THE ONLINE CITIZENS PROJECT: EFFECTS OFTRANSITIONAL PEER SUPPORT GROUPS FACILITATED BY PEER SUPPORT WORKERS FOR PERSONS LIVING WITH SEVERE MENTAL ILLNESS IN TIMES OF THE COVID-19PANDEMIC

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Cadernos Brasileiros de Saúde Mental, ISSN 2595-2420, Florianópolis, v.13, n.36, p.97-116, 2021
THE ONLINE CITIZENS PROJECT:
EFFECTS OFTRANSITIONAL PEER SUPPORT GROUPS FACILITATED BY
PEER SUPPORT WORKERS FOR PERSONS LIVING WITH SEVERE MENTAL
ILLNESS IN TIMES OF THE COVID-19 PANDEMIC
Projeto Cidadão Online: Efeitos dos grupos transitórios de suporte de pares facilitados por
trabalhadores de apoio para pessoas vivendo com transtorno mental grave em tempos de
pandemia Covid-19
Jean-François Pelletier
1
Janie Houle
2
Marie-Hélène Goulet
3
Charles-Édouard Giguère
4
Charles-Albert Morin
5
Robert-Paul Juster
6
Isabelle Hénault
7
Frédéric Denis
8
______________________
Artigo encaminhado:10/01/2021
Aceito para Publicação: 30/03/2021
ABSTRACT: From August to November 2020, the Online Citizens Project has
been offered as a transitional peer support group to persons living with Serious
Mental Illness (SMI) in the province of Quebec, Canada. The Citizens’ Project is a
support group where participants share their challenges and accomplishments with
each other and receive honest and confidential feedback. These groups had a
personal-civic recovery focus and consisted of a series of 10 weekly 90-minute
online workshops. To evaluate the impact of the intervention on the participants'
sense of citizenship, all study participants completed the 23-item French version of
the Citizenship Measure before (T1) and after (T2) the intervention (≤14 weeks
1
Associate Professor of Psychiatry, University of Montreal, Assistant Clinical Professor, Yale University. E-
mail: Jean-fancois.pelletier@yale.edu
2
Professor of Psychology, University of Quebec in Montreal. E-mail: houle.janie@uqam.ca
3
Adjunct Professor of Nursing, University of Montreal. E-mail: marie-helene.goulet@umontreal.ca
4
Statistician, Montreal University Institute of Mental Health. E-mail: cedouard-giguere.iusmm@ssss.gouv.qc.ca
5
Peer Support Worker, Research Assistant, Montreal University Institute of Mental Health. Email: charles-
albert.morin@umontreal.ca
6
Adjunct Professor of Psychiatry, University of Montreal. E-mail: robert-paul.juster@umontreal.ca
7
Peer Support Worker, Director, Quebec Association of Peer Support Workers. Email:
isabelle.henault@umontreal.ca
8
Associate professor of Public Health, University of Tours.E-mail: frederic.denis@chu-tours.fr

