CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
Mental Health First Aid Training: Reactions of Community Social Service Providers
A graduate project submitted in partial fulfillment of the requirements
For the degree of Master of Social Work
By
Cynthia Sanchez
in collaboration with Melissa De la Torre
May 2017
The graduate project of Cynthia Sanchez is approved:
_______________________________________
Dr. Wendy Ashley
__________
Date
_______________________________________
Dr. David McCarty-Caplan
___________
Date
_______________________________________
Dr. Judith A DeBonis, Chair
___________
Date
California State University, Northridge
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Dedication
I dedicate this paper to my parents and my loved ones.
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Table of Contents
Signature Page
ii
Dedication
iii
Abstract
v
Introduction
1
Literature Review
2
Method
9
Results
12
Discussion
15
References
17
iv
Abstract
Mental Health First Aid Training: Reactions of Community Social Service Providers
By
Cynthia Sanchez
Master of Social Work
The present study evaluates the effectiveness of Mental Health First Aid (MHFA)
standardized training that follows a specific curriculum of best practices in the Los
Angeles County. It offers social service providers with tools to assist individuals when in
a psychological crisis. This study uses a pre and post test to test the ability of the social
service providers before and after the 8-hour MHFA training. It demonstrates whether
the training increased social service provider’s mental health knowledge as well
confidence on how to manage a crisis. Social Service providers demonstrate a significant
overall improvement (M= 4.10, SD = .324 ) to post-test ( M = 4.51 , SD = .384 ), t ( 4.031), p < .002 (two tailed). The mean increase in post-test scores .41 with a confidence
interval ranging from -.641 to -.191. Results show social service providers participating
in the MHFA training are better informed and confident when to assess for risk of
suicide, how to encourage self-help, encourage professional help, and listen without
judgment.
Keywords: mental health literacy, youth, social service providers, mental health crisis,
suicide prevention
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Introduction
Mental Health First Aid (MHFA) is a training that was meant to increase
the awareness of social services providers working with vulnerable populations that are
being affected by mental health. Its purpose is to provide a better understanding on how
to assist an individual that is experiencing a mental health crisis. Social service providers
can then de-escalate a crisis to better link the individual to the best help needed. Just like
First Aid is helpful in an emergency health crisis, MHFA can offer the same to an
individual in a mental health crisis. Mental Health First Aid Training has been certified
on National Registry of Evidence-based Programs and Practices. These interventions
have been assessed and rated for quality in order to be ready for use. (Mental Health First
Aid, 2016, para1). “In the United States, MHFA is overseen by the National Council for
Behavioral Health, the Missouri Department of Mental Health, and the Maryland
Department of Health and Mental Hygiene, which collectively provide instructors,
training, and technical support. Their goal is to make MHFA trainings as available and as
familiar as CPR” (Substance Abuse and Mental Health Services Administration, 2017,
para 4). According to National Alliance on Mental Illness, in the United States 1 in 5
adults and 1 in 5 youth aged 13-18 experience severe mental illness (National Alliance on
Mental Illness, 2017). Due to the lack of knowledge and treatment of mental health, there
are higher rates of hospitalizations and suicides. Mental Health First Aid can help provide
knowledge amongst social services providers to lessen stigmatization that can prevent an
individual from seeking help.
1
Literature Review
Background
Mental Health First Aid (MHFA) began in Australia back in 2001 by a registered
nurse, named Betty Kitchner, and her husband, Professor Tony Jorm (Bonnar, 2015).
The purpose of creating MHFA was to educate adults that work with and care for
adolescents on the appropriate skills they will need to recognize mental health crisis, as
well as skills to better assist adolescents with early interventions (Kelly et al., 2011).
Professor Jorm and colleagues coined the term ‘mental health literacy’ in 1997. Mental
Health Literacy is being defined as: “knowledge and beliefs about mental disorders,
which aid individuals recognition, management, or prevention, which include knowledge
of disorders, when to seek help, and knowledge of risk factor” (Mental Health First Aid
Australia, n.d.) This term was coined due to lack of knowledge and stigmatizing attitudes
that prevented individuals from seeking help and prevented communities from supporting
individuals seeking mental health aid (Mental Health First Aid Australia, n.d.). In order
to improve the ‘mental health literacy’ in their community, Kitchner and Jorm developed
MHFA and it has since been successfully applied throughout Australia and as many as 20
different countries (Mental Health First Aid Australia, n.d.). The program has currently
trained over 1 million individuals world-wide. In 2008, there had been 250,000
individuals trained in the United States alone (Bonnar, 2015). It has now grown to
740,000 individuals in the United States (National Council for Behavioral Health., 2017).
