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Assumptions associated with mental health literacy training – Insights from initiatives in rural Australia

Rosemary J Anderson & David Pierce

To cite this article: Rosemary J Anderson & David Pierce (2012) Assumptions associated with mental health literacy training – Insights from initiatives in rural Australia, Advances in Mental Health, 10:3, 258-267, DOI: 10.5172/jamh.2012.10.3.258

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258 ADVANCES IN MENTAL HEALTH Volume 10, Issue 3, June 2012

Assumptions associated with mental health literacy training – Insights from initiatives in rural Australia

ROSEMARY J ANDERSON AND DAVID PIERCE Rural Health Academic Centre, The University of Melbourne, Ballarat, VIC, Australia

Abstract The impact of depression on the Australian community is well established. A number of approaches have been proposed to address this problem, including targeted programs to promote mental health literacy. This paper explores four assump- tions associated with community mental health literacy programs: that individuals would increase their mental health knowledge; increase their confi dence to help others experiencing mental ill health; report reduced stigmatising attitudes towards mental illness; and help others experiencing mental ill health. Findings from a rural Victorian community mental health literacy program focused on sports team coaches and other club leaders is reported in the context of these assumptions. Pre–post questionnaire data and focus group data were collected from participants in the mental health literacy program. Participants reported increased knowledge of key mental health conditions, increased confi dence to help others experienc- ing mental ill health and less stigmatizing attitudes toward mental ill health. Limited evidence was noted to support the assumption that, following training, individuals will help others experiencing mental ill health. Diffi culties in determining if transfer of benefi t to others has occurred following mental health literacy training are dis- cussed, along with a number of mechanisms that, if included in training, may extend the benefi t of that mental health literacy training to others.

Keywords: mental health literacy, mental illness, rural health, health literacy training

INTRODUCTION

The impact of depression on the Australian community is well established. Approximately 700,000 adults experience major depression each year (Australian Bureau of Statistics, 2007), with signifi cant individual distress and fi nancial cost. In addition, there are signifi cant hidden costs of mental illness for the individual and the com- munity (Hickie, Groom, & Davenport, 2004). Whilst the prevalence of major depression may not differ signifi cantly between urban and rural Australia, the experience of depression in rural Australia may differ and its impact may be greater compared to major cities (Judd et al., 2002). The social, emotional and fi nancial impact of mental illness in small regional communities can be dev- astating (Judd, Cooper, Fraser, & Davis, 2006). A number of factors may contribute to this includ- ing access to fewer health practitioners (Australian Institute of Health and Welfare, 2010), being less likely to be treated by a GP for psychological problems (Caldwell et al., 2004), having lower mental health literacy (Griffi ths, Christensen, & Jorm, 2010) and more social visibility with greater chance of confi dentiality breaches than

major city dwellers. Some groups in rural com- munities may be impacted upon more than oth- ers by urban–rural differences, including young people experiencing mental illness who can be emotionally isolated and more diffi cult to access (Fullagar, Gilchrist, & Sullivan, 2007).

Active help seeking behaviour and severity of suicidal ideation may have an inverse relationship (Wilson, Deane, & Ciarrochi, 2005; Wilson, Deane, Marshall, & Dalley, 2010). Wilson et al. (2005) found that the greater an adolescent’s suicidal ideation, the less intention to seek help, highlighting the increased risk to young people who experience depression and develop suicidal tendencies. In addition, community surveys have identifi ed that people have diffi culty recognizing mental disorders correctly (Jorm, 2000). These observations combined with the substantial num- bers of individuals experiencing depression, sup- port the need to develop effective strategies to promote mental health literacy and support posi- tive initiatives to address mental ill health, espe- cially in rural communities.

A range of strategies have been employed in the wider community in response to the burden of

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and potential impact on their local community are considered. Findings from a rural commu- nity mental health literacy program will also be reported in the context of such assumptions.

Mental health literacy initiatives A number of initiatives to promote mental health literacy have been undertaken and reported in the literature (Francis, Pirkis, Dunt, Blood, & Davis, 2002). Lack of information on mental health prob- lems among the general population has been a key driver in the development of such programs (Jorm, 2000). One such initiative, undertaken in Australia since 2000, is MHFA which provides mental health training to individuals, typically in a group setting. MHFA training aims to promote non-judgmental listening, to provide support, to encourage help- seeking and appropriate self-help strategies and to assess self harm risk (Kitchener & Jorm, 2002). Participants are informed about the prevalence of mental health issues, the signifi cant features of depression, anxiety and schizophrenia and the evidence-supported treatments for these conditions (Jorm, Kitchener, Kanowski, & Kelly, 2007)

Assumptions of mental health literacy initiatives A number of implicit and explicit assumptions (common understandings) associated with com- munity mental health literacy programs may be identifi ed. This paper explores, the empirical sup- port for four assumptions identifi ed from the liter- ature. It further explores these assumptions in the context of a project that offered MHFA in a rural setting. The four assumptions to be discussed are:

Assumption 1: Individuals who undertake men- tal health literacy training, will increase their knowledge of mental ill health (Jorm, Kitchener, O’Kearney, & Dear, 2004; O’Reilly, Bell, Kelly, & Chen, 2011; Pierce, Liaw, Dobell, & Anderson, 2010).

