Six strangers sit in a dimly lit Brooklyn classroom watching a woman have a panic attack. She bows over a metal folding chair, gasping for air as her eyes dart around the circle of bystanders, breathlessly pleading for one of them to help.
And then, one does; she sits the frantic woman down and asks her to breathe, slowly and deeply. “In….. and out, in….and out,” the stranger models. “It looks like you’re having a panic attack,” she says reassuringly. “It feels scary now, but they usually don’t last more than five minutes. It will be over soon.”
Such was one of the many scenarios played out at Mental Health First Aid (MHFA), an all-day course teaching volunteers how to recognize and respond to signs of crisis in strangers. Like physical first aid, MHFA is meant to supplement—not replace—professional support. But in imminent crises like panic, psychosis, addiction, and suicide, MHFA gives ordinary bystanders research-backed tactics to intervene.
“Mental health problems are really common, far more so than some of the things you learn about in a regular first aid course,” says Betty Kitchener, the nurse who co-founded MHFA on the other side of the world in 2000, in an explainer video.
COVID-19 has only made that more true. In a 2020 Centers for Disease Control and Prevention survey of roughly 5,500 US adults, 41 percent reported at least one adverse mental health condition, with 26 percent experiencing symptoms of anxiety (versus 8 percent in 2019) and 24 percent experiencing symptoms of depression (versus 7 percent in 2019). Separate CDC data found that overdose deaths during 2020 were higher than they had been during any 12-month period on record, and a recent analysis by Tulane University confirms that Google searches related to panic attacks have spiked.
As more Americans are witnessing mental health crises (or experiencing one themselves) for the first time, a growing number are participating in Mental Health First Aid—an 8-hour certification-based course, now adapted to a virtual setting—to learn short-term solutions. Since launching its virtual format in July 2020, MHFA has trained more than 62,000 people remotely. It’s likely why the American Red Cross recently created its own virtual “Psychological First Aid,” a course for people to “support [themselves] and others during COVID-19,” the website reads.
COVID consequences aside, mental health first aid trainings could also help address the nation’s impending shortage of professional therapists—a resource many Americans already find difficult to access and afford. And as cities heed growing calls to make “major changes” to their law enforcement systems, the two-decade-old MHFA model could offer ways for police and non-police to intervene in a mental health crisis proactively.
It’s likely why 20 US states—both blue and red—have made MHFA a funding priority since 2015. But for all of the potential mental health first aid holds in addressing mental health crises on the mass scale, the real test of the model will come as trainees are called to put their lessons to practice in the real world.
Stop, look, and listen
Mabel Martinez-Almonte learned a key part of mental health first aid as a 10-year-old kid, decades before she would come to teach it. Growing up during the early 1970s in a part of Brooklyn with “a lot of gang activity,” Almonte says she quickly became “streetwise”—learning the language and behaviors of people who hung out around her neighborhood so she could safely play outside with her two older brothers. But years later, when she’d meet people who’d instead grown up “sheltered,” she noticed something troubling about how they would interact with individuals who didn’t look or act like they did. “They might think, ‘Oh, if somebody has a tattoo, they must be a drug addict,’” she says. “[People] create these stereotypes out of fear and anxiety, but there’s no truth to them.”
Almonte would continue to confront stereotypes when she became a licensed occupational therapist and worked on an in-patient psychiatric unit, while using a wheelchair. “You would think that somebody with a physical disability should be concerned about encountering a really angry, agitated patient,” says Almonte. “But what I found is that 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.”
After 24 years of helping individual patients with stress management and coping skills, Almonte enrolled in MHFA as soon as she learned about it, thinking it would be “right up [her] alley” to teach others the mental health crisis interventions she practices. “I wanted to train as many nursing staff as possible,” she remembers, having often witnessed a vicious cycle: Psychiatric patients would be admitted through the emergency room, and nurses wouldn’t know what to do. The most common practice was to “give them some kind of medication to de-escalate whatever was going on,” Almonte remembers—but that wasn’t a long-term solution for the patient nor the underlying stereotypes in the system.
“These nurses would be petrified of being assaulted,” she remembers. She says their anxieties—made worse by a “culture of rumors” and a news cycle that disproportionately focused on a few rare cases of mental illness-related violence—were understandable. But in reality, Almonte reminded them, people with psychiatric diagnoses are much more likely to be the victims of assault than the perpetrators.