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between T1 and T2). The mean and standard deviation differences between the
two measurement times were compared between the experimental group and the
control group. The mean score to the Citizenship Measure for the experimental
group varied by -0.4%. The mean score for the experimental group varied by -
5.5%. For the control group, there was a decrease in the means for each of the 5
sub-scales of the Citizenship Measure. In total, the difference was statistically
significant (P=.04). Results suggest that the Online Citizens Project had a
protective effect on the sense of citizenship of the participants living with SMI in the
experimental group compared to those in the control group. The Citizenship
Measure can be used to gauge the effects of such an online intervention,
intentionally designed to promote the exercise of citizenship, namely the Citizens
Project.
Keywords: Online Citizens Project. Personal-Civic Recovery. Citizenship
Measure. Peer Support Workers. Transitional Peer Support Group.
RESUMO: De agosto a novembro de 2020, o Projeto Cidadãos Online foi
oferecido como um grupo de apoio de pares de transição para pessoas que vivem
com Doenças Mentais Graves (SMI) na província de Quebec, Canadá. O Projeto
dos Cidadãos é um grupo de apoio onde os participantes compartilham seus
desafios e realizações uns com os outros e recebem feedback honesto e
confidencial. Esses grupos tinham como foco o recovery e cidadania individual e
consistiam em uma série de 10 grupos semanais de trabalho online com 90
minutos de duração. Todos os participantes do estudo completaram a versão
francesa de 23 itens da Medida de Cidadania antes (T1) e depois (T2) da
intervenção (≤14 semanas entre T1 e T2) para avaliar o sentido de cidadania e o
impacto da intervenção nos participantes. As diferenças de média e desvio padrão
entre os dois tempos de medição foram comparadas entre o grupo experimental e
o grupo controle. A pontuação média da Medida de Cidadania para o grupo
experimental variou em -0,4%. A pontuação média para o grupo experimental
variou em -5,5%. Para o grupo controle, houve diminuição das médias para cada
uma das 5 subescalas da Medida de Cidadania. No total, a diferença foi
estatisticamente significativa (P = 0,04). Os resultados sugerem que o Projeto
Cidadãos Online teve um efeito protetor no senso de cidadania dos participantes
que vivem com SMI no grupo experimental em comparação com aqueles no grupo
de controle. A Medida de Cidadania pode ser utilizada para medir os efeitos dessa
intervenção online, intencionalmente concebida para promover o exercício da
cidadania, nomeadamente o Projeto Cidadão.
Palavras-Chave: Projeto Cidadãos Online. Individual Recovery Cidadania. Medida
de Cidadania. Trabalhadores de Suporte de Pares. Grupo Transicionais de
Suporte de Pares.

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1 BACKGROUND
In times of pandemics, social distancing, isolation, and quarantine may
exacerbate stress, depression and anxiety as confined people are detached from
their loved ones, deprived of personal liberties, and devoid of purpose owing to
altered routine and livelihood (HAWRYLUCK et al., 2004; JEONG,2016). Those
with pre-existing mental health problems or illnesses might suffer more from
limiting interpersonal interactions that are central to their recovery and wellbeing,
as well as reducing access to helpful but "non-essential" (often cancelled) mental
health services and support (VENNKATESH et.al.,2020). Because successful use
of quarantine and distancing as a public health measure requires that people
anticipate and reduce contact, as much as possible, with negative psychosocial
effects associated with this reduction (BROOKS et al., 2020), a feasibility study of
a trial was conducted in the province of Quebec, Canada, in partial response to this
problematic situation. This pilot trial consisted of offering a transitional measure of
online peer support for people suffering from severe mental illness (SMI, like
schizophrenia or other psychotic disorders), to possibly detect an effect of this Peer
Support Workers-delivered intervention in terms of both personal-civic recovery
(PELLETIER et al.,2015)and clinical recovery (reduction of symptoms).
Peer Support Workers (PSWs) are persons with first-hand lived experience of
mental illness, and who are further along in their own recovery journey. As
recommended by recovery-oriented best practices guidelines (VAN VUGT et al.,
2012; CANADA,2015), upon training and certification they can provide supportive
services when hired to fill such a paid specialty position directly in, or in conjunction
with, current mental health services. Indeed, recovery focuses on how individuals
can have more active control over their lives by exercising their agency beyond
symptoms of SMI. It is characterized by a search for the person's strengths and
capacities, satisfying and meaningful social roles, and mobilizing formal and
informal support systems. Because peer support is recognized as a good way to
channel the lived experience into social support that values this shared experience,
peer support has thus become one predominant concept in the recovery paradigm,

