Theory

Summary:

A key result from meta analysis is that although many factors are believed to increase the risk of developing a mental health condition, but focusing on treatment those factors is not the most efficient way to reduce the prevalence of mental health conditions. [citation required]

Instead, building protective factors across a community, resulting in a widespread sense of belonging seems to be extremely effective in reducing the risk of mental health conditions.

Individuals who feel a sense of belonging in their community have the sklls and environment they need to become more involved and to actively seek the help they need.

To make that happen in a community (a school environment, for example), the school community must develop group cohesion.  Group cohesion is created from strong, healthy connections between student peers and between students and trusted adult guides throughout the community.

To engage with one another optimally, a community must discover the strengths of individuals and groups.  Discovery must be practiced and developed as a skill.  Active learning and heavily peer-influenced activities and initiatives have been show to be effective as part of a methodology to kick-start discovery and ultimately lead to deep conversations, which are the most powerful method of learning and bonding in social networks.

When a whole school community is cohesive, and has strong, healthy connections throughout, it’s members become more activated, more engaged, and more energized.  The time spent building healthy connections is repaid manyfold by a reduction in suicide, pruning and disciplinary incidents, by an increase in attendance and performance, and by an emotionally recharged community that spends the bulk of their time working preventatively, instead of performing interventions after disruptive and damaging incidents.

The makeup of a healthy school environment is unique to every school.  A healthy school environment cannot be duplicated by simply following a written manual or video series and/or taking a one-time training - rather, such an environment is built by developing ecologically valid skills and practices that are unique to each community.  These skills and practices become cultural norms that are developed across years of consistency of practice.

14 Points

Characteristics/system beliefs:

Prevention: 

Effective and efficient Prevention builds individual and community protective factors and social norms.  Network health approaches that address these processes, such as maximizing youth-adult connections schoolwide and heightening influence of youth with coping, create more protective schools.  

NIMH - Upstream prevention is necessary.

Existing suicide intervention programming focuses on detecting and remediating risk after suicidal individuals are identified.  Although undoubtedly saving lives, this approach is insufficient on its own.

Wingman-Connect addresses an urgent need for preventions that are effective in reducing suicide risk across broad populations – particularly where stigma and concerns about negative career impacts remain major barriers to disclosing suicidal thoughts/behaviors.

Journal of Child Psychology and Psychiatry *: * (2019),

To date, suicide prevention has focused primarily on individual-level psychiatric risk factors and on strategies to refer and treat high-risk youth. Yet researchers and policymakers recommend strengthening positive social bonds because social integration can reduce suicidal behavior in youth

To our knowledge, this is the first study of any adolescent health problem, including suicidal behavior, that integrates adult connections into friendship networks at a school population level.

Network interventions addressing these processes, such as maximizing youth–adult connections schoolwide and heightening influence of youth with healthy coping, could create more protective schools. The present study is the first empirical evidence linking more integrated youth–adult networks (i.e., students sharing trusted adults with friends) to lower Suicide Attempts.

JAMA Open Network, October, 2020

Group training that builds cohesive, healthy military units is promising for upstream suicide prevention.

The Wingman-Connect program used group skill building for cohesion, shared purpose, and managing career and personal stressors.  Wingman-Connect is the first universal prevention program to reduce suicidal ideation and depression symptoms in a general Air Force population. Group training that builds cohesive, healthy military units is promising for upstream suicide prevention.

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

The current attention on the detection and treatment of suicidal military members is necessary, but ultimately insufficient to meet the needs of many suicidal service members. Results from our study suggest that the status quo progression for many service members at elevated suicide risk is one of worsening disconnection, evidenced by the trajectory of declining valued connections found in the active control condition.

Ecological Validity:

Approaches that are designed and built by and with the community (authenticity, organic, grassroots, culturally relevant) have higher transfers of beliefs and skills to daily life.  

NIMH

Data-informed implementation preparation.

