On the morning of September 16, 2013, a 34-year-old U.S. Navy technology contractor named Aaron Alexis shot and killed 12 people inside the Washington, D.C., Navy Yard before being killed by police. The media barrage that followed the shooting focused largely on Alexis's credentialed access to a government facility and on the military's process for vetting contractors.
Less publicized was the fact that a month before, in the early hours of August 7, Alexis had picked up the telephone in a hotel room in Newport, R.I., and called the police for help. He was hallucinating and had changed hotels three times during the night. He claimed that a stranger with whom he had recently and briefly argued had sent three people to follow him, and they were bombarding him with microwaves to keep him from sleeping. The responding officers came to the hotel, spoke with Alexis, called a supervisor and took a report. Then they left.
Those officers fulfilled their legal obligations: Alexis was alone, declined treatment, and stated that he was not thinking of hurting or killing himself. Thus, he failed to meet the legal criterion of posing “an imminent likelihood of serious harm” to himself or others that would have allowed police to take him to the hospital involuntarily for a psychiatric examination.
The Navy Yard incident joined a string of mass shootings by mentally ill individuals in the U.S. in the past three years, including the Sandy Hook Elementary School shooting in Newtown, Conn., that claimed the lives of 26 children and teachers in late 2012 and the 2011 shooting in Tucson that killed six people and wounded 13, one of them Representative Gabrielle Giffords of Arizona.
On a smaller scale, troubling scenarios involving people with mental illness play out across the country every day in homes, schools, workplaces, subways and restaurants. A professor watches a student's classroom behavior become more and more erratic; a father calls police for help when his adult son threatens other family members; a restaurant owner observes a customer melt down in front of other patrons. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly 20 percent of adults in the U.S. struggle with mental illness in any given year.
No one holds the magic formula for preventing the distress or violence that mental illness can cause, but one recent strategy aims to make the masses part of the solution. A program called Mental Health First Aid (MHFA) trains citizens to recognize early symptoms of mental illness or the signs of a mental health crisis and to guide distressed people to the right kind of assistance. According to the program, effective intervention by citizens requires neither simple compassion nor good cheer but rather a set of skills that emphasize the ability to listen actively, offer reassurance and helpful information, and gauge when someone has become dangerously unstable.
Recent studies in several countries show that the program succeeds in arming people with the knowledge and confidence they need to deescalate crises and provide help. As a result, MHFA is now included in SAMHSA's National Registry of Evidence-Based Programs and Practices. Also, as part of the Obama administration's Now Is the Time plan to increase school safety, 120 state and local school districts received funding for MHFA training in September 2014.
Mental illness can be hugely debilitating, especially because much of it goes untreated. One in five U.S. adults has a mental disorder, yet fewer than half of these people receive treatment. And many of those who do take years to find help. For example, half of individuals diagnosed with depression have delayed seeking help for eight years or more. The result, according to the World Health Organization, is a combined rate of disability and premature death in the U.S. that is exceeded only by those of heart disease and cancer.
Originally developed in Australia in 2000 by a husband-and-wife team and now adapted for use in 23 countries, MHFA has the dual goals of catching mental illness early on and keeping people safe in the event of a full-blown crisis. Betty Kitchener, one of MHFA's founders, herself suffered from depression. “It struck me: Why doesn't regular first aid teach about mental illness?” she told LIFE Communications, an Australian suicide prevention project. “Across our lifetime most of us aren't going to come across someone who's had a cardiac arrest. We're much more likely to come across somebody who is troubled by mental health problems.”
About 280,000 people have completed the eight-hour MHFA training in the U.S.; classes are available in every state. Some trainees work in social services and want to be better prepared to help the mentally ill people they encounter at their jobs. Others have lost relatives or friends to suicide and hope that MHFA training might save someone else's life. Among those who have taken the course are police in dozens of jurisdictions; public safety officials such as campus officers, sheriffs, and corrections and court staff; and doctors, teachers and clergy members. Specialized modules exist for rural communities and for people who work primarily with children. One version debuted in April 2014 for those in military service, veterans and their families.
In Philadelphia's MHFA program, the largest in the country, 7,000 residents are currently prepared to help people in distress and connect them to appropriate services. “We wanted to move away from a more passive approach, where people experiencing mental health issues come in for treatment, to an approach that would let us educate the community about mental illness and intervene earlier,” says Arthur C. Evans, Jr., commissioner of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services.
“That must be very scary”
The man in the video hears the knocking at the door, but the last thing he wants to do is answer. He pulls aside a curtain to peer at the two women—his neighbors—who are calling to him from his front porch, asking to talk. His gaze darts from left to right; his fear and agitation are almost palpable.
The women persist, and when a few minutes later he does respond, the older woman begins speaking to him in a calm voice. “Brian, why don't you come outside for a minute and stand here on the porch, and we can talk here?” she asks. “If you feel uncomfortable, you can go back inside. We'll leave the door open. I won't ask you to go anywhere that isn't safe.”
