A summary of participant demographics can be found in Table 1. A total of 12 participants participated in this study with women making up two thirds of the sample. Age spanned the range of working age (21 to 60 years). Six of the participants worked in the education, law and social, community and government services (including social work, police officers, and educational assistants), four worked in business, finance, and administration, one in management and one in health. Most participants had post-secondary education.
Self-reported mental health disorders included depression, anxiety, and PTSD. Consistent with the diagnostic criteria for these disorders, participants (n = 12) described emotional and physical fatigue that were often not recognized by those around them. The majority of participants had a familial history of mental health disorders; however, most participants did not report mental health conditions prior to the WMHI. Most participants had experienced their WMHI longer than 1 year ago and only one participant sustained the WMHI within recent months. At the time of the interviews nine participants had left their employer where they sustained their WMHI while three participants had stayed with their employer.
According to participant responses to the pre-interview questionnaire, participants identified their WMHI when it reached the extent that they had to take sickness absence or leave work. Participants’ WMHI’s were a result of cumulative stressors and/or direct or vicarious traumatic exposure. Participants may have sought treatment prior to declaring that there was a WMHI, mainly owing to lack of recognition or acceptance of a problem or a critical incident that resulted in a crisis in coping and declaration of the need to take time off.
At the time of the first interview, DASS-21 scores indicated that most participants (n-9) had at least one of depressive, anxious or stress scores in the severe range [45] and elevated in comparison to normative samples [38]. We considered the sample high functioning but distressed and most participants were still actively receiving help for their WMHIs at the time of the interviews.
Resources were categorized into workplace resources, healthcare resources, institutional resources, and personal resources according to the Work Disability Paradigm [46]. Patterns of resource access are described in sociograms [46] in the supplementary materials. Resource access varied considerably among participants as did the degree of support perceived by participants from the various sources. Trajectories of resource access are likewise described in the supplementary materials.
Table 1
Summary of Study Sample Demographics
ID
|
Gender
|
Age
|
Education
|
NOCC
|
Pre-existing MHIs
|
Family history of MHIs
|
Causal Incidents
|
WMHIs Sustained
|
Time Since WMHIs
|
Occupational Status
|
1
|
Male
|
41–50
|
Not reported
|
Business, finance, and administration
|
Bipolar
|
Bipolar
|
1
|
Depression, anxiety, mania
|
1 year
|
Different job, different employer
|
2
|
Female
|
51–60
|
College diploma
|
Business, finance, and administration
|
No
|
Depression, anxiety
|
1
|
Anxiety, PTSD, insomnia
|
1 year
|
Different job, different employer
|
3
|
Female
|
41–50
|
College diploma
|
Education, law and social, community and government services
|
No
|
Depression, anxiety
|
1
|
Depression, anxiety
|
2 months
|
Same job, but looking for different employer
|
4
|
Male
|
41–50
|
Master’s
|
Management
|
PTSD
|
Bipolar, depression
|
1
|
Depression, anxiety, insomnia, NSSRD
|
1 year
|
Same job, different employer
|
5
|
Female
|
41–50
|
College diploma
|
Education, law and social, community and government services
|
No
|
Obsessive compulsive disorder
|
9–10
|
Depression, anxiety, PTSD
|
12 years
|
Retrained in new occupation, currently unemployed
|
6
|
Male
|
31–40
|
College diploma
|
Education, law and social, community and government services
|
No
|
No
|
1
|
Depression, PTSD, insomnia
|
4 years
|
Currently training in new occupation
|
7
|
Female
|
51–60
|
College diploma
|
Education, law and social, community and government services
|
No
|
No
|
1
|
PTSD
|
1 year
|
Left employer, looking for alternate occupation
|
8
|
Female
|
21–30
|
College diploma
|
Education, law and social, community and government services
|
Yes – not specified
|
Depression, anxiety
|
2
|
Anxiety, NSSRD
|
3 years
|
Same job, different employer
|
9
|
Female
|
41–50
|
Bachelor’s degree
|
Business, finance, and administration
|
No
|
No
|
1
|
Depression, anxiety, PTSD, insomnia
|
6 years
|
Different job, same employer
|
10
|
Male
|
41–50
|
College diploma
|
Education, law and social, community and government services
|
No
|
No
|
1
|
Depression, anxiety, PTSD, insomnia, NSSRD
|
9 years
|
Different job, same employer
|
11
|
Female
|
31–40
|
Bachelor’s degree
|
Business, finance, and administration
|
Depression, anxiety
|
Depression, anxiety
|
1
|
Depression, anxiety, insomnia
|
2 years
|
Same job, different employer
|
12
|
Female
|
41–50
|
College diploma
|
Health
|
Not reported
|
Not reported
|
1
|
PTSD
|
5 years
|
Same job and employer, with accommod-ations
|
Note. ID = Participant Number, NOCC = National Occupational Classification Category, WMHIs = workplace mental health injuries, PTSD = post-traumatic stress disorder, NSSRD = non-specific stress related disorder, MHIs = mental health illnesses
*Occupations were classified using the Canadian National Occupational Classification system.
