I was recently browsing the blog of Pete Earley, the author of the book Crazy: A Father’s Search Through America’s Mental Health Madness, and I came across a post on a recent Manhattan Institute report criticizing Mental Health First Aid (MHFA). The Manhattan Institute is a conservative think tank, and I’ve previously taken issue with In Defense of Stigma, an article by MI fellow Stephen Eide. I was expecting to be entirely unimpressed by the report on MHFA, and while it certainly had some flawed assumptions, it also made some interesting points that I wanted to discuss.
The report, written by Caroline D. Gorman and published in June 2022, is titled Mental Health First Aid: Assessing the Evidence for a Public Health Approach to Mental Illness. Before we talk about what the report has to say, let’s take a quick look at what MHFA is.
Background on Mental Health First Aid
MHFA was originally developed in Australia in the year 2000. According to MHFA International, MHFA aims to “empower and equip individuals with the knowledge, skills and confidence needed to support a friend, family member or co-worker experiencing a mental health problem or experiencing a crisis such as being suicidal.”
In terms of the spectrum of intervention (prevention, early intervention for people who are getting sick, and treatment for people who have an illness), MHFA is primarily aimed at early intervention, although the skills that are taught can be useful at any point along the spectrum. MHFA International cites research that says, “People are more likely to seek help if someone close to them suggests it.”
MHFA objectives (Canada)
The Mental Health Commission of Canada identifies the following objectives for a mental health first aid course:
“Course participants will learn how to recognize signs that a person may be experiencing a decline in their mental well-being or a mental health crisis and encourage that person to:
- Talk about declines in their mental well-being
- Discuss professional and other supports that could help with recovery to improved mental well-being
- Reach out to these supports
- Assist in a mental health or substance use crisis
- Use MHFA actions to maintain one’s own mental well-being”
MHFA action plan (US)
The Mental Health First Aid site in the US identifies a 5-step mental health first aid action plan:
- Assess for risk of suicide or harm
- Listen nonjudgmentally
- Give reassurance and information
- Encourage appropriate professional help
- Encourage self-support and other support strategies
The Manhattan Institute report
What didn’t surprise me about the report was that it framed untreated mentally ill people as dangerous. It linked untreated mental illness with the New York City subway attacks in 2021 and 2022 and the school shootings in Newtown, Connecticut, and Parkland, Florida. I think that link is far more tenuous than the report’s author makes it out to be, but I’ll just let it be and move on to the issue of mental health first aid.
The report characterizes MHFA this way:
“In essence, it works similarly to that of a public screening program, meant to capture instances of disorder that otherwise may have gone unnoticed. The overarching goal of the program is to connect mentally ill individuals—the intended beneficiaries—with an appropriate level of treatment before a crisis leads to tragedy.”
But is it really? I’m not sure that it is.
Where is the money going?
The report notes that mental health first aid training for teachers was part of President Barack Obama’s response to the Sandy Hook Elementary School shooting in 2012. In 2015, Congress allocated $20 million to MHFA training for the general public. Since then, at least 20 states have provided funding for MHA. The federal budget for MHFA-like programs was $24 million for 2022 and $64 million for 2023. That’s not a huge amount in the bigger picture, but it’s not negligible, either.
Criticism of the evidence base
The main criticism with respect to research findings on MHFA is that there’s a lack of evidence to show that it improves outcomes for mentally ill people or helps them to receive appropriate treatment. Much of the research focuses on how training helps trainees rather than how it helps the “intended beneficiaries”, i.e. people with mental illness. There are few randomized controlled trials and limited independent research; much of the evaluation that’s occurred has been done by the developers of MHFA.
As one example of the lack of effectiveness, the report cited a study published in the Journal of Adolescent Health that found that training campus residence hall residence advisors in MHFA was not associated with any increase in utilization of mental health services by students living in those halls compared to students in residence halls where the advisors hadn’t received MHFA training.
Trainees’ mental health
One of the concerns raised that I thought was rather weak was that MHFA might make trainees more likely to seek mental health help themselves, which could lead to over-diagnosis. In the study that involved training residence advisors, the RAs who received training were more likely to seek professional help themselves. The report made that out to be a bad thing, but if the author is criticizing MHFA for not getting more people to seek help, isn’t that a good thing?