Assumption 2: Individuals who undertake mental health literacy training, in addition to increased knowledge of mental ill health, will develop increased confi dence to help someone experiencing mental ill health (Jorm et al., 2004; Jorm, Kitchener, Fischer, & Cvetkovski, 2010;

depressive illness. These have included enhanced access to psychological services through pub- lic funding, including the Australian Medicare funded Better Access program (Department of Health and Ageing, n.d.; Pirkis et al., 2011), where Australian residents may access subsidized treatment by appropriate mental health profes- sionals; and media and community initiatives that promote increased awareness of depression such as those undertaken by beyondblue, the Australian national depression initiative1. In addition, tar- geted local programs to address mental health lit- eracy have been suggested. An Australian Senate Select Committee has supported the use of men- tal health fi rst aid (MHFA) to address mental ill health in the community, recommending that 6% of the population be trained in MHFA, with spe- cifi c focus on groups that commonly interact with those experiencing mental health issues including teachers, police, welfare workers, and family car- ers (Senate Select Committee on Mental Health, 2006). The use of MHFA to address mental health literacy has been reported in a number of rural set- tings (Hossain, Gorman, Eley, & Coutts, 2010; Jorm & Kelly, 2007; Kitchener & Jorm, 2006).

Most strategies directly target the immediate recipient, such as the individual who accesses psy- chological services or the person who sees a media advertisement. Whilst there may be some second- ary gain for the community, the primary target remains the individual experiencing the diffi cul- ties. Training individuals in mental health literacy may assist those individuals by increasing their knowledge of depression. However, if the train- ing also increases their confi dence to assist others experiencing depression, benefi t beyond the indi- vidual being trained may occur.

Mental health literacy is important. A range of initiatives to improve mental health literacy in the community have been reported but few have explored the impact beyond the initial train- ing. This paper will explore assumptions that may underpin these mental health literacy pro- grams where both the individual being trained

1 beyondblue is a not for profi t organization which has undertaken programs to promote positive community responses to depression and related disorders.

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and netball clubs. In both phases, coaches and other club leaders were recruited to mental health literacy training through the internal communica- tion networks of participating sports clubs, and not on his or her community role.

The impact of both phases of the project was assessed using mixed research methods, including pre–post measures. The method has been previ- ously reported in detail (Pierce et al., 2010); a brief summary follows.

Participants completed a pre-training and 6 months post-training questionnaire measuring ability to recognise depression and schizophrenia from a brief clinical scenario, knowledge of treat- ment options, and both attitudes and confi dence to respond to mental health diffi culties in others. This was supplemented by focus group interviews investigating participants’ experience of mental health literacy training, their knowledge and atti- tudes towards mental health issues and the overall impact of the training upon their club. Interviews of key project stakeholders were undertaken at the end of the project. Measures of football club play- ers’ attitudes to depression and treatment options were undertaken in phase I using a self-completed questionnaire.

Both phases of the project received ethics approval (HREC 0710100) from The University of Melbourne. Participant consent in writing was obtained before data collection commenced. Data analysis used Wilcoxon signed rank test or Sign Test as a measure of signifi cance. Statistical sig- nifi cance was set at p < 0.05. Interview data were transcribed verbatim, with each entire interview read and re-read by both researchers to identify recurring themes. Emerging from this was much information about participants’ experiences, attitudes and expectations. Analysis focused on individual participants’ personal experience of the mental health literacy training, their experi- ence following the training and refl ections on the potential for and any identifi ed benefi ts of the training to the local community.

FINDINGS Participant demographics One hundred and sixty-two individuals under- took the training. Pre-training questionnaire data

Jorm, Kitchener, & Mugford, 2005; Kitchener & Jorm, 2002).

Assumption 3: Individuals trained in men- tal health literacy will report less stigma and prejudice towards those experiencing men- tal ill health (Jorm et al., 2004, 2005; Jorm, Kitchener, Fischer, et al., 2010; Kitchener & Jorm, 2002).

Assumption 4: Individuals trained in mental health literacy will use their mental health skills to help others who are experiencing men- tal ill health (Jorm & Kelly, 2007; Jorm et al., 2004; Kitchener & Jorm, 2004).

