Mental Health Intervention Protocol
Mental health first aid techniques are used to deal with immediate crises and the risks that come from them – most often, self harm and suicide, though other issues come into play (not eating, taking unusual risks, etc). These techniques are also useful in day-to-day, non-acute situations to help people better manage distress and overwhelming emotions.
Mental healthcare provided as first aid is necessarily imperfect. In no situation will you have access to the wide variety of therapies, medications and most importantly time needed to carry out comprehensive interventions, and you almost certainly do not have the skills to carry out such tasks.
The most common interventions used in community mental health are standard medical interventions to help people function better: making sure hydration and blood sugar are not causing reduced functionality, making sure the person is warm and feels safe and cared for, et cetera.
The acronym RAISED is used for mental health interventions. It should be used in a similar way to the DRABCDE acronym - to make sure that no potential issues are ignored or forgotten, and to produce reliable care - but unlike DRABCDE, in RAISED the order in which the acronym is followed is not important. You must ensure that Risk is considered first and Diagnosis considered last, but the rest can be dealt with in any order.
A mental health crisis is a situation in which someone no longer feels able to deal with emotions or experiences in the way in which they usually do. In general, the fastest way to end a mental health crisis is to convince a person that they have sufficient control over their situation to to be able to feel autonomous.
How to use RAISED
Advice on implementing RAISED
Your job is not psychiatry: it’s to enable someone to cope as they usually do in day to day life.
To do this, you should consider everything that is inhibiting their ability to cope by using the RAISED acronym. You should react calmly and carefully, maintaining good consent. This means that you should ask for someone's permission before intervening, apart from where there is a risk to life or limb, and you should respect their boundaries around what they are comfortable doing or discussing. You must remember that what helps one person will not necessarily help someone else who is experiencing something similar.
You should appear calm and reassuring and keep talking and prompting more from the person when things fall silent. You should calmly talk and fill the space in which a person may have time to panic or spiral into depression – see active listening protocol for advice on this. Doing this can reassure them and help minimise Stressors in and of itself. However, periods of silence can be helpful, and you should always adapt your approach based on what works and doesn't work for the person you are supporting.
You should ask clarifying questions to understand how the person you are supporting is feeling. Some examples of clarifying questions are: ‘I wonder…’; ‘Help me understand…’; ‘How did you learn…’; ‘What makes that so...(hard, scary)...’; ‘How would you like it to turn out?’; ‘What can we do to get there?’. You should avoid projecting any ideas you might have of how you might expect someone to cope in a situation on to the person.
In especially acute scenarios, where there is imminent risk of injury, you should talk more, filling space and keeping the person focused on you.
Making it seem like something is being done is in itself doing something: Even if sucking a boiled sweet or completing a simple task doesn’t actually improve someone's cognitive ability, the feeling of control they gain from doing so is often sufficient to help them cope with their stressors.
If possible, you should offer ongoing support to cope with their problems, but must not offer support which you cannot provide. For example, in a protest situation, “we’ll make sure you’re safe and clear of the demo” might be in your capacity, whilst “we’ll make sure you’re safe in the long term” may not. Be honest and open.
First, consider risk. Carry out a scene survey and check for physical dangers and then consider psychological risks. In situations like these you must consider and balance:
- Risk to yourself
- Risk to the person experiencing crisis
- Risk to others
For example, if you are on a demonstration and a person is having a uncomfortable time and crying, and at the same time there are riot control agents in the area, you should decide to check up on the person after you have moved to an area free from contamination (after checking for physical problems which are causing problems).
Another example is if someone is experiencing mental distress and you know that supporting them will seriously damage your mental health - this may be because their distress is caused by an issue which you have experienced, and/or because you are particularly tired or in a poor space mentally yourself. In this case you should pass off to a buddy or other carer.
The third factor to balance in this step is threats to others – it should be emphasised that the person in distress is very rarely physically or psychologically violent, and that this is a stereotype pushed by an oppressive media culture. Instead, in this step, consider the risk to other people who may care for them, or who else may be damaged by self harming behaviours if you do not do the care and they reach out to someone else who is less able to cope with the demands and who is then harmed by it.
Buddy format in mental health interventions
The ideal format for doing mental health interventions in less strenuous settings (“in the community”) is in a group of three people. Mental health interventions are often extended, and it is beneficial to have the ability for one person leave for a while to take a break (or to sleep, as interventions are often late at night), to get food, or to make a warm drink, whilst still maintaining a buddy pair who can check each other's work and make sure the person in distress is safe. This format can be replicated for virtual care, which is done online, over messaging or video call apps - a group chat or call with two or three carers as well as the person experiencing distress is less likely to lead to burnout amongst the carers.
In a protest situation, you will probably be working in a buddy pair, and given that interventions in a protest are generally faster, this is generally fine.
Affect is about ascertaining a person's general mood and what the shape of the problem is. This most usually breaks down into “panic” or “depression”, or some combination thereof. In this step you should also consider whether a person is perceiving a different reality to you - see Supporting people perceiving a different reality to you protocol.