The National Council, Missouri Department of Mental Health, and the Maryland
Department of Health and Mental Hygiene introduced Mental Health First Aid to the
United States in 2008.
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Populations Trained
Many populations have been trained in MHFA worldwide, such as school
personnel, police officers, faith leaders, health care professionals, and human resources
managers (Mental Health First Aid USA, 2013b). Many trainees are also known as social
services providers, who are people that carry different task in which one includes
focusing on health and psychological interventions, educational and habilitation
interventions, and lastly providing direct care (Bazzo, Ferrari, Minnies, Nota, Soresi,
2009, p. 112) . According to Kelly et al. (2011), many of the populations trained can
include parents, school professionals, adults who are involved in recreational activities
with young adults, such as sports and scout leaders. MHFA founders, Jorm & Kitchner
hoped that MHFA would become a certified training that would be mandatory for these
stated professions in order to work closely with the youth. In 2015, it was estimated that
2.16% of the adult population has attended a MHFA course in Australia since 2001
(Mental Health First Aid Australia, n.d.).
According to MHFA the major populations trained in the United States for Adult
MHFA are public safety workers, higher education professionals, rural areas, and older
adults (Mental Health First Aid USA, 2013d). Rural areas in the United States have the
biggest mental health disparities and are extremely underserved. More than 20% of
Americans live in rural areas and MHFA wanted to take the opportunity to increase
‘mental health literacy’ to this population (Mental Health First Aid USA, 2013a). The
adult Mental Health First Aid program has already been delivered to nearly 100,000
Americans through a network of more than 2,500 instructors (National Council for
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Behavioral Health, 2017). In the United States alone, each year more than one in five
Americans participate in MHFA training.
Mermon et al. (2016) reported there is also a lack of mental health training and
literacy in the minority and black populations. There is a high need of support to raise
awareness and stop the stigma that prevents these populations from seeking help
(Mermon et al., 2016). Providers need a significant way to develop open communication
to break down barriers with the black and minority population (Mermon et al., 2016).
Tailored culturally sensitive trainings can also improve the understanding of mental
health and improve the access as well as break down the negative stigma within these
communities (Mermon et al., 2016). Mental Health First Aid can ultimately be a positive
training to increase knowledge of Mental health and break down stigmatization.
MHFA Training Components
Mental Health First Aid training aims to educate individuals on how to easily
identify, understand and respond to mental illnesses and substance use disorders. By
providing individuals with the necessary skills, they are more likely to identify and assist
a person in crisis (Mental Health First Aid, 2013c). There are two types of Mental Health
First Aid courses: adults and youth. Both Mental Health First Aid courses are eight-hour
trainings provided by two instructors, which provide individuals with the necessary skills
to help people who are experiencing a mental health crisis. Although both courses aim to
have similar training components, the Youth MHFA course focuses on prevalent mental
health issues for youth and summarizes common adolescent development (Mental Health
First Aid," 2013d). The topics discussed during the course consists of anxiety,
depression, substance use, disorders in which psychosis may occur, disruptive behavior
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disorders (including ADHD), and eating disorders. However, Adult MHFA topics consist
of anxiety, depression, psychosis, and addictions (Mental Health First Aid," 2013a).
CPR helps one assist an individual having a physical health emergency, such as a heart
attack, while Mental Health First Aid helps one assist someone experiencing a mental
health or substance use-related crisis. The evidence behind the training demonstrates that
it increases the individual's confidence in assisting people experiencing a crisis, increases
their awareness of symptoms, risk factors and signs of mental illnesses, minimizes stigma
towards people with mental illness and increases their own mental well-being (Mental
Health First Aid Maryland, 2016). Participants also learn about strategies on how to help
someone in both crisis and non-crisis situations, and resources that are available for
people with a mental illness. Mental Health First Aid training consists of a mnemonic
five-step action plan that is known as ALGEE. ALGEE refers to 1) assessing for risk of
suicide or harm, 2) listening nonjudgmentally, 3) giving reassurance and information, 4)
encouraging appropriate professionals help, and 5) encouraging self-help and other
support strategies. The program topics cover a range of common mental health disorders
including depression, mood disorders, psychosis, substance use and abuse (Mental Health
First Aid, 2013a). Overall, Mental Health First Aid is a training appropriate for any
individual over the age of 18 who is interesting in learning how to help a person who is
experiencing a mental health related crisis or problem.
