Peer Support for Whistleblowers

Peer Support for Whistleblowers tsmith Tue, 06/27/2017 - 08:12

Article Type

Article

Changed

Wed, 03/27/2019 - 11:48

Author(s)

Jacqueline Garrick

MSW

LCSW-C

Whistleblowers report illegalities, improprieties, or injustices. They step forward wittingly or unwittingly to report perceived wrongdoing. But when a whistleblower takes on powerful and entrenched systems or people, retribution and retaliation often ensue, endangering their career and reputation. These negative consequences can have longterm impacts on the lives of those who believed they were acting in the public interest especially when patient care or public safety was at risk.

The following account is based on personal and professional experiences, conversations with more than a dozen other whistleblowers at the DoD, VA, several other organizations, and a literature review. This documentation of those informal peer conversations, combined with the research, is meant to provide insight into the experiences of a whistleblower and the need for peer support so that employees can remain resilient.

Adverse Whistleblower Experiences

Most employees do not set out to be whistleblowers. The process begins when the whistleblower perceives wrongdoing or harm that is being committed in their workplace. At a health care organization, whistleblowing often is focused on individual or organizational illegal or unethical activities, such as funding or contracting fraud, corruption, theft, discrimination, sexual harassment, public health safety or security violations, persistent medical errors, nepotism, or other violations of workplace rules and regulations. VA employees who experience, witness, or discover wrongdoing may choose to disclose their concerns to a supervisor, senior leader, the Office of the Inspector General (OIG), Human Resources or Equal Employment Opportunity (EEO) Office, Employee Assistance Program (EAP), Office of Special Counsel (OSC), Congress, or to a news organization.

According to the 2013 National Business Ethics Survey, more than 6 million American workers who reported misconduct experienced some form of retaliation.1,2 Retribution can manifest in various overt or covert ways, ranging from outright retaliation and further discrimination to other forms of marginalization. For example, a VA physician alleged that he was detailed to an empty office with no patients after reporting patient wait list mismanagement at his hospital. Other whistleblowers report having misconduct charges levied against them, demotions or loss of position, obstruction from promotion, poor performance evaluations, details to more minor assignments, relocation to more meager office space, or pressure to resign or retire.3

Whistleblowers are rarely rewarded for reporting misconduct within their organization. The Joint Commission describes barriers to reporting sentinel events by medical professionals fearing humiliation, litigation, peer pressure, and oversight investigations if they identify medical errors.4

Once allegations are made, the information often is conveyed to a supervisor or leader. For example, some whistleblowers who have reported a hostile work environment to the DoD EAP have noted that the EAP representative contacted the whistleblower’s manager to mediate the situation. This process can take months or years to resolve. In those instances, the managers are rarely relocated. The whistleblower usually is the one forced to move or take another job, which is not always consistent with their job description, and in turn, may impact their performance rating and opportunities for promotion.

Often, OIG and OSC investigations at the VA and other federal agencies can take as long as 2 years. During that time the whistleblower may remain in a lesser or unwanted position or leave the agency. However, even when OIG substantiates claims of wrongdoing, the agency can make recommendations only to leadership, which may or may not be enacted. Whistleblowers report having to submit Freedom of Information Act requests to learn of the outcome of an OIG investigation when leadership chooses to ignore the recommendation.

Civilian government employees are undervalued by society in general, and the negative stereotypes of lazy, shiftless workers abound, even though many civil servants work to protect the nation’s health, welfare, and safety. Civil servants are familiar with derogatory expressions, such as “bureaucratic bean-counter,” and “good enough for government work.” Even President Trump stated that he would come to Washington, DC, and “drain the swamp.” Yet civil servants can go years without a cost of living increase, a promotion, or a bonus but still be asked to perform additional duties or work long hours to the sacrifice of a work/life balance.

In the Federal Employee Viewpoints Survey and other employee environmental climate scans, high levels of workforce stress often are related to the number of grievances filed, the level of morale, the rates of absenteeism and retention, recruitment shortages, and lost productivity.5  Success in toxic environments usually is based on trying to maintain a “go along to get along” status quo, which means looking the other way when contracts are fraudulently awarded or employee discrimination occurs. If leadership is antagonistic to reform, then identifying wrongdoing may come at significant personal risk.

Retaliatory Practices

Once a whistleblower has stepped forward, retaliatory practices may follow. There are tangible legal, financial, social, emotional, and physical tolls to whistleblowing. “Be in for a penny. Be in for a pound,” an OIG official advised one whistleblower. Once a disclosure is made, the process may become arduous for the whistleblower and require individual resilience to face adversity.

Keeping in mind that OIG, EEO, EAP, and OSC are government agencies that investigate, police, and monitor the system, they do not represent the civil servants who document and identify much of the evidence of wrongdoing on their own. Most civil service employees are not subject matter experts on the U.S. legal code that outlines prohibited personal practices or the Federal Acquisition Regulation.

The Notification and Federal Employee Antidiscrimination and Retaliation (NO FEAR) Act authorized in 2002 (U.S. Code § 2301) is designed to inform and protect those who file grievances or disclosures, but operationalizing those protections can be overwhelming and confusing. If a whistleblower wants advice, he or she must retain legal counsel often at a substantial personal cost. Whistleblowers report spending from $10,000 to more than $100,000 in legal fees for a 1- to 2-year investigation.

These legal fees may force whistleblowers to use family finances or borrow money while hoping for justice along with remuneration in the end. In some cases, the financial impact is compounded when the whistleblower has been demoted, denied a promotion, or fired. For medical professionals, the impact might result in the loss of hospital privileges, professional credentials, or state licensure. The loss of income also can lead to loss of health insurance. The legal and financial burdens impact marriages, spousal job options, retirement, and other family choices (eg, vacations, children’s schools, and caregiving obligations).

During investigations, social status and the reputation of the whistleblower are often impugned. For example, whistleblowers are sometimes depicted as snitches, moles, spies, or tattletales and may be categorized as paranoid, disloyal, or disgruntled by leadership. Rarely are whistleblowers labeled protectors, patriots, or heroes, despite the few high profile cases that come to light, such as Karen Silkwood, Erin Brockovich, or Frank Serpico.