** Participants were asked to self-report mental health conditions as diagnosed by their healthcare practitioner, e.g., physician, psychologist and number of mental health injuries they sustained.
***Causal incidents are participant perceived number of incidents relating to their WMHIs.
Table 2
Summary of Participant DASS-21 Scores and Utilized Supports
|
DASS – 21 Scoresa
|
|
|
|
|
|
ID
|
Depression
|
Anxiety
|
Stress
|
Receiving Treatment
|
Workplace Resources
|
Healthcare Resources
|
Institutional Resources
|
Personal
Resources
|
1
|
Severe (0.77)
|
Moderate (0.32)
|
Extremely Severe (1.43)
|
Yes
|
|
PCP, psychiatrist, hospital, counsellor, crisis support group,
|
Community services
|
Partner, family, friends
|
2
|
Moderate (0.28)
|
Severe (0.80)
|
Severe (0.90)
|
No
|
Human resources
|
PCP, psychiatrist, psychologist, occupational therapist
|
Workplace insurance & benefits
|
Partner, family, friends, clergy
|
3
|
Severe (0.65)
|
Extremely Severe (1.60)
|
Extremely Severe (1.17)
|
Yes
|
Supervisor, EAP
|
PCP, EAP
|
Workplace insurance & benefits
|
Family
|
4
|
Extremely Severe (1.26)
|
Normal
(-0.16)
|
Mild
(-0.02)
|
No
|
Human resources
|
PCP, psychiatrist, psychologist
|
Workplace insurance & benefits
|
Friends
|
5
|
Severe (0.77)
|
Extremely Severe (2.55)
|
Severe (1.03)
|
Yes
|
Colleagues, manager, superintendent, union
|
PCP, psychiatrist, group therapy, hospital
|
Ontario Disability Support Program
|
Partner, family
|
6
|
Normal
(-0.21)
|
Severe (0.80)
|
Moderate (0.25)
|
Yes
|
Manager, colleagues, EAP, Critical Incident Stress Management
|
Psychiatrist, psychologist
|
WSIB
|
Partner, family, friends
|
7
|
Moderate (0.52)
|
Moderate (0.48)
|
Extremely Severe (1.17)
|
Yes
|
Colleagues
|
PCP, psychologist, group therapy
|
Spousal work insurance, community resources
|
Partner, friends
|
8
|
Normal
(-0.21)
|
Normal
(-0.16)
|
Moderate (0.51)
|
No
|
Colleagues, workplace group therapy
|
PCP, psychologist, group therapy
|
Employment insurance
|
Family, friends
|
9
|
Normal
(-0.45)
|
Normal
(-0.64)
|
Mild
(-0.15)
|
No
|
Colleagues, EAP, union
|
PCP, human resources
|
Workplace insurance & benefits
|
Friends
|
10
|
Severe (0.89)
|
Normal
(-0.16)
|
Mild
(-0.02)
|
No
|
Colleagues, workplace mental health training, human resources, unspecified mental health professional
|
Psychologist
|
Workplace insurance & benefits
|
Friends
|
11
|
Extremely Severe (1.74)
|
Extremely Severe (1.92)
|
Severe (0.77)
|
Yes
|
Colleagues
|
PCP, psychologist
|
None
|
Partner, family, friends
|
12
|
Severe (0.65)
|
Extremely Severe (1.12)
|
Extremely Severe (1.17)
|
Yes
|
Human resources
|
PCP, hospital physician, psychiatrist, psychologist, occupational therapist, social worker, group therapy
|
WSIB, in-patient program, work transition specialist, caseworkers, nurse consultants,
|
Partner
|
Note. ID = Participant number, DASS-21 = Depression, Anxiety, and Stress Scale, 21-point, EAP = Employee Assistance Program, PCP = Primary Care Physician, WSIB = Workplace Safety and Insurance Board |
aCategorized according to the DASS-21 scoring scheme as developed by Lovibond and Lovibond [49] and evaluated on a normal adult sample (N = 717) [47].
