By Katie Kerwin McCrimmon

First aid experts typically train to respond to emergencies like heart attacks or strokes.

But, both in the workplace and in families, first responders are more likely to encounter people who are struggling with behavioral health challenges such as anxiety, depression or substance use.

Experts estimate that one in four people in the U.S. will experience some sort of behavioral health challenge in a year. That’s why a 12-hour course, Mental Health First Aid USA, has become increasingly popular. The classes began in Australia in 2001 and now nearly 1,500 people have been certified to teach it across the U.S.

Among them are Moe Keller and Bianca Mikahn of Mental Health America of Colorado. Since the group started teaching the classes in 2010, they have trained more than 120 mental health first responders.

On a recent Monday evening, Keller and Mikahn were teaching students in Denver about the most rare and least understood of mental health challenges: psychotic disorders. These include schizophrenia, which affects about 1 percent of the population, and bipolar disorder, which impacts about 3 percent of adults each year.

To begin to understand what it feels like to have a psychotic break, the students gathered in groups of three. One pretended to have schizophrenia. The second tried to carry on a normal conversation with that person while the third whispered relentlessly into the first person’s ear.

Christian Newport, a program manager for TeenScreen Primary Care, tries to understand schizophrenia. She struggles to carry on a conversation with Sharon Liu, left, who works for Colorado's Division of Behavioral Health, while Sarah Serrar, right, a trainer and case manager for Long Term Care Options, distracts her by talking in her ear. (Click on image to enlarge.)

“Don’t trust her,” the voice said over and over.

The experience knocked some students off balance.

Her conversation “kept breaking off,” said student Christina Newport. “It was so disorganized. I didn’t even know what I was saying.”

“That’s the point of this,” said Keller, vice president of policy and systems advocacy at Mental Health America of Colorado and a former Colorado lawmaker. “They’re hearing it all the time,” Keller says.

She tells the students that it doesn’t help to tell the person that the voices aren’t real. To them, they’re absolutely real. Psychotic illnesses frequently start in late adolescence or early adulthood. For some people, a psychotic break can occur just once. For others, episodes of psychosis can recur periodically. Stress can aggravate psychotic illnesses. More men are at risk, but pregnancy and birth complications can be a risk factor for women.

In earlier classes, the students learned about other mental disorders including the most common: anxiety, which affects about 18 percent of adults, and major depression, which affects almost 7 percent of adults. The course also covers substance use and eating disorders and how to find resources to help individuals connect with professional care.

Few know what to do

While onlookers frequently jump in to help people with physical challenges in everyday life, discomfort, fear and stigma may cause people to disregard behavioral health challenges.

The students in this class learn that people often want and need help. So, rather than turning away, the students learn to offer assistance. Similar to learning CPR for someone who has stopped breathing, they learn ALGEE, a mnemonic device that teaches a first aid action plan with five steps:

Students learn the action plan.

• Assess for risk of suicide or harm
• Listen non-judgmentally
• Give reassurance and information
• Encourage appropriate professional help
• Encourage self-help and other support strategies

The students learn that they are not therapists. They are not supposed to diagnose people. Rather, they let the person know that they are concerned and try to connect them with qualified people who can help. Studies show that people who have studied mental health first aid are more likely to assist others and that their own mental health improves.

In the Denver class, students come from diverse backgrounds. Some have family members experiencing mental health challenges. Others are working with stressed clients who might need help. For instance, two of the students in this class are workers from Colorado’s unemployment office. With many clients experiencing job losses that have been the result of the most stubborn and protracted recession since the Great Depression, mental health first aid is a vital and practical tool. Still other students have experienced mental illnesses themselves and are eager to learn more.

One of the students, Larry Krause, could have taught the portion of the class on psychotic disorders. He was diagnosed with schizoaffective disorder after suffering his first major break with reality in his early 20s. For people with schizoaffective disorder, the symptoms of schizophrenia combine with a mood disorder like bipolar disease.

During a summer break from college, Krause started hearing voices insisting that he leave school in California and come back to Colorado. At that time, his father, who had been abusive when he was a child, was living in California. His more nurturing mother was in Colorado. A priest served as a mental health “first aider” and helped him get medical help. But doctors treated him for paranoia, which did not help.

“I crawled back to Colorado,” Krause said. The journey took months.

“The delusions would tell me that I couldn’t get on an airplane or something bad would happen. So, I’d take a bus and go to another city. I tried three times to go to LAX (Los Angeles International Airport).”

Eventually, Krause made his way to Arizona, boarded a bus there and called his mother to tell her he was returning home.

Now 56, Krause is doing well. Medications have kept the voices away for the last three years. He recently completed his college degree in psychology and is hoping to become a mental health case manager. Currently, he drives a van for Arapahoe/Douglas Mental Health Network.

Krause said that the voices he has heard in the past are extremely persuasive and disturbing.

“It’s very realistic. It’s not what people would expect. The voices have a plot,” Krause said. “That’s what makes it so hard. I’m sitting here talking with you, and at the same time, there’d be another plot going on.

“There’s a storyline. It’s good and evil. It’s worse than hearing something that just annoys you. It’s got a deeper plot and more meaning. And they can be very contradictory to what you believe. Then you’re arguing with this voice, trying to maintain your composure,” he said.

Krause has done well when he’s been able to work. He worked for several years making Pepsi bottles, then suffered a bad break from reality in 1989. New medications helped center him again. He got a job as a machinist and did well until 2002 when the company outsourced that work to China. He was placed on disability and once he was well again, returned to college. He graduated in 2008 and started his new job in 2009.

Krause decided to take the first aid class both to learn more about his own disorder and to prepare himself to work with clients in the future.

Larry Krause, left, studying Mental Health First Aid. (Click on image to enlarge.)

“It’s helpful. I’ve already used it,” he said.

Rather than being a liability, he thinks his own history of mental illness helps him.

“I have more insight than most people,” he said.

Krause often spends time at a Colorado clubhouse where people with mental illness can socialize. Recently, he spotted a man who was clearly agitated and upset. He didn’t know him, but stepped up to help.

“He was going through a lot of grief. He had bought a new car and someone had vandalized it,” Krause said. Rather than helping him, some other people were laughing at the man.

“He was obviously confused. I assisted him quickly. I saw that he wasn’t in danger of suicide or harm, then I proceeded to listen non-judgmentally. I think the guy had some real issues. Some people try to make light (of mental illness) and make it funny. It’s not funny to him.”

While Krause was able to calm the man, he didn’t feel as prepared as he wished with the final parts of the action plan: offering specific resources. He knows he’ll probably run into him again and hopes to be even better prepared next time.

Another time, Krause provided a safe haven on his van for a delusional client. The man thought the radio was talking to him. Krause understood well that the man was experiencing twin realities.

“He rode in my van all day long. Finally (his case managers) were able to give me a call once they found a place where they could take him. All morning we talked and traveled.”

From Krause’s perspective, it’s quite helpful if people say, “I understand that you have a problem and I’d like to know more about it” rather than sweeping it under the carpet.

“Do not patronize,” he said. “I think a lot of people want to help, but they don’t know how to help. People think you’re just going to snap out of it. They don’t understand that it doesn’t work that way.”

Krause thinks it would be great if more people boosted their mental health literacy.

“It would be wonderful if everybody took this course. I think it’s good for both ends of the spectrum. It’s good for me both as a provider and as a person who’s being treated.

“It’s going to be very useful for me,” Krause said. “I intend to get a case manager job, work full time, get off benefits and become a ‘productive member of society.’ I’ve done it before. I can do well. I intend to work until I’m 90.”