A specialised form of first-aid training can improve support for staff suffering from mental ill health, argue Dr Jo Borrill, Poppy Jarman and Jessica Agudelo.
Mental health problems are common across all sectors of society. It is estimated that in any one year approximately one British adult in four experiences at least one diagnosable mental health disorder. Within the working-age population of Great Britain, approximately 11 million people experience symptoms associated with mental ill health (Office for National Statistics, 2001) and around six million have symptoms that meet the diagnostic criteria for mental illness, mainly experiencing anxiety and/or depression.
Evidence shows that being at work is beneficial for people with mental health problems. Research also suggests that a large majority of people who are unemployed and using mental health services do want to work (Secker et al, 2001). However, many people with mental health problems are still experiencing stigma and discrimination in the workplace and others stop looking for work because they anticipate discrimination (Brohan and Thornicroft, 2010). Perceived stigma also means that people may conceal their problems or symptoms, resulting in delayed access to support and treatment.
Support from colleagues and line managers is clearly vital in helping people to manage distress or mental illness at work, but the 2008 report Mental health and work, commissioned by the Department for Work and Pensions, confirms that many people admit to feeling uncomfortable about working with people with mental health symptoms, and that lack of understanding may lead to people being denied promotion or access to training (Michalak et al, 2007). Even if work colleagues and friends are open and supportive to someone with mental health problems, they may be unsure of how to deal with someone who is particularly distressed or going through a crisis.
The authors of "Mental health and work" suggest that occupational health workers have less knowledge of mental health problems than of physical illness and are therefore not as well equipped to advise others about managing it. The authors recommend Mental Health First Aid (MHFA) as "a way of training workplace line managers to recognise mental distress and respond in a way that does not lead to unnecessary exclusion from the workplace".
What is MHFA?
MHFA England is a community interest company (CIC) that is focused on increasing the mental health literacy of the population by delivering quality-assured training programmes that are evidence based. MHFA is designed to offer help to someone experiencing a mental health problem before professional help is obtained.
Box 1: MHFA will help you to...
- Feel confident helping someone experiencing a problem.
- Spot the early signs of a mental health problem.
- Provide help on a first-aid basis.
- Help prevent someone from hurting themselves or others.
- Help stop a mental illness from getting worse.
- Help someone recover faster.
- Guide someone towards the right support.
- Reduce the stigma of mental health problems.
The programme was originally developed in 2000 at the Centre for Mental Health Research at the Australian National University in Canberra by Betty Kitchener and Professor Anthony Jorm. They presented MHFA as the mental health equivalent to physical first aid. MHFA is now an internationally recognised programme, running in more than 15 countries.
It was developed and launched in England in 2006 by the National Institute of Mental Health in England as part of a national approach to improving public mental health.
In 2009, MHFA England achieved CIC status, and is now at the heart of a network growing across England. The Youth MHFA course launched in 2010, and, in April 2011, the "Trauma Stress Reaction" course was launched nationally.
There are now more than 33,000 mental health first aiders, 1,900 youth mental health first aiders, 640 MHFA instructors and 110 Youth MHFA instructors.
The Royal Society for Public Health has accredited the MHFA instructor training programme. Approved instructors deliver either the MHFA or Youth MHFA course, which is usually taught over two days. The course covers the causes, symptoms and treatments of common mental health problems with the aim of giving professionals and non-professionals the knowledge and confidence to recognise signs of mental health problems, as well as encouraging individuals to seek the right help. It also provides people with the skills to enable crisis first aid to help people who may try to commit suicide or self-harm.
MHFA believes that we all have a personal responsibility to look after our own mental wellbeing and that of those around us, which includes the people we work with as colleagues, clients and friends.
MHFA sets out to teach skills that enable us to do this with confidence, in a systematic and empathetic way, using a skills intervention that addresses the continuing need for training in the workplace and beyond. The aims of MHFA training are clear and specific (see box 1).
Box 2: What people say about MHFA
- It made me look at mental health in a different way.
- I understand (people with mental health problems) much better and think I could help.
- I will use it in my work with asylum seekers.
- I will take the Mental Health First Aid manual to work with me and will encourage my staff to read it.
- It seems to me that MHFA is just as important as physical first-aid knowledge, and having some understanding about mental health issues should be compulsory.
- All people who manage others need to do this course.
- Thanks for the course - everyone should have knowledge of mental health issues.
Ensuring high-quality training is recognised as very important in achieving the MHFA aims, and regular feedback from participants in the training has indicated high levels of satisfaction with both content and delivery. For example, feedback from 23 training courses in North-East England found that 87% of trainers were rated by participants as "excellent" or "very good" and ratings for the training methods (such as slides and video clips) were similarly high.
Participants were particularly positive about the interactive learning exercises, which they felt enabled them to think about the issues from a more applied perspective: "really eye-opening - it really made me think". Trainees are also provided with a manual to take away and read in their own time, with the aim of extending and sustaining their learning.
The impact of MHFA
This question has been addressed in two ways to date: first, by finding out what participants think about the training immediately after delivery; and second, by using more complex evaluations to assess the affect that training has had on their professional practice and personal lives.
The first evaluations of MHFA were carried out in Australia (eg Jorm, Kitchener, Mugford, 2005), reporting very positive responses. Since then, a range of independent and in-house evaluations of MHFA training have been carried out, mainly using questionnaires but sometimes also interviewing participants about their experiences (Brandling and McKenna, 2010).
