Reimagining Behavioral Crisis Systems Through Peer-Led Workforce Development

Abstract

This three-paper dissertation examines how peer support specialists have been conceptualized, codified, and reimagined as a workforce across behavioral health crisis services in the United States (U.S.). The dissertation is grounded in four interrelated theoretical traditions. Sanism (Perlin, 1992; LeFrançois et al., 2013) provides a critical framework for understanding the structural devaluation of knowledge produced from lived experience, while Voronka's (2016) theory of peer identity explains how that devaluation operates through institutional incorporation. Standpoint theory (Collins, 1990; Harding, 1986; Hartsock, 1983) grounds the dissertation's centering of critical peer support experts as authoritative analysts of behavioral crisis systems. Critical peer support, developed in Chapter Four, names the practice tradition oriented by Mad Studies and DisCrit that sustains peer work outside or against institutional terms (Annamma et al., 2013; Dwornik, 2022; Hosking, 2008; Jones, 2024). Across three vantage points that are rarely studied together, the dissertation examines peer workforce development through peer-reviewed empirical research, state-level statutory implementation of 988, and the perspectives of experts in critical peer support engaged in sustaining and reimagining the practice. Chapter One introduces the structural conditions of behavioral crisis response, the U.S. federal policy environment shaped by passage of the National Suicide Hotline Designation Act of 2020, the theoretical traditions that ground the studies that follow, and my own position in relation to this work. Chapter Two presents a scoping review conducted in accordance with Joanna Briggs Institute methodology that identifies and synthesizes 24 unique studies (25 records) examining peer support specialists in behavioral health crisis services in the U.S.. The review documents how the institutional incorporation of peer support has displaced the structural conditions of peer work, produced scaling dynamics that erode peer values, and shaped differential access to peer-staffed crisis services for marginalized populations. Chapter Three reports findings from a descriptive policy review of state-level 988 legislation enacted between July 2020 and February 2024, analyzing peer workforce provisions across the 15 states that included peer-specific statutory language. Chapter Four reports findings from a Ripple Effects Mapping study with eight experts in critical peer support, a participatory qualitative method through which participants collectively mapped the values, ethics, and structural conditions of peer-led crisis practice. The study identifies five themes organized around the structural relationship between distance from formal behavioral health systems and the integrity of the practice tradition critical peer support specialists describe. Chapter Five synthesizes findings across the three studies and develops implications for social work practice, policy, and research.