By: LCol (Retd) S. Grenier MSC, CD
Mental illness knows no boundaries. Anyone, any age, at any time, with any educational background, working anywhere, can experience mental health issues. It is often experienced by those in the prime of their working lives. Combined, mental health problems are the leading cause of disability in Canada. The World Health Organization predicts that depression alone will become the second leading cause of disability by 2020 surpassing heart disease. Conservative estimates have established that approximately 10% of the working population have a mental health problem. One in every four Canadian workers will experience a mental health problem within the next 12 months and 500,000 are absent from the job every day for psychiatric reasons. From construction site to shop floor, retail outlet to law firm, front-line workers to senior officers, small business to multinational corporation, small town to large city, mental health issues have the potential to affect each and every workplace in many different ways. The realities of mental illness and its impact on work on individual companies and the Canadian economy as a whole make it a prime concern for all businesses.
It was April 1994 and I was in my 11th of service with the armed forces when I was sent to Rwanda to be part of General Romeo Dallaire’s United Nations Headquarters (HQ) team. The war had started already and there was talk that genocide was underway. After a total of eleven months spent abroad, returning home from this particular mission was especially difficult. The 6 years that followed remain, to this day, somewhat of a blur in my mind.
Looking back on my worst days when I was isolated from colleagues, misunderstood by my supervisors, and in complete disbelief of what was happening to my life, I realise that I was slowly becoming my own worst enemy by judging myself so harshly for not being able to do what I had been able to do in the past. Year after year, I found myself in and out of clinical care, attempting dozens of times to embark on medication regimens to assist with symptom reduction. Despite some of the best Mental Health care available in Canada, there was something missing in the whole equation: Hope. Hope that it was possible to recover and lead a productive life despite living with a mental health condition.
After struggling for years with posttraumatic stress disorder (PTSD) and depression, it was the actions of a few sympathetic colleagues at work and, later, one particular superior, that truly made the difference and allowed me to reach a turning point. A few years later, I realised that this phenomenon had been documented in the past under the name of Peer Support. I then decided to make this my priority by embarking on a path to help transform the mental health system by cloning this phenomenon and making it available in a more systemic and wider scale.
I first began this endeavour within the Canadian Armed Forces with the creation of an Operational Stress Injury Social Support program (www.osiss.ca), geared towards providing information and support for Military Members and Veterans, as well as their loved ones. Now retired from the military, I have expanded the scope of my work to that of empowering all types of organisations to provide hope to those struggling with mental health (MH) problems through the creation of Peer Support programs as a complement to clinical care.
Workplace Psychological Health and Safety
With processes and policies most often paralysed by dogma and rigidity, the need for increased humanity within organisational standards has never been greater. Indeed, a growing concern in Canada is the impact of mental ill health on people over the course of their careers, as well as the impact on overall workplace psychological health and safety. No other illness has such an impact on the Canadian workforce; many individuals are affected at the peak of their performing years. Twenty to twenty-five per cent of the labour force is affected by issues of mental health ranging from stress, to burn-out, to depression, which can result in significant long-term disability.
Based on my experience suffering from mental health conditions and my observing colleagues and friends endure the stigma surrounding mental illness in the workplace, I set out to create a new term to reframe these conditions within an organizational context. I felt that too much emphasis was placed on traditional diagnostic terminology, which only made matters all that more complex, therefore creating a barrier to the development of a culture of understanding and acceptance within workplaces.
After much reflection and research, I came across an article authored by Dr Allan Englishi who referred to these chronic conditions as being, to some extent, injuries. I decided to pick up on this idea and simply refine it, while later defining the cause of these particular types of injuries. In my view, the one common element that was at the source of any psychological injury was stress at its most fundamental form. Hence, the term stress injury was born, which I now use in my work with civilian workplaces as one of the pillars in redefining context and setting the grounds on which to move forward.
This term is neither meant as a diagnostic term, nor is it meant to be a legal term. Its purpose is simply to foster a broad understanding of two basic concepts; (1) that the mind, just as any other part of the human body, is not immune to illness or injury, and (2) that not all commonly known pathologies are so complex that only clinicians can be of help, which is foundational in demedicalizing these conditions.
Stress injuries are generally rooted in the occasion of four common human experiences that generally occur in varying combinations. Conceptually, these four causes are:
- Trauma is a cause that requires little explanation. After all, we as a society seem to have a good grasp of what constitutes trauma (vehicle accident, armed robbery, physical aggression, rape, and in my case, war).
- Fatigue is a cumulative wear and tear on individuals and often results from being asked to do more and/or do things more frequently with fewer resources. The workplace realities of growing demand and pressure for greater productivity, combined with everyday life events can easily result in a perfect breeding ground for stress injuries.
