Mental health first aid

The 2011 shooting of Rep. Gabrielle Giffords (D-Ariz.) and 18 others in a supermarket parking lot hit Mike Lange hard. Not only did the shooting occur near the retired lawyer's home in Tucson, it also killed one of his friends and a former colleague's son and injured one of his wife's former colleagues.

At first, says Lange, he played what he calls "the blame game."

"I was angry and wondered how this could have happened and why the [shooter's] parents didn't do more," he remembers. "But as I thought about it more, I realized it's more of a community responsibility."

Now Lange is putting that idea into practice. Soon after the shooting, he underwent a five-day training sponsored by a behavioral health agency called the Community Partnership of Southern Arizona (CPSA) to become an instructor in Mental Health First Aid — a public education campaign that teaches community members how to identify, understand and respond to signs of mental illness and substance use disorders before problems become crises. Since then, as a volunteer with CPSA, he has taught the 12-hour course more than a dozen times, sharing the program's message with members of his church, high school students, Indian Health Service staff and others.

The goal isn't to train people to be mental health experts or encourage them to make diagnoses, Lange emphasizes. Instead, he says, the program teaches them to be alert to "little red flags going up" and then offer help.

"We're more of a bridge, just like CPR or first aid," says Lange. "If someone has a cut, you give them immediate attention, then make sure they get professional help."

Originally developed in Australia, Mental Health First Aid is now being adopted in some parts of the United States and other countries around the world. President Barack Obama's plan to reduce gun violence calls for providing Mental Health First Aid training to teachers and other adults who interact with young people. Legislation introduced in Congress earlier this year would also support Mental Health First Aid implementation. And while some psychologists have questioned whether the training's evidence base is as robust as it should be, initial evaluations have shown that the program effectively reduces stigma, increases knowledge of mental illness and boosts confidence about responding appropriately to an emerging problem or a crisis. More wide-scale evaluations are underway.

Made in Australia

Mental Health First Aid got its start during a walk with the family dog, says psychologist Anthony F. Jorm, PhD, Mental Health First Aid's co-founder and a fellow in the Population Mental Health Group at the University of Melbourne's Melbourne School of Population and Global Health.

Jorm and his wife — co-founder Betty A. Kitchener, a nurse — were discussing her long history of depression. At age 15, she had attempted suicide, but received no professional help or even much comfort from her parents. The couple wondered if better support could have prevented future episodes and how they could help others who had similar problems. They came up with the idea of a first aid course that would focus on mental health just as the Red Cross first aid courses Kitchener taught focused on physical health.

"A lot of people never get to use conventional first aid skills because they're not that commonly needed," says Jorm. "But things like someone being suicidal, having a panic attack or being out of contact with reality are reasonably common." By 2001, Kitchener was piloting the first Mental Health First Aid class.

To develop the training, Jorm and Kitchener spent five years bringing together expert panels of clinicians, consumer advocates and caregiver advocates from the United States and other English-speaking countries. Using the "Delphi" method of systematically assessing consensus, these panels developed guidelines for addressing mental health problems and crises as well as the response protocol taught in Mental Health First Aid courses.

In the standard 12-hour training, participants learn about depression, anxiety and trauma, psychosis, eating disorders, substance use disorders and self-injury. They also learn a five-step action plan to help people who may be developing a problem or are already in a crisis: assessing people's risk of harm or suicide, listening nonjudgmentally, giving reassurance and information, encouraging appropriate professional help, and encouraging self-help and other support strategies.

The classes are highly interactive. To simulate what it's like to have — and talk to someone who has — the auditory hallucinations of schizophrenia, one exercise has a participant whispering in the ear of a second participant, who's trying to carry on a conversation with a third participant.

The classes are also effective, according to preliminary evaluations. In a 2012 article in American Psychologist, Jorm offers an overview of the evidence to date. Four randomized controlled trials have found that the training enhances participants' knowledge about mental illness, increases their confidence about providing help and actual helping behavior, and reduces stigmatizing attitudes. These improvements are still observed half a year later.

Jorm and Kitchener are now turning their attention to whether the training actually benefits Mental Health First Aid recipients. They hope to find out by training parents of adolescents and then assessing the long-term effect.

Although most of the research thus far has been carried out by Jorm and Kitchener themselves, independent evaluators are jumping in. In a 2011 non-randomized controlled trial of pharmacy students published in the Australian and New Zealand Journal of Psychiatry, for example, pharmacist Claire L. O'Reilly, PhD, of the University of Sydney and colleagues found that Mental Health First Aid training improved pharmacy students' recognition of mental disorders and their confidence in providing services to consumers with mental illnesses.

The move to independent evaluations is welcome, says Lynn Bufka, PhD, assistant executive director for practice research and policy in APA's Practice Directorate.

"You always like to have research confirmed by someone who's not invested in the origination of ideas," she says. "And the majority of the research has been done in Australia, so it's important to evaluate it in a variety of other settings."

The research to date has already prompted widespread adoption of Mental Health First Aid on its home turf and beyond, however. As Jorm and Kitchener report in a 2011 paper in the Australian and New Zealand Journal of Psychiatry, 1 percent of Australian adults have already undergone training.

On American shores

In the United States, Mental Health First Aid has joined similar efforts that were already under way when the Australian import arrived five years ago. There's the National Coalition for Mental Health Recovery's Emotional CPR program, for example, which also teaches people how to help others through emotional crises. There's also Psychological First Aid, which trains American Red Cross workers and others to provide basic care and support to individuals experiencing stress after disasters.