More often, whistleblowers’ reputations, especially in civil sectors, are damaged through acts of discrimination, such as bullying; mobbing (asking other employees to monitor and report on the activities of the whistleblower); ostracizing the employee from the team; devaluing the contributions or the performance of the whistleblower; blackballing from other jobs or opportunities; doublebinding with difficult tasks to complete; gaslighting by calling into question the memory of the whistleblower, the reality of the accusation, or its scope; and marginalization. Accusations of misusing funds, inaccurately recording time and attendance, and disputing their judgement are all tactics used to socially isolate and harass whistleblowers into dropping their case or leaving the organization.3

Furthermore, this level of ostracism has documented impact on the psychological and physical well-being of the employee and negative consequences to the overall functioning of the organization.6 Consequences, such as physical violence and property damage at the time of termination and at other betrayals have occurred.3,7 Other whistleblowers have reported being threatened in person or on social media, harassed, and assaulted, especially in the military.

Whistleblowers, similar to others who are bullied in the workplace often described feelings such as fear, depression, anxiety, loneliness, and humiliation.8 These feelings can lead to whistleblowers needing treatment for substance abuse, depression, anxiety, posttraumatic stress disorder (PTSD) and suicidal ideation.9 Multiple studies on depression and PTSD show a correlation to increased morbidity and mortality.10 However, whistleblowing retaliation is not clearly established as a traumatic stressor in relation to PTSD.11

Insomnia and other sleep disturbances are not uncommon among whistleblowers who also note they have resorted to smoking, overeating, alcohol misuse, or medication to manage their distress. Health consequences also include migraines, muscle tension, gastrointestinal conditions, increased blood pressure, and cardiovascular disease.12

Peer Support Models

Studies of peer-to-peer programs for veterans, law enforcement officers, widows, cancer patients, disaster victims, and others bound by survivorship suggest that peer groups can be an effective means of support, even though the model may vary or be adapted to a specific population. In general, peer support is centered on a common experience, shared credibility, confidentiality, and trust. The approach is meant to provide nonjudgmental support that assists with decision making and resilience and provides comfort and hope. Most peer support or mentorship models require some level of peer counselor screening, competency training on an intervention model, supervision, monitoring, and case management by a more senior or credentialed mental health professional.13

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) recognized that health care systems that support civil servants, military members, and veterans can benefit from partnerships with internal (eg, human resources, unions, or dedicated EAP) or external (eg, nonprofit and service organizations) employee peer support programs. The DCoE noted that peer networks facilitate referrals to medical care when threats of suicide or harm to others exists, offer additional case management support, and assist professionals in understanding the patient experience.13

Peer support offered at VA hospitals is conducted by peers who are supervised by mental health clinic staff (usually social workers).14 Law enforcement EAP is another example of peer support within an organization to augment mental health and resilience among officers who have experienced first-responder trauma.

External peer support resources can be accessed through partnerships or referrals. For example, the Tragedy Assistance Program for Survivors (TAPS) relies on survivors of military deaths to support each other through bereavement. Although the DoD offers casualty assistance and mental health care to grieving families, the level of peer support differs from TAPS.15 In another example, Castellano documented the benefits of a reciprocal peer support model implemented across 10 peer-based call center programs that manage high risk-populations.16 Core training was consistent across all programs, and mental health professionals supervised call center peer support providers. This peer/clinician collaboration enhances the overall community mental health efforts.

Temple University documented the patient care benefits for behavioral health services that augmented treatment with evidence-based peer support interventions.17 The researchers found that hospitals that used a peer model improved patient outcomes as demonstrated by fewer hospitalizations, increased life satisfaction and enhanced coping skills, increased medication adherence, and reduced substance abuse or suicidal ideation. Additionally, the peer providers themselves experienced positive health benefits based on their ability to help others, improved their own self-efficacy and gained social and economic growth based on their employment satisfaction.17

Peer Support Interventions

Peer support interventions have been effective with various populations and may be effective for whistleblowers as well. Since whistleblowing tends to involve legal processes that call for privacy and the confidentiality of all parties, whistleblowers experience isolation and alienation. Other whistleblowers can better understand the retaliation, discrimination, and isolation that results. In some instances, whistleblowers discovered years later that other employees had similar experiences. An organized, structured program dedicated to peer support can help employees within a health care system or EAP manage the impacts of identifying wrongdoing.18 Peers may be able to break down this isolation and help establish a new network of support for those involved in whistleblowing cases. Restoring a sense of purpose, meaning, and belonging in the workplace is of significant value for the whistleblower.19 Peers can mentor a whistleblower through the investigative process and help determine next steps. Peers can address building, maintaining, and sustaining resilience to overcome adversity.

Peers who already have experienced their own legal, financial, social, emotional, and physical risks and have developed the necessary resiliency skills to survive make ideal peer counselors.20 These peers have faced similar challenges but have perservered.21

Although peer counselors cannot replace an attorney or mental health provider, they can provide background information on the roles and functions of EEO, EAP, OIG, OSC, and the MSPB and how to navigate those systems. Peers can assist whistleblowers in preparing testimony before congressional hearings or for press interviews. Peer supporters also can encourage whistleblowers to seek care for mental and physical health care and to remain adherent to treatment regimens. They case manage a team effort to enable the whistleblower to overcome the adversity of retaliation.

Creating A New Normal

After the Civil War, the False Claims Act, known as the Lincoln Law, served to protect federal reconstruction activities in the South from individuals who attempted to defraud the federal government.22 Today, most Americans are familiar with WikiLeaks. For generations, whistleblowers have exposed wrongdoing in order to protect or reform governmen programs. Whistleblowers have exposed graft and corruption at the highest levels and in daily operations. They have fought for diversity and inclusion and a workplace free of sexual harassment and assault. They have protected taxpayer dollars from waste, fraud, and abuse.

Despite the personal sacrifices often required, most whistleblowers’ spirits are bolstered by the positive outcomes that their disclosures may produce. However, whistleblowers need compassionate and competent assistance throughout the process. Peers can foster the resilience needed to survive the adversarial nature of the whistleblowing process. Therefore, whistleblowers need to be viewed in a new light that involves advocacy, transparency, and peer support so that positive outcomes in government can be realized for all Americans.

