Military veteran engagement with mental health and well-being services: a qualitative study of the role of the peer support worker.

Abstract Background: Many UK military veterans experiencing mental health and well-being difficulties do not engage with support services to get the help they need. Some mental health clinics employ Peer Support Workers (PSWs) to help veteran patients engage, however it is not known how the role influences UK veteran engagement. Aims: To gain insight into the role of peer support in UK veteran engagement with mental health and well-being services. Method: A qualitative study based on 18 semi-structured interviews with veterans, PSWs and mental health clinicians at a specialist veteran mental health and well-being clinic in Scotland. Results: Four themes of the PSW role as positive first impression, understanding professional friend, helpful and supportive connector, and an open door were identified across all participants. The PSWs’ military connection, social and well-being support and role in providing veterans with an easily accessible route to dis-engage and re-engage with the service over multiple engagement attempts were particularly crucial. Conclusions: The Peer Support role enhanced veteran engagement in the majority of instances. Study findings mirrored existing peer support literature, provided new evidence in relation to engaging UK veterans, and made recommendations for future veteran research and service provision.


Introduction
There is growing awareness that some veterans experience difficulties in transitioning to civilian life when they leave military service (Samele, 2013). A UK veteran is defined as anyone who has served as a member of the British military forces for one day or more (Macmanus & Wessely, 2013). Veterans account for approximately 2.56 m of the UK population (Ministry of Defence, 2015). UK veteran needs are considered in a Military Covenant which includes the State's duty of care to ensure veterans do not suffer disadvantage as a result of their military service (Macmanus & Wessely, 2013). The majority of UK veterans make successful transitions into civilian life after military service (Iversen et al., 2005b), however a significant minority of UK veterans experience complex, comorbid mental health and well-being difficulties including depression, anxiety, anger, alcohol addiction, homelessness, unemployment, relationship breakdown, criminal offending and social exclusion (Fear et al., 2010;Johnsen et al., 2008;Klein & Alexander, 2012;Murphy et al., 2008;Murrison, 2010).
Research indicates that part of the problem is that many UK military veterans experiencing mental health and wellbeing problems have difficulties engaging with mental health treatment programmes to get the help they need (Iversen et al., 2005a;Kitchiner et al., 2012), as evidenced by their not seeking help or attending mental health appointments (Owen et al., 2016). Veterans do not engage for a number of reasons including mental health stigma (Klein & Alexander, 2012), not feeling understood (Murrison, 2010), poor recognition of treatment need (Iversen et al., 2010), feeling alien and disconnected from civilian support services (Ahern et al., 2015) and only accepting the need for help when a crisis point is reached (Murphy et al., 2013). This has led to questions in the UK about how best to configure mental health and wellbeing services to engage veterans, and to questions about whether veterans should attend civilian mainstream services or whether they require veteran specific services (Iversen et al., 2011;Murrison, 2010;The Scottish Government, 2007).
Various studies suggest Peer Support helps patients to engage with mental health services (Gillard et al., 2015). Peer Support is a wellness model in which individuals with shared experiences support others in recovery (Gillard & Holley, 2014). Peer Support has been associated with positive role modelling (Davidson et al., 2006), reduced mental health stigma (Vayshenker et al., 2016), recovery (Collins et al., 2016), trust (Greden et al., 2010), feeling authentic (Rebeiro Gruhl et al., 2016) and increased social connection .
A recent review article examining the development of an Optimal Integrated Care Pathway for military veterans suggested UK veterans found peer mentoring beneficial (Kitchiner & Bisson, 2015). However, there is currently limited research on Peer Support in relation to engaging the UK veteran population with mental health and well-being services.
Australian studies suggest veteran Peer Support Workers (PSWs) enhance veteran patients' sense of belonging, shared identity and self-determination (Bird, 2015). In addition, Canadian research suggests veteran PSWs increase veteran patients' sense of brotherhood, connection and mental health recovery (Westwood et al., 2010). Furthermore, US studies suggest that PSWs enhance veteran engagement with mental health services and the provision of veteran centred care (Chinman et al., 2015).
Peer Support research is encouraging but needs to be treated with caution in relation to the UK veteran population for a number of reasons. International veteran peer support research may not generalize well to the UK due to the different health and welfare systems (Klein & Alexander, 2012). In addition civilian peer support research may not generalize well to the UK veteran population due to the qualitatively different nature of the PSWs shared peer experience: PSWs employed to engage UK veterans tend to have shared peer experience of military service and adjustment to civilian life; whereas PSWs employed to engage UK civilians tend to have shared peer experiences of mental health difficulties and recovery.
Research is needed to explore the role of the PSW in veteran engagement in the UK, to understand the factors within this role which may promote veteran engagement. This qualitative study aims to inform this gap in the literature by exploring veteran, PSW and mental health clinician thoughts, feelings and experiences of the PSW role in veteran engagement at a UK clinic; providing insights and guiding future veteran research and service provision.

