Six bystanders observe a woman experience a panic attack in a poorly lit Brooklyn classroom. She knelt over a metal folding chair, gasping for oxygen as her eyes dart around the circle of onlookers, imploring urgently for one of them to assist her.
Then one does; she sits the agitated woman down and instructs her to take slow, deep breaths. The stranger models say, “In….. and out, in…..and out.” “It appears that you are suffering a panic attack,” she reassures. “It’s a little frightening right now, but they normally just last five minutes.” It’ll be over in no time.”
One of the many situations presented during Mental Health First Aid (MHFA), an all-day training that teaches volunteers how to recognize and respond to indications of crisis in strangers, was this. MHFA, like physical first aid, is meant to supplement rather than replace expert help. MHFA, on the other hand, provides regular bystanders with research-backed methods to intervene in impending crises such as panic, psychosis, addiction, and suicide.
Betty Kitchener, a nurse who co-founded MHFA on the other side of the world in 2000, says, “Mental health problems are considerably more common than some of the things you learn about in a standard first aid course.”
COVID-19 has only emphasized this point. In a poll of nearly 5,500 US people conducted by the Centers for Disease Control and Prevention in 2020, 41 percent said they had at least one mental health problem, with 26 percent reporting symptoms of anxiety (compared to 8 percent in 2019) and 24 percent reporting symptoms of depression (versus 7 percent in 2019). Separate CDC data shows that overdose deaths in 2020 were greater than in any previous 12-month period, and a recent Tulane University study confirmed that Google searches for panic attacks have increased.
As more Americans witness (or experience) mental health emergencies for the first time, an increasing number of people are enrolling in Mental Health First Aid—an 8-hour certification-based course that has now been translated to a virtual setting—to learn short-term answers. MHFA has trained over 62,000 employees remotely since introducing its virtual format in July 2020. It’s perhaps why the American Red Cross just launched a virtual version of “Psychological First Aid,” a course designed to help people “support [themselves] and others during COVID-19,” according to the website.
Aside from the COVID implications, mental health first aid training could also solve the country’s looming scarcity of professional therapists—a resource that many Americans already struggle to obtain and pay. The two-decade-old MHFA approach could give options for police and non-police to intervene in a mental health crisis proactively as cities respond to mounting demand to make “significant reforms” to their law enforcement systems.
It’s perhaps why, since 2015, 20 US states—both blue and red—have made MHFA a budget priority. But, for all of mental health first aid’s promise in tackling mass mental health emergencies, the model’s actual test will come when trainees are called upon to put their lessons into practice in the real world.
Stop, take a look, and pay attention.
Mabel Martinez-Almonte learnt a crucial aspect of mental health first aid when she was ten years old, decades before she went on to teach it. Growing up in a Brooklyn neighbourhood with “a lot of gang activity” in the early 1970s, Almonte says she rapidly became “streetwise,” learning the language and actions of the people who frequented her neighbourhood to play outside with her two older brothers safely. Years later, when she encountered people who had instead grown up in “sheltered” environments, she observed something worrisome about how they interacted with others who didn’t look or act like them. “They may believe that if someone has a tattoo, they must be a drug addict,” she explains. “These stereotypes are created out of fear and anxiety, but they are untrue.”
When Almonte became a licenced occupational therapist and worked on an in-patient mental unit while in a wheelchair, she continued to defy expectations. “You’d expect that someone with a physical limitation would be apprehensive about coming across a furious, irritated patient,” Almonte adds. “However, I discovered that it all comes down to how you approach the person; how you give them space; how you recognize that they are in misery and are sympathetic to them.”
Almonte registered in MHFA as soon as she heard about it, thinking it would be “exactly up [her] alley” to teach people the mental health crisis responses she performs after 24 years of assisting individual patients with stress management and coping skills. “I wanted to train as many nursing personnel as to possible,” she recalls, recalling a vicious loop in which psychiatric patients were in through the emergency room and nurses were unsure what to do. The most prevalent technique, according to Almonte, was to “give them some drug to de-escalate whatever was going on,” but this wasn’t a long-term answer for the patient or the system’s underlying prejudices.
She recalls thinking, “These nurses would be terrified of being molested.” Their fears, she adds, were natural, exacerbated by a “culture of hearsay” and a news cycle that disproportionately concentrated on a few rare episodes of mental illness-related violence. However, as Almonte pointed out, those with psychiatric disorders are far more likely to be assault victims than perpetrators.
