For up to four hours at a time, William Buhl attentively monitors a person who is on suicide watch at Nash Correctional Institution — a medium custody prison in Nashville. Buhl sits at a table outside a cell with a direct view of his subject. He observes their behavior, records notes every 15 minutes and offers an open ear.
He’s there as a peer observer — a fellow incarcerated person who has been screened and trained to observe and engage with people in mental distress and on suicide watch.
It’s a duty Buhl and other peer observers said they don’t take lightly. The objective is to keep people alive and see them improve.
“Lives are important, and they're valuable,” Buhl said. “Somebody out there loves us.”
Prison officials launched the Peer Observer Program as a suicide prevention strategy recommended by the department’s Suicide Prevention and Self-Directed Violence Workgroup. The group convened after a spike in suicides in 2018, when 11 people died in custody — up from six the year before.
Buhl became one of the North Carolina prison system’s first peer observers in November 2019 as part of the program’s pilot at Mountain View Correctional Institution, a medium security prison in Mitchell County.
He was motivated to take part because, about a year before, he lost a friend to suicide. Someone, he said, who was more like a brother.
Buhl, who has been incarcerated for nearly 20 years, can better relate to the struggles in prison that may contribute to mental deterioration: separation from family, the toll of long sentences, and interpersonal conflicts within cell blocks. His shared lived experience often means the people he observes are more likely to open up to him.
“Another inmate will talk to another inmate quicker, a lot of time, than they will staff, especially when they realize that we're wearing the same clothes they are,” Buhl said.
In 2024, peer observers worked 5,356 hours conducting suicide watches, according to Department of Adult Correction data provided to NC Health News.
Lewis Peiper, chief of behavioral health at the Department of Adult Correction who led the workgroup, said they learned ing peers to help monitor people on suicide watch from Gary Junker, the head of behavioral health at the time. Junker had helped implement a peer observer program at the federal prison in Butner when he worked there.
“They found that not only is there benefit to staff — for the staff not sitting on the watch — but it improved the experience of the watch for the people involved,” Peiper said. “Sometimes a person in a uniform within a prison population, they can be seen almost as an adversary … Having a peer, it can kind of just lower the tenor.”
A 2005 peer-reviewed evaluation paper on the federal peer observer program called it a “win-win solution.” The researchers found people spent less time on suicide watch when watched by another incarcerated person without compromising the standard of care. The researchers also found that observers themselves felt personal gain from being able to help.
Modeled after the federal program, Peiper said the use of peer observers in North Carolina prisons has so far been effective. A March 2022 cost-benefit analysis report by the North Carolina Division of Prisons’ Innovation Institute recommended expanding the program, which has slowly spread to 72 peer observers serving across five prisons.
“It's simple, yet it works,” Peiper said. “It has an impact on the environment and the experience of suicide watches on the individuals and on the prison.
“There's something powerful about when you bring folks in and have them trained into a role,” he said. “It's a trusted role. It's got guardrails on it for safety purposes, but they become great ambassadors for mental health. And they can have a reach well beyond what a licensed psychologist might be able to have on their own.”
What do peer observers do?
In 2024, 13 people in North Carolina prisons died by suicide — tying the record for most suicides in a year. In addition, 2,941 self-harm incidents occurred that required a self-injury risk assessment, according to department data provided to NC Health News. Of those, 32 percent included some type of action, such as cutting or burning oneself with scalding water, while the other 68 percent made written or verbal threats.
Peiper said the prison system’s policy is to place people deemed suicidal under “constant observation,” where they are placed in a cell with line-of-sight visibility for an observer and given items, such as a safety blanket, safety smock and vinyl-covered mattress — all tear-resistant.
Generally, a correctional officer provides the observation. It’s time-intensive to monitor someone closely 24/7 — and that’s made more difficult by chronic staff shortages at the Department of Adult Correction.
Department Secretary Leslie Cooley Dismukes told state lawmakers during her May 14 confirmation hearing that the correctional officer vacancy rate is near 40 percent, and the shortage is a “direct threat to public safety.”
At the five prisons that have peer observer programs, the majority of the observation is performed by these trained peers, which frees up staff time.
Although peer observation was not created as a solution to short staffing, Peiper said it’s a particularly valuable benefit when correctional staff are sorely needed in multiple locations at once. Peer observers do still require supervision, he noted, but not as much as people on suicide watch. Operating a peer observer program also requires additional behavioral health resources.
Christine Tartaro, a researcher at Stockton University in New Jersey who has studied correctional suicide for over 25 years and assessed the landscape of prison peer observer programs, said that prisons often struggle to have adequate resources for mental health care. It’s particularly a challenge to meet the need as the proportion of people with mental illness in prison increases — including in North Carolina, where about one-quarter of the total prison population (or about 8,000 people) has a mental health diagnosis that requires treatment.
Tartaro said it makes sense for prisons to use a resource they have in abundance: people who are incarcerated.
Incarcerated people interested in becoming peer observers are carefully screened and undergo interviews. In particular, Peiper said, they look for candidates who are working on their own individual rehabilitation and aren’t actively having their own mental health issues.
Once selected, peers undertake an initial four-hour training focused on understanding the job requirements, suicide prevention and strategies on how to handle situations that may present. They receive ongoing training and debriefings, as they serve in the role, to enhance their knowledge and skills as well as address any secondary trauma from what they might witness, he said.