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and PSWs are specialized in peer support. Yet, not much is known about the
measurable effects of PSWs from a consumer's perspective of personal-civic
recovery.
Decreasing pain and suffering, overcoming disability due to mental health
problems or illnesses, and helping affected individuals to be and to remain in
recovery by providing them with social support initiatives, not solely treating them
for their symptoms, is a major public health concern. This is even more true in
times of isolation, quarantine, and pandemic because lack of social support is
known to be an important factor that can negatively affect mental health and
wellbeing (HARANDI T F; TAGHINASAB M; NAYERI TD, 2017). Therefore, along
with other socio-political or historical considerations, recovery is now the official
leading paradigm in the transformation of mental health systems and policies in
Canada (CANADA,2012), as is also the case elsewhere around the world, and as
promoted by the World Health Organization (WHO,2013).In 2005, recovery was
introduced as aguiding principle of the 2005-2010 Mental Health Action Plan in the
French speaking province of Quebec, Canada (QUÉBEC,2015), a plan that also
introduced PSWs as a key feature of recovery-oriented services. Recovery
remained at the core of the 2015-2020 Mental Health Action Plan, but now with full
citizenship as a supplementary guiding principle and objective of continuing
transformation (QUÉBEC,2005). Citizenship emphasizes the social inclusion and
participation of people who are marginalized ‘mentally ill’. This approach offers a
more social and relational view of services and support for people with mental
health problems than has been common in mental health systems of care (QUINN;
BROMAGE; ROWE,2020). With the entry into force of this other more recent plan,
the use of a specific measure of citizenship, namely the Citizenship Measure,
became particularly relevant to assess whether such an orientation would indeed
lead to positive results in terms of citizenship in mental health. This tool was
developed through a community-based participatory research design in response
to a prompt (For me, being a citizen means…) suggested by persons in recovery
who were involved as research partners and research staff. Using a translation-
back-translation method (VALLERAND,1989) that involved the original authors of

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the Citizenship Measure and with a similar participatory approach, this tool was
then translated into French and thepsychometric properties of this French version
(Mesure de la citoyenneté) were validated. This 23-item French Citizenship
Measure covers the following five clusters: (1)Basic needs (5 items, Cronbach
α=0.60), (2)Responsibilities (4 items, Cronbach α=0.65), (3) Rights (6 items,
Cronbach α=0.67), (4) Resources (4 items, Cronbach α=0.60), and (5)
Relationships (4 items, Cronbach α=0.74).In the context of a pandemic, has the
online citizen project resulted in effects that could be measured using this measure
of citizenship?
2 METHODS*
2.1 Control Intervention
More than 4,000 patients are treated annually at the Institut universitaire en
santé mentale de Montréal (IUSMM, catchment area of about 600,000 inhabitants),
while an additional 2,000 patients per year are treated by means of outpatient or
ambulatory services. When a person in distress shows up at the Emergency
Department of IUSMM for the first time, he or she is systematically approached by
a Research Nurse after a first medical authorization is granted for that person to be
approached. The Research Nurse then explains the objectives of the Signature
Bank project, which is a large longitudinal study (LUPIEN,2017), and invites the
person to participate. Those who agree to participate are also asked if they would
be willing to be contacted for other research purposes (like for this pilot study).
Then, as with any other IUSMM patients, they are evaluated by the Evaluation and
Liaison Module during their hospital stay. A diagnostic is established or confirmed
by ward psychiatrists and coded according to the WHO International Classification
of Disease–10th Revision (ICD-10) (WHO,1993). Based on the diagnosis (or
diagnoses), after discharge, they are referred to a specialized outpatient clinic.
Pharmacotherapy, psychotherapy, or a combination of both are then generally
offered in accordance with the guidelines of the Royal College of Physicians and
Surgeons of Canada. Those Signature Bank participants aged 18 years old or
more diagnosed with psychotic disorders (ICD F20-F29 codes) and who also

