www.mhfa.com.

au

The Mental Health First Aid Program

Prof Tony Jorm and Betty Kitchener, ORYGEN Research Centre, University of Melbourne

Summary
• Mental Health First Aid is an award winning training program for members of the public
in how to support someone in a mental health crisis situation or who is developing a
mental disorder.
• The program has solid evidence for its effectiveness from randomized controlled trials
and qualitative studies. It increases knowledge, reduces stigma and, most importantly,
increases supportive actions. It even improves the mental health of first-aiders.
• Mental Health First Aid training can assist in early intervention and in the on-going
community support of people with mental illnesses. It is useful for people employed in
areas which involve increased contact with mental health issues and for carers of people
with mental illnesses.
• It is recommended that Mental Health First Aid training becomes a prerequisite for
practice in certain occupations which involved increased contact with people having
mental health problems, such as teachers and police.

Overview of Mental Health First Aid Training

First aid training is widespread throughout the world to give members of the public skills
to help an injured person before medical help arrives. However, first aid courses typically teach
little or nothing about helping people with mental health issues. This is curious given how
common these problems are. Most first-aiders would never get a chance to use their CPR skills,
but they would have a good chance of having close contact with someone in a mental health
crisis.
We have data from a national survey of Australian adults showing that many people lack
adequate skills in supporting someone they know who has a mental health problem (Jorm et al.,
2005). Because of the need for training in this area, we developed the world’s first Mental
Health First Aid (MHFA) course in Australia in 2000 (Kitchener & Jorm, 2002a). This course
had its beginnings back in Canberra in June 1999 when we formed an Advisory Group to direct
the curriculum of the MHFA course. The Advisory Group consisted of 3 mental health
consumers, 2 mental health carers, 2 teachers, 1 psychiatrist, 1 psych nurse, 2 first aid
instructors (Red Cross) and two mental health researchers.
The MHFA course is a 12-hour course that is usually run over 4 X 3-hour sessions. At
the end of the course, participants receive a Mental Health First Aid certificate. The course can
be taken by any member of the public. Most participants choose to do the course for one of three
reasons: their work involves people contact, they have someone close who is affected by a
mental health problem, or they see it as their duty as a citizen to learn first aid skills. We
emphasize that the course is not therapy and that it is not a substitute for getting professional
help. However, it is useful for people who may have experienced a mental health problem but
are currently functioning reasonably well. We also emphasize to participants that the course

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does not qualify them to be a counsellor, just as a conventional first aid course does not qualify
someone to be a doctor or a nurse. Its role is to promote first aid—the initial help that is given
before professional help is sought.

Course Content
The course teaches the symptoms, causes and evidence-based treatments for: depression,
anxiety disorders, psychosis and substance use disorder. It also addresses the possible crisis
situations arising from these mental health problems and steps to help. The crisis situations
include a person who is feeling suicidal; a person having a panic attack; a person who has had a
recent traumatic experience; a person who is acutely psychotic and perceived to be threatening
violence; and a person who has overdosed.
Although crises are dramatic consequences of mental health problems, it is better to
intervene early before such crises develop. We therefore emphasize in the course the need for
early intervention for mental disorders as they are developing.
Just as conventional first aid courses teach a series of steps under the acronym DRABC,
we teach mental health first-aiders to use the acronym ALGEE. (ALGEE is also the name of the
MHFA mascot pictured below).

1. Assess Risk of Suicide or Harm

2. Listen Non-judgmentally

3. Give Reassurance and Information

4. Encourage Person to Get Appropriate Professional Help

5. Encourage Self-Help Strategies

For example, for a person who may be depressed, the first-aider will initially assess if the person
is suicidal. Of course, this will not be an issue in all cases, but it is important that the first-aider
knows how to enquire about suicidal thoughts and how to respond. If the person is not suicidal,
the first-aider needs to listen actively and non-judgmentally before giving appropriate
reassurance and information. Such reassurance may help the person to feel hope and optimism
by realizing that: they have a real health problem; depression is a common illness; depression is
not a weakness or character defect; effective treatments are available for depression; appropriate
and effective help is available from a GP and / or counsellor; depression is not laziness, rather it
makes people motivationally challenged; depression takes a while to develop and sometimes
takes a while to resolve, but will get better faster with the right help. The fourth step is to
encourage the person to get appropriate professional help, such as seeing a GP or a clinical
psychologist; and the final step is to encourage the person to use some evidence-based self-help
treatments such as exercise, relaxation breathing exercises and light therapy.

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Mental Health First Aid Materials
To give participants information that they can take away from the course, we have developed a
Mental Health First Aid Manual (Kitchener & Jorm, 2002a). The manual gives information
about the major types of mental disorders, the best types of help available, local resources, and
how to apply the steps of Mental Health First Aid to various situations.
There is also a Mental Health First Aid web site (http://www.mhfa.com.au/) which is
very easy to navigate. Basic mental health first aid information is available, along with
information about the 12-hr Mental Health First Aid course and the 5-day Mental Health First
Aid Instructor Training Course. Instructors are able to advertise the courses they are conducting
on the website. The Mental Health First Aid Manual is available to be purchased or can be
downloaded as a PDF file.