Research design
Semi-structured interviews were conducted to address the exploratory research question. Interview transcripts were analysed using an inductive Thematic Analysis (Braun & Clarke, 2006).

Research setting
Participants were purposefully recruited to the study from a specialist NHS veteran mental health and well-being clinic in Scotland. The clinic employs veterans in PSW roles to promote veteran engagement with the service at all steps of the recovery process, from first contact, to treatment and recovery. The PSWs provide the well-being service at the clinic in partnership with external agencies, supporting matters such as housing, employment and finances. The PSWs also refer veterans to the on-site psychiatrist and psychologists for assessment and mental health treatment.

Participants
Veteran, PSW and mental health clinician (clinician) participants were recruited to the study.

Inclusion criteria
Veteran participants were included if they had been referred by the NHS to the clinic or had self-referred, and had experienced mental health treatment and/or well-being support in the last 12 months at the clinic. PSW and clinician participants were included if they had worked at the clinic for 3 months or more.

Exclusion criteria
Participants were excluded if they were not able to meet the researcher to participate, or were too mentally unwell to participate.
The study included 18 participants overall: veterans (n ¼ 10), PSWs (n ¼ 4) and clinicians (n ¼ 4). We took a pragmatic approach to determining sample size, based on the pool of participants available within the setting. We aimed to recruit an overall sample of at least 15 participants (Guest et al., 2006), drawn from the veteran, PSW and clinician groups, and encompassing a broad range of experiences. Seventeen veterans expressed initial interest in participating in the study, however seven did not respond to contact to arrange an interview. This is consistent with difficulties recruiting veterans to participate in other research studies (Hotopf & Wessely, 2005).
PSWs were aged between 35 and 54 years, two were male and two were female, all served in the army and had experience in the role of between 6 months and 3 years. Clinicians (C) were aged between 25 and 44 years, two were male and two were female and all had no military background. Clinicians included three psychologists and one psychiatrist, with experience in the role of between 11 months and 5 years. Veteran (V) characteristics are described in Table 1.

Materials and procedure
The study was approved by The Ethics Committee of the University of Stirling, and by NHS South East Scotland (reference NR/163AB4). One researcher (BW) recruited participants to the study. Participants currently attending or working at the clinic were approached in person (n ¼ 15), and former patients no longer attending the clinic were approached over the phone (n ¼ 3). Participants were informed the study was confidential and that all participant data were anonymised. Consented participants were interviewed at the clinic (n ¼ 17) or at NHS Education for Scotland (n ¼ 1) from May to July 2016. There was no recompense for participation. Using semi-structured interviews, participants were asked open questions to explore their thoughts, feelings and experiences of the PSW role. Questions included ''Can you tell me about your experience with your PSW?'' and ''How did your relationship with your PSW develop?'' Additional probing questions were used to explore answers in more detail.
Interviews were recorded and transcribed verbatim. Interviews lasted between 23 and 75 min. One researcher (BW) conducted the interviews. BW approached the study as an active participant and from a critical realist perspective (Wikgren, 2005), exploring participants' expressed views and implied meanings; and noting personal impressions and nonverbal observations before and after interviews in a reflexive journal.

Analysis
Braun & Clarke's (2006) guide to thematic analysis was followed. Data were analysed by participant group starting with veterans, PSWs and then clinicians. Two researchers (BW and MC) conducted initial analysis of the data. Familiarisation and coding were performed manually by reading and re-reading the interview transcripts, marking relevant statements with a highlighter and assigning a brief descriptive label for each statement in the transcript margins. BW systematically coded all data sets, and collated all statements under each code in separate files. Through a process of constant comparison BW and MC agreed initial grouping of codes. BW then systematically sorted all codes in to larger internally coherent sub-themes and themes. BW and MC reviewed the themes and agreed there was a congruency in the narratives of the three participant groups in relation to the research question, the codes and the entire data set. Participant (V, PSW & C) themes and sub-themes were merged together, defined and named.

Results
Participant (V, PSW & C) themes and sub-themes are outlined in Table 2.

