with others with similar backgrounds. To address this, for the proposed study, our team obtained support from the local jail to allow peer navigators with criminal legal systems involvement to meet with their clients inside the jail. The jail agreed to this on the basis that they will run an independent background check to rule out history of violent crime (for example, murder, sex offense).

Our findings suggest that peer navigators can help individuals with SMI successfully navigate often fragmented and complicated health care systems [29]. However, participants also spoke about limits of peer navigation relationship. Peer navigators can serve as part of a team consisting of clinicians, families, and other professionals [30]. As suggested in our study, providing the right support to peer navigators while they are on the job can enhance the impact of their service and reduce the risk of burnout.

Being released from the jail is often a vulnerable time for many individuals with SMI due to pervasive unmet needs. Unlike the traditional peer navigation services which commence upon community reentry, our participants endorsed that peer navigation should be initiated while participants are still in custody. This practice was suggested to enable smooth transition back to the community and anticipate and address potential barriers to service linkage. Their role in ensuring early engagement with services is well-documented [31].

There were some limitations to this study. Our sample size was relatively small, due in part to the COVID pandemic at the time of data collection. We employed Zoom-based data collection, which limited the number of peer navigators we could enroll in the focus-group discussions. Zoom-based conferencing technology was new to some of the participants to navigate. Some had trouble joining a Zoom meeting, although we offered remote assistance.

Conclusion

Participants saw peer navigation services for individuals with SMI with criminal legal system involvement as feasible and acceptable. Programs utilizing mental health peer navigators may enhance their impact by offering supportive supervision, emphasizing the voluntary nature of the service, and acknowledging recovery as a self-directed endeavor.