In England, most courses have been evaluated within the public sector, but a training course provided for managers in the private sector was delivered and independently evaluated in 2010, using scales to record participants' self-assessments of their learning, confidence, attitudes and intentions from the start of the course to completion (Borrill, 2010).
The same scales were also used in a larger evaluation of MHFA training in North-East England (Borrill, 2011), where participants included religious leaders, carers and volunteers in third-sector organisations. Both studies found that participants from a wide range of backgrounds report statistically significant increases in knowledge and in their confidence in helping people with mental health problems. In addition to completing the scales, participants were invited to provide their own personal reflections on the training. Examples of these are shown in box 2.
It could be argued that any training that is interesting and well delivered is likely to generate positive feedback, so it is also important to know whether or not MHFA delivers more than other forms of information dissemination, and whether or not the apparent impact on attitudes and behaviour can be maintained over time. Evaluations that have attempted this include a study of MHFA training for managers in Northumberland's Fire and Rescue Service (Robson and Bostock, 2010).
This research compared MHFA with a standard one-hour session of mental health training using a leaflet. It concluded that MHFA was more effective in promoting positive attitudes towards people with mental health problems. This may be because MHFA is particularly interactive and makes use of video clips of people talking about their own experiences of mental health problems, bringing the issues to life.
Another evaluation that is particularly compelling is the two-stage study of implementing MHFA training in Islington (Heer, 2010). This included not only immediate feedback and interviews, but also a follow-up survey.
Almost half of the participants completed the follow-up survey six to 12 months after the training, and more than two-thirds of these respondents said that they had already used the MHFA training to help or advise someone. This included providing help in a crisis, supporting people at work and giving help to friends and family (see examples in box 3).
The Islington evaluation concluded that this local training has had very positive results and recommended that it should continue to be provided to anyone living or working in the borough.
What next for MHFA?
The social mission of MHFA is to increase the mental health literacy of the whole population. This means extending the work to a wider range of settings and organisations, making the training accessible in and outside of the workplace, and ensuring that training is available to people from all walks of life.
Box 3: MHFA feedback
"One of my clients was feeling anxious about something that had happened while out in the community. I took them through the breathing techniques demonstrated on the course and this seemed to help; the person was able to calm down enough to explain what had happened."
"I listened to a client who suffers from, and is medicated for, depression, and referred this person to psychology and to a specific support group. I encouraged the client to see their GP about other issues that were affecting their mood and mental health."
The current goal is for MHFA to train one in 10 of the general population, addressing accessibility issues for our diverse communities. The Islington evaluation report recommended that MHFA should now be particularly targeted at groups that have been under-represented in mental health training to date, namely men, older people and the private sector workforce.
MHFA has already started making progress in this area by working in partnership with the Rugby Football League (RFL); MHFA has trained 30 youth mental health first aiders in RFL clubs to date.
Another very promising development was reported at the recent MHFA Awards Ceremony - which was hosted by Professor Lord Patel of Bradford at the House of Lords - when LinkLaters, a global law firm, spoke about its engagement with MHFA as part of developing mental wellbeing within the workplace. This sets an important precedent for other private sector employers.
Following the publication of the Government's mental health strategy (February, 2011), MHFA, in partnership with the London Deanery, also aims to build on appropriate referral pathways, assessment and management by training GPs and primary care staff in mental health, providing resources for diverse communities to recognise and manage mental health problems in a way that brings together community networking.
The MHFA movement is geared towards reducing the impact of human suffering. There is a long way to go before we can rest assured that society is an understanding, nurturing place for those in need of mental health support, but MHFA is rising to the challenge.
The authors of this article are: Dr Jo Borrill of the University of Westminster; Poppy Jarman, CEO of MHFA; and Jessica Agudelo, MHFA instructor. For more information, contact Poppy Jarman. Mobile: 07795 298944.
Borrill J. (2010). "Mental health first aid training: initial evaluation by private sector participants". Report for MHFA England.
Borrill J (2011). "Evaluation of mental health first aid training in North-East England". Report for MHFA England.
Brandling J, McKenna S (2010). "Evaluating mental health first aid training for line managers working the public sector". Mental Health Research & Development Unit, University of Bath. Report for MHFA England.
Brohan E, Thornicroft G (2010). "Stigma and discrimination of mental health problems: workplace implications". Occupational Medicine, 60, pp.414-415.
Heer B (2010). "Mental health first aid training evaluation (Islington)". Report for NHS Islington and MHFA England.
Jorm AF, Kitchener BA, Mugford SK (2005). "Experiences in applying skills learned in a mental health first aid training course: a qualitative study of participants' stories". BMC Psychiatry, 5, 43.
"Mental health and work". Report for Department for Work and Pensions.
Michalak EE et al (2007). "The impact of bipolar disorder on work functioning - a qualitative study". Bipolar Disorder, 9, pp.126-143.
Office for National Statistics. "Psychiatric morbidity among adults living in private households". London, Stationery Office.
Robson J, Bostock J (2010). "Evaluation of mental health first aid training with Northumberland Fire and Rescue Service". Report for MHFA England.
Secker J, Grove B (2005). "Challenging barriers to employment, training and education for mental health service users: the service user perspective". London: Institute for Applied Health & Social Policy, Kings College London.