References

1. Ethics and Compliance Initiative. National Business Ethics Survey (NBES) 2013. http://www.ethics.org/ecihome/research/nbes/nbes-reports/nbes-2013. Published 2013. Accessed June 5, 2017.

2. Schnell G. Whistleblower retaliation on the rise—bad news for whistleblowers and their employers alike. http://constantinecannon.com/whistleblower/whistleblower-retaliation-on-the-rise-bad-news-for-whistleblowers-and-their-employers-alike/#.WNJ1s4WcEYh. Published January 18, 2013. Accessed June 5, 2017.

3. Devine T, Maassarani T. The Corporate Whistleblower’s Survival Guide: A Handbook for Committing the Truth. San Francisco, CA. Berrett-Koehler Publishers; 2011:19-40.

4. The Joint Commission. What Every Hospital Should Know About Sentinel Events. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2000.

5. Reed GE. Tarnished: Toxic Leadership in the U.S. Military. Lincoln, NE; University of Nebraska Press, Potomac Books; 2015:60.

6. McGraw K. Mental health of women warriors: the power of belonging. In: Ritchie EC, Naclerio AL, eds. Women at War. New York, NY. Oxford University Press; 2015:311-320.

7. Blythe B. Blindsided: A Manager’s Guide to Catastrophic Incidents in the Workplace. New York, NY: Penguin Group; 2002:136-145.

8. Dehue F, Bolman C, Völlink T, Pouwelse M. Coping with bullying at work and health related problems. Int J Stress Manage. 2012;19(3):175-197.

9. Panagioti M, Gooding PA, Dunn G, Tarrier N. Pathways to suicidal behavior in posttraumatic stress disorder. J Trauma Stress. 2011;24(2):137-145.

10. World Health Organization. Meeting report on excess mortality in persons with severe mental disorders. November 18-20, 2015. https://www.fountainhouse.org/sites/default/files/ExcessMortalityMeetingReport.pdf. Accessed June 6, 2017.

11. American Psychiatric Association. Trauma- and Stressor-Related Disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association;2013:265-268, 749-750.

12. Ford DE. Depression, trauma, and cardiovascular health. In: Schnurr PP, Green BL, eds. Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association; 2004:chap 4.

13. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Best practices identified for peer support programs. http://www.dcoe.mil/file/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf. Published January 2011. Accessed June 6, 2017.

14. O’Brian-Mazza D, Zimmerman J. The power of peer support: VHA mental health services. https://www.mentalhealth.va.gov/docs/peersupport.pdf. Published September 21, 2012. Accessed June 6, 2017.

15. Bartone PT. Peer support for bereaved survivors: systematic review of evidence and identification of best practices. https://www.taps.org/globalassets/pdf/about-taps/tapspeersupportreport2016.pdf. Published January 2017. Accessed June 6, 2017.

16. Castellano C. Reciprocal peer support (RPS): a decade of not so random acts of kindness. Int J Emerg Ment Health. 2012;14(2):105-110.

17. Salzer M. Consumer-delivered services as a best practice in mental health care delivery and the development of practice guidelines. http://www.cdsdirectory.org/SalzeretalBPPS2002.pdf. Published 2002. Accessed June 14, 2017.

18. Robinson R, Murdoch P. Establishing and Maintaining Peer Support Programs in the Workplace. 3rd ed. Ellicott City, MD: Chevron Publishing Corporation; 2003:1-24.

19. Baron SA. Violence in the Workplace: A Prevention and Management Guide for Businesses. Ventura, CA: Pathfinding Publishing; 1995:99-106.

20. Southwick SM, Charney DS. Social support: learning the Tap Code. In: Resilience: The Science of Mastering Life’s Greatest Challenges. Cambridge, United Kingdom: Cambridge University Press; 2012:100-114.

21. Creamer MC, Varker T, Bisson J, et al. Guidelines for peer support in high-risk organizations: an international consensus study using Delphi method. J Trauma Stress. 2012;25(2):134-141.

22. Downs RB. Afterword. In: Sinclair U. The Jungle. New York, NY. Signet Classics; 1906:343-350.

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Ms. Garrick is the founder of the nonprofit organization Whistleblowers of America. At the time the article was initiated, she was a DoD political appointee.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

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Author(s)

Jacqueline Garrick

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LCSW-C

Author(s)

Jacqueline Garrick

MSW

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Author and Disclosure Information

Ms. Garrick is the founder of the nonprofit organization Whistleblowers of America. At the time the article was initiated, she was a DoD political appointee.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Author and Disclosure Information

Ms. Garrick is the founder of the nonprofit organization Whistleblowers of America. At the time the article was initiated, she was a DoD political appointee.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Article PDF

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Whistleblowers report illegalities, improprieties, or injustices. They step forward wittingly or unwittingly to report perceived wrongdoing. But when a whistleblower takes on powerful and entrenched systems or people, retribution and retaliation often ensue, endangering their career and reputation. These negative consequences can have longterm impacts on the lives of those who believed they were acting in the public interest especially when patient care or public safety was at risk.

The following account is based on personal and professional experiences, conversations with more than a dozen other whistleblowers at the DoD, VA, several other organizations, and a literature review. This documentation of those informal peer conversations, combined with the research, is meant to provide insight into the experiences of a whistleblower and the need for peer support so that employees can remain resilient.

Adverse Whistleblower Experiences

Most employees do not set out to be whistleblowers. The process begins when the whistleblower perceives wrongdoing or harm that is being committed in their workplace. At a health care organization, whistleblowing often is focused on individual or organizational illegal or unethical activities, such as funding or contracting fraud, corruption, theft, discrimination, sexual harassment, public health safety or security violations, persistent medical errors, nepotism, or other violations of workplace rules and regulations. VA employees who experience, witness, or discover wrongdoing may choose to disclose their concerns to a supervisor, senior leader, the Office of the Inspector General (OIG), Human Resources or Equal Employment Opportunity (EEO) Office, Employee Assistance Program (EAP), Office of Special Counsel (OSC), Congress, or to a news organization.