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consented to participate in our study were randomly allocated to this control
intervention only, while the other half of our study participants also received our
experimental PSW-led online group intervention. Exclusion criteria include (1)
active suicidal ideations, (2) marked cognitive impairment, and (3) no access to an
internet connection, or to an electronic device with a webcam and microphone to
participate in the online transitional peer support group.
2.2 Experimental Intervention
As part of the development of a new training program for PSWs in Health
Sciences at the University of Montreal, a group intervention by PSWs that we
became familiar with over the years was the Citizenship Enhancement Project
(ROWE et al.,2009), more commonly known as the Citizens’ Project. Initially
derived from research on mental health outreach to persons who are homeless
(ROWE,1999), this intervention was designed to address the specific community
and social inclusion needs of persons with SMI and comorbid criminal justice
histories. The Citizens’ Project is a support group where participants share their
challenges and accomplishments with each other and receive honest and
confidential feedback. Discussions are geared towards the rights, relationships,
roles, responsibilities, and resources of community membership (the “5Rs”).
Individual or group projects developed by participants are also discussed, for them
to share their knowledge and experience with others. PSWs services are provided
in and outside that setting. Indeed, drawing from social science theories that
propose social and civic participation as a measure of one’s inclusion in
society(BELLAH et al.,1996), the Citizens Project emphasizes the importance of
opening up opportunities for participation to persons at risk of marginalization. In
close collaboration with the Yale Program for Recovery and Community Health that
developed and evaluated the Citizenship Enhancement Project, we adapted and
transposed it in French into Projetcitoyen (PELLETIER et al.,2017; PELLETIER et
al.,2014), and then further moved the Projetcitoyen online for the specific needs of
this pilot project (hence the Online Citizens’ Project).
During the Online Citizens’ Project, PSWs trained at the University of
Montreal learned with participants via a series of 10 co-learning workshops that

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they organized and facilitated as focus group panels in a manner to simulate a
typical peer support group (WHO,2019). The difference between our experimental
and transitional online peer support groups and real community-based peer
support groups is that (1) they had to be facilitated by trained PSWs; (2) they had a
personal-civic recovery focus; and (3) they had a fixed, predetermined duration (a
series of 10 weekly 90-minute online workshops). Indeed, as defined by the WHO:
Peer support groups bring together people who have similar
concerns so they can explore solutions to overcome shared
challenges and feel supported by others who have had similar
experiences and who may better understand each other’s situation.
Peer support groups may be considered by group members as
alternatives to, or complementary to, traditional mental health
services. They are run by members for members, so the priorities
are directly based on their needs and preferences. Peer support
groups should ideally be independent from mental health and
social services, although some services may facilitate and
encourage the creation of peer support groups. (WHO,2020)
For this feasibility study of a trial (BOWEN et al., 2009) and in conjunction
with IUSMM mental health and social services, the objective was to offer social
support, in times of pandemic, to a sample of IUSMM patients. PSWs encouraged
participants to support each other in these difficult times, but more generally, they
proposed that participants project themselves beyond this situation and discuss
future challenges of inclusion and social participation (e.g., by attending already
existing ‘real’ community-based peer support groups, of which they became aware
during the pilot intervention). This is why this intervention is said to be transitional
(between formal mental health and social services, and community-based peer
support groups). In accordance with our model of PSW engagement (PELLETIER
JF, AUCLAIR É,2017; PELLETIER et al.,2013), PSWs startedeach workshop by
disclosing that they themselves were persons in recovery and fed the group
discussion with content drawn from their lived experience while asking participants