A “voltage drop” and poor sustainment are common as interventions transition from controlled efficacy trials to regular use. Conversely, scaled out interventions are more impactful with careful preparation using implementation science frameworks.

JAMA Open Network, October, 2020

group training design ecologically valid and appealing for participants. Wingman-Connect development benefited from strong organizational collaboration, resulting in an ecologically valid program.

Evidence-based Methodology: A commitment to follow the evidence of impact. Networks of Support’s structure and key elements strengthen relationship networks, cohesion, adaptive coping, and group norms. Group-based, interactive training uses research-informed strategies.

JAMA Open Network, October, 2020

Research Outcomes – Evidence Based Key Findings include:

• Increased class cohesion, morale, positive bonds, and acceptability of help seeking
• Reduction in suicide risks scores, depression, and reactivity to anger
• Nearly 50% reduction in occupational impairment (corrective training, negative counseling)

Measurable Impact on both Protective Factors and Risk Factors

Wingman-Connect was tested using the gold-standard research design with Airmen in Training from 2017-2019 (randomized controlled trial).  Training showed statistically significant increases in group and individual level protective factors, as well as reductions in negative outcomes including and depression and suicide risk.  

Class exercises create more cohesive units with skills extended into group culture.  Wingman Connect training is delivered to organizational units using interactive exercises to build key group and individual protective factors.

Wingman-Connect impact promoting more cohesive, healthy training classes was a mechanism that reduced risk for suicidal thoughts and behaviors. More cohesive, healthy classes ‘lifted up’ individuals who were vulnerable to fitness and mental health problems. Study findings suggest that group training for organizational units may be critical for ‘transfer’ of training concepts and skills into the organization’s culture.

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

The current attention on the detection and treatment of suicidal military members is necessary, but ultimately insufficient to meet the needs of many suicidal service members. Results from our study suggest that the status quo progression for many service members at elevated suicide risk is one of worsening disconnection, evidenced by the trajectory of declining valued connections found in the active control condition.

Program achieved the objective of strengthening the network structure of unit relationships over time, including socially integrating those currently at elevated risk for suicide. This is an especially important hypothesis since W-CP training has no content encouraging Airmen to form connections with at-risk peers.

NIMH

Effective upstream suicide prevention programs that can be implemented in real-world settings are urgently needed to address the significant and growing problem of suicides.

No RCT-validated universal programs shown to reduce vulnerability to suicide are in wide use. To fill this gap, we developed the Wingman-Connect Program–group-based prevention approach that strengthens protective relationship networks and skills for managing challenge.   This strategy of reducing suicide risk could be highly impactful as a complement to the predominant approach of trying to mitigate risk only after suicidal individuals are identified.

Wyman has led research (NIH, CDC funded) testing that program, which disseminates skills for social health through youth peer networks.  The high-energy, interactive training improves student connectedness and coping norms, and protective effects spread school-wide including adult help for suicidal youth.  A study aggregating three RCTs (N=78 schools; 39,900 students) showed fewer suicide deaths in schools implementing this approach.  

Consistency: 

This approach requires long-term commitment to intentional cultural integration and reevaluation of programming.  

A “voltage drop” and poor sustainment are common as interventions transition to regular use.  Conversely, multiple exposures are more impactful with careful preparation.  

Submitted to the National Institute of Mental Health, PAR21-130, 10/13/2022

Data-informed implementation preparation.

A “voltage drop” and poor sustainment are common as interventions transition from controlled efficacy trials to regular use. Conversely, scaled out interventions are more impactful with careful preparation using implementation science frameworks.

JAMA Open Network, October, 2020

Wingman-Connect’s group training design ecologically valid and appealing for participants. Wingman-Connect development benefited from strong organizational collaboration, resulting in an ecologically valid program.

Discovery: 

Discovery of personal strengths and how those strengths impact our social network, and the discovery of other’s strengths and how those strengths impact us and the social network.   Everyone’s competencies are recognized.

Dr. Peter Wyman’s interview 2022

Whole Community: 

Everyone is invited and contributes to the overall health of the social network.  