Assumptions 1 and 3 focus on the individual being trained. Assumptions 2 and 4 suggest that community mental health education programs, in addition to benefi ting individuals who are trained in mental health literacy will also benefi t mem- bers of their immediate community. The evidence for these four assumptions, both from the existing literature and a rural mental health literacy initia- tive will now be considered.

METHOD A community mental health literacy initiative was undertaken in rural Victorian football/netball clubs involving the training of sports team coaches and other club leaders in MHFA. It was undertaken in two phases during 2007–2009. Limited fi nd- ings from phase I have been previously reported (Pierce et al., 2010). Additional fi ndings from phase II and fi ndings of combined phase I and II data are now reported. The project used a key social structure of many rural communities, the local football club, as the conduit to increase men- tal health information and support to rural com- munities (Pierce et al., 2010). Sports clubs were felt to offer an important opportunity to access, among others, young rural males, a group who may not be readily reached through mental health literacy initiatives (Frey & Eitzen, 1991). Leaders within these football clubs were considered to be in positions that might allow the opportunity to help individuals with mental health related prob- lems. Phase II built on the experience of phase I and involved a wider group of rural football clubs

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training are reported in Table 1. Matched pairs (pre–post data) were used to calculate signifi cance of change.

A signifi cantly greater number of individuals correctly identifi ed depression and psychosis from brief vignettes of a young person presenting with these conditions following training. More partici- pants indicated that it would be helpful for Mary (experiencing depression) to receive antidepressant medication and for John (experiencing psychosis) to receive antipsychotic medication following training than before. Most participants (≥ 75%) expressed the view, before and after the train- ing, that help from GPs, Clinical Psychologists, Counsellors, Social Workers, Telephone Counselling, close family and friends, would be helpful for Mary and John. Physical activity, socialization, relaxation and self help books were also nominated by the majority of participants before training as being helpful for both Mary and John, and support for these activities did not alter after mental health literacy training.

The view that mental health literacy training increased participants’ mental health knowledge was supported by a number of those interviewed, as illustrated below:

I have enjoyed it. I have actually learnt some- thing out of it … I think it has opened my eyes I didn’t realise it was such a big problem till actually you see the facts and fi gures … It was good. (Participant AC)

Knowledge acquired from training may not just be factual information about depression but

were available from most participants (N = 150, 93%) and follow-up data from one in four par- ticipants (N = 39, 25%). A similarly low return rate of follow-up data was found in both project phases.

To preserve participants’ confi dentiality, follow up questionnaires were administered by club offi - cials with researchers unable to access participants directly. No consistent differences, however, in cohort characteristics were found between those returning and those not returning follow-up questionnaires.

One in three participants was female (N = 53, 35%) with a mean age of 42 years (SD = 11.3). More than half had undergone post-secondary education including a trade apprenticeship or university degree (N = 97, 67%). One in fi ve participants was considered likely to have pro- fessional contact working either as a health pro- fessional, educator or law enforcement offi cer (N = 30, 20%). Over both phases of the project, one in six participants (N = 26, 17%) completed an individual or focus group interview.

Data from the two phases of the study will now be presented as they relate to each of the four assumptions.

Assumption one: Increased knowledge Individuals, who undertook the mental health literacy training and who responded to the fol- low-up questionnaire, increased their knowledge of mental ill health symptoms and available treat- ments. Ability to recognize a depression scenario and a schizophrenia scenario before and after the

TABLE 1: NUMBERS TRAINED IN MHFA WHO CORRECTLY IDENTIFIED DEPRESSION AND SCHIZOPHRENIA/PSYCHOSIS VIGNETTES AND HELPFUL TREATMENT OPTIONS

Before MHFA training

After MHFA training

Signifi cance (matched pre–post pairs)**

Vignette Depression (Mary) 110/150 (73%) 36/39 (92%) z = −2.72, p = 0.007 Psychosis (John) 53/150 (35%) 30/39 (77%) z = −2.98, p = 0.003 Treatments Anti-depressant medication (depression vignette) 87/144 (58%)* 32/37 (82%)* z = −3.17, p = 0.002 Electroconvulsive therapy (depression vignette) 11/134 (7%)* 14/37 (38%)* z = −2.12, p = 0.034 Anti psychotic medication (psychosis vignette) 71/140 (51%)* 36/37 (97%)* z = −3.74, p < 0.001

*Variations in total numbers refl ect individuals not responding to specifi c questions; **Wilcoxon signed rank test.