- Grief is defined broadly as a sense of loss. However, in the context of stress injury, this concept reaches far beyond the typical feeling we humans associate with the death of a loved one. Though it is acknowledged that grief is most often associated with death, it is also a significant factor when less significant loss is experienced.
- Moral conflict is probably the most complex concept to grasp, yet I believe it to be the most common cause of stress injuries. Everyone goes to work with their own sense of moral beliefs, values, and understanding as to what is right and wrong. Such conflicts can therefore easily occur when one’s own sense of morality contradicts what he or she is asked to do or not do in their work.
Considering that all of these causes are omnipresent in all types of workplaces, there is a strong business case to be made for dealing with all aspects of psychological health and safety in Canadian workplaces. Indeed, according to a recent study published by Dr Carolyn Dewaii , Canadian workplaces expend up to 52 billion dollars per year related to loss of productivity due to mental ill health. Despite the development of more and more formal clinical programs, priority access to employee assistance programs and increased awareness of mental health problems throughout all spheres of Canadian society, a great deal still needs to be done.
A general reframing of these issues as leadership issues within workplaces is a good place to start. Leaders must set the conditions for mental health problems to be acknowledged and supported, and this can only be achieved by looking at these matters from a non clinical perspective. The preponderance and widespread use of clinical terminology in designing workplace mental health strategies has led to an overly medicalized paradigm, resulting in an indirect contribution to what is commonly referred to as stigma.
Stigma is not only associated with the phenomenon of judging others, but is also a result of choosing to turn a blind eye to a colleague who is not doing well, and therefore abdicating responsibility to lend a helping hand. While it is completely appropriate for us to rely on clinicians and mental health professionals to be the primary care givers in the context of complex and serious mental health disorders, we all have an active role to play in making a difference. Indeed, we must perceive our peers as human beings who go through life transitioning along a wide ranging mental health spectrum, rather than individuals who are either healthy and functional, or pathologically ill if they happen to struggle with a mental health condition.
Another more important step that can be taken to enable organisational change is the establishment and implementation of a peer support program. Though to date peer support has been largely viewed as a natural helping modality that is delivered at the community level and in some formal clinical program, it can also be an important approach to assist employees in dealing with their own mental health issues, generally leading to improving overall workplace psychological health.
How Peer Support (Social Support) Playsa Pivotal Role
It is important to look at how mental health problems evolve and to understand how the combination of clinical and social support can be utilized to improve health outcomes.
A meta-analysisiii was conducted a decade ago studying the risk factors for people developing mental illness following traumatic events. This analysis concluded that while risks were indeed multi-factorial, some risk factors were much more prevalent than others in predicting who is likely to develop a mental health problem.
While factors such as having been abused as a child or having suffered from depression in the past may well increase the risks of developing a mental health problem, these were not found to be predominant factors. Even the severity of the trauma itself was not deemed any more significant of a risk factor then many others.
In fact, the analysis concluded that one of the most predominant risk factors identified in the meta-analysis was the lack of social support (see figure 1).
Looking back at my own situation following my deployment to Rwanda back in 1994/95, as well as my work with countless individuals affected by mental ill health, it is interesting to note that a very common behavior for those who were gradually developing a mental health problem was the need or tendency to isolate themselves a behavior that tends to increase the severity of the problem. Although this meta-analysis looked at risk factors for the development of the specific mental health condition that is Post Traumatic Stress Disorder, I have theorized for years that this is also true for other types of mental health problems, such as anxiety related problems and depression, most often found in workplaces. If the most important risk factor is indeed the lack of social support, would the antidote not simply be the infusion of social support?
In light of this, my team and I at National Defence worked on a project to enhance our work force’s understanding of mental health and the importance of social support. A more recent and adapted version of this model was designed to re-establish a balance between clinical care and social support, as the continuum of care required for those affected by mental health problems extends beyond traditional clinical services.
This model can be the cornerstone of a gradual paradigm shift within workplaces that moves them away from the belief that mental health problems are based on character flaws or complex pathologies which can only be impacted by clinical care alone. This model places social support in perspective with clinical care to show that these two types of interventions are meant to work collaboratively. Another key aspect of this model (see figure 2) is that mental health and mental illness are simply two points on a continuum, and that mental health is no different than physical health. It is simply a dynamic and changing state that can improve or deteriorate given the right or wrong set of circumstances. This continuum also fosters the understanding that movement in both directions is the reality in the vast majority of people, indicating that there is always the possibility for recovery and a return to better health and functioning, following a period of persistent injury or clinical illness. This way, no one is written off simply because they are showing symptoms of an illness or are being treated for a disorder or disease. There is also a recognition that the earlier an intervention of some sort is provided, the easier it is to return to full health and functioning. Finally, the model also stresses the importance of both clinical and social support as key determinants; when these are combined, the outcome is stronger than when used separately.