Along the same lines, the report’s author expressed concern about findings from a different study that people who did not report having mental health problems themselves prior to training went on to report that they did have mental health issues after the training. The author rather conveniently left out this crucial bit in the paper that was published in BMC Psychiatry:
“In the present study there was a significant increase in the percentage who perceived themselves as having a mental health problem and a non-significant trend for an increased perception of family members as having mental health problems. However, in absolute terms the changes were not so great as to be a concern and may, in fact, reflect accurate re-labelling.”
Essentially, it was probably the same deal as with the RAs—getting training made people realize huh, I have a problem that I should seek help for. The “intended beneficiaries” end up being the trainees themselves.
Barriers to treatment
As the MHFA approach identifies stigma as a major barrier to seeking treatment, changes in trainees’ attitudes toward mental illness are often included as an evaluation metric. However, stigma reduction doesn’t necessarily translate into improved access to or quality of mental healthcare.
According to the report, “The underlying premise of MHFA is that a lack of knowledge about mental health leads mental illness to go unrecognized, which means people are not connected to treatment and fewer crisis situations are averted.” Yet when trainees’ knowledge was assessed prior to training, they were already pretty good at recognizing mental illness, so it’s questionable how much mental illness is actually getting recognized more often as a result of MHFA.
Can mental illness be prevented?
Another criticism in the Manhattan Institute report was that focusing on mental illness prevention doesn’t make sense when we don’t know what actually causes it, and therefore don’t know how to prevent it. I don’t entirely agree with that, as factors like adverse childhood experiences are known to increase risk, but I do think it’s a valid point that we’re not going to be able to just magically prevent mental illness from happening.
This bit struck me as rather odd: “Certain social circumstances may increase the risk of developing some mental illnesses. PTSD, for example, can occur from exposure to death, sexual violence, or the threat of either.” Given that it’s not possible to have PTSD without trauma, I’m not sure where the author was going with that.
Another odd bit: “Perhaps unsurprisingly, MHFA ignores primary barriers to managing mental illness-related crises: treatment access for the mentally ill most at risk of crisis and a scarcity of specialty health-care providers and services.” I’m not sure how that has anything to do with MHFA.
Odd statements aside, I think there is a valid point that taking a public health approach that emphasizes education and prevention (with MHFA being a representative example of such an approach) when there are serious issues with treatment availability doesn’t necessarily do that much to help people dealing with serious mental illness.
Should treatment be the priority?
The report points out systemic issues like a lack of psychiatrists in many parts of the US (especially rural areas), more than 60% of psychiatrists not accepting Medicaid, a lack of psychiatric inpatient beds, people getting discharged prematurely, and people not getting admitted to hospital because of insurance issues. In a given year, fewer than half of people with a diagnosable mental illness actually get treatment.
The report’s author calls for government support for treating serious mental illness, “in part because there are market failures in the provision of health care and services for this population.” That’s certainly something we can agree on. Among the recommendations she made were increasing funding to assertive community treatment and assisted outpatient treatment teams, supportive housing with case management, and mental health courts, and increasing psychiatric inpatient capacity.
It seems to me like this Manhattan Institute report is criticizing MHFA for not getting more scary crazy mentally ill people into treatment. I don’t actually think it’s realistic to expect that MHFA would do that. There are multiple, complex reasons why people with serious mental illnesses don’t engage in treatment, and MHFA is unlikely to address the majority of those reasons.
If MHFA can help to decrease stigma, I think that is a good thing for people with mental illnesses, even if it doesn’t get more people into treatment. One thing I would like to see is MHFA being delivered by people who have lived experience of mental illness. Contact is more effective for stigma reduction than education, so why not combine the two rather than just doing the educational component?
In terms of whether MHFA is the best place to be allocating limited public financial resources, I honestly don’t think it is. I think governments should be prioritizing treatment when they’re doling out public money; in particular, I think there needs to be a shift in emphasis from acute care after things have gotten really bad to community-based care that can help keep people out of hospitals. If private citizens, community groups, or employers want to pursue MHFA training, that’s great, but I’d like to see governments funding professional services. For example, I would much rather see students have access to counselling services in school than have all the teachers trained in mental health first aid.
What are your thoughts on the usefulness of mental health first aid?