According to the 2013 National Business Ethics Survey, more than 6 million American workers who reported misconduct experienced some form of retaliation.1,2 Retribution can manifest in various overt or covert ways, ranging from outright retaliation and further discrimination to other forms of marginalization. For example, a VA physician alleged that he was detailed to an empty office with no patients after reporting patient wait list mismanagement at his hospital. Other whistleblowers report having misconduct charges levied against them, demotions or loss of position, obstruction from promotion, poor performance evaluations, details to more minor assignments, relocation to more meager office space, or pressure to resign or retire.3

Whistleblowers are rarely rewarded for reporting misconduct within their organization. The Joint Commission describes barriers to reporting sentinel events by medical professionals fearing humiliation, litigation, peer pressure, and oversight investigations if they identify medical errors.4

Once allegations are made, the information often is conveyed to a supervisor or leader. For example, some whistleblowers who have reported a hostile work environment to the DoD EAP have noted that the EAP representative contacted the whistleblower’s manager to mediate the situation. This process can take months or years to resolve. In those instances, the managers are rarely relocated. The whistleblower usually is the one forced to move or take another job, which is not always consistent with their job description, and in turn, may impact their performance rating and opportunities for promotion.

Often, OIG and OSC investigations at the VA and other federal agencies can take as long as 2 years. During that time the whistleblower may remain in a lesser or unwanted position or leave the agency. However, even when OIG substantiates claims of wrongdoing, the agency can make recommendations only to leadership, which may or may not be enacted. Whistleblowers report having to submit Freedom of Information Act requests to learn of the outcome of an OIG investigation when leadership chooses to ignore the recommendation.

Civilian government employees are undervalued by society in general, and the negative stereotypes of lazy, shiftless workers abound, even though many civil servants work to protect the nation’s health, welfare, and safety. Civil servants are familiar with derogatory expressions, such as “bureaucratic bean-counter,” and “good enough for government work.” Even President Trump stated that he would come to Washington, DC, and “drain the swamp.” Yet civil servants can go years without a cost of living increase, a promotion, or a bonus but still be asked to perform additional duties or work long hours to the sacrifice of a work/life balance.

In the Federal Employee Viewpoints Survey and other employee environmental climate scans, high levels of workforce stress often are related to the number of grievances filed, the level of morale, the rates of absenteeism and retention, recruitment shortages, and lost productivity.5  Success in toxic environments usually is based on trying to maintain a “go along to get along” status quo, which means looking the other way when contracts are fraudulently awarded or employee discrimination occurs. If leadership is antagonistic to reform, then identifying wrongdoing may come at significant personal risk.

Retaliatory Practices

Once a whistleblower has stepped forward, retaliatory practices may follow. There are tangible legal, financial, social, emotional, and physical tolls to whistleblowing. “Be in for a penny. Be in for a pound,” an OIG official advised one whistleblower. Once a disclosure is made, the process may become arduous for the whistleblower and require individual resilience to face adversity.

Keeping in mind that OIG, EEO, EAP, and OSC are government agencies that investigate, police, and monitor the system, they do not represent the civil servants who document and identify much of the evidence of wrongdoing on their own. Most civil service employees are not subject matter experts on the U.S. legal code that outlines prohibited personal practices or the Federal Acquisition Regulation.

The Notification and Federal Employee Antidiscrimination and Retaliation (NO FEAR) Act authorized in 2002 (U.S. Code § 2301) is designed to inform and protect those who file grievances or disclosures, but operationalizing those protections can be overwhelming and confusing. If a whistleblower wants advice, he or she must retain legal counsel often at a substantial personal cost. Whistleblowers report spending from $10,000 to more than $100,000 in legal fees for a 1- to 2-year investigation.

These legal fees may force whistleblowers to use family finances or borrow money while hoping for justice along with remuneration in the end. In some cases, the financial impact is compounded when the whistleblower has been demoted, denied a promotion, or fired. For medical professionals, the impact might result in the loss of hospital privileges, professional credentials, or state licensure. The loss of income also can lead to loss of health insurance. The legal and financial burdens impact marriages, spousal job options, retirement, and other family choices (eg, vacations, children’s schools, and caregiving obligations).

During investigations, social status and the reputation of the whistleblower are often impugned. For example, whistleblowers are sometimes depicted as snitches, moles, spies, or tattletales and may be categorized as paranoid, disloyal, or disgruntled by leadership. Rarely are whistleblowers labeled protectors, patriots, or heroes, despite the few high profile cases that come to light, such as Karen Silkwood, Erin Brockovich, or Frank Serpico.

More often, whistleblowers’ reputations, especially in civil sectors, are damaged through acts of discrimination, such as bullying; mobbing (asking other employees to monitor and report on the activities of the whistleblower); ostracizing the employee from the team; devaluing the contributions or the performance of the whistleblower; blackballing from other jobs or opportunities; doublebinding with difficult tasks to complete; gaslighting by calling into question the memory of the whistleblower, the reality of the accusation, or its scope; and marginalization. Accusations of misusing funds, inaccurately recording time and attendance, and disputing their judgement are all tactics used to socially isolate and harass whistleblowers into dropping their case or leaving the organization.3

Furthermore, this level of ostracism has documented impact on the psychological and physical well-being of the employee and negative consequences to the overall functioning of the organization.6 Consequences, such as physical violence and property damage at the time of termination and at other betrayals have occurred.3,7 Other whistleblowers have reported being threatened in person or on social media, harassed, and assaulted, especially in the military.

