By Ruth Graham
January 23, 2015
If you are one of the millions of Americans who have been trained in first aid, you know what to do if you are walking down the street and see a stranger suddenly clutch his chest and collapse. But if that same man instead is shouting to himself, or having a panic attack, it’s much less clear what a compassionate stranger can do to help. Often, the default response is simply to cross the street.
A heart attack and a panic attack are both medical crises of a kind. But millions of ordinary people, beyond the medical establishment itself, have been trained to respond to that first kind of physical crisis. We call it first aid: immediate assistance for suddenly ailing or injured people, often with the goal of averting disaster while calling for professional help. Since the 19th century, everyone from wartime ambulance drivers to baby sitters have been trained to handle scenarios including wounds, choking incidents, and heart attacks. It’s not the same as being a doctor, but it’s a big help.
In just the last few years, experts have begun arguing that we need a program like this for mental health emergencies, too. Last year, a program called Mental Health First Aid received federal funding for the first time. In Australia, where the program originated, 1 percent of the adult population is said to have attended a course; there and in the United States and Europe, experts are beginning to test how well it works. In the United States, more than 300,000 people have been trained, including more than 2,000 in Massachusetts. The idea is to be able to respond to mental health emergencies calmly and proactively, and to be able to promptly steer those in need toward the right resources.
The program has the support of many mental health professionals, who say that its broad approach to a wide array of mental health emergencies is sorely needed. “What’s appealing about this is that it’s for everybody, like first aid,” said Linda Rosenberg, CEO of the National Council for Community Behavioral Health, a Washington-based nonprofit that co-administers the program in the United States. “Until now, people really avoided people who were psychiatrically in pain. We just didn’t know what to do.”
But the programs also inadvertently illuminate the extraordinary complexity of mental illness, and the limitations of a fraying safety net. Mental Health First Aid shows signs of benefiting the communities it serves in certain ways. But as far as other core goals go, it’s not clear whether it helps. That conundrum raises the question of just how far the metaphor of first aid really extends, and of how much even the most innovative individual programs can do to make up for the shortfalls of the system as a whole.
IN 2015, mental illness is still attended by some stigma and fear, but there are also signs that Americans are beginning to treat mental health more like physical health. The University of Chicago’s General Social Survey has shown that support for treatment and awareness of the neurobiological causes of mental illness rose significantly between 1996 and 2006, for example. High-profile suicides and crimes by the mentally ill have contributed to awareness, if not always empathy; the Affordable Care Act has moved to require insurers to cover mental health treatments as they do other medical care. “As a nation, we’re very interested in mental illness” at the moment, Rosenberg said. “We weren’t so interested 10 or 20 years ago. But mental illness has come out of the closet, the way cancer did 50 years ago.” Today an increasing number of people are not only comfortable talking about mental illness, but want to know how to help.
First developed in Australia in 2001 by a nurse and a mental health literacy professor, Mental Health First Aid training teaches a five-part “action plan”: assess for risk of suicide or harm, listen nonjudgmentally, give reassurance and information, encourage appropriate professional help, and encourage self-help and other support strategies. The basic eight-hour course covers a range of scenarios, from depression and anxiety to psychosis and substance-abuse disorders. It is intended for both public emergencies, like that panicking man on the street, and private ones, among a trainee’s own friends and family members. “With CPR, one of the problems is you never get to use it,” Rosenberg said. “You might take the training, but you very rarely see anyone having a heart attack in front of you. With mental health, you are likely to see someone in a crisis.”
Today, the program is being offered to everyone from pastors to teachers to EMTs. “It gives them a set of tools,” said Kathy Wilson, president and CEO of the Springfield–based nonprofit the Behavioral Health Network, which was the first Massachusetts organization to train instructors in the program. “With a person who might be having a psychotic episode, walking around with an umbrella whacking people, you might think to call the police. But a Mental Health First Aid responder can tell police, ‘I don’t believe this person is intentionally hurting people.’ It’s a whole different approach.”
Mental Health First Aid is not the only mental health program to use first aid as a metaphor. There’s QPR, a suicide-prevention course that explicitly compares itself to CPR. (The initials stand for “question, persuade, refer.”) Another approach called “psychological first aid,” designed for use by first responders to major disasters, is intended to minimize incidences of PTSD.
The concept of “gatekeepers”—the laypeople likeliest to encounter the mentally ill—has been around since at least the 1970s, when experts began to recognize that people including clergy, hairdressers, and bartenders were positioned to serve as potential intermediaries between suffering people and the mental health system. But the notion of formal training for these gatekeepers has gained momentum since the turn of the millennium. “Gatekeepers are part of the puzzle,” said Victor Schwartz, a psychiatrist and medical director of the Jed Foundation, a suicide-prevention organization that focuses on college students. “There’s been this recognition that in any community there are people likely to be hearing about troubles. It just makes sense for those people to have an understanding of how to think about what they’re hearing.”