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

Findings support a growing case for the unique contribution of group-level interventions to improve social health of broader populations. The Wingman-Connect Program trains all members of natural organizational units together to strengthen group bonds and the diffusion of suicide-protective norms and practices. Skill-building activities focus on relationships and practices supportive of mental health.

Group skill-building activities identify strengths of all group members, and members learn how a strong network supports all members’ health and fitness. W-CP uses high energy activities and peer-to-peer teaching; exercises inside and outside of training promote adoption of skills into unit culture.

NIMH

Program structure and key elements together strengthen relationship networks, cohesion, adaptive coping and group norms using group-based, interactive training based on research-informed strategies.

Foundational Action Steps:

Peer Influence: 

Social networks provide the mechanisms for the diffusion of norms and practices and the context for peer group monitoring and support.  Positive social bonds augment the protective factors while learning and modeling skills for growing relationships and developing connections to each other.  These connections reduce ‘Pruning’.  

NIMH

WINGMAN-CONNECT PROGRAM MODEL AND DEVELOPMENT

Wingman-Connect is an adaptation of a network-informed intervention. Since 2010, PI Wyman has led research (NIH, CDC funded) testing that program, which disseminates skills for social health through youth peer networks.  The high-energy, interactive training improves student connectedness and coping norms, and protective effects spread school-wide including adult help for suicidal youth.  A study aggregating three RCTs (N=78 schools; 39,900 students) showed fewer suicide deaths in schools implementing this approach.  

Wingman-Connect Program structure and key elements together strengthen relationship networks, cohesion, adaptive coping and group norms.

Program’s novel group intervention strengthens social bonds as well as peer network norms that incentivize healthy coping. This interactive training progresses from individual engagement (e.g., each participant shares career goals and values) to building group level skills and norms (e.g., mapping group strengths).

JAMA Open Network, October, 2020

Airmen learn skills to grow and sustain protective factors essential to job success, mental health and reduced suicide risk (Kinship, Purpose, Guidance, Balance). Class exercises create more cohesive units with skills extended into group culture.  Wingman Connect training is delivered to organizational units using interactive exercises to build key group and individual protective factors (Four Cores):

The study’s findings validate the underlying network health model: stronger bonds within a more cohesive healthy class reduced suicidal ideation and depression symptoms. These findings suggest that training classes became increasingly unified around healthy norms and encouraged classmates who were vulnerable to mental health or occupational problems at a key juncture of military training, in addition to meeting their needs for belonging. Work with recent social network modeling show that cohesive groups serve a protective regulatory function through norms and pressures to conform.

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

Wingman-Connect counteracted the typical drift towards disconnection for Airmen at elevated suicide risk. Six-month findings again showed that W-CP offset the typical trajectory of decreasing connections for Airmen at elevated suicide risk.

These findings are, to our knowledge, the first to show that a suicide prevention program for small personnel units improved significantly the group relationship network and socially integrated members over time. This study extends knowledge of the social and relationship impact of the Wingman-Connect Program as it decreased suicide risk.

Wingman-Connect Program counteracted the expected drift towards disconnection for Airmen at elevated suicide risk by targeting the unit’s relationship network itself. These groups built enhanced suicide protection into their relationship networks, with the most consistent benefits for Airmen at elevated risk of suicide and for those starting with fewest connections.

Program built enhanced suicide protection into unit relationship networks and counteracted standard drift towards disconnection for at-risk Airmen, despite no explicit content targeting connections specifically to at-risk Airmen. Findings support a growing case for the unique contribution of group-level interventions to improve social health of broader populations.

Mentoring: 

By focusing on patterns of relationships, network methods can clarify the contexts in which relationships form and exert influence on others.  Maximizing these protective bonds across school populations, increasing opportunities for group cohesion including integrated youth– adult networks, and promoting influence of youth with healthy coping skills is critical.  

