I was manning the emergency phone when a call came in reporting that a seafarer had stabbed two other crew members on board a vessel in the middle of the ocean. We focused on handling the emergency and prioritised the evacuation of the two injured crew. Fortunately, they arrived at the hospital in time and were saved despite serious injuries and severe bleeding. Later, I learned that the man who committed the stabbing had presented signs of psychological instability days before the incident. This was several years ago but the story stayed with me as a tragic example of how a situation can escalate and get out of control on board a ship. Although we managed to support the shipowners and avoid the worst possible outcome there is a question we need to ask - could this incident have been prevented? Could something have been done when the crewman first exhibited signs of mental instability?
Recently I attended a Mental Health First Aid course arranged by the charity Mind Hong Kong (Mind HK). One of Mind HK’s goals is to remove the stigma surrounding community mental health and provide various forms of support and training. Mental Health First Aid (MHFA) was first initiated by Australian co-founders back in 2000 and established as an NGO in 2012. The MHFA Standard course has now been taught by trained instructors in more than 20 countries. More than 3 million MHFA First Aiders in the world have already received this internationally recognised qualification.
I learned that mental health varies during a lifetime and displaying certain symptoms of mental problems at certain stages of our lives does not necessarily mean we have poor mental health. The difference is our natural resilience - our capacity to bounce back from adverse events. Decreased resilience is likely to indicate a possible deterioration of our mental health which, over time, can result in mental illness. MHFA is an immediate support that can be offered to a person developing a mental health problem or in a mental health crisis. As such it comes into play at the stage of early intervention and is given until appropriate professional treatment is received or until the crisis is resolved.
The short 12 hour training gives the First Aider basic knowledge of common mental health problems, teaches how to identify the signs of mental health problems or crisis and how to provide preliminary and suitable support before the mental health problem becomes worse. It is not expected that a First Aider makes a diagnosis and the course does not train participants to become mental health professionals. The course does provide an understanding of how to encourage persons in need to seek professional help.
The main MHFA concept is based on the ALGEE principle, an acronym to help us remember the essence of the MHFA principle that can be applied to most common mental disorders, such as for example depression, anxiety or psychotic disorders.
A: Approach, Assess and Assist the person with any crisis
L: Listen and communicate non-judgementally
G: Give support and Information
E: Encourage the person to get appropriate professional help
E: Encourage other supports
Assessing the situation
We were taught about the signs of mental illness which are multiple and multi-dimensional, and which taken together should raise an alarm of a possible problem. This is crucial as quite often the person experiencing a mental health problem is not fully aware of it. Taking depression as an example, we were given a long list of major symptoms of depression. According to The Diagnostic and Statistical Manual of Mental Disorder (DSM-5) of the American Psychiatric Association, the definition of depression is: an individual experiencing 5 or more symptoms, including one of the first two top symptoms, i.e. feeling unusually sad or having a depressed mood and having a loss of interest or pleasure in activities once enjoyed, with these symptoms happening almost every day and lasting for more than 2 weeks.
Bearing in mind that once a person has had one episode of depression, they are more prone to further episodes, it is here relevant to address suicide, which might be the result of untreated depression. What are the signs of suicidal thoughts that should alert us? There are many, ranging from signs that may not alert us at first such as social withdrawal from friends or family, insomnia or sleeping too much, feelings of helplessness, irritability, dramatic changes in mood, to signs of an acute situation like irrational behaviour or engagement in risky activities, talking or writing about death, and threatening to hurt or kill himself/herself. When noticing some of these signs, one should always encourage the person to express feelings and then ask if they have suicidal thoughts or plans. This is a good way to assess how serious the situation is and the need for professional help.
If I had to remember only one of the ALGEE elements, I would choose Listen and communicate non-judgmentally, which is much more challenging than I imagined. The stigma surrounding mental health can be quite prevalent especially in a very masculine and tough environment at sea. Adding to this the world’s obsession over the last decades with the pursuit of happiness, which seems to have become a must have, one can expect that being a little bit “down” is rather unpopular these days and often too easily dismissed. Despite it being rooted in the best heartfelt intentions, a little sentence like “Cheer-up, it will get better” should probably be banned from our language. Or at the very least it should be placed at the right time in a conversation, to instil hope, after having patiently and actively listened to the person we are willing to help.
