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The Burden of Proof

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People who suffer with mental illness or injury bear the burden of illness. Mental illness/injury does not just impact the lives of those afflicted. It creates significant costs (seen and unseen) to those who love them, work with them and those who lead them. Research is necessary to begin to untangle the knots in our understanding of what’s going and what we should do about it. There is much at stake. All the more reason to get it right, right? As the demand for help increases, so too do the demands for evidence-based strategies to help increase. Research bears the burden of proof.

First responders are highly trained professionals whose place of work is in the epicentre of crisis. Their training and medical directives help them to swiftly zero in on the clinical presentation and make discerning judgements using medical pathways to interrupt negative health outcomes. During times of crisis, the expert mind narrows its attention to the problem and relies on antecedent expertise to do the work of being a first responder. Crisis demands hypervigilant attention to the problem, and rightfully so. Research shares a similar quality of attention to the process of inquiry and the scientific method. Evidence emerges in an epicentre of inquiry where health outcomes are examined by another quality of attention; a beginner’s mind.

A beginner’s mind functions like that of the aperture on a camera lens. When you cultivate a beginner’s mind, you open up the minds eye from foveate (focused; like looking at your phone) to panoramic vision (looking out at the horizon). You intentionally shift your perspective to take in more of what’s happening. In that way, you might understand it better and, as a result, be better positioned to find more meaningful answers to complex landscapes. Mental health, illness, injury and the scientific method benefit from both perspectives. What follows is an invitation to widen the aperture of our mind’s eye as it relates to what we know about mental ease, dis-ease and the evolution of evidence.

Widening the aperture on health

It’s really a misnomer to say that we have a health care system in Canada. We have a disease care system. Our health care system operates from the medical model which is pathogenically borne. This model holds the assumption that humans are inherently healthy; until they are not. In this model, we typically engage the system when symptoms of illness or injury appear. Until then, it is assumed that you are healthy. This national (and many would argue rational) approach to health care often shapes the lens in which we define health; individually and empirically.

If we define health as being the absence of disease, it follows logically that we view mental health in the same way. In our current system, one sees a medical physician for a physical condition, a psychologist or psychiatrist for a psychological condition. So, if you aren’t in need of a medical physician, psychologist or psychiatrist, you are therefore healthy. But, is that true? Just because you don’t have a diagnosis of diabetes today (but eat poorly and are overweight) or find that stigma keeps you from seeking help for your persistent and pervasive depressogenic thoughts doesn’t mean that you are healthy. When we focus our health lens downstream, we are vulnerable to missing important variables that lie upstream. We owe those who are suffering with mental illness and injury a downstream approach. We also owe all first responders an upstream approach to understanding how to create and cause their mental well-being. Evidence that emerges from a downstream approach will undoubtedly inform those investigating health upstream, but we want to be mindful that we investigate mental health away from the pathogenic perspective so that we understand the causes of both; psychopathology and well-being.

We quite naturally and reflexively think of health from this pathogenic perspective because of the systems we work in and the training we undertake to become a paramedic. In school, you vocationally habituated your mind to receive and perceive all scenarios with this filter of pathogenesis. The public are the beneficiary of your capacity to do so. It’s critical. It’s necessary. Paramedicine in Canada is cusping on significant changes; including role and scope of practice. It’s an opportune time to expand not just how we frame health (notably mental health), but how we study it.

The antonym to the pathogenic perspective is the salutogenic one. Aaron Antonovsky (1996) created the model of salutogenesis more than 40 years ago. Salut refers to health and genesis; the creation of. His model existed, in part, as a way of challenging the health promotion researchers of the day (1970s). Antonovsky could see that health promotion was really just an extension of the pathogenic inquiry in that it focused simply on preventing disease versus creating health in the absence of it.

Forty years later, this is often still the case. Take for example the flu shot campaign. Does getting the flu shot create your health? Does doing so move you towards your best potential or is it about not getting influenza? We should not eliminate one perspective for the other but ensure that research seeks to answer both perspectives as it relates to mental health, illness and injury. We simply do not have enough evidence to suggest that the absence of mental illness means you are left with mental wellness and resiliency.