When watching someone on suicide watch, peer observers can serve up to four hours in a 24-hour period.
“The observers are not there to be counselors, but they do have some basic conversations, and they’re taught in the training kind of how to be ive but to not step into the role of being a counselor,” Peiper said.
Correctional officers still circulate regularly, and a behavioral health clinician meets with the incarcerated person daily to assess their mental health and whether they can return to their regular housing unit.
Tartaro cautioned that incarcerated peers should not be a substitute for mental health staff. Instead they should act as a supplementary set of eyes or source of social .
“Allowing the incarcerated to supplement doesn't all of a sudden mean that we back away and say, ‘Okay, well now the staff don't need to do anything,’” Tartaro said.
Peer connection
Brandon Blakeney, who has been a peer observer since mid-2023 — first at Mountain View and now at Nash Correctional — still re his first observation. The man on suicide watch came to the door to talk to him and said he had never been on self-injurious behavior precautions before and was scared, having never felt so low.
“I got goosebumps a few times when the guy was discussing with me about his past history and the events that led up to him feeling like he wanted to end it,” Blakeney said. “I related to him because I have had some of those same experiences.
“Just hearing him discuss what was affecting him in such a way gave me a much deeper appreciation for all of the things that guys go through in prison,” Blakeney continued. “If you spent an hour in prison just as a fly on the wall, you'd see a lot of masking, a lot of, I guess, what we call ‘perpetrating the fraud’ because you're not necessarily expressing who you really are or what you feel.
“When you're in those vulnerable moments that are so rare, you just appreciate life,” he continued. “The impact of me being able to be there when someone is contemplating ending their life, I can't measure it.”
Compared to having a staff member there, having a peer on suicide watch changes the dynamic, Blakeney said.
“He realizes that somebody's actually paying attention to him that cares and wants to see if he's okay,” Blakeney explained. “That changes people's perspective, too, because there are a lot of guys in prison who don't have any — and just a friendly four hours does the world for people.”
During his four years working as a peer observer, Buhl said he’s seen how the presence of peers can help someone improve — though some take longer than others. For example, Buhl recalled one man on suicide watch that he and other peer observers watched for 30 days. When Buhl ran into him later in a medication line, the man came over and hugged and thanked him.
“That was reward enough for him to say he appreciated it,” Buhl said. “This was a guy that went through a lot of stuff, like 26 surgeries, over trying to harm himself. It said a whole lot to everyone on the team that he thought that much of us.”
Prison staff can also see how peers make a difference. Peiper said that Mountain View Correctional’s warden was initially skeptical about implementation of the peer observer program, but now is sold. For example, when Mountain View reopened in January after being closed for several months after Hurricane Helene tore through western North Carolina, Peiper said the staff there was intent on getting the peer observer program running again.
Impact beyond suicide watch
The impact of peer observers extends beyond suicide watch. Peer observers and prison staff alike told NC Health News that the role creates more openness around mental health in prison.
The peer observers are sought out daily by the prison population to discuss various issues.
“They point us out on the yard and then approach us,” Blakeney said. “We could be going to chow or just going from one place to the next, and somebody might pull up and say, ‘Hey man, I'd like to speak with you about something.’ It's always an opportunity for a door to be open, is what being a peer observer is like.”
A guard tower at Nash Correctional Institution, a medium custody prison in Nashville. The prison can house up to 654 incarcerated men. The peer observers also find a sense of purpose from their role — for which they receive no pay.
“To me, it's a very important program to be able to help another inmate and say, ‘Hey, I'm here for you,’” Buhl said. “I give up that rec time. I give up canteen time. I give up my time that I can watch a movie or spend time doing whatever to go back there to sit those four hours and push everything aside — because somebody needs help.”
Blakeney said serving as peer observers also helps the observers themselves. He said he ed the program at the “perfect moment” when things in his life outside of his control were “hardening his heart.”
Being a peer observer, he said, has made him a better person and father because he’s now in tune with more things beyond himself.
“You get to see the impact you can have on somebody that just needs somebody to be near them. Not even conversation — just your presence sometimes is enough,” Blakeney said. “It's just one of those things that opened up my life.”
Involving peersOther prisons around the country have incorporated peers into their suicide prevention efforts.
The Federal Bureau of Prisons and at least 15 state departments of correction have written policies around the use of incarerated people as components of their suicide prevention programs, according to a 2023 study in the Journal of Correctional Health Care.
Robert Cramer, a UNC Charlotte researcher who studies suicide and has worked with the N.C. Department of Adult Correction on suicide prevention efforts, said that using peers is innovative and in line with a public health approach driven by the notion that anyone can help with suicide prevention.
“A lot of public health programs are really oriented toward, how do you get laypersons to be able to, in some way, engage in ive conversations and get the person in distress to help?” Cramer explained.
Peiper said the Department of Adult Correction will keep empowering peers to the mental health of those in its facilities, including with the launch of peer specialist roles. The goal is to have the first group of incarcerated people in these jobs this fall, he said.
“The ultimate goal is to have [peer observers] be integrated in a broader and statewide peer-ed model within behavioral health services across all of our facilities,” Peiper said.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