JAMA Open Network, October, 2020

Airmen learn skills to grow and sustain protective factors essential to job success, mental health and reduced suicide risk (Kinship, Purpose, Guidance, Balance). Class exercises create more cohesive units with skills extended into group culture.  Wingman Connect training is delivered to organizational units using interactive exercises to build key group and individual protective factors (Four Cores):

• Group cohesion and belonging (Kinship)
• Informal and formal support and help-seeking (Guidance)

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

Specific modules and activities build healthy relationships and accountability (Kinship) informal and formal help-seeking (Guidance).

An Outcome Evaluation of Suicide Prevention Program Delivered by Adolescent Peer Leaders in High Schools   Am J Public Health. 2010 September; 100(9): 1653–1661

The norms most strongly enhanced through the intervention were students' perceptions that adults in their school can provide help to suicidal students and the acceptability of seeking help from adults.

Active Learning:

High-energy activities maintain interest, motivation, and create shared positive emotional experiences and create norms that incentivize adaptive coping skills.  Space is created to practice skills that grow healthy bonds and draw upon resources in social environments to meet goals, manage career and personal challenges, and prevent behavioral health problems.

JAMA Open Network, October, 2020

Active Learning and Transfer of Training to Life

• Drawing out ‘real-world’ strengths from participants as a primary method to teach Kinship, Purpose, Guidance, & Balance.
• High energy activities maintain interest, motivation, and a shared positive emotion.
• ‘Real-world’ exercises inside and outside of training reinforce the application of skills in groups and in individual activities of daily life.

Deep Conversations:

Personally meaningful - participants are invited to share personally relevant goals and values referenced throughout. Drawing upon ‘real life’ strengths and conversations as the primary way to teach.  Provides space for culturally relevant customs, celebrations, and traditions.  

JAMA Open Network, October, 2020

Wingman-Connect impact promoting more cohesive, healthy training classes was a mechanism that reduced risk for suicidal thoughts and behaviors. More cohesive, healthy classes ‘lifted up’ individuals who were vulnerable to fitness and mental health problems. Study findings suggest that group training for organizational units may be critical for ‘transfer’ of training concepts and skills into the organization’s culture.

Outcomes:

Group Cohesion:

Through collaborative activities, participants develop skills for managing personal challenges and create shared healthy norms.

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

In more connected, healthier units, vulnerable members can borrow strength from adaptive members. Stronger units also promote job fitness, as shown by W-CP’s impact reducing occupational problems, an effect that may reduce future problems that precipitate new instances of suicidal thoughts and behaviors. In that sense, W-CP may specifically assist vulnerable Airmen in overcoming barriers to forming meaningful social connections.

Wingman-Connect Program’s interactive training created more dynamic relationship networks. Airmen in W-CP groups made more changes in who they named as valued connections, even as the overall average number of valued connections increased. The largest dynamic changes were for Airmen with elevated suicide risk in W-CP groups, who made on average three times more new valued connection nominations.

Group skill-building activities identify strengths of all group members, and members learn how a strong network supports all members’ health and fitness. W-CP uses high energy activities and peer-to-peer teaching; exercises inside and outside of training promote adoption of skills into unit culture.

JAMA Open Network, October, 2020

Research Outcomes – Evidence Based Key Findings include:

• Increased class cohesion, morale, positive bonds, and acceptability of help seeking

Wingman Connect strengthens skills to grow and sustain healthy social bonds.  Natural organization (tech school classes) units train together to incorporate skills into culture, build cohesion and shared purpose.  The objective is preventing occupational and behavioral health problems.

Positive Impact on Training Classes Together & Developing Positive Connections.  Wingman-Connect training increased class cohesion, morale, & positive bonds.  Participants gain an understanding of group norms and how everyone influences the social network.

Wingman-Connect trained natural organization units (technical school classes) and combined individual and group skills. Participants learned skills to grow healthy bonds and draw resources in their social environment to manage career and personal challenges and meet goals. Group skills focused on building cohesion and a unit culture organized around healthy norms including shared mission and mutual support.

