“5 thoughts on the "efficacy of Mental Health First Aid" articles”

There have been a series of articles in Personnel Today, New Scientist and others on a systematic review by Cochrane of various studies looking at the outcomes of Mental Health First Aid. As a self-aware MHFA Evangelist, here’s my thoughts.

A couple of weeks ago I spoke at a Morton Fraser Lawyers Frasers lawyers webinar on workplace wellbeing.

We managed to get through some questions but following the webinar and reviewing the missed questions something stood out:

“Personnel Today recently reported that a survey had found that there is no reliable evidence to suggest that mental health first aid is effective . . discuss!”

First of all thank you to whoever asked this question. I would have struggled to answer on the spot but I’m glad it was posed and I’ve now had time to look and reflect.

The next day I noticed that Elizabeth Lerpiniere of Thrive Mental Health had shared the new scientist article about the same systematic review and was quite rightly defending the position of Mental Health First Aid – and challenging possible stigma that was built into the writing of the articles and maybe even in the research.

I don’t think the articles really tell the story of what the review actually says – and for some reason seem to build a narrative that there’s a strong indication MHFA is not effective. I know that these sites and their copywriters have a duty to ‘lean one way’ on their narrative so that people share articles and call out any unnecessary clickbait. Well it worked and here I am. I’ve taken the bait – and here’s my 5 thoughts on the articles and the study.

1.      "absence of evidence is not evidence of absence"

What is really clear from the Cochrane review is a strong, consistent message that the evidence  and studies they were looking at were not reliable.  They were subject to bias, low reliability and could not be used to draw a firm conclusion. In a lot of cases there was a complete absence of evidence that they could use to measure or conclude anything in regards to the outcomes they were looking at:

“We cannot draw conclusions about the effects of MHFA training on our primary outcomes due to the lack of good quality evidence”

This however in the articles is less clear – the answer to the question is MHFA effective? here is that we don’t know – which is not to say it doesn’t work. In fact any adverse effects from MHFA don’t appear to have been measured at all according to the summary of findings – so there’s no way to know if it doesn’t work or could make things worse.

“We are not confident in the evidence….we were not able to obtain precise results that would tell us whether MHFAtraining was better than the interventions to which it was compared.”

(cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013127.pub2/epdf/standard – Page 3)

I’d want the writers of the articles to do better to make that clear. My own view on reading the articles for is that there’s almost an emphasis on saying “MHFA does not work.” That’s a great discussion point and a good way to get clicks – but its not really what the Cochrane review says. Maybe I’m just taking it personally.

2.      ‘We think that it works’ and ‘we know that it works’ are not the same thing.

For myself and fellow MHFA instructors we need to recognise that our belief in the impact of the course – which probably feels very strong and evident – is mostly at the micro level.

We hear amazing anecdotes about the learning on the course being applied. I regularly have people come back for day two of the course having already had “the conversation” with a loved one or colleague that they didn’t need to have before.

I have managers telling me they are very excited to be able to support their staff better and direct them to services. I’ve had this happen on one of my own teams where a team member said in a one to one – “ It really helps having a Mental Health First Aid instructor as your boss – some amazing advice.”

I also know that family members and loved ones have accessed services after I’ve had conversations with them, using the A.L.G.E.E. model and I suspect they would have not accessed those services at all or much much later.

On a personal level knowing of this type of direct action is enough for me to advocate and promote mental health first aid and for a lot of my clients these type of testimonials are what they need to feel confident in the training.

But we do need to acknowledge that a lot of people will need convincing of the strengths of the course at a more “macro” level and that evidence matters.

I think as instructors we have a duty to put pressure on our respective countries’ MHFA organisation to look at outcomes and research at a higher level and be prepared to challenge articles and reviews like this.

3.      Our analogy of "It's the same idea as Physical First Aid but for Mental Health" doesn't always seem to be landing yet.