Effective communication is key. It requires a proper attitude as well as verbal and non-verbal skills. Let’s forget about checking our mobile phones, crossing our arms or staring with a judgmental look when actively listening. To be a truly active listener, we need to put our mobile phones down, keep our arms open and be fully focused on what the person says. What about sitting next to the person to give a sense of proximity without the discomfort of a confrontational face to face? Our body language can make a huge difference to encourage a reluctant or reserved person to open up and share safely some very personal thoughts. This is true for any mild mental issue and possibly even more so for crisis situations when trying to assist a person with suicidal ideations or psychotic disorder.
An appropriate attitude also requires acceptance, respect of the other person’s feelings and privacy, confidentiality, listening with patience without pressuring the person to talk, asking open-ended questions, being sincere and expressing empathy and understanding of how they feel. In other words, this is not “rocket science”, but it is very useful to learn how to do it in order to avoid clumsiness in the process.
First of all the First Aider will guide the person by helping them realize what they are going through and more importantly realize that there is hope and they can get help. It is about giving information on the available forms of support and treatments, whether by consulting psychological practitioners such as psychologists, counsellors, social workers or medical practitioners such as psychiatrists. We might not think about it but consulting a general practitioner should still be a good starting point and a good advice especially if the person experiencing difficulties is reluctant to get help from more specialised professionals. Then there are all other sorts of strategies to recommend from relaxation, to yoga, acupuncture or cognitive behavioural therapy.
Is there anything at all we can do between listening and recommending professional help? The answer is yes. In the MHFA course we were asked to imagine having a conversation with a co-worker who suddenly starts acting oddly, sweating, shaking, complaining about chest pain, difficulty breathing, swallowing and feeling dizzy. Most of us would feel worried, helpless, not knowing how to react and at best we would call an ambulance if we suspected a heart attack. The latter is definitely a good decision as it could well be a heart attack, or another physical problem best assessed by doctors so in case of doubt, we should always call an ambulance. However, chances are that this could be a panic attack, which may last around 10 minutes and any one of us can learn how to assist a person experiencing such a severe episode of anxiety.
In the course we were taught that when a panic attack is assessed, the first task is to reassure the co-worker that the situation is not life threatening, that they are safe, and the symptoms will pass. You should also find, if possible, a quiet environment where they can sit or lie down comfortably, not touch them unless you ask first and they allow you to, and from that point try to help them slow down their heart rate through breathing exercises. Rebalancing the breathing is key, especially as a panic attack may come with hyperventilation, which is at the origin of symptoms like light-headedness and tingling in the fingers. The best is to guide the person through cycles of slow breathing and have them follow your voice or your hand if you choose to mark breathing in and out cycles with up and down hand movements until they start feeling better.
Although panic attacks are most likely to involve people with anxiety disorders it is not necessarily so. Considering that more than 25% of people will have at least one panic attack in their lifetime which may occur without warning or for no specific reason, it is worth knowing about it and learning how to respond and especially onboard a ship where access to a doctor would not be immediate.
Psychological disorders are frequent, complex, multi-dimensional and expressed in multiple ways combining often psychological, behavioural and physical symptoms. They range from non-severe and short episodes, which can be treated, to long-lasting and life impacting illnesses and sometimes acute and possibly life-threatening crisis. Because we all have been, are or will be touched by mental issues either personally or through friends or relatives, it is useful to be well-informed to fight the stigma surrounding it. Why not go one step further and learn how to respond appropriately and help people around us?
I found Mental Health First Aid to be extremely valuable and easily accessible. It certainly makes good sense to have crew trained in MHFA in a similar way as they are trained to provide traditional first aid. Living and working on a ship means being subjected to a challenging and potentially dangerous environment and maybe more than anywhere else, we should avoid having crew suffering over long periods of time from undetected mental illnesses that could amount to real hazards. Could early intervention with the crewman who injured his colleague have been prevented? Perhaps an empathetic and trained Mental Health First Aider could have helped him and prevented the attack.
Each of us can become a First Aider within hours and can help a person experiencing psychological difficulties with fairly simple tools. We all have a role to play to look after people around us, and even more so onboard a ship with a small group of isolated and interdependent individuals sharing a small living space for long period of times. So let us start by setting a clear intention to raise mental health awareness and then take steps to respond to the issue and hopefully contribute to increasing the wellbeing of our seafarers.
Above article has been initially published at Gard's website and is reproduced here with the author's kind permission.
The views presented hereabove are only those of the author and not necessarily those of SAFETY4SEA and are for information sharing and discussion purposes only.
About Sandra Guiguet
Sandra Guiguet works as Gard's Senior Manager in Hong Kong.