Evidence-based—the small print

The term evidence-based is often asked for before decisions are made at the level of an organization as it pertains to helping those who suffer with mental health issues or injuries. It makes sense to ask for evidence but be sure to read the small print before any decisions are made to adopt or reject any initiatives based solely on evidence-based knowing. Given paramedics close proximity to the medical community and growing research community, asking for evidence makes perfectly good sense. Organizations struggle with decisions on how to address serious issues related to mental health, partly because of trying to sort through the evidence to date.

Most every research study, good or bad, produces evidence. When we say it has to be ‘evidence-based’, what do we mean by that? How much evidence is enough? Whose evidence is the right evidence and who decides that? Practicing self-reflection as a profession as it relates to our engagement with ‘evidence’ can often generate important insight and wisdom. Consider your own experiences in this profession as it relates to evidence-based protocols/procedures or policies. Is there empirical evidence behind everything you are required to do or should do or expected to do? Can you identify a protocol or procedure that is still being used despite a lack of evidence or emerging evidence to the contrary?

‘So what? Now what?’ are provocative and critical questions that can help navigate organizational change when evidence (or lack of) arrives on our doorstep. Developing a pathway or protocol to help services navigate rapidly evolving evidence that safely addresses the cost of changing or adding something with the cost of doing nothing may be the very first step in navigating how to address mental health, illness and injury in professions where the risks are high. Understanding evidence is one thing. Knowing what to do with it is a very different thing.

What I have heard over and over again in conversation with leaders and front-line workers in EMS related to mental health challenges are two main themes. One, we desperately need help and two, it HAS to work, it needs to be evidence-based. Of course, we should strive to provide evidence-based interventions. Period. But here’s the issue that surrounds that call to action. The evidence to date is only as good as our global understanding of the brain and mind. And, while there is an explosion of evidence as it relates to both, we truly are in our infancy of understanding. Evidence is emerging and evolving so rapidly that it is challenging to point to the evidence as it relates to mental health issues. When we repeatedly demand ‘it has to be evidence-based’, we run the risk of rushing or overestimating evidence without due process. What may be true today, may be very different tomorrow.

Without doubt, research is a noble endeavour. The confluence of evidence-based research findings and digital capitalism should give us all extra pause on demanding evidence-based anything. We have enough experience in history when evidence was produced (ethically or not), widely disseminated and adopted, and then it turned out to be not so good evidence and in fact, harmful or lethal. We are most aware of these types of evidence errors when it comes to big pharma. When they get it wrong in the end (or worse, at the beginning), we often come to learn that the methodology and analysis were flawed or skewed. Or we made conclusions prematurely or without further testing. Even noble endeavours are prone to the lure of pride, ego and financial fringe benefits; even if it comes as an award for a large grant.

Billions of dollars are on the table as digital capitalism takes swift advantage of our wearable technology, our insatiable appetite for quantifying ourselves in apps. More and more we turn to our phones to track intimate physical and mental information. Our phones, our watches and now clothes are capturing and recording sensitive biometrics that are being mined and sold, often unknowingly. While noble, research is not a perfect science or without unscrupulous practices that can go unnoticed simply because it was produced by a reputable name, corporation or academic institution.

Research itself is costly and time consuming. We are likely years away from understanding, fully, the complexity of the human brain and its relationship to the mind. Recently reported in our social media accounts were the summary findings of a 32-year-long longitudinal study from a university in the US on what factors were important to health. After more than three decades, their findings included that good health included eating well, moderating alcohol intake, avoiding cigarettes and exercising regularly. How useful are the findings in this study in 2019? Given the speed at which technology is impacting our lives, longitudinal studies will need to carefully consider how things like technology, artificial intelligence and climate change will influence the research investigation. Future investigations will need to ensure that we don’t waste the two most precious commodities we have; time and money.