Instructor Training
Because the Instructor Training Course is only 5 days long, successful applicants need to meet
the following criteria: substantial knowledge about mental illness and treatments, good teaching
skills, and “fire in the belly” to improve the mental health literacy of the community and to
reduce the stigma surrounding mental illness. There are now over 800 instructors in Australia,
covering all states and territories. The interest in training as an instructor has been strongest in
rural areas, both because of the shortage of mental health services in these areas and the greater
concern to support others in the local community. Instructors usually work through an employer
such as: an NGO (e.g. Lifeline, Red Cross, Anglicare), a state area health service, a government-
funded human service (e.g. Family Court, welfare housing service, corrective service, police), a
large employer (e.g. a university, government department), or work as fee-for-service private
practitioners.

Evidence That it Works (Kitchener BA & Jorm AF, 2006, Jorm et al, 2007)
A factor that really sets Mental Health First Aid apart from other educational approaches is the
rigorous evaluation of its effectiveness. This began with an uncontrolled trial with 210
participants who were given questionnaires at the beginning of the course, at the end, and 6
months later. The course was found to produce a number of benefits, such as improved
knowledge of mental health problems, a decrease in stigmatizing attitudes, increased confidence
in providing help to others, and an increase in the amount of help actually provided (Kitchener
& Jorm, 2002b).
A problem with this evaluation was, of course, that there was no control group. So we
next did a randomized controlled trial with a wait-list control group (Kitchener & Jorm, 2004).
This was done in a workplace setting with 301 public servants. The results were similar to the
earlier uncontrolled trial, but one surprising additional finding is that the course had a mental
health benefit to participants. This effect was unexpected because the course does not provide
therapy and promises no personal benefits. Also, participants are not recruited because of their
own mental health problems; however, we found that the people in the trial tended to have
somewhat worse mental health than the general population. We think the course may have
improved mental health by providing participants with good quality information which allows
them to make better choices about their own mental health care.
While this randomized control trial provided stronger evidence that the course is
effective, the teaching was all done by Betty Kitchener who is the originator of the course.
Perhaps she was an exceptional teacher who could inspire participants. We next wanted to find
out if other instructors could achieve similar changes. We therefore conducted a second
randomized controlled trial in a large rural area of Australia, using staff from the local health

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services as the instructors (Jorm et al., 2004). The results of this study were similar to the earlier
trial, confirming that the benefits of the course were present with other instructors.
As another approach to evaluation, we have also collected systematically stories from
people who have used the skills learnt from a mental health first aid course (Jorm, Kitchener &
Mugford, 2005). We have found that most participants actually use their skills to help someone
and that there are usually positive effects. Importantly, we have found no evidence of negative
effects, for example through the first-aider being over-confident and taking on more than they
should.

Mental Health First Aid in Other Countries

http://www.mhfa.com.au/international.shtml

Mental Health First Aid has spread to the following countries:

Country Hosting Website

organization
Canada Alberta Mental http://www.mentalhealthfirstaid.ca/Pages/default.aspx
Health Board
England National Institute for http://www.mentalhealthfirstaid.csip.org.uk/
Mental Health in
England
Finland Suomen http://www.mielenterveydenensiapu.fi/index.php
Mielenterveysseura
(The Finnish
Association for
Mental Health)
Hong Kong 1. The Mental Health http://www.mhahk.org.hk/
Association of Hong
Kong (Adult MHFA)
2. Private MHFA
Instructors
Northern The Health http://www.healthpromotionagency.org.uk/work
Ireland Promotion Agency /Training/MentalHealthFirstAidtraining.htm
(HPA) for Northern
Ireland
Japan National Center of
Neurology and
Psychiatry, National
Institute of Mental
Health

Scotland NHS Health http://www.healthscotland.com/smhfa/

Scotland, Edinburgh
Singapore Changi General http://www.traumarecovery.com.sg/mhfa.html
Hospital –
Department of
Psychological
Medicine
United States SAMHSA,
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 National Council of http://nccbh.browsermedia.com/cs/home
Community
Behavioral Health
Care

A summary of the worldwide spread of the program can be found in Kitchener & Jorm (2008).

Mental Health First Aid for Culturally and Linguistically Diverse Australians
The Mental Health First Aid program has core elements that translate across various cultural
groups. However, there is always a need for some cultural modification and translations. In
Australia, we have developed the course to suit the mainstream of society, but we recognize this
is not suitable for cultural minority groups.
A version of the course has been developed for Aboriginal and Torres Strait Islander
people and Aboriginal instructors have been trained across the country.
Cultural adaptations of the course have also been developed for a number of groups with
non-English speaking backgrounds, including Vietnamese, Croatian and Italian. Instructors
have been trained from each of these communities.

Mental Health First Aid for Supporters of Youth

The most critical time for early intervention is when people are first developing a mental
disorder. Often this occurs during adolescence and early adulthood. To cover this crucial period
of life adequately, we have developed a Youth Mental Health First Aid Program which is aimed
at adults who have frequent contact with young people. It emphasizes the mental disorders and
the crisis situations that are most common in this age group and includes additional modules on
eating disorders and deliberate self-harm. There are currently over 80 Youth Mental Health First
Aid instructors in Australia. This course is also being adapted for use in a number of other
countries.