Whistleblowers, similar to others who are bullied in the workplace often described feelings such as fear, depression, anxiety, loneliness, and humiliation.8 These feelings can lead to whistleblowers needing treatment for substance abuse, depression, anxiety, posttraumatic stress disorder (PTSD) and suicidal ideation.9 Multiple studies on depression and PTSD show a correlation to increased morbidity and mortality.10 However, whistleblowing retaliation is not clearly established as a traumatic stressor in relation to PTSD.11

Insomnia and other sleep disturbances are not uncommon among whistleblowers who also note they have resorted to smoking, overeating, alcohol misuse, or medication to manage their distress. Health consequences also include migraines, muscle tension, gastrointestinal conditions, increased blood pressure, and cardiovascular disease.12

Peer Support Models

Studies of peer-to-peer programs for veterans, law enforcement officers, widows, cancer patients, disaster victims, and others bound by survivorship suggest that peer groups can be an effective means of support, even though the model may vary or be adapted to a specific population. In general, peer support is centered on a common experience, shared credibility, confidentiality, and trust. The approach is meant to provide nonjudgmental support that assists with decision making and resilience and provides comfort and hope. Most peer support or mentorship models require some level of peer counselor screening, competency training on an intervention model, supervision, monitoring, and case management by a more senior or credentialed mental health professional.13

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) recognized that health care systems that support civil servants, military members, and veterans can benefit from partnerships with internal (eg, human resources, unions, or dedicated EAP) or external (eg, nonprofit and service organizations) employee peer support programs. The DCoE noted that peer networks facilitate referrals to medical care when threats of suicide or harm to others exists, offer additional case management support, and assist professionals in understanding the patient experience.13

Peer support offered at VA hospitals is conducted by peers who are supervised by mental health clinic staff (usually social workers).14 Law enforcement EAP is another example of peer support within an organization to augment mental health and resilience among officers who have experienced first-responder trauma.

External peer support resources can be accessed through partnerships or referrals. For example, the Tragedy Assistance Program for Survivors (TAPS) relies on survivors of military deaths to support each other through bereavement. Although the DoD offers casualty assistance and mental health care to grieving families, the level of peer support differs from TAPS.15 In another example, Castellano documented the benefits of a reciprocal peer support model implemented across 10 peer-based call center programs that manage high risk-populations.16 Core training was consistent across all programs, and mental health professionals supervised call center peer support providers. This peer/clinician collaboration enhances the overall community mental health efforts.

Temple University documented the patient care benefits for behavioral health services that augmented treatment with evidence-based peer support interventions.17 The researchers found that hospitals that used a peer model improved patient outcomes as demonstrated by fewer hospitalizations, increased life satisfaction and enhanced coping skills, increased medication adherence, and reduced substance abuse or suicidal ideation. Additionally, the peer providers themselves experienced positive health benefits based on their ability to help others, improved their own self-efficacy and gained social and economic growth based on their employment satisfaction.17

Peer Support Interventions

Peer support interventions have been effective with various populations and may be effective for whistleblowers as well. Since whistleblowing tends to involve legal processes that call for privacy and the confidentiality of all parties, whistleblowers experience isolation and alienation. Other whistleblowers can better understand the retaliation, discrimination, and isolation that results. In some instances, whistleblowers discovered years later that other employees had similar experiences. An organized, structured program dedicated to peer support can help employees within a health care system or EAP manage the impacts of identifying wrongdoing.18 Peers may be able to break down this isolation and help establish a new network of support for those involved in whistleblowing cases. Restoring a sense of purpose, meaning, and belonging in the workplace is of significant value for the whistleblower.19 Peers can mentor a whistleblower through the investigative process and help determine next steps. Peers can address building, maintaining, and sustaining resilience to overcome adversity.

Peers who already have experienced their own legal, financial, social, emotional, and physical risks and have developed the necessary resiliency skills to survive make ideal peer counselors.20 These peers have faced similar challenges but have perservered.21

Although peer counselors cannot replace an attorney or mental health provider, they can provide background information on the roles and functions of EEO, EAP, OIG, OSC, and the MSPB and how to navigate those systems. Peers can assist whistleblowers in preparing testimony before congressional hearings or for press interviews. Peer supporters also can encourage whistleblowers to seek care for mental and physical health care and to remain adherent to treatment regimens. They case manage a team effort to enable the whistleblower to overcome the adversity of retaliation.

Creating A New Normal

After the Civil War, the False Claims Act, known as the Lincoln Law, served to protect federal reconstruction activities in the South from individuals who attempted to defraud the federal government.22 Today, most Americans are familiar with WikiLeaks. For generations, whistleblowers have exposed wrongdoing in order to protect or reform governmen programs. Whistleblowers have exposed graft and corruption at the highest levels and in daily operations. They have fought for diversity and inclusion and a workplace free of sexual harassment and assault. They have protected taxpayer dollars from waste, fraud, and abuse.

Despite the personal sacrifices often required, most whistleblowers’ spirits are bolstered by the positive outcomes that their disclosures may produce. However, whistleblowers need compassionate and competent assistance throughout the process. Peers can foster the resilience needed to survive the adversarial nature of the whistleblowing process. Therefore, whistleblowers need to be viewed in a new light that involves advocacy, transparency, and peer support so that positive outcomes in government can be realized for all Americans.

Whistleblowers report illegalities, improprieties, or injustices. They step forward wittingly or unwittingly to report perceived wrongdoing. But when a whistleblower takes on powerful and entrenched systems or people, retribution and retaliation often ensue, endangering their career and reputation. These negative consequences can have longterm impacts on the lives of those who believed they were acting in the public interest especially when patient care or public safety was at risk.

The following account is based on personal and professional experiences, conversations with more than a dozen other whistleblowers at the DoD, VA, several other organizations, and a literature review. This documentation of those informal peer conversations, combined with the research, is meant to provide insight into the experiences of a whistleblower and the need for peer support so that employees can remain resilient.

Adverse Whistleblower Experiences

Most employees do not set out to be whistleblowers. The process begins when the whistleblower perceives wrongdoing or harm that is being committed in their workplace. At a health care organization, whistleblowing often is focused on individual or organizational illegal or unethical activities, such as funding or contracting fraud, corruption, theft, discrimination, sexual harassment, public health safety or security violations, persistent medical errors, nepotism, or other violations of workplace rules and regulations. VA employees who experience, witness, or discover wrongdoing may choose to disclose their concerns to a supervisor, senior leader, the Office of the Inspector General (OIG), Human Resources or Equal Employment Opportunity (EEO) Office, Employee Assistance Program (EAP), Office of Special Counsel (OSC), Congress, or to a news organization.