Almonte emphasized these points at Brooklyn’s SUNY Downstate Hospital, where I met her and five others taking MHFA in January 2020. Beyond the panic attack improvisation, Almonte used quizzes, videos, and live role play to help us consider what to do if someone is having hallucinations, showing signs of addiction, or exhibiting other concerning behaviors. The answers, we learned, are contained in a handy mnemonic device, ALGEE: (A)ssess for risk of suicide or harm, (L)isten non-judgmentally, (G)ive reassurance and information, (E)ncourage appropriate professional help, and (E)ncourage self-help and other support strategies.
While most trainees attended MHFA that day to get professional health and social work accreditations, Cindy Yee, a New York born-and-raised millennial working in e-commerce, was there for personal reasons. “My mom has some erratic behaviors, and it can be hard to adjust to [her] mood swings,” Yee said. “So I thought, ‘Maybe I should just be a bit more proactive in understanding what’s going on with her, and figuring out what self-care techniques could work for us, because it does get very exhausting.”
Fourteen months after taking MHFA, Yee tells me it has, in fact, helped her better understand and interact with her mom. “I would sometimes lose my temper, but now I just let her talk and listen instead of snapping,” Yee says, adding that some of the benefits have passed on to her other family members, too.
Yee also says the training has helped her “feel a lot more empathetic” for fellow New Yorkers she sees in distress. But so far, Yee says, that’s been more “observing than intervening,” especially during COVID. “When I’m taking a train, I notice more incidents where someone is crying or laughing,” says Yee, a first-generation immigrant who’s lived in the city for her whole life. “Even though people kind of clear away, I’m like, ‘Okay, maybe I’ll just stay for five minutes in case the person needs something.’”
“Aiming to be as evidence-based as possible”
Yee’s instincts to help are exactly what Betty Kitchener had hoped for when she conceived of Mental Health First Aid. As a teenager in the suburbs of Sydney, Australia, in the 1960s, she suffered from severe depression and had attempted suicide. But unlike the crisis hotlines, internet guides, and school counselors typically available to today’s teens, Kitchener had no expert help.
One evening in 1997, while walking her dog down the streets of Canberra with her psychologist husband, Anthony Jorm, Kitchener began to wonder how many others had similarly suffered from a mental illness in solitude. More importantly, what would it take to support them? Her husband had an idea: Just as Kitchener had taught first aid for physical emergencies, could they develop such a course for psychological triage?
The duo spent the next three years researching that question. On weekends, they’d bring together nurses, psychologists, teachers, regular first aid instructors, and mental health care recipients to co-design the curriculum, which they piloted for a local Australian group in November 2000. Two years and many sessions later, they found an encouraging answer: In the first uncontrolled study of MHFA, participants reported that the training improved their mental health literacy.
MHFA has since reached 4 million people across 24 countries, where those early results have been consistently replicated by Jorm, Kitchener, and a slew of independent researchers. Studies from Sweden, Canada, and California consistently find that MHFA improves its trainees’ mental health literacy, reduces the stigmas they hold around mental illness, and gives them greater confidence in providing help to those in distress.
But where the studies fall short, critics say, is in measuring whether recipients of mental health first aid find it helpful. Amy Morgan, a senior research fellow at the Melbourne School of Population and Global Health at University of Melbourne, says that’s the “holy grail” question of mental health first aid—and one that’s inherently “really hard” to answer.
Like physical first aid, part of that difficulty comes from its design; people give emergency care where and when it’s needed, and often never see their patient again. So, to compensate, Morgan and her team designed a randomized controlled study training people with teenage children in MHFA. In the experimental group, the researchers measured whether teens with trained parents showed mental health improvements over time, compared with a control group whose parents didn’t learn MHFA. But despite multiple attempts, Morgan admits those studies are “still a bit inconclusive.”
“We just didn’t get the participant numbers we needed,” says Morgan, explaining how they only recruited 300 parents instead of the 1,000 they set out to find. Beyond the time commitment barrier true of most long term observational studies, which require folks willing not just to undertake training sessions but also to report back as weeks and months go by, she says parents who signed up often did so because they had concerns about their child, and, therefore, didn’t want to be in the control group that went without MHFA.