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to share their own lived experience and coping strategies, for this to be in line with
experiential learning (YARDLEY S; TEUNISSEN PW, DORNAN T,2012).
2.3 Primary and Secondary Outcome Measures
Several instruments have been developed by clinicians and academics to
assess clinical recovery. Based on their life narratives and to assess personal-civic
recovery, measurement tools have also been developed through community-based
participatory research and validated by persons in recovery (e.g., the Citizenship
Measure questionnaire, also developed by the Yale Program for Recovery and
Community Health). As consumers of mental health services typically tend to
prefer interventions to help them recover, reintegrate with society, and achieve
their personal goals (UK,2012), this pre-post research feasibility trial design was
proposed to evaluate the outcomes on personal-civic recovery (primary outcome),
and on clinical recovery and stress- or anxiety-related responses to the COVID-19
pandemic (secondary outcome).
The COVID-19 Stress Scales (36 items) (TAYLOR et al.,2020), the Recovery
Assessment Scale (24-item measure of personal recovery) (CORRIGAN, 2004) [
1
,]
and the Citizenship Measure (23-item measure of civic recovery) (ROWE et al.,
2012) were repeated, along with the following measures of clinical recovery, which
are routinely collected from all Signature Bank participants:
• Anxiety: State-Trait Anxiety Inventory Form Y6 (6 items) (MARTEU;
BEKKER,1992);
• Depression: Patient Health Questionnaire (9 items) (KROENKE;
SPITZER; WILLIAMS,2001);
• Psychosis: Psychosis Screening Questionnaire (12 items)
(BEBBINGTON; NAYANI,1995);
• Alcohol abuse: Alcohol Use Disorders Identification Test (AUDIT-10,
10 items) (WHO, 2020);
• Drug use: Drug Abuse Screening Test (10 items) (LAM et al.2015);
• Social functioning: WHO Disability Assessment Schedule (12 items)
(WHO, 2020);

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3 ETHICAL CONSIDERATIONS
Declaration of Helsinki protocols were followed, and participants gave written
informed consent. The study was approved on June 16, 2020, by the Research
Ethics Committees of the Montreal Mental Health University Institute (#2020-1948).
For all participants, an overseeing mental health expert have ruled that all these
adult participants were deemed ethically and medically capable of consenting for
their participation.
4 RESULTS
T tests were performed with the Statistical Processing for Social Sciences
software (SPSS, version 24) to compare the outcomes between study participants
living with SMI who were randomly allocated to the experimental group (N=9, no
missing data) or to the control group (N=6, no missing data). Among all the 9
validated self-reported questionnaires mentioned in the Methods section and
assuming equal distribution, as shown in Table 1, in total it is only for the
Citizenship Measure that statistically significant differences (i.e.P≤.05, 95%
confidence interval) were found between the experimental group and the control
group (P=.04). No other statistically significant differences were found to a
questionnaire as a whole between the experimental group and the control group
(inter-group comparison). For the control group, there was a decrease in the
means for each of the 5 sub-scales of the Citizenship Measure, as shown in Table
2. The mean score (X/115) to the Citizenship Measure as a whole for the
experimental group varied by -0.4% (98/115 at T1 and 97/115 at T2), where as the
mean score for the experimental group varied by -5.5%, which is ten times more
for that measure (87/115 at T1 and 81/115 at T2), as reported in Table 3.
Table 1: Means, standard deviations and statistical significance for each questionnaire
Experimental
Group
Control
Group
Inter-
groupCompariso

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n
Questionnaire
Mean
SD
Mea
n
SD
P value
COVID-19 Stress Scales (x/144)
18.67
25.19
17.50
12.85
.92
RecoveryAssessmentScale (x/120)
96.44
10.11
93.33
11.67
.59
CitizenshipMeasure (x/115)
97.67
11.62
81.00
16.60
.04*
State-Trait Anxiety Inventory (x/14)
15.00
2.83
13.50
0.84
.23
Patient Health Questionnaire (x/27)
6.78
7.63
11.00
8.10
.32
Psychosis Screening Questionnaire
(x/12)
3.22
5.87
4.67
5.79
.65
Alcohol Use Disorders Identification
Test (x/40)
1.44
1.74
5.50
5.65
.06
Drug Abuse Screening Test (x/10)
2.11
2.26
1.50
2.35
.62
WHO Disability Assessment
Schedule (x/48)
6.11
7.47
13.67
9.61
.11
* P=<.05, 95% confidence interval.
With theexception for the I can handle stressof the Recovery Assessment
Scale (P=.05), significant differences were found only to the Citizenship Measure
as a whole, to 2 of its subscales, and to 6 of its 23 items, as presented in Table 2.
Table 2: Differences to the Citizenship Measure
Experimental
Group
Control
Group
Inter-group
Comparison
Items (x/5) and clusters of the
Citizenship Measure
Mean
SD
Men
SD
P value
1- Your basic needs are met
3.44
1.33
3.67
0.82
0.72
2- You do things to take care of your
home
4.33
0.87
4.17
0.75
0.71
3- You are safe in your community
4.67
0.50
4.00
0.89
0.09
4- There are laws that will protect you
4.44
0.73
3.50
1.05
0.06
5- You have or would have access to
employment
4.33
0.87
2.67
1.03
0.00*