If someone is depressed or suicidal, help them build a future in which they can see themselves. Talk about future plans and act as thought it is assumed they will be around to take part. Reassure them that the problems they are experiencing can be dealt with and make plans for dealing with them together if this is something you are confident you can support with.
If someone is panicked, reassure them of their safety and their support system and offer assistance with their Stressors if you can provide it. Do not minimise their problems, but assure them that they are up to the task of dealing with them.
If someone is experiencing sudden emotional swings, respect their feelings in the current moment and accept that they are real emotions, not 'fake feelings' or equivalent. Use non-judgemental language and deal with feelings as they come
If someone is nonverbal, provide time and space, reduce possible stressors, and offer a pen and paper or digital notepad to pass messages.
On a demonstration you are anecdotally more likely to run into panic than depression, but you should not make assumptions.
In and Out
Similar to the CSAMPLE step “Last in and out”, this is one of the most (possibly the most, following Risk) important things to consider in a mental health intervention.
The most common factors exacerbating mental health crises encountered by QueerCare are low blood sugar, missed medication or a lack of hydration.
Low blood sugar is very rarely the root cause of the crisis - this is more likely to be previous trauma or chronic mental health conditions or many other issues - but what makes the person unable to cope with this cause as they usually do in day to day life is impaired cognition as a result of low blood sugar. A common cause of this is people not eating sufficient meals.
Most QueerCare kits include easy to use sweets for countering low blood sugar. Not only does the act of eating something serve to give the person a feeling of control that is frequently lacking and a distraction from the issue at hand, but when using boiled or similar sweets, glucose is absorbed directly into the bloodstream through the mucus membranes in the mouth, rapidly bolstering a persons functionality and thus ability to cope with their situation.
Please note that giving someone something to eat may not always be appropriate, such as if someone is experiencing sensory overload or an eating disorder crisis and this would make their distress worse. In these situations you should consider other steps in RAISED that can be taken to increase the person's feelings of agency and control over their situation.
It is also advisable to have water in your kit or when doing an intervention: dehydration has a similar effect on cognition to low blood sugar.
This step also encompasses any medication or other substances the person has taken - not only mental health medication, but, for example, painkillers, which can both inhibit cognition or the lack of which can have a person in pain, or non-medical substances which can cause changes in emotion or perceptions of reality.
On demonstrations, people frequently skip breakfast and then run around the streets for several hours, causing mood dips and difficulty thinking clearly. When combined with stressors this can easily cause a mental health crisis.
The "out" section mainly comprises two things: If a person has impaired bowel function, this can cause significant discomfort, exacerbating and/or causing a mental health crisis. And iff a person has not urinated for a long time, this is a sign of dehydration.
Stressors (and Sleep)
At this stage, consider what stressors are acting upon a person. If they can cope in day to day life, what's changed here? Is there an exam coming up? Bad news? Relationship issues? Recent experience of violence? Use your knowledge and active listening skills to determine what these are, and consider suggesting ways you can work together to make them less of an overwhelming issue. Don't minimise someone's stressors, but help them to feel assured that they are up to the task of dealing with or working through them.
In this stage you should also consider how much sleep the person you are supporting has had recently and whether this is impacting their ability to feel able to cope.
Look for factors in someone's environment (physical or otherwise) which are causing their mental health to be worse.
These factors are often especially important for people who have sensory issues and you should consider both directly all five senses (sight, sound, smell, taste and touch) as well as specific combinations, such as a triggering person or disturbing event in proximity.
Common factors in the environment include:
- Bright sunlight or lights
- Pitch black or very dark rooms
- Flashing or strobing lights
- Triggering or difficult smells
- Loud music
- Sharp bangs or cracks
- Scratchy, uncomfortable or restrictive clothing
(When considering taste, people will often mention a bitter taste- this is a common symptom of a panic attack)
When you've worked out potential factors causing someone to be less able to cope than normal, either remove them from the area or remove the factors from their vicinity: move to a different room, for example, or turn down loud music.
In this step you should be aware that someone may be perceiving something distressing in their environment which you are not perceiving - see Supporting people perceiving a different reality to you protocol.
The most important thing to consider in this step is that it comes last.
You are, unless you have significant experience and knowledge of mental health care, not skilled or knowledgeable enough to make even tentative diagnoses and you must not attempt it. The topic of mental health diagnoses is complicated, political and often very personal for an individual.
However, it is worth considering still (and specifically asking) if a person has been diagnosed with any mental health conditions - for example, it may tell you that sudden emotional swings are a risk, or if you should avoid offering food because of an eating disorder.
You should be careful and cautious about assumptions you make because of someone's diagnosis, and if you are not familiar with that diagnosis it is best not to make assumptions based upon it. Media and medical representations of diagnoses often bear little resemblance to people's lived reality - listen to people who have been diagnosed with the diagnosis in question and base your work off of that and your personal experience with the person you're caring for.