It’s inevitable that at some point in everyone’s career, work will become challenging, whether as a direct result of the work itself, problems outside of work or, as is often the case, a combination of both. I was once told to ‘man up’ by a former employer, in response to personal issues affecting my work. Hardly the human touch. Fortunately, employers have become more enlightened, recognising the vital importance of wellbeing at work and taking steps to provide more support for employees.
Mental Health First Aid (MHFA) is an increasingly popular part of this shift; an international public health programme that aims to increase mental health literacy in society. MHFA was founded in Australia by trauma nurse Betty Kitchener and Anthony Jorm, a mental health literacy professor, whose aim was to break down the stigma around mental health and achieve parity with physical health. Almost two decades on and their work has grown into a global movement, with 2.6 million MHFA-trained people in 25 countries.1
In recent years, the Duke and Duchess of Cambridge and the Duke and Duchess of Sussex have achieved much in terms of normalising conversations about mental health, as have a host of celebrities and sports professionals. Mental ill health costs UK employers an estimated £34.9 billion per year, equating to £10.6 billion lost to sickness absence, £21.2 billion in reduced productivity, and £3.1 billion in substituting staff members who vacate their roles due to mental illness.2
With one in four people in the UK experiencing a mental health issue each year, many of whom are in work, the business consequences of ignoring mental health conditions are considerable. In response, employers of all sizes, across the sectors, have been keen to demonstrate a commitment to improving the mental health and wellbeing of their employees; a commitment that has contributed to the rapid rise of MHFA.
What is MHFA?
MHFA aims to teach managers and staff how to spot the signs and symptoms of common mental health issues, provide non-judgmental support and reassurance, and guide a person to seek the professional support they may need in order to recover. Courses typically last up to two days, after which time learners can refer to themselves as ‘qualified’ mental health first aiders. Mental Health First Aid England is the largest, but by no means only, provider in town when it comes to MHFA training. Since 2010, its 1,800 instructors have licensed some 360,000 people and it is marketed as the only licensed and accredited provider in England.
Support for MHFA
Independent research and evaluation in the UK and abroad shows that workplace mental health training can make a lasting difference to people’s knowledge and confidence around mental health, and responsible employers now have an opportunity to address the lack of awareness about mental health in the workplace.3 Those who choose to do so are likely to improve the workplace for staff, encourage early intervention to aid recovery, increase confidence in dealing with mental illnesses and reduce stigma. In October last year, MHFA England produced an evaluation document which summarised the efficacy of a number of MHFA programmes, all of which presented a favourable view.4
What do the detractors say?
Despite its popularity, MHFA is not without criticism, with much of this coming from the mental health community.5 Critics have pointed out that MHFA is sold on its evidence base, and while courses do improve learners’ attitudes to mental health and increase their confidence in starting difficult conversations, there is very little evidence that these changes help people suffering from mental distress.
Research funded by IOSH and undertaken by the University of Nottingham6 found positive outcomes as well as areas for concern, including inadequate boundaries for employees and a lack of proof that MHFA is effective in helping people in mental distress. Of particular note, the study highlighted significant issues with co-workers contacting first aiders outside working hours, issues around a lack of clarity with boundaries and potential safety concerns for the MHFA trainer, who receives nothing in the way of clinical supervision, and the potentially vulnerable recipients of ‘first aid’.
Last year, the Health and Safety Executive (HSE) also published a summary of the evidence on the effectiveness of MHFA training in the workplace, which reached similar conclusions: that ‘there is limited evidence that MHFA training leads to sustained improvement in the ability of those trained to help colleagues experiencing mental ill health, or that the introduction of MHFA has improved the organisational management of mental health in workplaces’.7 Moreover, MHFA is predicated on the notion that further help is readily available with adequate signposting. This, of course, is far from the reality in the current context of well-publicised under-investment and a reduction in spending on mental health support. The danger here is that the MHFA programme might actually lead to increased demand for support that is either inaccessible or not available.
Is MHFA a threat to the counselling and psychotherapy professions?
There has been much discussion within the therapy profession about MHFA, with it raising ethical questions and concerns. It’s clear that there are risks in passing responsibility for mental health at work on to lay people, who are not sufficiently trained or adequately supported professionally or organisationally. Nicola Neath, Chair of BACP’s Workplace division, explains: ‘Mental health first aid can conceal systemic problems that may be exacerbating mental health issues in a workplace, whereas in-house counselling services or EAPs will work with the individual and the organisation to address systemic problems.’