“It’s all about how you encounter the person; how you give them space; how you acknowledge that they are in distress at the moment and are empathetic to them.” Mabel Martinez-Almonte
Almonte reinforced these ideas at SUNY Downstate Hospital in Brooklyn, where I visited her and five other MHFA students in January 2020. Aside from the improvised panic attack, Almonte used quizzes, films, and live role-plays to help us think about what to do if someone is suffering hallucinations, showing signs of addiction, or exhibiting other worrying behaviours. We discovered that the answers are incorporated in a useful mnemonic technique called ALGEE: (A)ssess for suicide or harm risk, (L)isten nonjudgmentally, (G)ive reassurance and information, (E)ncourage appropriate professional aid, and (E)ncourage self-help and other support techniques.
Cindy Yee, a New York born-and-raised millennial working in e-commerce, was at MHFA that day for personal reasons. The majority of trainees were there to earn professional health and social work accreditations. “My mother has some irregular habits, and adjusting to [her] mood swings can be difficult,” Yee added. “So I thought, ‘Maybe I should just be a little more proactive in understanding what’s going on with her and figuring out what self-care strategies would work for us because it’s getting a little taxing,'” she says.
Yee tells me that fourteen months after starting MHFA, it has helped her better understand and interact with her mother. “I used to lose my cool, but now I just let her talk and listen instead of snapping,” Yee recalls, adding that some of the advantages have also been passed down to her other family members.
Yee also claims that the training has made her “feel a lot more compassionate” toward fellow New Yorkers in need. But, thus far, it’s been more “observing than intervening,” especially during COVID, according to Yee. “I notice more incidences when someone is sobbing or laughing while I’m on the train,” says Yee, a first-generation immigrant who has lived in the city her entire life. “Even though people are leaving, I’m thinking, ‘Okay, maybe I’ll just wait for five minutes in case of the individual needs something,'” she says.
“We are attempting to be as evidence-based as feasible.”
Betty Kitchener had hoped for Yee’s instincts to aid when she came up with the idea for Mental Health First Aid. She struggled with severe depression and tried suicide as a teenager in the suburbs of Sydney, Australia, in the 1960s. On the other hand, Kitchener lacked the crisis hotlines, online resources, and school counsellors that are commonly available to today’s teenagers.
While walking her dog around the streets of Canberra with her psychologist husband, Anthony Jorm, one evening in 1997, Kitchener began to wonder how many people had suffered in silence from a mental illness. What, more significantly, would it take to help them? Her husband had an idea: could they design a course for psychological triage the same way Kitchener had taught first aid for physical emergencies?
That question was researched over the next three years by the couple. They’d invite nurses, psychologists, teachers, regular first-aid instructors, and mental health care recipients together on weekends to co-design the curriculum. They launched for a local Australian group in November 2000. They got a hopeful answer after two years and several sessions: Participants in the first uncontrolled study of MHFA said the training enhanced their mental health literacy.
MHFA has since reached 4 million people in 24 countries, with Jorm, Kitchener, and several other independent researchers routinely replicating those early findings. According to studies from Sweden, Canada, and California, MHFA enhances trainees’ mental health literacy, lowers stigmas associated with mental illness, and increases their confidence in helping others in distress.
However, critics claim that the studies fall short in determining if those who receive mental health first assistance feel it helpful. That, according to Amy Morgan, a senior research researcher at the University of Melbourne’s Melbourne School of Population and Global Health, is the “holy grail” question of mental health first aid—and one that is naturally “very hard” to answer.
Part of the difficulties stems from the fact that, like physical first aid, it is designed so that people provide emergency care where and when it is needed and then never see their patient again. As a result, Morgan and her team devised randomized controlled research to train parents of adolescent adolescents in MHFA. The researchers compared kids with trained parents to a control group whose parents did not learn MHFA to see if their mental health improved over time. Despite several tries, Morgan admits that the research is “still a little inconclusive.”
“We just didn’t receive the participant numbers we required,” Morgan says, explaining why they were only able to enrol 300 parents instead of the 1,000 they had hoped for. Beyond the time commitment required by most long-term observational studies, which require participants to not only attend training sessions but also to report back as weeks and months pass, she claims that parents who signed up did so because they were concerned about their child and didn’t want to be in the control group who did not receive MHFA.