MHFA Effectiveness
MHFA conducted pilot programs in Canada, Sweden, and Australia (Hadlaczky,
Hkby, Mkrtchian, Carli & Wasserman, 2014). A total of 15 programs used similar data
and psychometric scaling measures tested to determine if MHFA training resulted in
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changes in the individual's knowledge, attitudes, and behaviors in regard to mental health.
During the training, participants were given a scenario involving an individual with
depression, and a second scenario with an individual with schizophrenia. They were
asked to rate their attitudes towards the individuals. The results demonstrated
participants’ attitudes towards individuals living with depression and schizophrenia, and
whether the training affected their perception. Results show change in all three areas and
that MHFA is effective with increasing overall mental health knowledge (Hadlaczky et
al., 2014). The research also stated the course effectively decreased negative attitudes
towards individuals that suffer from mental health illness and increased help-seeking
behavior (Hadlaczky et al., 2014).
In 2014, individuals from a social services department in Maryland were provided
MHFA training. There was a total of 20 training classes ranging in class size from 17–30
attendees, in which 406 individuals were trained. However, only 384 individuals
submitted evaluation forms once the training was completed (Aakre, Browning-McNee &
Lucksted, 2015). The study measured the participants’ likelihood in providing help, their
ability to identify appropriate assistance behaviors and their MHFA knowledge. In the
midst of the training, the participants were given four different vignettes pertaining to
depression, depression with alcohol misuse, social phobia, and psychosis. The pre and
post vignette questionnaire measured whether the five elements of ALGEE were
implemented. Overall, it was determined that the individual's’ mental health knowledge
had improved. The participants reported feeling confident and able to respond to a young
person in mental health crisis by implementing ALGEE elements accordingly (Aakre,
Browning-McNee & Lucksted, 2015).
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During 2010, Mental Health First Aid Training was provided to staff from the
Swedish social insurance agency, employment agencies, social services, schools, police
departments, correctional treatment units, rescue services, and recreation centers. After
the training was completed, the participants agreed to a six month and two-year follow-up
(Svensson & Hansson, 2014). A pretest assessment was mailed out to the participants a
month before the training was conducted. Six months after the training, they were sent
the same assessment as a follow-up. A new questionnaire was created for the two-year
follow-up in order to measure whether the participants had improved their skills in:
making contact with a person with mental health problems, taking time and
listening non-judgmentally, being aware of how a sad and depressed person
communicates, asking if someone has suicidal thoughts, giving information about
effective treatment, giving information about how to get right kind of help,
recognizing signs of mental disorders, assessing the seriousness when a person is
in a crisis. (Svensson & Hansson, 2014, para 18).
In order to participate in the two-year follow-up, the participants needed to have come in
contact with an individual with a mental health disorder since the training was completed.
The results demonstrated that after two years the individuals who participated in the
Mental Health First Aid training continued to have knowledge of mental health and
treatment. The participants also continued to feel prepared and confident to come in
contact with individuals with mental health problems (Svensson & Hansson, 2014).
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There are not many published Mental Health First Aid training evaluations within the
United States. Studies evaluated were conducted in Canada, Sweden and Australia. Only
one published study found was in the United States. Overall, the studies analyzed
demonstrated that the individuals who obtained the training had a greater knowledge of
mental health and acquired the skills on how to recognize and assist a person in a mental
health crisis.
Aims and Objectives
The present study evaluates the effectiveness of Mental Health First Aid training
in the Los Angeles County. As of July 1, 2016, a total of 1 0,137,915 people reside in the
Los Angeles County (United States Census Bureau, n.d.). In Los Angeles County alone
1,419,709 individuals live with a mental illness. Due to the immense number of
individuals living with a mental illness, there is also a high need to educate social service
providers on how to support individuals with a mental illness. The intention of the study
is to investigate whether individuals completing the training will demonstrate skills in
identifying an appropriate response to people in emotional distress, and have an increase
in self-confidence to responding to individuals in a mental health crisis
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Method
Participants
A total of 16 individuals participated in the MHFA training. The trainees had
different social service provider roles throughout Los Angeles. They consisted of case
managers, students, and support staff. All participants who participated became aware of
the training from their employers or school campus. The trainees participated in the
training and completed the evaluations in fall 2014.
Measures
The data collected was to evaluate the course and instructors and to determine if
there was a change in the participants’ knowledge and confidence based on the training
using a pre and post-test.
MHFA 8-hour course evaluation form.