According to the 2013 National Business Ethics Survey, more than 6 million American workers who reported misconduct experienced some form of retaliation.1,2 Retribution can manifest in various overt or covert ways, ranging from outright retaliation and further discrimination to other forms of marginalization. For example, a VA physician alleged that he was detailed to an empty office with no patients after reporting patient wait list mismanagement at his hospital. Other whistleblowers report having misconduct charges levied against them, demotions or loss of position, obstruction from promotion, poor performance evaluations, details to more minor assignments, relocation to more meager office space, or pressure to resign or retire.3

Whistleblowers are rarely rewarded for reporting misconduct within their organization. The Joint Commission describes barriers to reporting sentinel events by medical professionals fearing humiliation, litigation, peer pressure, and oversight investigations if they identify medical errors.4

Once allegations are made, the information often is conveyed to a supervisor or leader. For example, some whistleblowers who have reported a hostile work environment to the DoD EAP have noted that the EAP representative contacted the whistleblower’s manager to mediate the situation. This process can take months or years to resolve. In those instances, the managers are rarely relocated. The whistleblower usually is the one forced to move or take another job, which is not always consistent with their job description, and in turn, may impact their performance rating and opportunities for promotion.

Often, OIG and OSC investigations at the VA and other federal agencies can take as long as 2 years. During that time the whistleblower may remain in a lesser or unwanted position or leave the agency. However, even when OIG substantiates claims of wrongdoing, the agency can make recommendations only to leadership, which may or may not be enacted. Whistleblowers report having to submit Freedom of Information Act requests to learn of the outcome of an OIG investigation when leadership chooses to ignore the recommendation.

Civilian government employees are undervalued by society in general, and the negative stereotypes of lazy, shiftless workers abound, even though many civil servants work to protect the nation’s health, welfare, and safety. Civil servants are familiar with derogatory expressions, such as “bureaucratic bean-counter,” and “good enough for government work.” Even President Trump stated that he would come to Washington, DC, and “drain the swamp.” Yet civil servants can go years without a cost of living increase, a promotion, or a bonus but still be asked to perform additional duties or work long hours to the sacrifice of a work/life balance.

In the Federal Employee Viewpoints Survey and other employee environmental climate scans, high levels of workforce stress often are related to the number of grievances filed, the level of morale, the rates of absenteeism and retention, recruitment shortages, and lost productivity.5  Success in toxic environments usually is based on trying to maintain a “go along to get along” status quo, which means looking the other way when contracts are fraudulently awarded or employee discrimination occurs. If leadership is antagonistic to reform, then identifying wrongdoing may come at significant personal risk.

Retaliatory Practices

Once a whistleblower has stepped forward, retaliatory practices may follow. There are tangible legal, financial, social, emotional, and physical tolls to whistleblowing. “Be in for a penny. Be in for a pound,” an OIG official advised one whistleblower. Once a disclosure is made, the process may become arduous for the whistleblower and require individual resilience to face adversity.

Keeping in mind that OIG, EEO, EAP, and OSC are government agencies that investigate, police, and monitor the system, they do not represent the civil servants who document and identify much of the evidence of wrongdoing on their own. Most civil service employees are not subject matter experts on the U.S. legal code that outlines prohibited personal practices or the Federal Acquisition Regulation.

The Notification and Federal Employee Antidiscrimination and Retaliation (NO FEAR) Act authorized in 2002 (U.S. Code § 2301) is designed to inform and protect those who file grievances or disclosures, but operationalizing those protections can be overwhelming and confusing. If a whistleblower wants advice, he or she must retain legal counsel often at a substantial personal cost. Whistleblowers report spending from $10,000 to more than $100,000 in legal fees for a 1- to 2-year investigation.

These legal fees may force whistleblowers to use family finances or borrow money while hoping for justice along with remuneration in the end. In some cases, the financial impact is compounded when the whistleblower has been demoted, denied a promotion, or fired. For medical professionals, the impact might result in the loss of hospital privileges, professional credentials, or state licensure. The loss of income also can lead to loss of health insurance. The legal and financial burdens impact marriages, spousal job options, retirement, and other family choices (eg, vacations, children’s schools, and caregiving obligations).

During investigations, social status and the reputation of the whistleblower are often impugned. For example, whistleblowers are sometimes depicted as snitches, moles, spies, or tattletales and may be categorized as paranoid, disloyal, or disgruntled by leadership. Rarely are whistleblowers labeled protectors, patriots, or heroes, despite the few high profile cases that come to light, such as Karen Silkwood, Erin Brockovich, or Frank Serpico.

More often, whistleblowers’ reputations, especially in civil sectors, are damaged through acts of discrimination, such as bullying; mobbing (asking other employees to monitor and report on the activities of the whistleblower); ostracizing the employee from the team; devaluing the contributions or the performance of the whistleblower; blackballing from other jobs or opportunities; doublebinding with difficult tasks to complete; gaslighting by calling into question the memory of the whistleblower, the reality of the accusation, or its scope; and marginalization. Accusations of misusing funds, inaccurately recording time and attendance, and disputing their judgement are all tactics used to socially isolate and harass whistleblowers into dropping their case or leaving the organization.3

Furthermore, this level of ostracism has documented impact on the psychological and physical well-being of the employee and negative consequences to the overall functioning of the organization.6 Consequences, such as physical violence and property damage at the time of termination and at other betrayals have occurred.3,7 Other whistleblowers have reported being threatened in person or on social media, harassed, and assaulted, especially in the military.

Whistleblowers, similar to others who are bullied in the workplace often described feelings such as fear, depression, anxiety, loneliness, and humiliation.8 These feelings can lead to whistleblowers needing treatment for substance abuse, depression, anxiety, posttraumatic stress disorder (PTSD) and suicidal ideation.9 Multiple studies on depression and PTSD show a correlation to increased morbidity and mortality.10 However, whistleblowing retaliation is not clearly established as a traumatic stressor in relation to PTSD.11

Insomnia and other sleep disturbances are not uncommon among whistleblowers who also note they have resorted to smoking, overeating, alcohol misuse, or medication to manage their distress. Health consequences also include migraines, muscle tension, gastrointestinal conditions, increased blood pressure, and cardiovascular disease.12

Peer Support Models

Studies of peer-to-peer programs for veterans, law enforcement officers, widows, cancer patients, disaster victims, and others bound by survivorship suggest that peer groups can be an effective means of support, even though the model may vary or be adapted to a specific population. In general, peer support is centered on a common experience, shared credibility, confidentiality, and trust. The approach is meant to provide nonjudgmental support that assists with decision making and resilience and provides comfort and hope. Most peer support or mentorship models require some level of peer counselor screening, competency training on an intervention model, supervision, monitoring, and case management by a more senior or credentialed mental health professional.13

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) recognized that health care systems that support civil servants, military members, and veterans can benefit from partnerships with internal (eg, human resources, unions, or dedicated EAP) or external (eg, nonprofit and service organizations) employee peer support programs. The DCoE noted that peer networks facilitate referrals to medical care when threats of suicide or harm to others exists, offer additional case management support, and assist professionals in understanding the patient experience.13

Peer support offered at VA hospitals is conducted by peers who are supervised by mental health clinic staff (usually social workers).14 Law enforcement EAP is another example of peer support within an organization to augment mental health and resilience among officers who have experienced first-responder trauma.

