Abstract
Mental Health First Aid (MHFA) is a training course for members of the public in how to assist someone who is developing a mental illness or in a mental health crisis situation (e.g. the person is suicidal or has had a traumatic experience). This first aid is given until the person receives professional help or until the crisis resolves. The course teaches how to give mental health first aid using the Action Plan shown in Table 1.
The Mental Health First Aid action plan
MHFA began in Australia in 2001 with one part-time volunteer instructor (B.A.K.) working in partnership with a researcher (A.F.J.). From this small beginning it has expanded rapidly, so that in 2011 there are over 850 instructors in Australia who have trained over 170,000 adults. This is 1% of the adult population. Furthermore, the programme has spread internationally, starting with Scotland in 2004. Since then it has spread to Canada, China, England, Finland, Hong Kong, Japan, Nepal, New Zealand, Northern Ireland, Singapore, South Africa, Sweden, USA and Wales.
This rapid expansion far exceeded our expectation as the developers. Here we discuss some of the factors that have contributed to this remarkable growth.
MHFA builds on the familiar first aid model
An important factor in the uptake of MHFA is that it builds on a familiar concept. First aid training dates back to the 19th century in English-speaking countries and is now widely available internationally. In Australia, for example, 11% of adults have done first aid training in the previous 3 years [1]. First aid training is seen not only as required for professional practice in certain fields such as child care, but also as part of a citizen's responsibility to care for other members of their community. By using the first aid model, MHFA links to an existing social concept of early lay assistance and is readily understood and accepted by the public. This model is accepted for medical emergencies, but has not been traditionally associated with mental illnesses.
MHFA fulfils a public need
National surveys have shown that mental illnesses are very common [2–3], so that it is inevitable that members of the public will often have contact with people who are affected. Furthermore, many people with mental illnesses either do not get professional help or they delay getting professional help [4]. In such cases, the person's social network can play a role in facilitating professional help-seeking [5–7].
While contact with people affected by mental illnesses may be common, members of the public often lack mental health first aid knowledge and do not feel confident in providing assistance. For example, national surveys of mental health literacy in Australian adults and youth have found that many people believe it would be harmful to ask a person about suicidal feelings, and there are substantial minorities who would not encourage professional help [7–9]. Similarly, prior to receiving MHFA training, many people report that they are not confident about assisting someone with a mental health problem [10,11], and this may be a factor motivating their attendance.
Despite the obvious need, traditional first aid courses have ignored mental illness, creating a gap that MHFA has been able to fill.
The course has been tailored to meet different needs
The MHFA Program began with delivering a standard face-to-face MHFA course (currently 12 h), written to be applicable to a broad range of people [12]. However, it soon became apparent that tailoring was needed for specific cultural, age and special needs groups.
Versions of the MHFA course have now been developed for Aboriginal and Torres Strait Islander peoples [13] and Vietnamese Australians [14], and a course for Chinese Australians is near completion. All these courses are taught by MHFA instructors from the relevant cultural group.
Because mental illnesses often have their first onset during adolescence, a Youth MHFA course has been developed for adults to assist adolescents [15]. This 14-h course focuses on mental illnesses as they present during adolescence, and has additional training on adolescent development and communication.
An adaptation has also been produced to provide MHFA to people with an intellectual disability, with additional content on how mental illnesses may appear and how appropriate assistance may be given to people with an intellectual disability [16]. Another adaptation for people with special needs is the captioning of film clips used in MHFA courses to be suitable for those with hearing impairment.
While maintaining fidelity to the course curriculum, MHFA instructors can also enhance the relevance of the training to various audiences by adapting the activities and examples used during the course. This has been done for specific occupation groups (e.g. teachers, police, court staff) and for particular geographical areas (e.g. farming communities).
Similarly, as the course has been taken up by other countries, the MHFA teaching materials have been adapted to the culture and mental healthcare system of the adopting country. This tailoring to various national needs has contributed to the acceptability of the MHFA Program in diverse countries.