*Individual Z-scores are bracketed in corresponding categories of Depression, Anxiety, and Stress according to the DASS-21 point scale and were calculated using Sinclair et al. (2011) mean and standard deviation of a non-clinical U.S. adult sample.
**Workplace resources were defined as individuals within the workplace who may provide guidance in WMHI recovery. Healthcare resources included formal supports for mental health recovery. Institutional resources included financial support to aid in mental health recovery. Personal resources were participant’s personal networks which were utilized during their help-seeking journey.
Thematic Analysis
Three main themes - self-preservation, fatigue, and trust - that were composed of seven subthemes were derived from the data. In Table 3 we summarise the themes, subthemes and prevalence among participants. Figure 1 illustrates the inter-related nature of these determinants on help-seeking for WMHIs and are presented in detail in turn.
Table 3
Summary and Description of Themes and Subthemes
Theme
|
Subthemes
|
Description
|
Participants
|
Workers concealed injuries and distanced themselves from stressors as a means of self-help and self-preservation.
Participants in non-supportive and stigmatizing environments experienced the need to look internally to find strength and strategies in an effort to persevere and overcome the WMHI and associated hardships.
|
Workers concealed WMHIs while attempting to regain coping capacity to preserve self-image during recovery.
|
Individuals used time-off work under the guise of a physical ailment or vacation to regain mental health coping capacity to avoid acceptance of or the label of a person with a mental health issue.
|
P2, P3, P4, P5, P9, P10, P11
|
Workers were reluctant to disclose mental health problems and access support because of fear of being demoted and/or facing harassment and/or losing their jobs
|
Experiencing or seeing negative consequences of disclosure made workers reluctant to disclose problems and seek help.
|
P3, P4, P11, P12
|
Workers decided to change occupations or employers to distance themselves from the workplace situation or environment which caused or continued to cause WMHIs.
|
Individuals that decided to change occupations either had previous education allowing them to move to a different occupational field or decided to be retrained in an effort to leave their current occupational field. Other workers decided to leave their employer while remaining in the same occupational field. Individuals felt this was required for mental health recovery.
|
P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11
|
Complex help-seeking pathways and accumulated stressors caused fatigue leading to reduced independence in decision-making.
Participants experienced mental and physical feelings of exhaustion as a result of the complexity of obtaining resources and accumulated workplace stressors. This feeling of fatigue resulted in individuals deferring decisions regarding their help-seeking journey.
|
Workers experienced complex routes in obtaining resource supports for WMHIs recovery.
|
Due to a lack of a prescribed path to resource supports, participants were required to expend significant effort identifying and pursuing resources they felt would help in their recovery.
|
P1, P2, P4, P5, P7, P10, P11, P12
|
Workers experienced an accumulation of emotional distress until coping capability was depleted.
|
An on-going experience of compounding workplace stressors caused diminished coping capabilities resulting in the individual's WMHI.
|
All participants
|
Workers experienced a decreased ability to make decisions regarding their own WMHIs help-seeking trajectory.
|
Workers experienced a reduced capacity to act independently in mental health recovery decision-making. Individuals unwittingly relinquished decision-making control for resource supports pathways to recovery. This included deferring decisions to physicians, insurance, and colleagues, amongst others.
|
P2, P3, P5, P6, P12
|
Trust contributed to resources accessed.