Positive first impression
Most of the veteran participants suggested the PSW role enhanced their engagement with the service, beginning with an immediate positive impression of the PSW role as welcoming, credible and reassuring.
You just come in, and you feel welcomed there. . . ''Come in, how are you? You like a coffee, tea?'' Straight away, it's like it lifts a burden away from you. (V9) I can't really speak too highly of him. If it hadn't been for PSW2, I wouldn't have been getting the help. . . I'd already made my mind up in that first interview. (V7) All of the participants (V, PSW & C) suggested the PSWs military veteran experience was particularly crucial. Most (V, PSW & C) suggested this was because many of the veterans attending the service distrusted civilians and had an enduring sense of veteran identity, regardless of their length of military service or number of years being a veteran. This shared veteran identity facilitated easy conversations between the veterans and the PSWs, grounded in shared veteran experiences, which were more positive and reassuring than their interactions with civilian and NHS services.
It makes a huge difference, I think if she hadn't been a veteran it would have been much more like dealing with  Some participants (PSW & C) also suggested the PSW's military veteran identity engaged veterans with the service by normalising veteran help seeking behaviour and enhancing the credibility of the clinicians' and the service overall.
The clinical team wouldn't be taken half as seriously, if it wasn't for the Peer Support Workers. (C1) Some participants (PSW & C) suggested the PSW role did not help veterans to engage with the service in a minority of instances due to mental health stigma. For example, some veterans attend the service for clinical treatment only, and insist they do not require PSW contact after the initial registration meeting. In addition, some clinicians and PSWs postulated that a minority of veterans may fail to engage with the service when they feel the veteran connection is too personal, such as when the veteran and PSW served in the military at the same time, in the same regiment.
Our services within the same regiment overlapped. . .he never came back to the service. . . perhaps it did work against me. (PSW2) So I've certainly had the case where people have not wanted to talk about something with their Peer, because they know they were there. (C2)

Understanding professional friend
Most participants (V, PSW & C) suggested the PSW role made the veterans feel their military, mental health and wellbeing issues were understood, without the need for lots of explaining. This perception of understanding was crucial to the engagement as it appeared to reassure the veterans and minimise their mental health stigma, frustration and embarrassment while talking about their vulnerabilities, thoughts and feelings. All of the PSW and clinician participants suggested the PSW role required careful training and supervision, and recruitment of PSWs with veteran experience and the correct skills and competencies, particularly compassion. They suggested this was important because the PSW role included many challenges: working directly with actively unwell patients, managing veterans that behaved in difficult and demanding ways at times, and managing personal conflicting beliefs about behaviour or entitlement to the service. Most participants (V, PSW & C) suggested the PSW role engaged veterans with clinical assessment at the service by selling clinician expertise and treatment method credibility. This is reflected in the participant characteristics (Table 1) which includes four veterans who agreed to self-refer for mental health assessment at the service following discussions with their PSW. I think when you're feeling bad, they're [PSWs] an essential part of the team. . . You maybe need to be dragged a little bit, or pushed a little bit towards something. (V10) Being very directive with some [veterans]. . . you need this, you will turn up. (PSW3) Putting a kind of friendly face on that, and reassuring them [veterans] it's all evidence based stuff. (PSW2) I've heard them [PSWs] say ''oh don't worry, that person will see you''. . . our psychiatrist is really nice.'' (C3) Many participants (V, PSW & C) also suggested the PSW role enhanced veteran engagement with on-going mental health treatment at the service by improving the clinical process and treatment experience in direct and indirect ways. Direct ways included meeting the veterans before and after mental health treatments. Indirect ways included providing the clinicians with information about the veteran patient's well-being progress between mental health treatments, and helping the clinicians to better understand veterans' feelings and behaviours about military contexts. I think the real expertise of the service is. . . [PSWs] specialist knowledge. (C4) It's an ongoing process in therapy. . . you need to be reformulating. . . establishing safe bases. . . draw more from the PSW to sort of help with that. (C1) Most PSW and clinician participants highlighted the subjective nature of veteran engagement, and how important it was for the PSWs to exercise discretion and judgement, and pro-actively manage the amount and nature of the engagement with each veteran on a case by case basis over time. This was important because the PSWs did not want the veterans' to form attachments to the clinic when they were no longer required, the PSW role ultimately aimed to support veterans' with transitioning to engage with civilian life as their mental health and well-being improved.
You can normally sense when it's time to let them go. . . there's a girl I've had on the books. . . now she's engaged with other things outside. . . volunteering. . . I don't need to be interfering in that. (PSW3)

Open door
Many participants (V, PSW & C)} suggested the PSW role enhanced veteran engagement with the service over multiple engagement attempts in many instances, providing a nonjudgemental open door conduit for veterans to dis-engage and re-engage with the service as needed. They felt this aspect of the PSW role was crucial because veterans often needed multiple attempts at engaging with the service; needed to reengage as their circumstances changed over time; or engaged with the service in crisis. This is reflected in the participant characteristics (Table 1) which shows that four of the five reengaged veteran participants were receiving mental health treatment at the service at the time of this study.
It was just in destructive mode. I had lost a lot in my life. . . business. . . the family broke up. . . prison. . . But at the time I couldn't connect. . . It was just too much for me. (V2) It makes me feel more confident asking. Cause before I thought I'll just struggle on my own. (V3) They're not really wanting, or not being able to access help at that time. (C1)) You're always a client of ours, you're never discharged. (PSW2)