Now Mental Health First Aid is quickly spreading across the United States, says Bryan Gibb, director of public education at the National Council for Community Behavioral Healthcare. In 2008, the council joined with the Maryland Department of Health and Mental Hygiene and the Missouri Department of Mental Health to bring Mental Health First Aid to this country and adapt it to the American context. The three entities now manage, operate and disseminate Mental Health First Aid USA.

The appeal? "Anyone could take the program and walk away with useful skills," says Gibb.

Since its U.S. launch, the program has certified 3,000 instructors who have trained more than 100,000 people in all 50 states. High-profile incidents of violence, such as the Aurora theater shooting and the Newtown school massacre, are part of what's driving that interest, says Gibb. But while such tragedies offer an opportunity to talk about the need for early intervention, promoting Mental Health First Aid as a violence prevention initiative can reinforce stereotypes about mental illness.

"We try to temper concern with facts," says Gibb. People with mental illness are no more likely to be violent than other people and are in fact more likely to be victims of violence than perpetrators, he emphasizes. "We also try to make the point that most interactions that a First Aider will have are low intensity," he says.

While it's often workplaces that offer the training, more and more city and county governments are coming on board.

In Philadelphia, for instance, psychologist Arthur C. Evans Jr., PhD, commissioner of the city's Department of Behavioral Health and Intellectual disAbility Services, has put into place what he says may be the country's "most audacious" Mental Health First Aid program.

The program will help solve what Evans says is one of the greatest challenges that behavioral health systems face. "There are some people who have mental illness who recognize they have a problem and go into treatment voluntarily; people who have reached a threshold of dangerousness to themselves or others can be involuntarily committed to treatment," he explains. "Then you have this gray zone."

Mental Health First Aid can help reach people in that zone, Evans believes. About a year and a half ago, the city started training criminal justice and public safety staff, then expanded the program to other employees. The city has also forged an agreement with the American Red Cross that will result in first aid training that covers both physical and mental health conditions, something Evans believes is the country's first holistic training. The goal is to train 10 percent of the city's population — more than 150,000 people — in Mental Health First Aid over the next two years.

"The fact that we already have 1,300 more people in the city who can recognize problems and intervene is enormously important," says Evans. "[W]e recognize that we have to have more than just mental health professionals who can intervene with people."

The city will also participate in an evaluation conducted by Drexel University researchers.

"A lot of the research done so far has been focused on whether the training was effective, whether people feel more comfortable and confident — all important questions," says Evans. "But we need to take it a step further and look at whether it actually results in people intervening with people."

The U.S. Substance Abuse and Mental Health Services Administration is reviewing Mental Health First Aid for possible inclusion in the National Registry of Evidence-Based Programs and Practices, Gibb adds.

Future directions

When President Obama invited APA CEO Norman B. Anderson, PhD, and other mental health stakeholders to a meeting after the Newtown tragedy, a key recommendation APA made was to launch a national public health campaign to encourage help-seeking behavior among people with mental health problems, says Ellen Garrison, PhD, APA's senior policy advisor.

The president listened. In addition to calling for Mental Health First Aid training in his plan to reduce gun violence, Obama announced his plan to launch a "National Dialogue on Mental Health." The initiative aims to reduce the stigma associated with mental disorders and to encourage those who need mental health care to seek treatment. Vice President Joe Biden's office contacted APA regarding this initiative, says Garrison, adding that APA is now working with several organizations on related efforts.

Congress is also taking action, with broad, bipartisan support for efforts to increase the public's knowledge about mental health. The Mental Health Awareness and Improvement Act of 2013, for example, includes a mental health awareness training provision.

"It's noteworthy and laudable that the legislation calls for the use of evidence-based programs," says Garrison.

But while the mental health bill passed the Senate by 95 to 2 as an amendment to a gun safety bill, she says, it was lost when the gun safety bill was withdrawn by the majority leader due to a lack of sufficient support. APA and other mental health organizations are now urging the Senate to reconsider the mental health legislation in a separate vote.

Meanwhile, several states have passed similar legislation, often focused on teachers, coaches and other adults who work with adolescents.

Of course, adds Garrison, it's also crucial to ensure that services are available to those who do seek help after a Mental Health First Aid or similar type of intervention. People in rural areas, young adults who aren't in college and older people may face barriers to care, says Garrison, explaining that expanding access to mental health services is a major part of APA's federal advocacy efforts. State, territorial and provincial psychological associations could play a key referral role, she adds.

Meanwhile, Jorm and Kitchener have been busy tailoring the training for particular groups. They're piloting a course for teens who want to be able to help their peers, for example. In addition, lesbian, gay, bisexual and transgender groups are asking for a Mental Health First Aid adaptation to meet their needs. A version that blends face-to-face and Web-based learning is another emerging priority because of feedback from workplaces on the difficulty of scheduling 12-hour training sessions for multiple employees. An eight-hour version of the standard training will soon be available in the United States.

The fact that Obama mentioned Mental Health First Aid amazes Jorm, who notes that what started as a chat during a dog walk has snowballed.

"We didn't realize we'd get so big," says Jorm. "We like to think what would happen if we got 1 percent of the world to take Mental Health First Aid."

For more information about Mental Health First Aid in the United States, visit Mental Health First Aid.

Rebecca A. Clay is a writer in Washington, D.C.