Participants felt that reliable and trustworthy resources were best found through individuals who could relate to their occupation. Alternatively, participants experienced a reciprocal mistrust between themselves and stakeholders when trying to access resource supports.
|
Workers trusted WMHI resources referred from within their group and not under the perceived influence of employers.
|
Individuals felt confident in a referee’s guidance for mental health resource supports as a result of perceived feelings of relatedness to their job. Participants expressed a lack of trust in the motives of the employer and the employer provided mental health resources due to a perceived conflict of interest. This led to decreased trust, efficacy, and uptake of offered treatments.
|
P6, P7, P10, P11 P12
|
Workers felt the need to convince stakeholders of what they felt was an invisible illness
|
Participants expressed feeling distrusted because of the continual need convince stakeholders of the legitimacy and severity of their mental health injury for the purpose of obtaining access to treatments, workplace accommodations, and financial support.
|
P4, P10, P12
|
Workers Concealed Wmhi’s And Distanced Themselves From Stressors As A Means Of Self-help And Self-preservation
The help-seeking narrative of participants began with reluctance to acknowledge and/or disclose their mental health struggles. The primary response of most participants (11 of 12) to WMHI’s was self-preservation by minimising, concealing and subsequently leaving their work or workplace. Fear of reprisal was a strong motivating factor. Nonetheless, these strategies had their limit and as participants continued at work, all eventually made changes to their work situation to distance themself from work stressors.
WMHIs were concealed in order to preserve self-image and regain coping capacity
For many participants the initial response to their emerging WMHI was not to seek help, but to deny or minimise their injury in an effort to avoid personal acknowledgement of “weakness” and/or being labelled as having a mental health condition. For example, in discussing his WMHI, Participant 4 admitted to his own internalised stigma, namely his thoughts that having a mental health injury meant he was mentally weak.
I guess I also have a bit of a stigma towards mental health because I certainly feel weaker, having had it ... so it kind of again why I drove myself not to take it [time off], I was just trying to get through the next year to get the vacation up not to admit to myself I needed a break, not to admit to myself I was having a problem that I could fix it myself, um ... yeah that’s a blow to the ego for sure.
Participant 10 used a physical issue, for which he was accommodated with time off work, to try and recover from his WMHI. As a police officer, this participant was conscious of the potential repercussions of disclosing a mental health problem including the loss of professional identity.
...but we as an industry, we have a big hesitation with any conversation around that because of the self-image and you identify yourself as a cop and if you lose access to your gun…so I think a lot of guys and girls will avoid that conversation and that was the same for me…
Initially participants believed that, if given some time to recover, they would be able to regain coping capacity and avoid labels of a WMHI from themselves and their employer and colleagues. Participants preferred to use their sick time or vacation time or a physical injury to conceal their mental health problem in the workplace. For the participants that discussed concealing their WMHI to gain pockets of time for recovery, this was largely unsuccessful and, as a result, they needed to employ increasingly drastic self-preservation tactics.
Workers were reluctant to disclose mental health problems and access support because of fear of being demoted and/or facing harassment and/or losing their jobs
Consistent with much previous research [48, 49], participants expressed concerns about the social and economic consequences of disclosing mental health problems with a particular focus on work and the workplace - i.e., losing out on promotions, being demoted, being assigned to undesirable modified duties and losing their jobs. These concerns were not unfounded as Participant 5 described how she was let go by her employer after taking time off work for her WMHIs:
So, they didn’t want to hire me full time, so they basically said there was no position for me. And they tried to make me feel guilty by saying, you know, there’s other people that come to work every day and they deserve the rollover [conversion to full-time employment] more than you and so you know, you shouldn’t fight it and let them have it. …they sent me a letter saying that I was a good employee and, but they had to, but they were saying goodbye, in a way that made it look like I wasn’t being fired.
Participant 4 highlighted the insidious stress of working with a WMHI label when he stated “...you are always worried about your job, what is being said and will they [the employer] in fact find wiggle room to fire you because they're worried you'll take more time off …”.
Even actions taken by employers with the intent of protecting the employee from harm, could still be a deterrent to employees in accessing appropriate support. As a police officer, Participant 10 explained that he was reluctant to step forward for fear of being stuck on a desk job and so chose to suffer in silence rather than come forward. Participants did not need to experience these outcomes directly; they were well-aware of other workers experiencing similar problems who suffered similar consequences. Fear of scenarios such as these deterred participants from disclosing mental health problems and accessing appropriate mental health supports.