There is a strong partnership with research
Research findings have been very influential in the international spread of MHFA, with many countries first learning of the programme through research publications. From the very first courses taught, evaluation data were collected on the effects of MHFA training. The first evaluation study was published in 2002 and was followed by a succession of others. To date, there have been five controlled trials, nine uncontrolled trials and three qualitative studies, as summarised in Table 2. While the initial evaluations were carried out by the originators of the programme, there are now many independent evaluations from Australia and other countries. There are a number of consistent findings that have emerged across these studies. Participants show increased knowledge of how to provide mental health first aid, their attitudes towards appropriate treatments become more positive, stigma reduces, they become more confident in providing support, and they report more supportive behaviours towards others. These benefits are still evident half a year after completing the training.
Summary of studies that have evaluated MHFA training
RCT, randomized controlled trial.
Research has also been important in guiding the contents of the training. Again, conventional first aid training has been a model to follow. International guidelines have been developed about how to give resuscitation and other first aid techniques, based on systematic reviews of the literature and expert consensus [33]. These guidelines provide the content that is taught in first aid courses. Similarly, there is a need for mental health first aid guidelines that provide the content for MHFA training. To fill this need, a series of Delphi expert consensus studies has been carried out using panels of professionals, consumer advocates and carer advocates. Guidelines have been produced covering a range of developing mental illnesses and mental health crisis situations [34–44] and are publicly available from the MHFA website (www.mhfa.com.au) and the National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines Portal (www.clinicalguidelines.gov.au). These guidelines have formed the basis of the second edition MHFA manuals and curriculum content [12,13,15,16].
This commitment to evidence-based content and evaluation of outcomes in controlled trials has enhanced the perception of the training programme within the mental health sector and has resulted in numerous Australian and international awards.
There are procedures for quality control
It is important for the reputation of the MHFA Program that there are procedures for quality control. A range of procedures have been implemented to protect the quality of the training delivered. These include rigorous selection, training and assessment of candidate instructors; well documented teaching materials; annual requirements for the number of courses taught by each instructor to maintain accreditation; standardised feedback questionnaires from course participants; and continuous updating of instructors through newsletters, website (www.mhfa.com.au) and annual instructor conferences. Similar procedures have been adopted by the overseas MHFA organizations.
There is a sustainable funding model
In Australia, MHFA has received a number of start-up grants from governments to launch into new areas, such as Youth MHFA, Aboriginal and Torres Strait Islander MHFA and e-Learning MHFA. However, it receives no on-going government funding. Like conventional first aid training, it is primarily funded on a fee-for-service basis, either from training instructors or running courses. A UK report has cited MHFA as an example of ‘radical efficiency’ in provision of public services, because it delivers services in an innovative way at a lower cost and with better outcomes than a government controlled service could [45].
In other countries, there have been a variety of models, with MHFA either run through non-government organisations or through government agencies. However, all rely on income from running courses. In this regard, the conventional first aid model of funding, which is known to be sustainable, has been very influential.
The future
While growing from 0 to 1% of the adult Australian population over a decade is a notable milestone, it is likely to be only the beginning. In 2006, the Australian Senate's Select Committee on Mental Health recommended that MHFA programmes aim for 6% of the population to be trained and accredited, ‘targeting those with the greatest probability of coming in contact with mental health issues – teachers, police, welfare workers and family carers’ [46]. Even this goal might be modest. If 11% of Australian adults have done conventional first aid training in the previous 3 years [1], it is feasible to equal this with MHFA training. To do so would require that, like conventional first aid, MHFA certification becomes a requirement of certain occupations and roles, and that periodic refresher courses are required to stay current.
In this way, it will be possible to spread the skills to assist people affected by mental illness beyond health professionals to the whole community, encouraging earlier recognition and treatment, reduced stigma and enhanced social support.