Should Bystanders Intervene When They Identify Mental Illness?

I’m trying to have a conversation, but the hissing voice keeps interrupting: Don’t trust her, it says. Is she looking at you?

I laugh inappropriately. My eyes dart and my brow furrows. My friend looks worried, uncomfortable. She’s asking simple questions, but I stutter the answers. At first I’m not threatened by what the voice in my head says, but then I hear this: You are a failure. It knocks the wind out of me.

Thankfully, this is not a real auditory hallucination, but an exercise. And I don’t have schizophrenia, but for the first time, I genuinely understand how the illness might alienate and terrify.

The voice in my head is a fellow participant who is reading from a script in a training called Mental Health First Aid. We've gathered in a well-lit conference room in Marin, California on a warm fall day. Most of the attendees are experienced professionals from local government agencies that manage housing, employment, and health benefits. They encounter mental illness in the form of depression, anxiety, bipolar disorder and other diagnoses often, but like most of us, they don’t know if or how they should try to help. This training, which ranges from eight hours to two days, aims to teach them the skills to do just that.

The program, which has been taught in the U.S. since 2008, seems tragically useful these days, given the relatively recent shootings in, among other places, Tucson, Aurora, Sandy Hook, the Washington Navy Yard, and the Los Angeles Airport. In each case, the shooter showed signs of mental illness prior to the rampage, but he never accessed help, or if he did, it wasn't enough to suppress a violent, psychotic break from reality.

When a nurse in Australia developed Mental Health First Aid more than 10 years ago, it wasn't to prevent mass shootings—and that’s still not the goal. Rather, the educational program is meant to familiarize laypeople with mental illness, from its signs and symptoms to how it can be treated. MHFA is also predicated on the idea that if you nudge someone toward getting support and treatment as early as possible, particularly if he or she might be experiencing psychosis, the likelihood of recovery increases dramatically.

MHFA was part of the president’s gun violence reduction plan following the Sandy Hook school shooting; he proposed to spend $15 million on training for teachers. Legislation for that funding has bipartisan support, but it was attached to the doomed gun control legislation and hasn't been called up for a vote since.

Anyone can attend a MHFA class, and its techniques can be used with friends and family just as with acquaintances or strangers. More than 120,000 people nationwide have received training, according to the National Council for Behavioral Health.

The group’s CEO, Linda Rosenberg, helped import MHFA to the U.S., and like many advocates of the program, likens it to the typical first aid offered at community recreation centers. The major difference, she says, is that the average person is more likely to encounter someone who is depressed or suicidal than someone in the throes of a heart attack.

Back at the training in Marin, instructor Gina Ehlert, a cheerful woman in business attire, is comparing physicawhere the l ailments, which tend to elicit sympathy, to mental illnesses, which can unnerve or frighten bystanders instead.

“If there were an individual trying to cross the boulevard in a wheelchair, we’d run to help them,” she says. “But if that person seemed to have a mental illness, we wouldn't.”

That’s where the auditory hallucination exercise becomes revelatory: Those who experience it are able to understand why someone might scream back at a voice in his head. Instead of reacting with fear, the mental health first aider could use the program’s five-step plan to intervene.

The program doesn't urge students to approach every person who might be in need, but rather to use the skills when they feel emotionally prepared and it feels safe and appropriate to do so. This could mean talking to a distressed-seeming stranger on the street, but the trainers also note that it’s also acceptable to keep walking if the circumstances just aren't right.

When a first aider does engage, the technique starts with assessing for suicide risk or harm. If there’s a threat of either, the first aider is advised to seek professional help immediately, even if it’s against the person’s wishes. The next step is to listen non-judgmentally. Ehlert shares a handout that highlights helpful and counter-productive things to say. “I am concerned about you” is good, but, “You’ll get over it, you've just got to ignore it and get on with life” is not.

Three additional steps focus on reassuring the person that he or she has been heard; offering resources for and encouraging mental health treatment; and urging the person to seek the support of family and friends.

Ehlert stresses that mental health first aiders are not junior clinicians.. “Part of the training is that we give you a certificate at the end—not a cape,” she says. “You can’t save the world.”

Technically, it is part of Capt. Joseph Coffey’s job to save the world—or at least the small corner of it known as Warwick, Rhode Island. Coffey is a genial police officer with a strong New England accent who uses the word gentleman generously.

“Officers responded to a gentleman smashing windows in a car,” he says, describing a recent incident in which the man confronted cops by throwing rocks. The scene was tense, and in years past, it might have ended tragically.

In 2008, as many as four people experiencing mental illness died during encounters with Rhode Island police. Since then, state law enforcement adopted MHFA. The majority of officers in Coffey’s department have received training, and cadets regularly attend an eight-hour course.

For Coffey’s charge, the cultural shift made a huge difference. Instead of rushing the window-smashing man, he retreated and spoke calmly. Officers detained the suspect and didn't send him to the police station, but to the hospital for an evaluation.

The empirical measure of MHFA’s success isn't whether a person in need gets help, though that’s ideal. Instead, studies look at if the bystander feels more comfortable talking about mental illness and can accurately identify signs and symptoms.

These studies, several of which have been conducted by the program’s founder, show that MHFA can be effective. The Substance Abuse and Mental Health Services Administration found the evidence convincing enough to add MHFA to its registry of evidence-based practices this summer.

Coffey, also a national MHFA trainer, has seen the benefits firsthand. Ten percent of the department’s calls involve mental illness, but when the offense is minor he says officers increasingly look for alternatives to arrest, like contacting a behavioral health worker or taking the suspect to the hospital for an evaluation. Another benefit is that crisis situations less frequently escalate to the point where someone barricades himself inside a house with a weapon.

Coffey says the majority of police encounters with mental illness are positive, and it frustrates him that mass shooters may give the opposite impression. Data show that mental illness rarely leads to extreme violence, though a recent JAMA Psychiatry study found that patients with a history of antisocial behavior prior to a first episode of psychosis may be at a heightened risk for violence.

Rosenberg considers the finding yet another reminder that early intervention is critical. But such interventions won’t happen unless friends, family, teachers and others know how they might make a difference.

When they do, the difference can be huge. “If we can prevent today’s depressed person from becoming tomorrow’s barricaded person,” Coffey said, “then we've done our job.”