Workers changed occupations or employers to distance themselves from the workplace situation or environment that caused WMHIs
Ultimately, most participants (n = 9) switched employers or occupations. Two participants felt that changing jobs but remaining with the same employer was sufficient to aid in their recovery from their WMHI. For some, walking away from their jobs resulted in a decrease or loss of income, but that was considered more psychologically acceptable than further mental stress, complete job loss, or possible permanent disability leave. Participant 4, for example, felt the only way to recover was to simply leave the job; “In my case it [WMHI] went away cause I switched jobs, I think I'd probably be back off again at some point if I was still working there.” Participant 7 firmly asserted that she would not return to her field (human services) owing to its triggering nature. “Like the bad memories and the nightmares and everything like that. Um, so I’m going to look at going into something else.” (P7)
Some participants self-advocated for workplace accommodations in an attempt to stay at work and access treatment support with limited success. Participant 4 received accommodation support from his psychologist to change his work schedule to reduce travel and be able to attend appointments, but this was not supported at the workplace. Consequently, P4 was unable to consistently attend treatment and subsequently left the job and workplace. P12 had similar problems with accommodations recommended by their psychologist denied by WSIB and the workplace.
Participants 9 and 10 managed to obtain ‘back door’ accommodations at the same employer. P9 requested a transfer to a different unit, which was denied but managed to bid into a different position through seniority provisions in the collective agreement. Participant 10 strategically initiated a change in positions due to a physical health issue, wherein he moved to a more administrative role with reduced work-related mental stress. Participant 12 was unique in obtaining permanent workplace accommodations which entailed moving her from rural work to urban work, where she felt better supported by other first responders and less likely to experience the same type of events which caused her WHMI.
Interestingly, even with the change of employer, occupational fields, or jobs, the resulting impact of the initial WMHI continued to follow participants into their new jobs as they still felt the need to protect themselves through concealment. Participant 11 discussed what it is like for her in her new job with a new employer:
It’s good yeah, I like this, the new job yeah it's a lot of the energy is going towards again looking healthy to seem more healthy than I actually am. ...I haven’t disclosed at work that I'm unwell and I’m quite afraid that it might backfire but for as long as I can keep going without disclosing that I’m, I’m going to do that.
Complex help-seeking pathways compounded stress and fatigue and lead to reduced independence in decision-making for help-seeking
This theme reflected the combined effort required to navigate complicated pathways to support compounding already present fatigue. Consequently, participants deferred decision-making for help-seeking to others, sometimes to their detriment.
Workers Experienced Complex Routes In Obtaining Resource Supports For WMHIs Recovery
Sociograms depict the complex pathways participants encountered in accessing workplace resources, healthcare resources, institutional resources and personal resources. Sociograms indicated that participants accessed between 4 (P3) and 16 (P12) workplace, healthcare, institutional, and personal resources. Sociograms also revealed the complex and varied nature of referral and access patterns for participants. A few (P3, P4, P9) were relatively simple, including 4 or 5 supports and direct pathways of referral and access. Others (e.g., P10, P12) were extremely complex with multiple direct and indirect pathways to help and with the participant being bounced back and forth between supports (e.g., P11).
Resource pools varied as well. Some participants had rich pools of personal resources (e.g., P2), while others were modest (e.g., P10, P12). The use of institutional resources was absent in six participants (P1, P3, P4, P7, P9, P11) who dealt with their WMHI without accessing any form of insurance or system support. Some made extensive use of workplace resources and found them helpful (P10, 4), while others made little use (P2, P4) and found any they used unhelpful. All accessed healthcare supports to varying degrees with varying degrees of helpfulness. For some, the Primary Care Physician provided the sole (P3, P8, P9) and most helpful source of healthcare support, while others had a rich network of healthcare support (P12). For those participants that experienced more straightforward paths, such as Participants 3, 4, 8, and 9, significant effort was still required for them to obtain help as was evidenced by their narratives.
The narrative trajectories shown in the supplementary material present a sequential overview of participant-accessed resources and the outcome from help-seeking. Help-seeking trajectories, when viewed together, highlighted that there was no singular or prescribed pathway to treat WMHIs. Most participants reported an arduous and complex help-seeking journey and sometimes the paths selected were unhelpful and the participant had to step back and try another route. Even those that had few points on the trajectory reported difficulty finding or accessing services or healthcare practitioners.
In addition to experiencing difficulty in finding help, participants also experienced difficulty accessing the available and suggested treatments. Participant 4, 10, and 11 discussed difficulties in accessing resources because of the times these were offered. For example, Participant 10 discussed how mental health supports in the workplace were scheduled around times that were only beneficial to office administrators, and as a result many of the individuals that worked in the field were not able to access these workplace resources. For Participant 11, some treatments prescribed by primary physicians were only available during regular work hours, thus making it difficult to attend. Participant 3 reported difficulty getting appointments with their family physician - a significant barrier, as most participants sought out guidance from their primary physician for treatment or referrals.