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Cluster 1 : Basic needs (items 1-5,
x/25)
21.22
2.82
18.00
3.69
0.08
6- You are included in your
community
4.11
0.93
3.67
0.82
0.36
7- You have responsibilities to others
in the community
4.22
0.97
3.17
0.98
0.06
8- You can influence your community
or local government
3.44
1.13
3.33
1.03
0.85
9- You have knowledge about your
community
3.44
1.13
3.50
0.84
0.92
Cluster 2 : Responsibilities (item 6-9,
x/20)
15.22
3.11
13.67
3.20
0.37
10- You or your family have choices in
education
4.22
0.83
3.00
1.26
0.04*
11- You stand up for what you believe
in
4.22
0.97
4.00
0.89
0.66
12- You have the right to be in a
relationship with a partner of your
choice
4.44
0.53
3.83
1.17
0.19
13- You have privacy
4.56
0.53
3.00
1.10
0.00*
14- You have the right to disagree
with others
4.44
0.53
3.83
0.98
0.14
15- You can make choices about how
you spend your money
4.44
0.73
3.33
1.21
0.04*
Cluster 3 : Rights (items 10-15, x/30)
26.33
3.08
21.00
4.56
0.02*
16- You have access to adequate
healthcare
4.56
0.53
3.83
0.98
0.09
17- You have or could have access to
adequate and affordable housing
4.33
0.71
3.67
1.21
0.20
18- You would have access to public
assistance, if needed
4.33
0.71
3.17
1.33
0.04*
19- You have choices in your mental
healthcare
4.33
1.00
3.50
1.05
0.14

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Cluster 4 : Resources (items 16-19,
x/20)
17.56
2.46
14.17
3.92
0.06
20- You are treated with dignity and
respect
4.67
0.50
3.33
1.21
0.01*
21- Others feel accepted by you
4.44
0.53
3.83
0.75
0.09
22- Otherslisten to you
4.11
0.93
3.33
1.03
0.15
23- Your personal decisions and
choices are respected
4.11
0.60
3.67
0.82
0.24
Cluster 5 : Relationships (items 20-23,
x/20)
17.33
2.00
14.17
3.19
0.03*
Total (items 1-23, x/ 115)
97.67
11.62
81.00
16.60
0.04*
* P=<.05, 95% confidence interval.
To find out in which direction the differences were oriented, we further
compared the evolution of scores on the Citizenship Measure between T1 and T2
for the experimental group, and for the control group. Table 3 shows these
variations, also expressed in percentages, for the items and sub-scales to which
statistically significant differences were previously found (P=<.05, Table 2).
Table 3: Pre-post statistically significant differences
Items (x/5) and clusters of
the Citizenship Measure
Experimental
Group
Control
Group
Inter-group
Difference
You have or would have
access to employment
-0.44 (-8.9%)
-0.83 (-
16.7%)
7.8%
You or your family have
choices in education
0.11 (+2.2%)
-0.33 (-
6.7%)
8.9%
You have privacy
0.22 (+4.4%)
0.00
(0.0%)
4.4%
You can make choices about
how you spend your money
-0.11 (-2.2%)
-0.17 (-
3.3%)
1.1%
Cluster 3 : Rights (6 items,
x/30)
0.33 (+1.1%)
-0.33 (-
1.1%)
2.2%
You would have access to
0.00 (0.0%)
-0.83 (-
16.7%