What is Peer Support?
Peer support has as many definitions as the number of people who seek to define it. In the words of a reputable peer support advocate in the US, Sherry Mead, “peer support is a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful”iv. Peer Support involves people with lived experience of mental health problems – either personally or through support of family members.
Community-based mental health organisations in Canada deserve all of the credit for developing the concept of peer support. Like-minded individuals in the UK, Australia, New Zealand, and the United States also began to work tirelessly at identifying the benefits of this phenomenon named Peer Support, and by and large, it was deemed as having a great deal of potential to assist with, and maintain, recovery.
Understanding how Peer Support Works
To fully understand how social or peer support works, we need to look at mental health from a slightly different perspective then the more traditional medical models suggests. To do so, two important aspects must be considered: (1) peer support anchors itself in the recovery model, (2) the recovery model is not intended to be in opposition to the medical model, but rather a complement to it (see figure 3).
|Medical Model||Recovery Model|
|The diagnosis is the foundation||The relationship is the foundation|
|Begins with the illness assessment||Begin with the welcoming, outreach and engagement|
|Services based on diagnosis and treatment needed||Services based on personal stuffing and helping needed|
|Services work towards illness reduction goal||Services work towards quality of life goals|
|Treatment is symptom driven and rehabilitation is disability driven||Treatment and rehabilitation are goal driven|
|Track illness progress towards symptom reduction and cure||Track personal progress towards recovery|
|Services end when illness is cured||Services end when the person manages their own life and attains meaningful rules|
|The relationship only exists to treat the illness and must be carefully restricted to keep it professional.||The relationship may change and grow throughout and continue after service end.|
The Impact of Peer Supporton the Individual
It is impossible to know exactly how each person experiencing a mental health problem feels, or how they see their lives and perceive the world around them; everyone’s circumstance is unique. Connecting with another person who has lived with similar problems (or is perhaps still doing so) — a peer — can be a vital link for someone struggling with their own situationvi. Peer support can help navigate the intricacies of treatments and other available assistance which, to someone with mental illness, can seem to be an overwhelmingly complicated maze – as it often does for so-called “normal” individuals. Peer support can also help people regain independence and mastery over their own mental health recovery processes, literally transforming lives and enabling people to participate fully in, and contribute to, their families, jobs, and society.
The impact of mental illness is further compounded by the fact that stigma hinders help-seeking behaviors. Research has shown that peer support alleviates stigma and fosters healthier coping strategiesvii. This outcome is linked to what is called experiential knowledge.
Experiential knowledge, the capacity to draw from one’s lived experience to guide a peer, creates a shift in attitude and increases empathy and connectedness to a higher level than what is usually observed in the patient-therapist relationshipviii. These elements combine in a synergy that appears to not only enhance empowermentix but also assists in gaining control over one’s own symptomsx.
Studies on depression have shown that peer support can be, in some cases, as effective as group cognitive behavioral therapyxi. Seven randomized control trials (RCTs) on the effectiveness of peer support, reported by Repper and Carter (2011), yielded evidence showing that it translates into stronger social networks, increased self-confidence, lower readmission rates, and longer community tenure. The RCTs also highlight the fact that receiving peer support is associated with a higher rate of employment. The sense of hope for a better future conveyed by the peer supporter further along in their recovery should not be underestimated. Having a positive role model often provides the needed impetus to make constructive, life-changing choicesxii.
Although much research still needs to be done, the current evidence was sufficient for the Scottish government to launch a pilot study to assess the delivering for mental health peer support workersxiii. This initiative is seen as a necessary step to help provide consistent evidence on a larger scale.
Dr. David Goldbloom, Chair of the Mental Health Commission of Canada, long-time professor of psychiatry at the University of Toronto, and senior medical adviser for education and public affairs at the Centre for Addiction and Mental Health, characterizes peer support quite simply by saying: “My informed hunch is that it works for a couple of reasons: it relieves the sense of isolation and shame […], [and] it does not involve the inherent power imbalance that exists between health care providers and health care recipients”.
Moving Forwardon Peer Support in Canada
The Mental Health Commission of Canada has recognized the value of peer support, and considerable work has been done – and is ongoing – on developing Guidelines for Peer Support Practice, for which the key has been the engagement of peer supporters from across Canada. As part of this work, initial surveys identified over 600 organizations and individuals involved in peer support, and close to 300 of these have also provided their input on the key requirements for peer supporters; requirements that are being used to inform the Guidelines mentioned above.
An independent organization, Peer Support Certification Accreditation (Canada) – or PSAC(C)
(www.psac-canada.com) – is also currently being developed to certify those peer supporters who meet PSAC(C)’s Standards of Practice and who are interested in becoming officially recognized workers in the field of peer support. PSAC(C) will also develop processes to accredit training organizations that meet PSAC(C)’s training standards which are currently in the initial development stages. Finally, PSAC(C)’s third main role will be to carry out research on the impact of peer support within various types of organizations.