The purpose of the evaluation was to determine the participants’ satisfaction and
reaction to the training and instructors. MHFA instructors also provided the trainees a
questionnaire with 17 evaluation questions, 9 practical application questions and 4
demographic questions. Twenty-one of those questions was rated on a 5-point Likert
scale ranging from 1 (strongly disagree) to 5 (strongly agree). The instructor's evaluation
was measured by asking participants, “the instructors demonstrated knowledge of the
material presented” and “the instructor's presentation skills were engaging and
approachable”. Practical application of the training was measured by asking questions
such as, “how confident are you to help someone going through a mental crisis or
problem”, “how confident are you to provide a distressed person basic first aid level
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information and reassurance about mental health problems,” and “how confident are you
to recognize and correct misconceptions about mental health and mental illness”.
County of Los Angeles Department of Mental Health Adult System of Care
MHFA pre and post-Test.
The pre and post-test was used to determine if the training changed the
participants perception of mental health after the training was completed. The pre and
post-test has 12 test comparison questions and 1 final question. The purpose of the
questionnaire was to determine whether the trainees would assist an individual with
mental health issues and their beliefs and knowledge regarding mental health.
The instructors provided the trainees the pre and post -test questionnaire before the
training and after. Overall, both pre and post-test compared how confident the trainees
felt before and after the training was conducted. The confidence of the pre and post-test
questionnaire was rated using a 5-point Likert scale.
The pre and post-test questionnaire also included demographic questions. The
demographic questionnaire included questions such as age, gender, primary language,
ethnicity and highest education level. Also, included were questions regarding the
number of individuals the trainees knew that experienced mental health issues, how often
were their interactions with individuals’ mental health issues, their experience with
individuals with mental health issues and their role in the community.
Research Design
Secondary data collected from two standardized instruments commonly used by
MHFA trainers was used to explore the pre and post-test responses and course evaluation.
The data was previously collected by CSUN Garrett Lee Smith Suicide Prevention Grant
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which was funded by SAMHSA. The study used an exploratory, descriptive pre and posttest design to evaluate whether the MHFA training resulted in changes in the participants.
The questionnaires were administered in paper-and-pencil format to the entire trainee
group (n=17) by the MHFA trainers.
Procedure
Participation in this study was anonymous and voluntary, and the relevant
institutional review board (IRB) determined it to be exempt from IRB review.
Questionnaires were distributed by the MHFA instructors before the pre and post-test
immediately after taking the 8-hour training (2 days at 4 hours each day). The MHFA
trainers were certified by the program and followed a standardized training using the
evidence based curriculum. At the end of the course, trainees were also asked to take a
satisfaction evaluation form. No payments or incentive were given to the trainees.
Written responses on the survey questions ranged from multiple choice to short answers
to short sentences.
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Results
Secondary data from 1 MHFA training class had a total of 17 social service
providers. A total of 17 MHFA 8-hour Course Evaluation questionnaires and 16 County
of Los Angeles Department of Mental Health Adult System of Care MHFA pre and
posttest questionnaires were received. Only 13 of the pre-test were completed, however
all 16 of the post-test were completed. Both pre and post-test had missing open ended
question data. A total of 33 questionnaires were received by the research team.
Participants Characteristics
The majority of our participants were 16 (94%) women. There was only 1 (6%)
male who participated. The participants ranged from 18- 50 years old, in which the
majority (46%) were 26-30 years old. From the social services providers, 1 (6%) had a
High School Diploma/GED, 2 (12%) had a two-year college degree, 7 (43%) had a fouryear college degree, 3 (18%) had a Master’s Degree and 3 (18%) reported having more
than one degree. A total of 62% (n= 16) of participants reported knowing 11 or more
individuals who have experienced mental health issues, and 37% reported frequent
interactions with individuals with mental health issues. The majority of the participants
44%, described having a neutral experience with individuals with mental health issues.
Course and Instructor Evaluation
To keep track on how to better the training and get critical feedback, the trainees
were given an evaluation after the two-day 4-hours training. The purpose was to evaluate
the instructors and give the trainees the opportunity to give feedback anonymously. The
MHFA training consisted of two instructors complying with the standardized curriculum
of this training. The evaluation scored the instructors on how the instructors presented the
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curriculum and how effective their delivery was; whether they had positive or negative
impact. The evaluation had a unanimous positive feedback of the trainers in which
ultimately affected the positive outcome of the trainees confidence in a mental health
crisis. The only limitation of the evaluation was that the trainees felt the training itself
was not long enough. They felt they needed extra days to explore more. At the end of the
post test there was an extra additional commentary question that provided the trainees the
opportunity to openly answer what improvements would they recommend for the
training.
Practical application.