The study’s findings validate the underlying network health model: stronger bonds within a more cohesive healthy class reduced suicidal ideation and depression symptoms. These findings suggest that Wingman-Connect classes became increasingly unified around healthy norms and encouraged classmates who were vulnerable to mental health or occupational problems at a key juncture of military training, in addition to meeting their needs for belonging. Work with recent social network modeling show that cohesive groups serve a protective regulatory function through norms and pressures to conform.

NIMH

Novel Intervention Targeting Peer Social Networks of Military Members

The Wingman-Connect Program’s novel group intervention strengthens social bonds as well as peer network norms that incentivize healthy coping. This interactive training progresses from individual engagement (e.g., each participant shares career goals and values) to building group level skills and norms (e.g., mapping group strengths).

Program structure and key elements together strengthen relationship networks, cohesion, adaptive coping and group norms using group-based, interactive training based on research-informed strategies.

Connection to Guidance:

Informal and formal help-seeking. Cohesive youth–adult networks may promote more help-seeking for students and for their friends with whom they share a common bond to a supportive adult.

Journal of Child Psychology and Psychiatry *: * (2019), Peter A. Wyman, Trevor A. Pickering, Anthony R. Pisani, et al.

Social networks provide the mechanisms for the diffusion of norms and practices and the context for peer group monitoring and support. Network characteristics influence the spread of many health behaviors.  By focusing on patterns of relationships, network methods can clarify the contexts in which relationships form and exert influence on others.

Cohesive youth–adult networks may promote more help-seeking for students and for their friends with whom they share a common bond to a supportive adult.

Maximizing protective bonds across school populations, increasing opportunities for group cohesion including integrated youth– adult networks, and promoting influence of youth with healthy coping.  Our findings suggest effective interventions will involve youth and adults.

NIMH

Wyman has led research (NIH, CDC funded) testing this approach, which disseminates skills for social health through youth peer networks.  The high-energy, interactive training improves student connectedness and coping norms, and protective effects spread school-wide including adult help for suicidal youth.  A study aggregating three RCTs (N=78 schools; 39,900 students) showed fewer suicide deaths in schools implementing this approach.  

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

Wingman-Connect Program’s interactive training created more dynamic relationship networks. Airmen in W-CP groups made more changes in who they named as valued connections, even as the overall average number of valued connections increased.

Goals:

Belonging:

Positive social bonds augment the protective effects of inclusion and support and build trust. All participants experience the positive and appropriate engagement of others.  Everyone is invited to participate.  

JAMA Open Network, October, 2020

Group training that builds cohesive, healthy military units is promising for upstream suicide prevention.

The study’s findings validate the underlying network health model: stronger bonds within a more cohesive healthy class reduced suicidal ideation and depression symptoms.  These findings suggest that Wingman-Connect classes became increasingly unified around healthy norms and encouraged classmates who were vulnerable to mental health or occupational problems at a key juncture of military training, in addition to meeting their needs for belonging.

Help Seeking:

The norms most strongly enhanced are students' perceptions that adults in their school can provide help and the acceptability of seeking help from adults.

JAMA Open Network, October, 2020

Research Outcomes – Evidence Based Key Findings include:

• Increased class cohesion, morale, positive bonds, and acceptability of help seeking.

NIMH

Wyman has led research (NIH, CDC funded) testing this approach, which disseminates skills for social health through youth peer networks.  The high-energy, interactive training improves student connectedness and coping norms, and protective effects spread school-wide including adult help for suicidal youth.  A study aggregating three RCTs (N=78 schools; 39,900 students) showed fewer suicide deaths in schools implementing this approach.  

Social Science & Medicine                     Social Science & Medicine 296 (2022) 114737

Wingman-Connect Program’s interactive training created more dynamic relationship networks. Airmen in W-CP groups made more changes in who they named as valued connections, even as the overall average number of valued connections increased.