Others have expressed concern with the ‘first aid’ metaphor, which implies that physical and mental health are equivalent and that a toolkit (or sticking plaster) can be used to help treat ‘wounded’ individuals. Some argue that this metaphor not only over-simplifies mental health, it also serves to separate it from the often deeper and wide-ranging problems that contribute to mental illness. Moreover, some BACP members have also raised concerns that by ‘normalising’ mental health, MHFA may serve to undermine the therapy profession.
However, there is a lack of evidence to suggest that this is the case in practice, with few clear examples of organisations using mental health first aiders in place of qualified and experienced mental health professionals. Indeed, it’s important to stress that one of the key messages woven through most MHFA programmes is that those undertaking training do not emerge as qualified mental health professionals.
Interestingly, it could be that out of the MHFA movement, a new strand of work for the therapy profession could emerge. Andrew Kinder, Professional Head of Mental Health Services at Optima Health and a BACP Governor, points out that employers have a duty of care to their employees and the possibility of boundaries being crossed puts this in serious jeopardy. To avoid this, mental health first aiders need to be provided with good clinical supervision, delivered by a qualified professional. While recognising these challenges, Andrew goes on to suggest that there is ‘an opportunity for those in the counselling and psychotherapy professions, to deliver training and supervision to first aiders as part of a tiered approach to employee wellbeing’.
Earlier this year, at the Health and Wellbeing at Work conference at the NEC, Louise Aston, Wellbeing Director from Business in the Community (BITC), spoke about how to promote wellbeing through the lens of responsible business, one that takes a whole-person approach and recognises that, ‘there is no health without mental health’.
Louise argues that this approach to wellbeing needs to be embedded into the DNA of an organisation, advocated for by strong leadership and clearly aligned with business objectives. Moreover, wellbeing needs to be embedded organisation wide through joined-up approaches that focus on ‘good’ work, effective job design, fair pay and work/life balance. MHFA has a role to play within this, but it’s not a panacea, it’s reactive and shouldn’t be used as the ‘cheap option’ for employee wellbeing. She goes on to suggest that organisations should have better specialist support, as line managers can’t be expected to be counsellors. However, they can signpost to appropriate support, including workplace counselling paid for by the employer, while recognising one size doesn’t fit all.
Heather Smith (Assoc CIPD) is an HR professional and a BACP member, who believes in ‘the importance of employee resilience and wellbeing standards that are thoughtfully aligned with organisational strategy and design’. Heather trained as a psychodynamic counsellor and runs her small private practice in Warrington. She’s noticed a shift in the way employers are thinking about mental health and wellbeing, driven by several factors, notably resourcing.
Heather explains, ‘In my experience, many employers have realised that to attract and retain the best talent into their business, they must reflect a workplace that goes beyond offering just a competitive salary. Employees are attracted to organisations that share their value set, and they want to be part of a culture where they’re encouraged to succeed in their role and know that they’ll be supported during the darker times’.
Heather’s view of where MHFA fits within the workplace is shared by other people I interviewed for this article. She explains, ‘I agree that MHFA has its place in an organisation that embeds the resource in its wider wellbeing plan, one that is linked with external mental health providers and is backed by senior leaders with a clear vision of how it will benefit the strategic goals of the business.’
The shift in attitudes towards mental health and its place in an organisation’s wellbeing plan has been noticed too by Alison Pay, Managing Director of Mental Health at Work. Alison says, ‘Just three years ago, people were not ready to talk about mental health in workplaces; there was a real lack of understanding and associated stigma.’ Alison feels part of the problem is that people confuse mental health with mental illness and these are at opposite ends of a continuum. She continues: ‘If organisations understand the impact that they can have in supporting employees and create a longer-term programme to drive behaviour change, then this can help individuals to seek the support they need from professionals at an early stage, before they reach crisis.’
Alison believes that awareness raising and tackling stigma must be the bedrock of employee support: ‘If people who need support don’t understand what’s available to them, such as an EAP or in-house counselling, or if they fear harming their career prospects, then they won’t use these services.’ For Alison, it’s about understanding how to have a conversation about mental health, but not to provide or engage in counselling, as this is the domain of trained, professional therapists.
While supportive of the broad aims of mental health first aid, Nicola Banning, a workplace counsellor in the public sector and editor of BACP Workplace, has concerns about what it could mean for the therapy profession. She says: ‘I think that our economy is running on a culture of volunteering, and the MHFA movement fits this model. Just think about what has happened in our libraries, our hospitals and schools – they are propped up by an army of volunteers.