Morgan also can’t exclude the possibility that MHFA could inadvertently harm. “If someone is averse to talking about their problem or opening up, it may do damage if people want to assist and that person just doesn’t want it,” she says. “The course teaches [trainees] to respect people’s wishes” regarding receiving care, she says.
Despite obvious risks, Morgan claims that the curriculum is regularly modified to be as “evidence-based” as possible. MHFA keeps track of peer-reviewed research that assesses its impact (or lack thereof) and reevaluates its training content every three years to ensure that it is updated. “In compared to other types of mental health training courses, it goes through a lot of studies.”
“A significant shift”
Marcie Timmerman shares her screen during a Zoom meeting with 15 people in March 2021 to display a video of a man talking his friend through a panic attack. “So, how did he fare? Timmerman, the Executive Director of Mental Health America Kentucky and completed her first and only “on-the-ground” investigation, wonders if he followed ALGEE “Right before COVID, MHFA training.
Timmerman has always worked in the mental health field. Still, her first job as a receptionist for a company that administered psychological testing to Ohio police officers taught her the value of providing real-time mental health crisis care when a client called in suicidal. “I had no idea how to manage it,” she recalls, “and I believe that’s the situation for a lot of frontline employees.” “However, now that I’ve gone through the ALGEE steps and used the suicide assessment tool, I’d know what to do if the next individual called.”
We discovered that the tool entails directly asking suicidal people if they have a plan—whether they’ve decided when and how they’ll commit suicide. If this is the case, and the person’s immediate safety appears to be in jeopardy, first-responders should dial 911; if not, they should follow the ALGEE steps of listening nonjudgmentally, asking how long they’ve felt this way, and offering support to locate professional help. “It’s all about asking the correct questions,” Timmerman adds, “and simply being able to do that keeps me calm.”
COVID has “certainly [been] a driver” in encouraging more people to take the course, according to Timmerman, who is now an official MHFA instructor. In 2020, Mental Health America observed four times the number of mental health screenings it had in previous years, with a “decided rise” in the intensity of reported anxiety and sadness among those tested patients, she says. It’s also true that opioid overdoses are on the rise in Timmerman’s home state of Kentucky, a trend that MHFA just addressed by incorporating Naloxone resuscitation into its curriculum.
Another major driver of interest in MHFA, according to Timmerman, is the national conversation on racism, criminal justice, and mental illness that erupted in the aftermath of George Floyd’s murder; 10% of 911 calls are related to mental health situations that most cops are unprepared to handle, and people with untreated mental illness are 16 times more likely to be killed by cops.
To help reduce tension, several police departments, such as Charlotte-Mecklenburg in North Carolina, are training their officers in MHFA. In New York City, Columbia Wellness Center psychiatrist Sidney Hankerson is training Harlem church leaders to provide MHFA to African American and Latinx populations with the lowest rates of mental health care in the US. Those discrepancies, according to Hankerson, are mainly attributable to stigma, mistrust, and a history of systematic racism perpetrated by medical professionals against communities of colour, as he explained in a 2017 lecture at Columbia University. He cites the 1972 Tuskegee study. Doctors withheld syphilis treatment from Black men without their knowledge or agreement to track the evolution of their symptoms, as just one example of the complicated history of healthcare for people of colour in the United States.
Timmerman claims that people from BIPOC cultures make up more than half of her classes and that they recently changed the MHFA curriculum to be more inclusive in terms of characters, settings, and cultural norms. She says she’s glad of the “huge transformation” she’s seen in her lifetime in her community in Kentucky, which has its stigmas around mental health care, and that the governor’s simple mention of mental health in a broadcast COVID address “would have been unthinkable of 20 years ago.”
“It’s simply such a tone shift,” Timmerman says. “People finally realize that we all have stress and anxiety.”
She claims she’s noticed a shift in tone among other mental health practitioners as well. Like the nurses Almonte earlier witnessed, one student, acknowledged being afraid of patients with psychosis at a recent training with domestic violence specialists. However, Timmerman claims that the trainee “couldn’t stop asking questions, even into the break” after the group’s deep dive into what psychosis is, where it stems from, and its myths about violence.
Timmerman recalls her saying, “Wow, I had no idea.” “Seeing her light up like that was incredible.”