Systemic barriers proved to be another obstacle to help-seeking. When deciding which mental health supports were a good fit, some participants found themselves on the wrong side of the eligibility requirements. Participant 10, for example, was denied access to a counselling program supported by workers’ compensation, which resulted in anger and disengagement from help-seeking despite worsening WMHI symptoms. Others described that support programs sponsored by workplaces required formal diagnoses of conditions, like PTSD, that were hard to obtain in the first place and therefore left many workers not eligible for the program. Where benefit coverage was available to receive psychological services for a diagnosis, the number of sessions covered was limited resulting in large out-of-pocket expenses for the worker.
The challenge of accessing certain systems was also a barrier to help-seeking. The significant amount of time taken to process claims through the workers’ compensation system resulted in either delays in treatment or significant out of pocket expenses for participants should they decide to cover treatment costs. In some cases, these hassles resulted in participants opting out of that system. For example, Participant 8 had previous experience making a workers’ compensation claim for a physical injury and, as a result, decided to pursue an employment insurance claim for their WMHI to avoid what they considered to be persistent, invasive, and repetitive questioning by compensation caseworkers which they previously experienced during their physical injury claim. Although Participant 8 felt that EI was not an ideal system because it provided less financial and mental health service support, its simplicity was less emotionally taxing therefore more appealing.
Other participants did access support through workers’ compensation, with variable experiences, seemingly due to changes in claims adjudication. Submitting a claim prior to a change in legislation (2016) that de facto recognized compensation entitlement for psychological injuries in first responders, Participant 12 faced delays in accessing treatment due to the timeliness of the workers’ compensation claims adjudication process. As a result, P12 had to pay out of pocket for psychological services to receive a diagnosis that enabled their entitlement to benefits - a seemingly Kafkaesque situation. Applying after this change in legislation, Participant 6’s claim was accepted without question. While Participant 6 agreed that workers’ compensation required significant detail for claim acceptance, he felt that the experience of the caseworker that was assigned to him allowed them to discuss some of the more specific stressors because the caseworker already had a good understanding of the participant’s work environment and the common WMHIs in that occupation.
Despite further changes in legislation in Ontario to increase workers’ compensation entitlement for WMHI’s many participants remained uncertain about which avenue to pursue. For example, when Participant 7 was asked why she did not pursue a WSIB claim after legislation had passed in 2018 for chronic mental stress in the workplace, she replied that it had not occurred to her that she might be entitled to support owing to her problems being psychological rather than physical.
All these experiences provide evidence that help-seeking is a complex process requiring much energy, thought, and action. Help-seeking occurred at a time of reduced energy, decreased self-agency, and high stress. This affected the agency of some participants in accessing mental health supports.
As a result of complexity and fatigue, some workers deferred decisions regarding help-seeking to others, with positive and negative results
Some participants (n = 5), including those with a straight-forward path to accessing help, still felt a sense of reduced capacity in decision-making and thus deferred decision making to others. For example, when asked about taking alternatives to treatment options dictated by workers’ compensation, Participant 6 responded “I kind I let them dictate how that was going to go.” adding “... basically whatever WSIB said I had to do, I did…”
Deferring decisions was not necessarily negative for the worker. Participant 5 related the support of their manager in accessing treatment support.
...one day I got to work and I freaked out, like I couldn’t go in the gate, I just freaked out in the parking lot and another officer was there and she went and got my manager, my manager said the psychiatrist is in today, I want you to go see him. So, I went and saw the psychiatrist and he became my psychiatrist and he put me in the hospital at one point and that’s when I got diagnosed.
Participant 12 enlisted the aid of her spouse who recognized that she was not coping well and insisted that she seek treatment. Also, a first responder, her husband recognized her symptoms of PTSD and understood the type of help needed.
Nonetheless, deferring decision-making to others had its risks. This was evident in the data from P5 whose manager advised against filing a workers’ compensation claim, despite the apparent material relationship between work conditions and the WMHI. Going along with this suggestion precluded P# from income replacement and treatment support afforded through the workers’ compensation system.