External peer support resources can be accessed through partnerships or referrals. For example, the Tragedy Assistance Program for Survivors (TAPS) relies on survivors of military deaths to support each other through bereavement. Although the DoD offers casualty assistance and mental health care to grieving families, the level of peer support differs from TAPS.15 In another example, Castellano documented the benefits of a reciprocal peer support model implemented across 10 peer-based call center programs that manage high risk-populations.16 Core training was consistent across all programs, and mental health professionals supervised call center peer support providers. This peer/clinician collaboration enhances the overall community mental health efforts.

Temple University documented the patient care benefits for behavioral health services that augmented treatment with evidence-based peer support interventions.17 The researchers found that hospitals that used a peer model improved patient outcomes as demonstrated by fewer hospitalizations, increased life satisfaction and enhanced coping skills, increased medication adherence, and reduced substance abuse or suicidal ideation. Additionally, the peer providers themselves experienced positive health benefits based on their ability to help others, improved their own self-efficacy and gained social and economic growth based on their employment satisfaction.17

Peer Support Interventions

Peer support interventions have been effective with various populations and may be effective for whistleblowers as well. Since whistleblowing tends to involve legal processes that call for privacy and the confidentiality of all parties, whistleblowers experience isolation and alienation. Other whistleblowers can better understand the retaliation, discrimination, and isolation that results. In some instances, whistleblowers discovered years later that other employees had similar experiences. An organized, structured program dedicated to peer support can help employees within a health care system or EAP manage the impacts of identifying wrongdoing.18 Peers may be able to break down this isolation and help establish a new network of support for those involved in whistleblowing cases. Restoring a sense of purpose, meaning, and belonging in the workplace is of significant value for the whistleblower.19 Peers can mentor a whistleblower through the investigative process and help determine next steps. Peers can address building, maintaining, and sustaining resilience to overcome adversity.

Peers who already have experienced their own legal, financial, social, emotional, and physical risks and have developed the necessary resiliency skills to survive make ideal peer counselors.20 These peers have faced similar challenges but have perservered.21

Although peer counselors cannot replace an attorney or mental health provider, they can provide background information on the roles and functions of EEO, EAP, OIG, OSC, and the MSPB and how to navigate those systems. Peers can assist whistleblowers in preparing testimony before congressional hearings or for press interviews. Peer supporters also can encourage whistleblowers to seek care for mental and physical health care and to remain adherent to treatment regimens. They case manage a team effort to enable the whistleblower to overcome the adversity of retaliation.

Creating A New Normal

After the Civil War, the False Claims Act, known as the Lincoln Law, served to protect federal reconstruction activities in the South from individuals who attempted to defraud the federal government.22 Today, most Americans are familiar with WikiLeaks. For generations, whistleblowers have exposed wrongdoing in order to protect or reform governmen programs. Whistleblowers have exposed graft and corruption at the highest levels and in daily operations. They have fought for diversity and inclusion and a workplace free of sexual harassment and assault. They have protected taxpayer dollars from waste, fraud, and abuse.

Despite the personal sacrifices often required, most whistleblowers’ spirits are bolstered by the positive outcomes that their disclosures may produce. However, whistleblowers need compassionate and competent assistance throughout the process. Peers can foster the resilience needed to survive the adversarial nature of the whistleblowing process. Therefore, whistleblowers need to be viewed in a new light that involves advocacy, transparency, and peer support so that positive outcomes in government can be realized for all Americans.

References

1. Ethics and Compliance Initiative. National Business Ethics Survey (NBES) 2013. http://www.ethics.org/ecihome/research/nbes/nbes-reports/nbes-2013. Published 2013. Accessed June 5, 2017.

2. Schnell G. Whistleblower retaliation on the rise—bad news for whistleblowers and their employers alike. http://constantinecannon.com/whistleblower/whistleblower-retaliation-on-the-rise-bad-news-for-whistleblowers-and-their-employers-alike/#.WNJ1s4WcEYh. Published January 18, 2013. Accessed June 5, 2017.

3. Devine T, Maassarani T. The Corporate Whistleblower’s Survival Guide: A Handbook for Committing the Truth. San Francisco, CA. Berrett-Koehler Publishers; 2011:19-40.

4. The Joint Commission. What Every Hospital Should Know About Sentinel Events. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2000.

5. Reed GE. Tarnished: Toxic Leadership in the U.S. Military. Lincoln, NE; University of Nebraska Press, Potomac Books; 2015:60.

6. McGraw K. Mental health of women warriors: the power of belonging. In: Ritchie EC, Naclerio AL, eds. Women at War. New York, NY. Oxford University Press; 2015:311-320.

7. Blythe B. Blindsided: A Manager’s Guide to Catastrophic Incidents in the Workplace. New York, NY: Penguin Group; 2002:136-145.

8. Dehue F, Bolman C, Völlink T, Pouwelse M. Coping with bullying at work and health related problems. Int J Stress Manage. 2012;19(3):175-197.

9. Panagioti M, Gooding PA, Dunn G, Tarrier N. Pathways to suicidal behavior in posttraumatic stress disorder. J Trauma Stress. 2011;24(2):137-145.

10. World Health Organization. Meeting report on excess mortality in persons with severe mental disorders. November 18-20, 2015. https://www.fountainhouse.org/sites/default/files/ExcessMortalityMeetingReport.pdf. Accessed June 6, 2017.