Mental Health First Aid, with its broad focus, has quickly become one of the most prominent gatekeeper programs: It has “perhaps the most momentum,” said Daniel Eisenberg, an associate professor of health management and policy at the University of Michigan School of Public Health. “There’s a lot of enthusiasm in general for the concept.” The program has increased its reach dramatically within the last several years, and is now being used in 23 countries. Within the United States, where it launched in 2008, Rosenberg says more than 300,000 people have taken the course, including Chirlane McCray, the first lady of New York City. Funding is beginning to follow: Congress allotted $15 million last year to train teachers and others who work with students in the program, under the auspices of the Substance Abuse and Mental Health Services Administration. This year’s federal budget includes another $15 million.
So how well does it actually work? The program’s promoters tout it as “evidence-based,” a phrase that operates these days as a password to respectability and government funding. In reality, that evidence is mixed and preliminary. Much of the existing research on the program’s efficacy has been conducted by its founders in Australia. More troublingly, it tends to focus primarily on how trainees feel after training—not on actual benefits to the mentally ill. More research is coming soon. Bruno Anthony, director of research and evaluation at the Georgetown University Center of Child and Human Development, is currently enrolling participants in a 1,500-person study that will track trainees for more than six months. (The National Council initiated the project and is cooperating with it.)
Eisenberg, who coconducted a randomized control trial of the program’s effectiveness on 32 college campuses for a study published last year, calls his results “glass half-full, glass half-empty.” The resident advisers who were randomly assigned to the program reported higher levels of confidence in their abilities to recognize mental health issues months later, and were more likely to use counseling or therapy themselves. But there was no evidence that the college students under the trainees’ supervision wound up using more mental health services, or that the trainees were more likely to discuss mental health issues with them. Eisenberg and others say that one key improvement would be incorporating occasional tuneups and reviews, to keep the training fresh.
Even if the clearer benefit is to the trainees, though, that could still change things for those with mental illness down the line. Wilson says the class goes a long way to de-stigmatizing mental illness, a valuable end in itself. “If [more people] can change their perception of mental illness, and of individuals experiencing mental illness, it gives a person with mental illness an opportunity to be managed differently,” she said.
Other local groups turning to mental health training give a hint of additional possible benefits. Captain Joseph Coffey, of the Warwick, R.I., police department, helped develop a mental health training module for public safety officers that is now mandatory for most police-academy attendees in the state. “We were skeptical at first,” he said, but he has observed that people who have positive interactions with trained officers tend to call on those specific officers by name if they have another mental-health crisis—often before the situation escalates. Between 10 percent and 15 percent of the calls his department receives are related to behavioral health, he said: “You have to train your officers based on the needs of your community.”
THESE FACTS SUGGEST a fundamental question about these gatekeeper programs: Just how useful a metaphor is “first aid” for dealing with mental illness? With traditional first aid, there’s a discrete mechanical problem that theoretically can be resolved in one crucial moment, even if the person in need goes on to require further care. Serious mental health crises are infinitely more complex.
No one begrudges Mental Health First Aid for borrowing a metaphor that so clearly communicates its basic mission. On the other hand, no one would ever call first aid a success if it didn’t actually save anyone from choking, but just made the trainees feel better. “What you’re doing as a Mental Health First Aid person is not necessarily providing a service that is actually going to help somebody,” said Anthony, who is conducting the Georgetown study on the program’s effectiveness. “Talking may be some help and may be useful, but what you’d really like, for somebody who has these issues and you recognize them, is to get more help....It’s close to what CPR is, but it doesn’t have that absolutely clear thing where you absolutely know what to do every time.”
That gets at a much larger problem exposed by the first-aid model. Referring sufferers to local services is a crucial part of these programs, and yet the country’s mental health system is often not up to the job. “Initiatives like Mental Health First Aid are good as far as they go, but they are emblematic of the approach that’s been taken to reform of the mental health system for decades now, which is a piecemeal and uncoordinated approach,” said Paul Appelbaum, director of the Division of Law, Ethics and Psychiatry at Columbia University’s College of Physicians and Surgeons. Without a more cohesive mental health system, he said, “these individual local efforts, as praiseworthy as they are in their own right—often they’re extremely praiseworthy—are really not likely to make a huge difference.”
Mental health advocates don’t deny that the system has its failings. But they emphasize that the new movement to give basic crisis-management tools to a wider set of laypeople has value all the same. “There’s no doubt that our mental health system nationwide has tremendous, tremendous gaps in it,” Schwartz said. “But we shouldn’t stop selling Band-Aids just because we may not have the capacity to be doing surgery. You do what you can.”