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public assistance, if needed
16.7%)
You are treated with dignity
and respect
0.22 (+4.4%)
-0.83 (-
16.7%)
21.1%
Cluster 5 : Relationships (4
items, x/20)
-0.44 (-2.2%)
-2.83 (-
14.2%)
11.9%
Total
-0.44 (-0.4%)
-6.33 (-
5.5%)
5.1%
4 DISCUSSION
Two inter-group differences from T1 to T2 for items of the Citizenship
Measure stand out as being greater than 15% (Table 3), namely the You would
have access to public assistance, if needed item (16.7%), and the You are treated
with dignity and respect item (21.1%). This may suggest that, for participants in the
transitional peer-support groups facilitated by PSWs (the Online Citizens’ Project),
these groups were indeed considered complementary to formal health and social
services. With universal coverage, in Canada and Quebec, access to public health
and mental health services is free for all citizens. It is therefore possible that
access to the Online Citizens Project as a psychosocial support program is
perceived and accepted as part of public assistance.
Also, in times of pandemic, social distancing, and confinement, participation
in the groups, even though remotely online, is an opportunity for staying in touch
with others, and thus to possibly feel treated with dignity and respect by others. It is
also an opportunity to show interest and respect towards other members of the
group. Indeed, one other item of the Relationships sub-scale, the only sub-scale for
which the inter-group difference is greater than 10%, reads like this: Others feel
accepted by you.
All of the above points to the relational and collective dimension of
citizenship. This is in line with the concept of collective citizenship suggested by
Quinn, Bromage, and Rowe (2020). So far, they write, the citizenship approach has
mostly operated in the context of systems of care in the United States that favour
highly individualized conceptions of, and approaches to, mental health care. These
systems of care thus operate in the social and political context of highly

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individualized concepts of the citizen. The transposition of this approach into a
system of universal coverage of health and mental healthcare, i.e., that of Quebec
and Canada, which remain culturally and certainly geographically close to the
United States, therefore, seems to reinforce this relevance of a more collective and
inclusive approach to citizenship in mental health.
4.1 Limitations and strengths
The small size of the samples for this pilot project considerably limits the
scope and generalizability of the results presented and discussed in this paper. A
subsequent randomized controlled trial would be needed to draw more solid
conclusions about the effectiveness of citizenship-oriented transitional online peer
support groups facilitated by PSWs, even though the global context may be quite
different. Indeed, the very specific situation of the COVID-19 pandemic worldwide
must be taken into account. When the pandemic has subsided, people’s own
personal goals and needs during the pandemic may be different from that post
pandemic, and the effects of the response may also be different, including for
people living with SMI. But although there will likely be some “return to normal,”
some of the innovations developed in response to the COVID-19 pandemic will
most likely remain a part of everyday clinical and educational operations
(WOOLLISCROFT,2020). It is thus fortunate that the whole intervention was
intentionally designed to be readily adaptable to other pandemic or non-pandemic
situations.
This study did not detect a clear improvement in terms of recovery, self-
confidence, or even citizenship among participants, as might have been
reasonably expected (RESNICK; ROSENHECK,2008). Having been carried out in
a time of a pandemic, this study rather made it possible to observe the
maintenance of certain capacities, especially in terms of citizenship and
relationships. When the current pandemic is over, it will be more difficult to detect
and attribute such effects to a common and widespread stressor. People will
continue to individually experience stressful and destabilizing events of different
amplitudes, but not necessarily simultaneously, as was the case for the public