The woman tells Brian that she has been concerned about him for some time, and she asks him specific questions. She is kind but frank and a little detached. As the conversation unfolds, Brian discloses that he believes someone is following him and that he thinks he is in danger. “That must be very scary,” the woman says. He also admits that he has stopped taking his medication and that he does not want a crisis team to visit, because they will force him to take the drugs again. “Well, that's possible,” the woman says, “but they may just want to talk with you first and see what's going on.” Ultimately Brian agrees to let them call a crisis team.
The neighbor in this instructional video has been trained in MHFA. She offers Brian neither simple friendship nor a skilled clinical assessment. Instead she blends concern with a level of objectivity that lets her listen nonjudgmentally. She also prepares him for what will happen next. Other elements covered by the course include assessing people for risk of suicide or self-injury—by, say, looking for signs of physical harm or extreme distress—and encouraging individuals to get professional help. The process requires a high degree of empathy, good listening skills and the ability to keep calm, but trainers say virtually anyone can master it.
In addition to instructional videos, MHFA trainees receive basic information about mental illness to allay the fear and helplessness many feel when encountering someone in distress. They learn the symptoms of conditions such as psychosis, anxiety, depression and substance abuse, and they discover that the most intimidating conditions are rare (schizophrenia affects 1.1 percent of adults in the U.S.; anxiety more than 18 percent). Trainees also engage in role-playing. In one exercise, designed to give an idea of what living with auditory hallucinations is like, a trainee must maintain a lucid conversation while another trainee whispers urgently in his or her ear the entire time.
These methods seem to be effective. In their 2014 meta-analysis of 15 papers assessing MHFA training programs, researchers at the Karolinska Institute in Stockholm found that MHFA training increases mental health literacy, decreases negative attitudes about mental illness and bolsters confidence about assisting a mentally ill person.
“Tell me more about the wiring”
It was close to 1:00 a.m. the first time Warwick, R.I., police officer Joshua Myer arrived at the home of a schizophrenic man in his 20s. Relatives had called police for help when the man became agitated and violent, and although no weapon was involved, tensions quickly escalated. “He met us at the door ready to fight,” Myer remembers. The man lunged at Myer's partner. The two officers subdued him, handcuffed him and took him to the department for booking; only after several hours was he transported to the hospital for a psychiatric exam.
Although 10 percent of the Warwick Police Department's calls involved behavioral health issues, including mental illness and substance abuse, the training for such situations had been lacking. Education existed for encounters with so-called emotionally disturbed persons. Yet those sessions, Warwick police captain Joseph Coffey says, were more about “how to deal with ‘crazy’ or ‘psychotic’ people,” such as the man who takes hostages and barricades himself in a room, and not how to talk to people living with depression, post-traumatic stress disorder or anxiety—in other words, the nonviolent majority of mentally ill people.
By the time Myer saw the man with schizophrenia again, just over two years later, Myer had taken MHFA. “He wasn't ready to fight, but he was still charged up. He'd broken things in the house already,” Myer recalls. “I tried to keep his attention on us. That actually is a big deal when you're hearing voices.” Myer kept repeating the man's name and told him they were there to make sure he got help, not to hurt or arrest him. Myer's approach worked: within half an hour the officers were able to take the man to the hospital. “The training made a huge difference,” Myer says.
MHFA training is now part of the curriculum at one of Rhode Island's three police academies and is one of the most popular in-service programs at precincts. Coffey, also a national MHFA trainer, says its key benefit is enabling officers to recognize symptoms of mental illness and act accordingly: “The appropriate response may not be an arrest. Can we give the person a summons and get him to the hospital?”
MHFA can be particularly helpful with people who are in the early stages of a psychiatric illness, when symptoms can be easy to miss: someone may seem withdrawn, unusually quiet or disinterested in his or her typical activities. In such cases, being able to recognize warning signs can help prevent a crisis. Robert Davison, executive director of the Mental Health Association of Essex County in New Jersey, remembers receiving a call from a mother concerned about her 20-year-old son. The young man seemed troubled and was spending an unusual amount of time alone, the mother said. Then she mentioned that her son had stripped the wiring out of his bedroom walls. “I said, ‘Take a step back and tell me more about the wiring,’” Davison recalls. The son later admitted that he thought he was receiving radio transmissions through the wires. “She didn't know that that was a distinct symptom of psychosis,” Davison says. “Had she known, she might have contacted me earlier.”
Alexis, the naval contractor, had had run-ins with police over the years, and some of his friends said they had seen him change in the weeks before the Navy Yard shooting, becoming more isolated and withdrawn. With more specific knowledge, one of these people might have brought him into care long before the red flag on that August night in Newport.
Deliver Mental Health First Aid in Five Steps
MHFA includes a five-step method for helping someone showing signs of mental illness:
- Assess the person for risk of suicide or harm. Are there signs of injury to his or her body? Is the person in extreme distress? Has the person become aggressive or lost touch with reality? If the person is suicidal, always call for professional help.
- Listen nonjudgmentally. Be patient and understanding; listen carefully before offering help. Let the person know he or she can talk freely without being criticized.
- Give reassurance and information. Empathize and express hope; offer practical help and relevant information. Respond truthfully to any concerns.
- Encourage seeking professional help. Describe treatment options for the distressed person and sources of support for family members.
- Recommend other forms of assistance. Suggest accepting help from family members, friends or those who have had their own mental health problems.