This is a comparison that MHFA instructors use a lot to try and encourage people to understand they don’t have to be counsellors to support someone with a mental health problem or crisis. We know that if you find someone with a broken leg you wouldn’t be expected to do diagnose the break, carry out the x-ray, do the surgery or set the cast on the persons leg. You would have enough basic knowledge and confidence to support the person, identify help and stay with them until help arrives. Because of stigma, perceived ‘complexity’ of mental health problems and lack of societal ‘norming,’ people are often not able to approach a mental health crisis as confidently as they might a physical one – that is what Mental Health First Aid designed to tackle.

The first thing I did after reading this article was have a quick search for systemic reviews or studies about the efficacy of Emergency First Aid at Work.  Outcomes measured tended to be around gaining of practical knowledge, confidence to act in an emergency situation and actual performance in real emergency situations. There certainly weren’t any studies to determine if Emergency First Aid at Work improves the health and wellbeing of staff – it’s well understood that’s not what it’s for.

So with this in mind – why was the main outcome of the Cochrane Review this:

“The main outcome of interest was the effect of MHFA training on the mental health and well-being of individuals at a time point between six months and a year.”

Is there a still a pervasive misunderstanding – even at a research level – that a first response mental health intervention should be a fix-all for someones mental health? Is there an assumption that the same type of ‘cascading responsibility’ you have from First Aider – 999 – Ambulance – Doctor just doesn’t apply to Mental Health problems?

Mental Health First Aiders are here to tell you that there is that same type of route – and the more people that can take that first response role, the more people that could be helped in a mental health crisis.

You’d give someone a paracetamol without doing a blood test or a brain scan – and you’d call an ambulance on an unconscious person without being a doctor.

We need to keep building the message that you can also feel this type of confidence with limited knowledge when someone is suicidal, or having a panic attack, or appearing to be experiencing psychosis.

Anyone can help and anyone could save a life.

4.      The E.E of A.L.G.E.E was not measured – and that’s the most important part.

The two E’s in A.L.G.E.E are about encouraging someone towards professional support or other help. It’s the First Aid equivalent of getting them in the ambulance, to the doctor, or getting them to go home and have a Lemsip.

I often tell my learners – even if the A.L.G part doesn’t feel like it went well – if you’ve hit the E.E. with the person you have supported then they are in a position to be supported by someone with more expertise and responsibility and that’s a win.

While one of the desired outcomes of the Cochrane review was  to examine “mental health service usage” - the not one of the studies used this as a measure. It’s made very clear in the summary findings that any measure of signposting to services or accessing services were not included - which means there's no way to know if this happened (or not).

We did not find any evidence relating to mental health service usage

I’d be really interested to know if workplaces or communities who have a cohort of mental health first aiders can look at whether help seeking behaviour and service access improves (or not) – and maybe this can be the focus of further research.

At the very least, as MHFA instructors we’d love people to understand that signposting is the main goal and for that to be clear. There’s work to do at our individual level to improve that understanding.

5.      I’ll still be advocating for the course – but I’ll keep my unwavering belief in check.

My initial inclination about these articles was to be frustrated, angry and defensive. But that’s not good enough. The people that these articles influence who don’t take on MHFA might be the ones that need it most and in my eyes it’s a bigger win to change one person's perspective or challenge one person's stigma than it can be to preach to a group of the converted.

I’m fortunate to be surrounded by good mental health advocates, positive feedback and other MHFAiders – but I’m also aware of my bubbles and my echo chambers.

As MHFA instructors – lets keep working together to be critical about what we do. Let’s do our best to listen to and understand the deniers and conscientious objectors out there and keep changing minds at the grassroots level.

Every time we give someone the confidence to support someone or ask about suicide – it could save a life.

FINAL THOUGHT - SOUND THE DUNNING-KRUGER FOGHORN.

My understanding of this type of research is limited. I have read the two shorter versions of the Cochrane review and I’m working on the big one – I realise my thoughts might be influenced by my ignorance and lack of expertise and I’m happy to be called out, or supported to learn more. This is also my excuse for poor referencing.