Zachary Kaminsky jogged past the woman standing alone on the bridge, lost in his own thoughts. But once across, he paused. Something felt off. When he ran back, the young woman was standing too close to the edge, looking over the side, clearly in distress.
“Can I help?” he asked. “I am not leaving. I care about you.” She was inconsolable, but as they kept talking, she stepped away from the railing. Another passerby called 911, and they waited with her until the ambulance arrived.
Only a month earlier, Dr. Kaminsky, a molecular biologist, had taken a suicide first aid course called ASIST. He researches suicide prevention at the Royal, a psychiatric hospital in Ottawa. While he doesn’t work directly with patients, he wanted to know what to do if ever confronted by a suicide attempt. That day on the bridge, the training kicked in.
“They tell you to be yourself, to be human,” he says, when asked what he most remembers from the course. Don’t stop talking. Don’t give up. “Just be there, and try to do your best.”
A caring human doing their empathetic best at the right time – this is the most valuable resource in mental health care.
Yet, two years into a pandemic, with anxiety and depression rising, Canada’s mental health care system faces a serious crunch: more people needing care and a shrinking supply of already overwhelmed clinicians to treat them.
The country’s psychiatrists were aging fast even before COVID-19 arrived on the scene; in 2019, half of all psychiatrists were over the age of 55. Burnout rates are rising among mental health workers. Psychologists and social workers are leaving a beleaguered public system for lucrative private practice.
To fill some of the gaps, programs that empower laypeople are expanding. A growing body of research shows that with the right training, regular citizens – neighbours, caregivers, community mentors, even the local barber – can improve outcomes for teenagers and adults struggling with mental health issues. The programs deliver care in a wide variety of ways, including brief social contacts, basic talk therapy and mental health first aid in a crisis situation. Some examples, such as the training that Dr. Kaminsky received, are meant to build skills in the general population; other programs train people for specific roles in their community, both as volunteers and paid non-specialists. They have been found to work as early interventions, to provide a wider safety net for people with complex mental illness, or to deliver extra support at particularly vulnerable times, such as when patients go home after a hospital stay.
These programs do not replace specialist care – and they’re not meant to. But training laypeople capitalizes on two significant findings in mental health research: People do better in therapy when it happens with someone they trust, and they recover faster when they have the support of their community.
Sometimes, says Denise Waligora, a first aid training and delivery specialist with the Mental Health Commission of Canada, people just need someone “to sit in the darkness with them.”
Still, lay-workers are not simply cheap, second-tier help to patch up a broken system, says Srividya Iyer, a psychologist and associate professor at McGill University. These programs, Dr. Iyer says, often deliver the kind of nimble, holistic, grassroots care that a system focused on hospitals and credentials has too often been missing. “If we re-envision a system where multiple people play roles, we would have a much better system.”
This approach has been working for more than a decade in lower-income countries, in places where doctors and psychologists are a scant resource, but there are plenty of examples in wealthier nations. Distress lines are answered by laypeople with training, peer support workers and groups use shared experiences to heal. Increasingly, mental health apps and online programs are supported by trained coaches, because virtual self-help works better with even a brief human check-in.
In the Netherlands, youth volunteers have been trained to offer empathetic conversations at drop-in centres. An American program that used trusted adults to support teenagers who had attempted suicide was found to reduce the number of deaths, compared with a control group, more than a decade later. England designed a national public psychotherapy program around training psychology undergraduates to provide evidence-based therapy to people with mild symptoms of depression and anxiety. A pilot project in California trained Spanish-speaking members of a Latino community – some with less than high-school education – to deliver eight weeks of group therapy; a paper published last year found that the “health promoters” significantly reduced symptoms of depression and anxiety in participants.
Indigenous communities already have a long history of supporting well-being through elders and knowledge-keepers. Dr. Iyer is part of a program in Ulukhaktok, NWT, that carries on that tradition, training members of the community in mental heath first aid and suicide intervention to deliver care to young people.
Another approach, known as “caring contacts” – often adopted informally by community groups when in-person meetings stopped during the pandemic – has shown success in combatting loneliness and improving outcomes after a psychiatric hospital stay or emergency room visit. In Texas, for example, university students made weekly “sunshine calls” to isolated seniors for one month after receiving a brief workshop in active listening; a trial published in JAMA Psychiatry last year found that when compared with a control group, the Texas seniors who received calls showed improvements in mental health, as well as reduced loneliness. In Hamilton, early results of a small pilot that used phone calls from non-clinical volunteers to stay in touch with patients after a suicide-related hospitalization found that there were fewer emergency room visits and readmissions among the intervention group; pending ethics approval, the study will be scaled up this year.