Am J Public Health. 2010

Training improved the peer leaders' adaptive norms regarding suicide, their connectedness to adults, and their school engagement, with the largest gains for those entering with the least adaptive norms. Trained peer leaders in larger schools were 4 times as likely as were untrained peer leaders to refer a suicidal friend to an adult. Among students, the intervention increased perceptions of adult support for suicidal youths and the acceptability of seeking help.

The norms most strongly enhanced through the intervention were students' perceptions that adults in their school can provide help to suicidal students and the acceptability of seeking help from adults.

Adolescents are far more likely than are adults to be aware of suicidal behavior in their friends; increasing students' partnering with adults to help suicidal peers may be a key process for reducing adolescent suicidal behavior.

Context of this project:

Defining the Social Network Health Approach within an integrated system of care:

This toolkit describes the Social Network Health Approach to preventative mental health care, drawing on published research from the University of Rochester Center for the Study and Prevention of Suicide and from the implementations by preventative mental health care professionals in close cooperation with them.

Preventative care is only one category of care within a holistic integrated system of mental health care.  Simplistically and fundamentally, it is critically important to address both Preventative and Emergency care within an integrated system.  Preventative care is clearly preferable, when effective, to emergency care when the risk of suicide is in play.

Active Research

The Network Health Approach describes tools and methods that are under active study, development, and use.

This means that this toolkit will be updated as new research dictates, and, most importantly the version history will reflect changes accurately. 

To ensure that you have the latest information, you can check the most recent update date on any page in this wiki, view and read the full version history, see when it was last peer-reviewed, sign up for updates to this toolkit, join our discussion group, and apply to become an editor.

We will update this with new research as it develops.  We have a research page where new contexts in which these tools can be used will be described as the tools are applied, researched, and tested within them.

Schools First

Throughout this toolkit, we will assume the context of a school.  We are focused on helping there because the need for preventative solutions and research is strong.  However, this approach has been proven effective in other contexts such as in the United States Air Force, Police departments, and other contexts you can learn more about on the research page.

Universality of the Approach

Programs are developed from approaches. Ecological validity is one part of the Network Health Approach that demands that a program is developed specifically and uniquely for a community - that’s what makes this approach so broadly applicable. This contention is supported by researched implementation across a breadth of communities.

Difference from previous approaches

A network health approach to preventative care builds individual and community protective factors and social norms.  Network health approaches that address these processes, such as maximizing youth-adult connections schoolwide and heightening influence of youth with coping, create more protective schools.  

Historical Context

The history of preventative mental health care is beyond the scope of this wiki, but it is worth arguing that the characteristics of this approach are different than what has been created in the societies of most of the world over the last 100 years, but they are not that different from what existed and still does exist in most cultures in the more distant past. Not an immediate focus, but the fact that research has taken humanity full circle to rediscovered excellence is notable and in some cases relevant.

Medical Model v. Strengths model

The medical model of care requires identification of a weakness to begin recommending treatment. In mental health care, some issues have no strong correlates that can be identified as weaknesses early on. Interestingly, there are correlates that can be identified as risk factors in communities that are much stronger indicators of future risk, and more readily identifiable, than individual risk factors. In some cases, strengths-based models that seek to identify strengths of individuals and communities have been shown to be more effective in reducing risk factors than a weakness-based medical model. Treating a community preventatively withy a strengths based-model can also be done without isolating individuals as weak links, separating them from connections. Instead, a strengths based preventative care program identifies strengths and integrates individuals into broader communities.

In the parlance of Social Emotional Learning in US schools there Tiers - Tier 1 (prevention-based) comes before Tier 3 (isolation-based) because it is, colloquially, terrible to have to isolate people - generally, Tier 1 is the success case and Tier 3 is the last line of defense for individuals who need it. This is appropriate prioritization from the perspective of a social network health approach. In practical implementation, however, far fewer communities put as many resources into effective Tier 1 programming as Tier 3.

TBD - We could make a matrix of all the characteristics of programs out there and see where this approach fits - that might be overkill to start with, but it would be useful to those who are trying to find the right approach in a sea of approaches.