The Need for National Guidelines for Mental Health First Aid
Another direction is to develop guidelines for Mental Health First Aid. Just as there are national
guidelines for conventional first aid, we need to develop guidelines for how best to help
someone in a mental health crisis situation or who is developing a mental disorder. We are
developing these guidelines using the Delphi method with international panels of clinicians,
service users and carers who have expertise in the relevant area. A number of guidelines have
been published (Jorm et al, 2008; Kelly et al, 2008; Langlands et al, 2007, 2008) and others are
in development. When the guidelines are completed, this will facilitate getting national
accreditation of courses. Our ultimate aim is that a Mental Health First Aid certificate a
prerequisite for certain professions such as teachers, police and nurses.

References
Jorm, A.F., Blewitt, K.A., Griffiths, K.M., Kitchener, B.A. & Parslow, R.A. (2005). Mental
health first aid responses of the public: Results from an Australian national survey. BMC
Psychiatry, 5: 9.
http://www.biomedcentral.com/content/pdf/1471-244X-5-9.pdf

Jorm, A.F., Kitchener, B.A., Kanowski, L.G. & Kelly, C.M. (2007). Mental health first aid
training for members of the public. International Journal of Clinical and Health
Psychology, 7, 141-151.

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http://redalyc.uaemex.mx/redalyc/pdf/337/33770110.pdf

Jorm, A.F., Kitchener, B.A & Mugford, S.K (2005) Experiences in applying skills learned in a
Mental Health First Aid training course: a qualitative study of participants’ stories. BMC
Psychiatry, 5,43.
http://www.biomedcentral.com/content/pdf/1471-244X-5-43.pdf
Jorm, A.F., Kitchener, B.A., O’Kearney, R. & Dear, K.B.G. (2004). Mental health first aid
training of the public in a rural area: a cluster randomized trial [ISRCTN53887541]. BMC
Psychiatry, 4, 33.
http://www.biomedcentral.com/content/pdf/1471-244X-4-33.pdf

Jorm, A.F., Minas, H., Langlands, R.L. & Kelly, C.M. (2008). First aid guidelines for psychosis
in Asian countries: A Delphi consensus study. International Journal of Mental Health
Systems, 2, 2.
http://www.ijmhs.com/content/pdf/1752-4458-2-2.pdf

Kelly, C.M., Jorm, A.F., Kitchener, B.A. & Langlands, R.L. (2008). Development of mental
health first aid guidelines for suicidal ideation and behaviour: a Delphi study BMC
Psychiatry, 8, 17.
http://www.biomedcentral.com/content/pdf/1471-244X-8-17.pdf
Kitchener, B.A. & Jorm, A.F. (2002a). Mental Health First Aid Manual. Canberra: Centre for
Mental Health Research.
http://www.mhfa.com.au/course_manual.htm
Kitchener, B.A. & Jorm, A.F. (2002b). Mental health first aid training for the public: evaluation
of effects on knowledge, attitudes and helping behavior. BMC Psychiatry, 2, 10.
http://www.biomedcentral.com/content/pdf/1471-244X-2-10.pdf
Kitchener, B.A. & Jorm, A.F. (2004) .Mental health first aid training in a workplace setting: A
randomized controlled trial [ISRCTN13249129]. BMC Psychiatry, 4, 23.
http://www.biomedcentral.com/content/pdf/1471-244X-4-23.pdf

Kitchener, B.A. & Jorm, A.F. (2006). Mental health first aid training: review of evaluation
studies. Australia and New Zealand Journal of Psychiatry, 40,6-8.
http://www.mhfa.com.au/documents/ANZJPMHFAtrialreviewJan2006_000.pdf

Kitchener, B.A. & Jorm, A.F. (2008). Mental Health First Aid: an international programme for
early intervention. Early Intervention in Psychiatry, 2, 55-61.
http://www.blackwell-
synergy.com/action/showPdf?submitPDF=Full+Text+PDF+%28117+KB%29&doi=10.1
111%2Fj.1751-7893.2007.00056.x

Langlands, R.L, Jorm, A.F., Kelly, C.M. & Kitchener, B. (2008). First aid for depression: A
Delphi consensus study with consumers, carers and clinicians. Journal of Affective
Disorders, 105, 157-165.
http://www.ncbi.nlm.nih.gov/pubmed/17574684?ordinalpos=1&itool=EntrezSystem2.PEntrez.P
ubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA

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Langlands, R.L., Jorm, A.F., Kelly, C.M. & Kitchener, B.A. (2008). First aid recommendations
for psychosis: Using the Delphi method to gain consensus between mental health
consumers, carers and clinicians. Schizophrenia Bulletin, in press.
http://www.ncbi.nlm.nih.gov/pubmed/17768307?ordinalpos=2&itool=EntrezSystem2.PEntrez.P
ubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Current 20 March 2008