Research is also a process and a pathway for the privileged. The research community would benefit from addressing diversity and inclusion issues that most organizations these days grapple with. It matters in the context of knowledge generation and dissemination, especially as it relates to mental health, illness and injury. As we investigate these complex constructs, we should strive to understand them (those who design the research questions and those who participate) from a wide variety of lens and experiences (gender, race, age, SES, religion). For decades we investigated myocardial infarcts from the male perspective to discover years later that women often present in very different ways to our male counterparts when having an AMI. As the research community grows in paramedicine awareness of issues that relate to who is at the table and who is not and the cultivation of novel initiatives to include more diversity will benefit everyone. Research should not just benefit us all but be inclusive of all those it impacts.

In summary and as we move forward in figuring out how to support first responders’ mental well-being and how to best support psychological illness or injury it might be helpful to bear in mind some of the following for consideration:

1. Be sure to include in future research not just a downstream (pathogenic) approach to understanding mental disorders and the potential negative impact engaging trauma and suffering have on first responders, but to be sure to gain insight into the upstream dimensions of what causes health. Understanding disease processes does not necessarily equate to understanding what constitutes health. It may very well be that the autogenic perspective inspires more people to participate in research studies.

2. Include diverse populations in all studies and be deliberate in cultivating interest and support for populations who are historically underrepresented. Novel initiatives to encourage and support diversity in graduate schools should be looked at with a beginner’s mind.

3. A fulsome discussion surrounding how an organization will stay current with emerging evidence. And, maybe more importantly, what the pathway or process will look like when emerging evidence supports change.

4. Become skilled and knowledgeable about creating a business case for justifying new strategies, technologies that makes sense for leaders and decision makers. Front line staff and middle managers should be able to speak the language that often becomes foreign to them as you move up the leadership ladder. Economic drivers must be understood and transparent.

5. Support a publication for grey literature. Traditionally not viewed as the same ‘quality’ as other research, we should be celebrating, sharing and gleaning what’s good in any and all research. Most graduate thesis never see the light of day, yet they may hold important ideas that will serve future research inquiries.

6. Access to commonly used databases for all health care professionals. Keeping knowledge tucked away and at a significant cost keeps research and knowledge acquisition for the privileged. It’s a practice that warrants discussion and change.

Evidence doesn’t end suffering

Many of us are forging our ways through illness while others are forging a path empirically to try and help, but maybe the real question we should be asking more often is ‘while evidence may not yet exist, is this something we should consider and study along the way’. We’d all like the answer to ‘how do we address, prevent and treat’ serious mental health disorders’.

Crisis calls for focused and hyper vigilant attention to the problem to minimize suffering. Research demands a bifocal view of the problem. A panoramic scan of the landscape and repeated and repeatable scans of the micro and macro views to find solutions to solving problems of what do we know about the suffering and how do we address it. It requires the ongoing moving of the lens, moving back and forth until we feel like we have a picture-perfect view of what’s in front of us.

Evidence alone won’t end the suffering. No one wants to endorse a practice or an intervention that may not work or worse, do more harm. It’s the single best reason for why research matters. It’s how we integrate and implement the knowledge into the systems we live and work in that will make real differences in the lives of those who suffer. We’re likely to screw up along the way. There’s evidence to suggest we already have. Ask anyone who has had to navigate a psychological injury at work, and you’ll understand we don’t quite have things figured out yet. The best evidence out there won’t matter one bit if it’s not used in the right manner or at the right time. Evidence is important, but it alone won’t solve what ails us.

References

Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion. Health promotion international, 11(1), 11-18.

Wendy Lund

Wendy Lund

Wendy Lund, MSc in Mindfulness Studies

Former Faculty | Centennial College Paramedic Program

Wendy investigated the experience of trauma in paramedics for her MSc. After completing grad school, Wendy retired from a 32-year career in academia teaching the sciences to share proactive resiliency strategies as the Founder of Wellth Management Inc.

She can be reached at: wendy@wellthmanagement.ca | Twitter: @WorkWithHeartWM/@WLund100 or on LinkedIn: wellthmanagement

Canadian Paramedicine

Canadian Paramedicine

Canadian Paramedicine provides a platform for exchanging ideas and innovative programs, emerging news, trends, research, politics, and association information affecting Paramedicine in Canada and around the world.

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