Youth-Nominated Support Team – Version II (YST-II)
*Note: The National Mentoring Resource Center makes these “Insights for Mentoring Practitioners” available for each program or practice reviewed by the National Mentoring Resource Center Research Board. Their purpose is to give mentoring professionals additional information and understanding that can help them apply reviews to their own programs. You can read the full review on the Crime Solutions website.
In considering the key takeaways from the research on this program that other mentoring programs can apply to their work, it’s useful to reflect on the features and practices that might have influenced its rating as “Promising” (that is, a program that, based on review of available evaluation research, shows evidence of effectiveness for influencing juvenile justice or related outcomes).
The case of the Youth-Nominated Support Team model represents an interesting wrinkle in how we view the “effectiveness” of a mentoring program. This program model, originally reviewed for inclusion in Crime Solutions back in 2014, was initially rated as “No Effects,” meaning that the outcomes detailed in the 2009 article by King and colleagues were not strong enough to suggest that this program, from a policymaker perspective, could be deemed as “successful.” It was, at best, a mixed bag of positive and nonexistent impacts. The original Insights for Practitioners” piece, included below, notes several aspects of the program model and resulting outcomes that cast doubt as to whether this particular approach to supporting youth who had attempted suicide was worthy of further study or investment. The results examined during the study window, which tracked youth for just a year, simply did not show enough variation between youth who had received the program and those who had not, to allow one to say that the program had “worked.”
However, the story of the impact of this mentoring work for our most vulnerable youth was not over. King and colleagues revisited the program, and the cohort of participants, in 2019, checking in over decade after the original study to see if there were any differences between the treatment and comparison group. And it turns out, there were: The youth who had participated in YST were significantly less likely to have died in the years since. And for a program with suicide prevention at its heart, this was not only good news, it also meant that its rating in the Crime Solutions system, which values the longest-point-in-time results the most, changed from “No Effects” to “Promising”—in other words, we now have some evidence that this program somewhat achieved, albeit at a longer time scale, what it set out to do: Keep young people alive.
So, what are we to make of this new evidence about this program? A few thoughts:
1. Mentoring might often have “sleeper effects” and we should keep that in mind when judging the results of a program.
One of the most interesting aspects of trying to measure the impact of mentoring is when to consider it “done.” While the relationship itself and interactions between mentors and youth, especially in a program, likely have well-defined beginnings and ends, the influence of the mentor may extend far beyond the treatment period or the in-person time they spent in relationship. A program like YST was designed to work with youth who had just attempted suicide, and for many not for the first time. These are youth who are obviously in crisis, dealing with complex mental health, substance misuse, and trauma issues. The work of the mentors largely focused on helping youth stick to treatment plans and acting as an additional support, especially if another attempt seemed like an emerging possibility. At the time of the first evaluation, these youth did not report many improvements over their non-mentored peers, although there were some positive findings around suicidal ideation and adherence to treatment plans. In the immediate wake of the time period of the program, it looked like perhaps the program was a nice, but not terribly effective add-on to mental health services for suicidal youth.
But the beauty of mentoring is that in some ways, it never ends. The words, wisdom, and skills taught by a mentor may stay with us long after the relationship ended, bubbling up through our subconscious in critical moments and in moments of quiet reflection. The authors of the most recent study speculated as to why these mentoring teams seemed to have contributed to a difference in the death rates of these groups long, long after the end of the program. One of the possibilities, and one hinted at in the original study, was that these mentors not only really encouraged youth to stick with their mental health treatment plans, but also facilitated their participation in drug treatment and other services as needed. They also speculated that this caring team of adults may have taught these young people the skill of communicating and accepting help from caring adults and others while in the program. Both of these things, the seeking of and adherence to treatment and the ability to ask for and trust the help of others, didn’t end when the formal evaluation of the program did. They are things that many of these young people may carry with them today.
One can imagine how, over the decade plus that followed, those skills might have helped the YST youth seek and utilize supports in a way that the comparison youth did not. Given the prevalence of drug overdoses in the causes of death among the comparison group youth, one can’t help but wonder how an openness to substance abuse treatment and other forms of support might have influenced those morbidity statistics. Unfortunately, there were young people in both groups who committed suicide during this time, and others who died in other ways related to unhealthy behavior. But what these results suggest is that a mentoring relationship has the potential to set a long chain of events in motion, one that can be hard to see in the moment, right after the end of a program cycle. Sometimes it may take a long time to see those results show up. All mentoring programs should keep this in mind when they get back evaluation results that at first glance seem less that what was hoped. There may be positive future possibilities unfolding all around those “disappointing” outcomes and it sometimes may pay to revisit people many years later to see if the seeds that were planted long ago bore the fruit that was so hoped for.