Development of a Workplace-based Peer Support Program
The workplace is where people spend the vast majority of their time, and as such, is the most logical place in which to consider having an impact.
More and more workplaces are now turning to alternative and innovative ways of dealing with the growing negative impact that mental health problems are having of their organizations. Some workplaces are looking for tangible evidence and outcomes aimed at reducing costs and ensuring return on investment (ROI). Given that workplace peer support is a relatively new type of program, there is not yet sufficient evidence to guaranty ROI. However, some organizations are satisfied with the current research, thus bringing them to launch such initiatives based on the assumption that the effects in the workplace are bound to be positive, given the current evidence demonstrating the efficacy of peer support in other settings. While we cannot say with any degree of certainty what the impact of peer support will be in specific workplaces, it is definitely not a leap in logic to suggest that if implemented in an appropriate way, it has the potential to become a promising best practice for workplaces to adopt as a complement to other services currently provided. As the current evidence cannot guaranty ROI, it is safe to say that any organization that launches a peer support initiative does so as it is for them a natural step forward and extension to their current efforts in the area of occupational health and wellness.
Launching such a program requires an ability to allow for program development to occur from the grassroots of the organization. Consultation and engagement with front line employees ensures that program policies are grounded in tangible experience, are practical, and will be workable once launched. Also, it requires engagement on the part of senior leadership to ensure sustainability and appropriate accountability.
Workplaces that engage in developing such a program also need to have their readiness to introduce peer support assessed. Some organizational cultures are, unfortunately, completely incompatible with the concepts of peer support. For example, the organization may not be willing or able to accept the fact that an identified peer supporter may have to momentarily absent themselves from their primary work to meet with an individual requiring help, thinking that this will negatively impact productivity. Another question that might arise is whether an employee who self-identifies as a peer supporter (and therefore as someone who has lived with or who is currently living with their own mental health challenges) would face stigma from others in the organization, thus resulting in a negative impact on their own mental health condition.
In any organization, evaluation of the impact of the program can be carried out in three ways: (1) a confidential evaluation can be carried out by the external organization using specific approaches that evaluate, anonymously, the impact on the peer supporter and the individual being helped. (2) A second approach is to evaluate the peer support process in itself by assessing various factors such as implementation, number of peer supporters, and overall acceptance. (3) Finally, some non-attributed, anonymously based outcome measures may also be relevant, such as overall organizational benefits statistics, absenteeism data, and occupational health data.
Looking back on my years spent in therapy with countless reputable clinicians and taking various types of medications to alleviate my symptoms, it is now clear to me that the way my workplace dealt with me as an individual struggling with mental health issues greatly impaired my potential to recover. I recall multiple sessions with my therapists attempting to understand and come to grips with the reasons behind my state of mind. We discussed and revisited countless specific events that occurred during my time spent in Rwanda. We discussed and analysed my reactions to the sight of thousands of dead bodies lying across the country side and the multiple massacre sites I had stumbled upon. We revisited a particular scene of a young girl laying face down with her head turned to one side and with her skull cracked open like an egg shell; she had been brutally murdered along with her grandfather and left to the side of the road. A scene that would replay in my head and that would later make it impossible for me to look at my own daughter sleep in that same position. Dozens of sessions were spent reviewing the events of an 8 year old boy being shot a few feet away from me, of the reckless militias putting a machete to my throat asking if I was from Belgium, of an AK 47being stuck up my nose to make the point that I could not pass a certain checkpoint, and of our convoy being ambushed and shot at by the warring factions.
While there is no doubt in my mind that each of these experiences had cumulated to a degree where they had largely impacted my mental health, we had been so focussed on trying to find the cause of my problem by reviewing the past that we had completely missed the here and now; i.e. the passive and observant role that my workplace had played to my demise.
Every day I would go to work only to face coworkers who would ignore the obvious. They would turn a blind eye to someone who was obviously feeling terrible, who could not concentrate, who was extremely irritable and gradually more and more absent from the day to day interactions normally associated with work and therefore isolating himself.
Luckily, through all of this, I had the chance to come across a rather informal manifestation of peer support which provided me with the hope I needed to pull through and remain on the path to recovery. I believe that everyone deserves this chance in life, and this is why, following my retirement from the military, I have decided to dedicate my time and energy to assisting organisations in implementing these types of services within their workplaces.
At a time when society is arguably more fragmented than ever before, and technology and social media have overtaken face-to-face communication, the power of human interaction through peer support has never been greater and nowhere can it have more impact than in the lives of people experiencing mental health problems.
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