(Mis)trust Contributed To Resources Accessed And The Perceived Value Of Those Resources
Although not as prevalent as the first two themes, two facets of trust emerged that influenced participant help-seeking - trust in the source of help and feeling mistrusted by others in seeking help.
Workers trusted WMHI resources referred from within their group and not under the perceived influence of employers
Participants, and in particular first responders, in the sample placed a high degree of trust in resources that were recommended by colleagues and other first responders owing to their shared experiences in the field. As P7 related:
… so the officers and fire guys and EMS, we all, we all kind of talk and say hey, have you tried so and so or hey, I’m seeing so and so, this is what they do and it’s really working or it’s not really working. ...I know a lot of the guys and myself included, like, that’s your first go to is your, you know, your fellow workers,”
Participant 10 also discussed how, when they were at the point of needing time off work for mental health recovery, they sought out a colleague who experienced a similar situation and had also sustained a WMHI and sought help. Participant 10 said “I think the first time I went for a note for work would’ve been with the woman that my other deployed friend referred me to.”
Conversely, some participants (n = 3) viewed employer-supported resources with skepticism related to the motivation to provide support resources and the dual allegiances of employer-sponsored providers. Some participants felt employer provided resources were a band aid for postering over the problems in the workplace rather than a meaningful attempt to solve the workplace mental health problems. Participant 4 talked about their human resource department and their role in providing mental health resource supports:
...they would do a typical poster you'd see at work, ya know here’s an employer, I think it was called EAP, employer-employee assistance program and there’s mental health in it and they would say ya know "take a walk at lunch time for mental health" so on and so forth ... it was a poster of points every couple of months from HR, it was kinda an afterthought, certainly with physical stuff [i.e., physical injuries] was more important...
Not only did participants have concerns around how attuned their employer was with their needs for mental health supports, but participants also had doubts around confidentiality of the supports being provided by employers. Participant 4 expressed this concern when stating:
…part of me also thinks, the company pays for it, maybe it’s not as confidential as going some of the other routes, more regulated, like the psychiatrist with the patient doctor confidentiality and the psychologist was paid for by me so there’s no obligation to come back or write anything to the employer.
Participant 10 echoed this mistrust when contrasting reaching out to colleagues for help versus accessing workplace support.
... it’s a lot easier if you're ya know speaking to your colleagues about versus reaching out and do what the company's offering cause there’s that mistrust, the suspicion, ya know if I tell them this, am I gonna get burned on that ya know that sorta thing.
In a similar vein, P2 described how being mandated to attend a psychotherapist of the insurer’s choosing affected their response to the intervention.
They were helpful but again, that’s like, it can only be as helpful as you allow it to be, right, you know, if somebody, if somebody says the insurance company says I have to do this so I am sitting here and I’ll just, we can just sit and stare at each other for 10 sessions, for 10 hours, whatever but that’s the thing right.
Workers felt the need to convince stakeholders of what they felt was an invisible illness
While participants felt that they may not always be able to trust stakeholders they also felt that they, themselves, were not trusted throughout the process. To obtain help they felt the need to constantly convince others of what seemed to be an invisible illness to the outside world. When Participant 12 experienced a WMHI and sought help through workplace resources, she felt she had to go through the incident meticulously and justify it was severe enough to cause injury just to receive support.
I really forensically went through the call too, so then I could take it to them because at that point it became me having to justify why I was having the reaction that I was having so I had to like explain whether it was scary enough to be able to be approved [for treatment support] and, and that’s what has happened every uhm, recurrence since, is it has to be scary enough to have brought my PTSD symptoms back.
Some participants (n = 4) discussed the invisibility of mental health injuries and the perceived workplace attitudinal differences between mental health and physical injuries. Participant 8 stated “I'm sure if I had broken my leg or my arm ya know what I mean in a cast it would have been a lot different because there was something physical instead of me just being off work for mental health.”
In addition to workplace parties, sometimes health care professionals needed to be convinced of their invisible illness. Participant 11, for example, had a difficult time in convincing her doctor that she had sustained a WMHI and the severity of her injury. The time spent trying to convince her primary physician resulted in additional delays in obtaining care by a psychiatrist. Having to participate in independent medical examinations was also a sign to workers that they were not to be trusted despite the gravity of the circumstances leading to the problem. In convincing others about the severity of their problem, participants discussed how having to retell stories again and again resulted in retraumatization.