2. When thinking about how to support youth, remember that it should be perceived.
The other reason that the authors of this second study speculated may have driven these differences in mortality rates is that the YST youth in the original study reported more “perceived” support than their comparison group counterparts. That distinction may sound funny at first glance: wouldn’t all kids in mentoring programs, or suicide prevention efforts for that matter, report increased support. They are getting more support, right?
Well, like many things, support is in the eye of the beholder. National Mentoring Resource Center Research Board member Tim Cavell once said at a conference, “All programs have lots of matches… the question is how many relationships you have.” The gap he was speaking to is that you can easily go through the motions of a mentoring relationship—doing the activities and making all the meeting times—but still have a young person who is not feeling the benefits in their heart or in their head. Perceived support measures the feelings of the recipient, not just the raw output of relationship time. The authors noted in both studies that YST youth reported more perceived support from others than their comparison peers. This may not only have led to them having some mild positive differences at the time of the first study, but one can imagine that that perceived support carried on well after the period of the program. These support teams were, after all, comprised of individuals who the youth had asked to be part of this, who they felt they could trust and who likely had ties or connections that may have lasted for quite some time. By empowering youth to form a hand-picked team of caring adults, they may have set the stage for longer-term supportive relationships and, as noted above, taught the skill of asking for and accepting help.
But too often, mentoring programs confuse their statistics about match “dosage” as evidence that youth are supported. A better way of knowing that is to simply ask them. They will let you know whether they feel supported or if there is more attempted support than actual support in the program.
The last thing to note about this sobering look at the mortality of young people is the huge role that drug overdoses played in the final results. While there is a growing body of research highlighting how mentors can support young people with substance misuse issues, it’s clear there is more work to be done on this front, particularly around the deadly range of opioids that have gripped so many communities over the last decade or so. We hope that OJJDP’s recent investments in opioid-focused mentoring work will lead to new research that further addresses the potential short and long-term value of having mentors working alongside clinicians and others.
Original Insights for Practitioners (originally posted in 2015):
One of the most ambitious trends in mentoring in recent years is the integration of mentoring with clinical supports for youth facing a variety of traumas and mental health needs. There is a fairly robust body of research on the value of close, supportive relationships⎯whether between patient and therapist or the patient and family and friends⎯in treating common mental health issues, such as depression or suicidal ideation (see the chapter on Youth with Mental Health Needs in the second edition of the Handbook of Youth Mentoring for a nice review of this research). So it seems logical to speculate that mentors, and the power of mentoring relationships, might be a good stand-alone or supplemental treatment for individuals with mental health needs.
There is also a growing interest in the idea of “networked” approaches to mentoring, in which a youth is paired with one or more mentors who work together, often in concert with other caring adults in the youth’s life, to create more of a “web” of support. This idea offers a promising strategy for harnessing the full range of caring and support available to a young person and, depending on the program model, this type of support can be focused on a particular need or circumstance (see also the chapter on Social Networks and Mentoring in the Handbook of Youth Mentoring for additional information on this theory).
One can see a real blend of these two ideas⎯mentoring as a clinical supplement and a networked approach⎯in the Youth-Nominated Support Team – Version II (YST-II) model. In this program, youth who have been hospitalized with suicidal thoughts or actions were asked to nominate a “team” of caring adults they already know to support their transition out of hospitalization. This is a particularly dangerous time for suicidal youth, as the risk of another attempt is markedly higher during this transition phase. The idea behind the YST-II program is that during this vulnerable period youth would be surrounded by multiple caring adults, ensuring that they would always have someone to turn to and many individuals checking in on the youth’s mood and progress. This team of adults was trained by a clinician to provide targeted support around suicide prevention and were individually tasked with having weekly contact with the youth.
The model makes a lot of sense on paper. Youth who are suicidal often follow through with an attempt based on three factors: perceptions of a lack of belonging, the sense that they are a burden to others, and having the means to actually commit suicide (e.g., acquiring a firearm or lethal drugs, being alone unsupervised for long periods of time, etc.). (See Why People Die By Suicide by Thomas Joiner for more details on this research.) It makes sense that having this team of highly trained, caring mentors, in addition to one’s family, would be a tremendous asset in each of those three areas. Mentors can help these youth feel loved and valued, help them feel positive about themselves and their future, and keep an eye on them to make sure that they stick to their treatment plans (especially medications) and have constant support. And that fact that these were adults the youth already knew meant that much of the potential awkwardness and trust-building of most program-arranged mentoring relationships could be bypassed in favor of deeper and more robust early support.