Part III of the evaluation questionnaire asked if the participants felt confident to
recognize the signs of someone dealing with mental health problems as well as if they felt
more confident in assisting an individual with a mental health problem.
Table 1
Trainees Practical Application
As a result of this training, I feel more
confident that I can…
Strongly
Disagree
Disagree
Uncertain
Agree
Strongly
Agree
M(SD)
Recognize the signs that someone is dealing
with a MH problem or crisis
7 (41%)
10 (59%)
4.59 (0.50)
Reach out to someone who may be dealing
with a mental health problem or crisis.
7 (41%)
10 (59%)
4.59 (0.50)
3 (18%)
13 (76%)
4.81 (0.40)
1 (6%)
4 (24%)
11 (65%)
4.63 (0.62)
1 (6%)
5 (29%)
10 (59%)
4.56 (0.63)
Actively and compassionately listen to
someone in distress.
Assist a person who may be dealing with a
mental health problem or crisis to seek
professional help
Assist a person who may be dealing with a
mental health problem or crisis to connect with
community, peer, and personal supports.
Table 1 demonstrated that 59% of participants felt confident in being able to reach out,
assist and recognize the signs that someone is dealing with a mental health problem or
crisis. Seventy-six percent reported that they would actively and compassionately listen
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to someone in distress. Lastly, 65% reported that they would assist a person who may be
dealing with a mental health problem or crisis to seek professional help.
Pre and Post Test
A paired-samples t-test was conducted to evaluate the impact of the training on
the participants’ pre and post-test scores. There was a statistically significant increase in
the post-test scores from pre-test (M= 4.10, SD = .324) to post-test (M = 4.51, SD =
.384), t ( -4.031), p < .002 (two-tailed). The mean increase in post-test scores t = .41 with
a confidence interval ranging from -.641 to -.191.
The final question of the post-test asked the participants whether the presentation
helped them understand people with mental illnesses. A total of 75% of the participants
reported that they strongly agree with understanding an individual with a mental illness
while 25% agree. The larger average score indicates that the training helped individuals
become more confident with assisting and approaching an individual in mental health
crisis. The participants also reported that the training was “great”, “informative”,
“educational” and “helpful”. Overall, the findings were statistically significant in
demonstrating the participants confidence in approaching and assisting an individual in a
mental health crisis.
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Discussion
The aim of this study was to examine whether the participant’s Mental Health
knowledge, beliefs, and confidence with assisting a person in emotional distress or crisis
increased after taking an 8-hour MHFA training. Results indicated significant, positive
changes in trainees’ ability to approach and assist a person in mental health crisis. The
positive findings are reinforced by the participants’ probability in assisting an individual
in crisis comparable to previous research data that indicated an increase in helping
behaviors (Hadlaczky et al., 2014). Follow-up MHFA application research is needed in
order to determine whether the trainees used their learned skills when assisting an
individual in crisis. The fact that scores improved significantly is essential due to sample
of employee’s social services providers of community services agencies, in which the
majority completed postsecondary education. MHFA is a training intended for the
general public whom do not have any training in mental health, and not intended for
individuals with advanced training. As previously stated, the pilot studies done in
Canada, Sweden, Australia, and Maryland discussed an increase of mental health
knowledge and the ‘likelihood’ in providing help in a mental health crisis after the
completion of the course. Overall, the trainees felt more comfortable with the practical
application of the learned skills.
Limitations
Although the outcome of this study was overall positive, there were some
negative setbacks regarding the data. In the evaluations, some of the questions were left
blank. Of the 17 participants that were a part of the evaluation, one participant did not
complete the pre and post-test. We can assume that the length of the training possibly
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affected the completion of both tests. Our recommendations are to ask the participants to
complete only one set of questionnaires, either the evaluation or pre and post-tests to
gather information about the training due to the duplication of questions. Another
limitation we came across was the lack of studies of MHFA training conducted in the
United States. Most of the MHFA studies that were found were conducted in Australia
since the training was developed in that country. Furthermore, the training should also
focus on demonstrating ‘real life’ scenarios of how MHFA has improved individuals
lives.
Conclusion
The study demonstrated the increase in confidence, comfort, and likelihood in
helping individuals in emotional distress and crisis. Due to the significantly positive
findings, it is important to continue to promote MHFA training by educating social
service providers in various settings to assist and encourage individuals in distress. The
overall results of this study attest to the effectiveness of MHFA training and how it can
benefit other agencies nationwide and ultimately worldwide. MHFA has the possibility of
becoming a training that can better educate and improve the communities perception of
mental health.
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