11. American Psychiatric Association. Trauma- and Stressor-Related Disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association;2013:265-268, 749-750.

12. Ford DE. Depression, trauma, and cardiovascular health. In: Schnurr PP, Green BL, eds. Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association; 2004:chap 4.

13. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Best practices identified for peer support programs. http://www.dcoe.mil/file/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf. Published January 2011. Accessed June 6, 2017.

14. O’Brian-Mazza D, Zimmerman J. The power of peer support: VHA mental health services. https://www.mentalhealth.va.gov/docs/peersupport.pdf. Published September 21, 2012. Accessed June 6, 2017.

15. Bartone PT. Peer support for bereaved survivors: systematic review of evidence and identification of best practices. https://www.taps.org/globalassets/pdf/about-taps/tapspeersupportreport2016.pdf. Published January 2017. Accessed June 6, 2017.

16. Castellano C. Reciprocal peer support (RPS): a decade of not so random acts of kindness. Int J Emerg Ment Health. 2012;14(2):105-110.

17. Salzer M. Consumer-delivered services as a best practice in mental health care delivery and the development of practice guidelines. http://www.cdsdirectory.org/SalzeretalBPPS2002.pdf. Published 2002. Accessed June 14, 2017.

18. Robinson R, Murdoch P. Establishing and Maintaining Peer Support Programs in the Workplace. 3rd ed. Ellicott City, MD: Chevron Publishing Corporation; 2003:1-24.

19. Baron SA. Violence in the Workplace: A Prevention and Management Guide for Businesses. Ventura, CA: Pathfinding Publishing; 1995:99-106.

20. Southwick SM, Charney DS. Social support: learning the Tap Code. In: Resilience: The Science of Mastering Life’s Greatest Challenges. Cambridge, United Kingdom: Cambridge University Press; 2012:100-114.

21. Creamer MC, Varker T, Bisson J, et al. Guidelines for peer support in high-risk organizations: an international consensus study using Delphi method. J Trauma Stress. 2012;25(2):134-141.

22. Downs RB. Afterword. In: Sinclair U. The Jungle. New York, NY. Signet Classics; 1906:343-350.

References

1. Ethics and Compliance Initiative. National Business Ethics Survey (NBES) 2013. http://www.ethics.org/ecihome/research/nbes/nbes-reports/nbes-2013. Published 2013. Accessed June 5, 2017.

2. Schnell G. Whistleblower retaliation on the rise—bad news for whistleblowers and their employers alike. http://constantinecannon.com/whistleblower/whistleblower-retaliation-on-the-rise-bad-news-for-whistleblowers-and-their-employers-alike/#.WNJ1s4WcEYh. Published January 18, 2013. Accessed June 5, 2017.

3. Devine T, Maassarani T. The Corporate Whistleblower’s Survival Guide: A Handbook for Committing the Truth. San Francisco, CA. Berrett-Koehler Publishers; 2011:19-40.

4. The Joint Commission. What Every Hospital Should Know About Sentinel Events. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2000.

5. Reed GE. Tarnished: Toxic Leadership in the U.S. Military. Lincoln, NE; University of Nebraska Press, Potomac Books; 2015:60.

6. McGraw K. Mental health of women warriors: the power of belonging. In: Ritchie EC, Naclerio AL, eds. Women at War. New York, NY. Oxford University Press; 2015:311-320.

7. Blythe B. Blindsided: A Manager’s Guide to Catastrophic Incidents in the Workplace. New York, NY: Penguin Group; 2002:136-145.

8. Dehue F, Bolman C, Völlink T, Pouwelse M. Coping with bullying at work and health related problems. Int J Stress Manage. 2012;19(3):175-197.

9. Panagioti M, Gooding PA, Dunn G, Tarrier N. Pathways to suicidal behavior in posttraumatic stress disorder. J Trauma Stress. 2011;24(2):137-145.

10. World Health Organization. Meeting report on excess mortality in persons with severe mental disorders. November 18-20, 2015. https://www.fountainhouse.org/sites/default/files/ExcessMortalityMeetingReport.pdf. Accessed June 6, 2017.

11. American Psychiatric Association. Trauma- and Stressor-Related Disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association;2013:265-268, 749-750.

12. Ford DE. Depression, trauma, and cardiovascular health. In: Schnurr PP, Green BL, eds. Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association; 2004:chap 4.

13. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Best practices identified for peer support programs. http://www.dcoe.mil/file/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf. Published January 2011. Accessed June 6, 2017.

14. O’Brian-Mazza D, Zimmerman J. The power of peer support: VHA mental health services. https://www.mentalhealth.va.gov/docs/peersupport.pdf. Published September 21, 2012. Accessed June 6, 2017.

15. Bartone PT. Peer support for bereaved survivors: systematic review of evidence and identification of best practices. https://www.taps.org/globalassets/pdf/about-taps/tapspeersupportreport2016.pdf. Published January 2017. Accessed June 6, 2017.

16. Castellano C. Reciprocal peer support (RPS): a decade of not so random acts of kindness. Int J Emerg Ment Health. 2012;14(2):105-110.

17. Salzer M. Consumer-delivered services as a best practice in mental health care delivery and the development of practice guidelines. http://www.cdsdirectory.org/SalzeretalBPPS2002.pdf. Published 2002. Accessed June 14, 2017.

18. Robinson R, Murdoch P. Establishing and Maintaining Peer Support Programs in the Workplace. 3rd ed. Ellicott City, MD: Chevron Publishing Corporation; 2003:1-24.

19. Baron SA. Violence in the Workplace: A Prevention and Management Guide for Businesses. Ventura, CA: Pathfinding Publishing; 1995:99-106.

20. Southwick SM, Charney DS. Social support: learning the Tap Code. In: Resilience: The Science of Mastering Life’s Greatest Challenges. Cambridge, United Kingdom: Cambridge University Press; 2012:100-114.

21. Creamer MC, Varker T, Bisson J, et al. Guidelines for peer support in high-risk organizations: an international consensus study using Delphi method. J Trauma Stress. 2012;25(2):134-141.

22. Downs RB. Afterword. In: Sinclair U. The Jungle. New York, NY. Signet Classics; 1906:343-350.

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