Discussion
The PSW's military connection was particularly crucial to how the PSW role engaged veterans with the service in direct and indirect ways. From the initial positive impression of the service and throughout the veteran's treatment pathway at the service, the PSW's military connection helped to reduce veteran mental health stigma and normalise veteran mental help seeking behaviour. In addition the PSW role helped to provide veteran patients with a more veteran centred clinical process and treatment experience, and create an environment of belonging, shared identity and understanding. These findings mirror existing international veteran research (Bird, 2015;Chinman et al., 2015;Westwood et al., 2010). These findings also appear to support recommendations for mental health services to be veteran led (The Scottish Government, 2007) and suggest PSW roles designed to engage UK veterans should include veteran experience as an essential recruitment criteria.
The PSW role as the open door conduit to the clinic was also extremely important to the engagement.
Participants suggested veterans often needed PSW support to dis-engage and re-engage with the service over the course of multiple engagement attempts. The PSW role supported this multiple engagement attempt process by welcoming the veterans back to the clinic in a non-judgemental way, without issuing penalties for previous non-attendance at clinics or long wait lists to see clinicians for assessment. This finding appears to support the recommendation for veteran mental health services to be accessible (The Scottish Government, 2007), and provides new research detail about the level of accessibility and support UK veterans need. This finding also raises questions about the configuration of services. For example, are current mental health pathways in the UK adequately accommodating this veteran need for multiple engagement attempts?
The PSW's role in providing veterans with social and well-being support grounded in shared peer experience were also identified as key to the engagement. The PSW's in this study had shared peer experience of being a veteran, which included knowing military people in common, experiencing military deployments at the same place, and having a shared understanding of the cultural differences between military and civilian life. Consistent with existing civilian PSW research, the veteran PSW role provided friendship, social connection and trust (Greden et al., 2010;Lucksted et al., 2015), and helped reduce mental health stigma (Vayshenker et al., 2016), improve quality of life (Repper et al., 2013) and inspire positive role modelling (Davidson et al., 2006). This finding is interesting because the veteran PSWs in this study have shared peer experience of being a veteran, whereas the civilian PSWs in the civilian studies have shared peer experience of recovering from a mental health difficulty. This finding suggests that PSWs with qualitatively different shared peer experiences can engage mental health patients with mental health services in similar ways.
PSW supervision, training and competencies were considered important to veteran engagement with the service. The need for PSW supervision and training mirror existing research (Repper & Carter, 2011), however this study also highlighted the need for competencies such as compassion and judgement. Compassion was considered important in the PSW role to ensure veterans attending the service felt fully supported regardless of their behaviour or length of military service. Judgement was considered important in the PSW role to ensure veterans were engaged with the service on a case by case basis to support their individual needs. These findings demonstrate the subjective nature of veteran engagement and the PSW role, and highlight the need for future PSW research to acknowledge this, and include both quantitative and qualitative evaluation. In addition, these findings suggest veteran experience, competencies and support environment are all important in how the PSW role engages veterans with services. Future research could explore the lived peer experience required to optimise the PSW role in veteran engagement with mental health and well-being services. For example, would PSWs with both veteran and mental health lived experiences provide additional benefits to the PSW role in veteran engagement with services? Future research could explore the role of the PSW in veteran engagement with mental health services with a Randomised Control Trial methodology testing differences in engagement when there is no PSW, civilian PSW not attached to veteran services and PSW within veteran services.
Some of the PSW's and clinician's hypothesised that the military connection may dis-engage a minority of veterans that directly served in the military at the same time and in the same regiment as the PSW, due to mental health stigma. There is no evidence that this is the reason a minority of veterans fail to engage with the service, however it is a possibility. Future research could explore this further, and services may want to bear this in mind when assigning PSW's to veteran clients.

Limitations
The study includes veteran participants that successfully engaged with PSWs at one clinic in Scotland and mostly served in the army. The study, therefore, has limited representation of veterans that served in other military forces, and no representation of veterans that failed to engage with the PSWs, veterans opting for clinical only treatment at the clinic and veterans engaged in mainstream NHS services without PSW support. These are limitations and it would be beneficial to understand the perspectives of these veteran groups in future research.

Conclusions
This exploratory study suggests the PSW role enhanced veteran engagement with mental health and well-being services in direct and indirect ways in the majority of instances. The PSW role provided a positive first impression of the service, an understanding professional friend, a helpful and supportive connector to the services provided and an open door to re-engage with the service when needed. The PSWs military connection, social and wellbeing support, and role in providing veterans with an easily accessible route to dis-engage and re-engage with the service over multiple engagement attempts were particularly crucial. Study findings mirrored existing peer support literature, provided new evidence in relation to UK veterans and made recommendations for future veteran research and service provision.