They do incredible work, but there is a systematic erosion of professional expertise and skill, being replaced by free labour. I’m troubled by the disconnect in all the rhetoric about mental health at work, because too often the words ‘counselling’ and ‘counsellor’ are missing. The task for our profession and our professional bodies, is to make sure that counsellors are an integral part of the solution and that our work is understood, valued and paid for.’
Despite the concerns, it seems likely that we may soon see the provision of MHFA training in workplaces enshrined in law. The ‘Where’s your Head At? campaign, led by Bauer Media Group, MHFA England and Natasha Devon MBE, was launched last May, and saw more than 200,000 people sign a change.org petition supporting legislative change. Alongside this, over 50 leaders from across business, education and mental health signed an open letter to the Government, calling for changes to the law.
In November 2018, and following the publication of this letter, the HSE announced new First Aid guidance on mental health, signalling a fundamental shift in how mental health support will now be assessed and provided for in the workplace. The guidance, located on the HSE’s website, now provides employers with advice on how to support employees experiencing a mental health issue, including training staff as mental health first aiders. However, this did not represent a legal change to make MHFA training mandatory.
Following a debate held in Parliament earlier this year, on legislative change around mental health first aid in the workplace, a cross-party group of MPs overwhelmingly backed a motion to introduce legislation to put mental and physical first aid on an equal footing through First Aid regulations. Despite the support, Government Minister for Mental Health, Inequalities and Suicide Prevention, Jackie Doyle-Price MP, opposed the motion, saying: ‘We would not want to have legislation that became a floor of service in mental health.’
While it remains important to continue the debate on mental health in the workplace, it is encouraging that the Minister was not prepared to rush into supporting what could effectively become a ‘minimum’ set of standards for employers.
What is BACP’s position?
While BACP does not currently hold a position on MHFA, we do share our members concerns. We agree that the supporting evidence base for MHFA is weak in terms of demonstrating its value for money and helping people suffering from mental distress.
Moreover, further research is needed to determine whether MHFA is being used as intended or adopted as a minimum standard of employee support. To this end, we would welcome clear evidence, showing that MHFA is being applied consistently and responsibly within organisations. This means that appropriate systems and provision are in place such that professional boundaries are not crossed, and both first aiders and recipient are afforded adequate protection under their employer’s duty of care.
BACP is keen to work more closely with MHFA training providers and other professional bodies, including BITC and Acas, to ensure that organisations understand the valuable contribution that counselling and psychotherapy can play in supporting employees, and where this fits within a tiered approach to wellbeing at work.
Finally, in my role as BACP Workforce Lead, I’d encourage you to get in touch and share your views on, or experiences of, MHFA with me, whatever they might be.
Kris Ambler leads the development and delivery of BACP’s workforce strategy, helping to bring professionals and employers together. With a background in occupational psychology, Kris understands the value of counselling in organisations, and is a passionate advocate for the counselling and psychotherapy professions.
1 Mental Health First Aid England. Why train with us? [Online.] https:// mhfaengland.org/instructors/why-train?/ (accessed 13 April 2019).
2 ACAS. Mental ill-health in the workplace is costing UK employers billions. [Online.] http://www.acas.org.uk/index. aspx?articleid=3915 (accessed 13 April 2019).
3 Mental Health First Aid England. A whole organisation approach to mental health. [Online.] http://www.bdld.org.uk/index_ htm_files/MHFA%20Workplace%20 Brochure.pdf (accessed 13 April 2019).
4 Mental Health First Aid England. Summary of evaluations of Mental Health First Aid [Online.] 2018. https://tinyurl. com/yxcey9jz (accessed 13 April 2019).
5 https://www.independent.co.uk/voices/ mental-health-first-aid-theresa-maydepression-anxiety-nhs-underfundedservices-turned-away-a7842571.html (accessed 13th April 2019).
6 Narayanasamy M, Geraghty J, Coole C, Nouri F, Thomson L, Callaghan P, Drummond A. Mental health first aid in the workplace: a feasibility study. Wigston: IOSH; 2018.
7 Bell N, Evans G, Beswick A, Moore A. Summary of the evidence on the effectiveness of Mental Health First Aid (MHFA) training in the workplace: Prepared by the Health and Safety Executive. Buxton: HSE; 2018.