Research suggests that peer support workers – people who have first-hand experience with a mental illness – are a cost-effective resource in mental health care, and are increasingly used in hospitals and community clinics. But first-hand experience with a mental illness is not a requirement for many of these programs. The idea is to build up capacity within groups that share similar life stories, to bolster the skills of leaders and mentors already trusted in communities. In cities across the United States, for instance, a program called the Confess Project has trained Black barbers to be mental health advocates with their customers by actively listening, and by reducing the stigma around getting help.
As the pandemic highlighted, there are challenging inequities in Canada’s health care system. Racialized Canadians often wait longer for mental health care, and face language and cultural barriers. Training lay people in underserved populations or diverse neighbourhoods helps builds health care resources and knowledge in the places where patients actually live and work.
Mental health is not only about medical care; it is affected by family circumstances, unemployment, poverty and racism – problems that often need a flexible, whole-person solution, beyond a diagnosis and a prescription, and often require embedding mental health support into other services. In Edmonton, for instance, multicultural health workers, who counsel immigrant and refugee families navigating health care, schools and family services, have also been trained in basic talk therapy techniques and trauma-informed care, and to recognize when people might need a referral to more formal treatment.
Advocates of non-specialist programs make the case for wider benefits as well: Train more people to be confident caregivers, and we might build more compassionate communities.
Often that begins with a conversation in a safe space, says Steve Jones, an acting platoon chief with the Burlington Fire Department in Ontario. Years ago, during an evening shift when he was still captain, Mr. Jones made a confession to his crew gathered around the kitchen table at their fire station. He was just back from a workplace mental health training course, he told them, and he’d realized he was struggling and needed to practise self-care. How were they doing?
One by one, the men volunteered their stories. One said he’d been missing work because his daughter was dealing with anxiety. Another explained why he was always checking his phone during shifts: His wife had severe depression, and he was worried he might get a call one day that she’d harmed herself. A third firefighter spoke up. This was the slacker guy nobody wanted to work with, who never got out of his chair. A few weeks ago, this crew member had driven his car to the top of a bridge, with a suicide note already written. His colleagues at the kitchen table were the only people he’d ever told.
Two hours later, they were still talking. In the six years since, a workplace mental health course, the Working Mind, developed by the Mental Health Commission of Canada, has been offered to the entire fire department, including family and spouses. The program has since expanded into a peer support program.
As more people took the training, Mr. Jones says, they developed a common language to talk about mental health, both for themselves and if they saw warning signs in colleagues. “There’s pent-up demand to be able to just talk about this stuff. Like, it’s okay to say I’m barely treading water and know that you are not alone.”
Mental health first-aid programs, another example of layperson training, are designed to teach people how to respond to a panic attack or psychotic episode, to actively listen when they see someone is struggling, to recognize warning symptoms in themselves. To date, according to the commission, nearly 600,000 Canadians have received such training. About 450 companies, including Loblaws and Ikea, as well as government departments, have contracted with the commission to deliver programs to employees.
Mental health first aid has been found to decrease what researchers call “social distance” from people with mental health problems. “One of the things that prevents people from reaching out and offering support is they think, ‘Oh, I need to have a fix,’” Ms. Waligora says. “But we can’t fix the broken leg. We can’t take cancer away. And we still offer to help.”
Programs using laypeople or non-specialists aren’t a panacea, of course. Training people in mental health first aid, for example, has been found to improve their knowledge, reduce stigma and boost their confidence to help – especially in closer-knit groups and workplaces – but research also shows that those benefits wane with time. A few days in a workshop, a well-run support group or a caring contact in a crisis can’t compensate for a bogged-down health care system. In published trials with the best results, client outcomes are measured and tracked, and community health workers and volunteers receive support and supervision – which requires a clinician with time and desire to provide it. And certainly, families and friends cannot be expected to manage complex mental illnesses alone, without evidence-based, timely treatment.
Still, research suggests that training people who are personally invested in a patient’s recovery can make the difference in how well treatment works. A 2019 Yale study found that training parents to manage their child’s anxiety was as effective as delivering cognitive behavioural therapy to the young patient – and went further in reducing family stress. The U.S. study that formalized a team of adult volunteers to reduce suicides in high-risk young people worked, in part, researchers theorized, because the trained coaches helped teenagers keep medical appointments and stay in therapy.
The same concept is now being piloted at the Royal, part of a community-based project involving Dr. Kaminsky. Teenage patients will choose a team of adults – often coaches, relatives or family friends – to receive a review of their treatment plan, along with mental health training. The adults will maintain weekly contact with both the patient and an advising clinician. Dr. Kaminsky has big ambitions for the idea. Why can’t it work, he asks, for in-patients with depression when they go home? Could trained friends and family monitor a patient through social media?
After all, a key ingredient of good care is help that comes at the right time, offered by someone who is paying attention and ready to listen. Mr. Jones offers his own anecdotal evidence: After that night at the kitchen table, the firefighter who had been contemplating suicide started therapy. His colleagues rallied around him. Six months later, he was promoted to captain.
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