Morgan also can’t completely discredit the risk that MHFA could possibly, unintentionally, create harm. “If someone’s resistant to talking about their problem or opening up, perhaps, if people really push and want to help, and that person just doesn’t want that, it might cause damage,” she says. Still, she underscores, “the course teaches [trainees] to respect people’s wishes” about receiving care.
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Despite hypothetical dangers, Morgan says the curriculum is constantly being updated to be as “evidence-based” as possible. MHFA tracks and chronicles the peer-reviewed studies measuring its impact (or lack-thereof), and reevaluates its training content every three years to make sure its up to par. “It does undergo a lot of research in comparison to other kinds of training courses in the mental health area.”
“A major shift”
In a 15-person Zoom call in March of 2021, Marcie Timmerman shares her screen to show a video of a man talking his friend through a panic attack. “How did he do? Did he follow ALGEE?” asks Timmerman, who serves as Executive Director of Mental Health America Kentucky, and did her first and only “on-the-ground” MHFA training right before COVID.
Timmerman has always worked in the mental health space, but in her first job—as a receptionist for a group administering psychological tests to Ohio police officers—she learned the importance of real-time mental health crisis care when someone called in and said they were suicidal. “I had no idea how to handle it, and I think that’s the case for a lot of frontline staff,” she remembers. “But now, using the steps of ALGEE and the suicide assessment tool, I would know what to do if that next person calls.”
The tool, we learned, involves directly asking people who are suicidal if they have a plan—if they’ve decided when and how they’ll do it. If so, and if it seems the person’s immediate safety is at risk, first-aiders should call 911 immediately; if not, they should follow the steps of ALGEE —listening non-judgmentally, asking how long they’ve felt this way, and offering support to find the person professional help. “It’s about asking the right questions, and just being able to do that keeps me calm,” Timmerman says.
Timmerman is now an official MHFA instructor, and says COVID has “absolutely [been] a driver” in pushing more people to take it. In 2020, Mental Health America saw four times the number of mental health screenings they had in other years; of those screened patients, she says, there’s been a “decided increase” in the severity of reported anxiety and depression. It’s true, too, that there’s an increase in opioid overdoses in Timmerman’s home state of Kentucky—a development MHFA recently addressed by adding Naloxone resuscitation to its curriculum.
But another major driver of interest in MHFA, Timmerman says, comes from the national conversation on racism, criminal justice, and mental illness that followed George Floyd’s murder; 10 percent of 911 calls relate to mental health situations most police aren’t prepared to deal with, and people with untreated mental illness are 16 times more likely to be killed by law enforcement.
Some police departments, like Charlotte-Mecklenburg in North Carolina, are training their officers in MHFA to help tackle that tension. And in New York City, psychiatrist Sidney Hankerson of the Columbia Wellness Center is helping to train Harlem faith leaders to bring MHFA to African American and Latinx communities, who have the lowest rates of mental health treatment nationally. Those disparities, Hankerson said in a 2017 presentation at Columbia University, are largely due to stigma, mistrust, and a history of systematic racism inflicted by medical professionals against communities of color. He references the 1972 Tuskegee study, where doctors purposely withheld syphilis treatment from Black men without their knowledge or consent in the name of documenting the progression of their symptoms, as just one example of the fraught history of healthcare for people of color in America.
As for Timmerman, she says more than half of her classes have consisted of people from BIPOC communities, and notes how MHFA’s curriculum was recently updated to be more inclusive in the characters, settings, and cultural norms it espouses. In her community in Kentucky, which faces its own unique stigmas around mental health care, she says she’s proud of the “major shift” she’s witnessed in her lifetime, adding that the governor’s mere mention of mental health in a televised COVID address is something that “would have been unheard of 20 years ago.”
“It’s just such a tone change,” says Timmerman. “People really recognize now that there’s stress and anxiety in all of us.”
She says she’s seen that tone change among other mental health professionals, too. In a recent training with domestic violence specialists, one trainee—like the nurses Almonte once observed—admitted feeling scared of patients with psychosis. But Timmerman says that after the group’s deep dive into what psychosis is, where it comes from, and its myths around violence, the trainee “couldn’t stop asking questions, even into the break.”
“She was like, ‘Wow, I had no idea,’” Timmerman recalls. “It was just amazing to see her light up like that.”