But in spite of the fact that YST-II seems like the type of support that would complement traditional treatment nicely, the research on the model to date shows no difference for participants compared to those who got treatment-as-usual once leaving the hospital. Not only did it not make a difference in the number of attempts, it also didn’t impact some common precursors of an attempt, such as depression, hopelessness, and everyday functionality. There was a slight decrease at 6 weeks post-treatment in suicidal ideation, but only for youth who had multiple previous attempts, and even then, the decrease did not hold up over time.
So why did this program with such a sound theory fail to produce measurable results? There are several possibilities:
- The mentoring provided through the program was not very long-lasting nor, it seems, robust. The intervention was designed to last only 12 weeks, the most critical time for these youth when leaving hospitalization. The average “team member” contacted these youth 9.51 times, with 7.62 being in-person. So youth did not consistently get the full volume of support the model intended. Particularly concerning, almost one-third of the 233 treatment youth did not have even two team members maintain contact over the entire 12 weeks. One wonders how a suicidal adolescent would feel knowing that their team members weren’t making as frequent contact as intended.
YST-II is based on an earlier version that was a 6-month intervention that produced slightly more encouraging results. Ultimately, the authors of the published article wonder themselves if “the intervention was too ‘lightweight’ in its intensity to overcome or divert the developmental trajectories of these adolescents.” Perhaps a model that provided longer term relationships with more diligent follow-through by the “team” would have produced better results.
- It’s also unclear just how much “mentoring” was happening in these relationships. Other than tracking their contacts with the youth, the researchers didn’t attempt to assess the quality or closeness of these relationships. In theory, since these were all caring adults that the youth already had a relationship with, one can see how they might assume that these relationships were already close. But there was no data in this study of the youth’s perceptions of support or whether they found these relationships helpful.
Perhaps these adults had difficulty transitioning into the role required here? The program did provide training on the youth’s psychiatric disorders and treatment plan, as well as suicide warning signs and strategies for communicating with adolescents. And the support team members were encouraged to do things like help the youth problem-solve and convey hopefulness and caring during their check-ins. But providing this kind of support was likely a challenge to some of the participants and it’s unclear as to how much the program prepared them for this shift in the nature of their relationships with the child. Being someone’s baseball coach or neighbor or teacher is very different than talking directly with them about suicide and depression. One might wonder if perhaps more training is needed to prepare support team members (or youth themselves) for the change that this model will make to their pre-existing relationships.
- One also wonders about the composition of these support teams. In YST-II, parents had final say about who would serve on the support team. Indeed, it would be difficult to imagine an intervention involving minors where parents would not be granted this type of role. One wonders, though, how this played out in this particular intervention. In some instances, parents could have wound up impacting the make-up of these teams in ways that made them less appealing or helpful to the youth. Perhaps, for example, some parents exerted some control over who participated by disagreeing with the youth about their nominations. It’s worth noting that YST-II removed the option (included in YST-I) for a same-age peer to be part of the team. One wonders if perhaps being confronted with a team of parent-approved adult supporters, and no peers, might have played a role in how enthusiastic youth were about the program or how valuable they found the support. It’s entirely possible that a model like this could wind up intensifying a youth’s contact with an already-dysfunctional support system.
- A final possibility behind the “no effects” results is something that the authors of the study note themselves: That this approach actually intensifies the feelings of being a burden for these youth. The authors speculate that “it’s possible that an increase in burdensomeness occurred among some YST-II participants,” although they point out that they have no data confirming this. For a youth who already feels low coming out of a suicidal episode, one can easily see how having this team of adults have to check in on you and devote all this time to your well-being could easily be interpreted as being even more of a “burden” on loved ones. So programs that want to employ mentors in these types of mental health circumstances are well-advised to be aware of the subtle negative messages that can unintentionally be sent by providing the very caring and intensive help these youth need.
The bottom line is that suicide prevention is exceedingly difficult. The study authors note that “multiple evidence-based interventions⎯in combination or in sequence⎯will likely be needed” to turn around this dire circumstance for youth. But we should applaud the researchers behind YST-II for their valuable contributions to our understanding of the intersection between mentoring and mental health services. This program did no harm and there are some hints that it could have a positive impact with more robust design and implementation. Other programs, ideally in collaboration with researchers to ensure rigorous evaluation, should pick up where this idea left off and see what features, such as deeper training or more intensive staff support, can make a difference. But this program also shows that mentoring programs wishing to serve youth with mental health needs must be designed extremely carefully and strive for full fidelity to the model being recommended. In these situations, it really is a matter of life or death.
For more information on research-informed program practices and tools for implementation, be sure to consult the Elements of Effective Practice for Mentoring™ and the "Resources" section of the National Mentoring Resource Center site.