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health measures imposed on all inhabitants of a same territory and jurisdiction to
limit the spread of the COVID-19 virus.
The smallness of the sample size is both a limitation and a strength. This
smallness makes it difficult to generalize the results, but an a priori power analysis
of these results, conducted using G*Power3 (FAUL et al., 2007) enabled us to
determine a predictable sample size that could be used for the planning of a larger
subsequent study. To detect to the Citizenship, Measure an effect size of 0.28
(Cohen's d), with a power of 80% and an alpha of 5%, the result to this bilateral
matched sample t-test showed that a minimum sample size of 103 participants with
two groups of equal size of n = 52 (and a minimal sample size of 52 participants
with two groups of equal size of n = 26 to the Recovery Assessment Scale) would
be required to obtain the desired power.
The transitional self-help groups were themselves relatively small, never
having exceeded 8 participants simultaneously. It will thus be recommended to
distribute the 103 participants that we need, according to our power calculation, in
small groups of no more than 10 participants, with the expectation that they will not
all be there at a same time. Taking into account a possible overall attrition rate of
30%, as happened in our pilot study, it will therefore be necessary to recruit around
150 participants and to plan groups of no more 10 people.
Indeed, as discussed during the debriefing sessions held between the
facilitating PSWs after each of these groups to discuss what worked or not and
why, such a size turned out to be sufficient, in fact representing a limit not to be
exceeded so that there can be a real and genuine group dynamic among
participants. It is this feeling of being part of the same group that allowed
participants to feel that they were members of a group, and not just anonymous
individuals in a crowd. This smallness allowed participants to get to know each
other, and to recognize each other as fellow members of a same group in which
they were all equals to one another.
In French, it is the word concitoyen that should be used to speak of this bond
of equality between people who are members of the same political community, for
example a republic of which they are all citizens (citoyens, not to be confused with

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nationality). In English, the equivalent of the French word concitoyen would be:
fellow citizen. In theory, this “fellowship” is the conceptual key to this functioning.
Being themselves persons in recovery and fellow members in and of the
transitional self-help groups, PSWs can horizontally communicate the hope for
civic-recovery by invoking a shared experiential reminiscence of inclusion. This
communication is not top-down, from experts to non-experts, since the epistemic
authority of the PSWs is not academic or voluntarily studied, for example through
college lessons that could be repeated once well learned. Their more “moral”
epistemic authority is acquired through the personal experience of civic-recovery,
an experience that has been the subject of a reflective feedback on oneself and
with the support of other peers for it to become communicable knowledge. This
experiential knowledge and wisdom can then be shared, not passed on during the
transitional self-help groups, namely the online Citizens Project. This reciprocity
between fellow citizens grappling with similar (mental health) challenges makes it
possible, in particular, to prevent what Patrick Corrigan, Larson and Rususch
called the Why Try Effect (CORRIGAN., LARSON; RUSUSCH,2009) a
phenomenon which consists in applying to oneself the disabling stereotypes about
the “mentally ill”. By offering themselves as capable role models who have been
there and done that, PSWs can prevent self-stigma that very often comes with the
announcement of such labelling diagnoses and which causes some people to
abandon themselves, thus giving up in advance to ask for and receive (mutual)
help, or to undertake change because they may feel incapable or worthless. This
horizontal fluid circulation and knowledge sharing between members of the small
groups and PSWs make it possible to establish this reciprocity, which is necessary
for mutual understanding as a cornerstone of self-understanding and in interaction
with other fellow citizens. The economist Ernst Friedrich Schumacher once
proposed that small is beautiful, (SCHUMACHER,1973) a concept now often used
to champion smaller, and more appropriate technologies or polities that are
believed to empower people more. This might be the case with the online Citizens
Project as a transitional self-help group facilitated (not led) by PSWs.

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5 CONCLUSION
Access to peer support groups facilitated by PSWs is likely to allow members
of these small groups to cope better with their personal daily challenges by
maintaining meaningful relationships of mutual respect. In addition, and as its
name suggests, the Citizen Project was initially designed as an intervention
promoting the exercise of citizenship for people living with SMI. In this regard, this
study may not have resulted in clear and statistically observable improvements, but
in a maintenance that could be empirically observed with the use of a tool
specifically designed for this purpose of assessing citizenship, namely the
Citizenship Measure.
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