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Assumption three: Decreased stigma Mental health literacy and mental health stigma are linked (Griffi ths, Christensen, & Jorm, 2008) – those offering mental health literacy training may hope that with increased participant knowledge and enhanced confi dence stigma and prejudice toward those experiencing mental ill health would decrease. In the research reported in this paper participants’ willingness to have someone with a mental illness in their life was used as a proxy indicator of mental ill health stigma. Findings of change in stigma fol- lowing mental health literacy training are reported in Table 2.

Overall, following the training there was greater social acceptance of both Mary (experiencing depression) and John (experiencing schizophrenia) to either move next door or to marry into one’s family. Despite this increase, one in four partici- pants remained unwilling to have John move next door and two in four remained unwilling to have him marry into the family. There was no signifi - cant difference between participants’ responses pre and post training on spending an evening social- izing with either Mary or John or working as close colleagues. Most participants indicated their will- ingness to involve Mary and John in social activi- ties and have them as a work colleague (N = 35/38, 92% and N = 32/37, 87% respectively).

Assumption four: Transfer of training benefi t to others Limited evidence was found for an increase in the number of participants who, following mental

health literacy training, reported using their newly acquired skills to help oth- ers who were experiencing mental ill health. Pre–post matched data from 39 participants indicated that contact with a person who experienced mental ill health did not differ sig- nifi cantly from pre train- ing to post training (64 and 72% respectively), z = −0.905, p = 0.37. Some participants (N = 16,

have an applied aspect to it, recognizing the ben- efi ts of early identifi cation of mental ill health.

Identifying [mental ill heath], being able to identify, that is the key thing. I think sometimes we identify things too late. (Participant GK)

Assumption two: Increased confi dence In addition to increased knowledge of depression and psychosis, participants’ confi dence to help others experiencing mental ill health improved. Data from participants, from whom paired pre– post questionnaires were available, showed signifi - cant increase in confi dence. Pre-training responses indicated that half of the participants (N = 20/39, 51%) felt ‘not at all confi dent’ or ‘a little bit con- fi dent’ to help someone experiencing mental ill health. Following – training, most participants (N = 35/39, 90%) indicated that they felt ‘moder- ately confi dent’ or ‘quite a bit confi dent’ that they could help someone who was experiencing mental ill health, z = −3.98, p < 0.001.

This increased sense of confi dence was expressed by participants during the focus groups:

Yes certainly it [the mental health literacy training] gave me a lot more confi dence in my understanding and knowledge but also how to approach the situation with a netballer in particular. So by having these little acronyms and warning signs so we can identify things early and hopefully we can stop some of the issues from getting worse in the fi rst place. (Participant GK)

TABLE 2: WILLINGNESS TO HAVE MARY (DEPRESSION) AND JOHN (SCHIZOPHRENIA) INVOLVED IN PARTICIPANTS’ LIVES BEFORE AND AFTER MHFA TRAINING

Before MHFA training

After MHFA training

Signifi cance (matched pre–post pairs)**

Depression vignette Moving next door 114/149 (76%)* 36/39 (92%) z = −3.26, p = 0.001 As a friend 142/150 (95%) 38/39 (97%) z = −2.07, p = 0.039 Marry into your family 102/147 (69%)* 31/38 (82%)* z = −3.00, p = 0.003 Psychosis vignette Moving next door 86/149 (58%)* 27/37 (73%)* z = −2.22, p = 0.027 Marry into the family 59/146 (40%)* 19/37 (51%)* z = −2.56, p = 0.01

*Variations in total numbers refl ect individuals not responding to specifi c questions; **Wilcoxon signed rank test.

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Similarly, data from both phases of the men- tal health literacy program reported in this paper support the existing literature (Jorm et al., 2005; Kitchener & Jorm, 2002) that those undertak- ing mental health literacy training will develop increased confi dence in their capacity to help others who experience mental ill health. As with change in knowledge, individual’s confi dence was measured using a pre–post (training) approach. In phase I of the mental health literacy project discussed in this paper it has previously been reported that following training two out of three people reported increased confi dence in their capacity to help someone with a mental health problem (Pierce et al., 2010). The second assumption, that those undertaking mental health literacy training, in addition to an increased knowledge of depression and psychosis, will report increased confi dence to help someone experiencing mental ill health, is also supported.

The link between greater knowledge of mental ill health, in particular depression, and lower levels of personal stigma has been previously reported in the literature (Griffi ths et al., 2008). Specifi cally, individuals trained in mental health literacy express less stigma and prejudice towards those experienc- ing mental ill health (Jorm et al., 2005; Kitchener & Jorm, 2002). The combined fi ndings of phase I & II of the community program reported in this paper further support the existing literature, with those trained in mental health literacy reporting increased willingness to have a person experiencing depression or psychosis living next door or marry- ing into their family. Despite reduction in stigma refl ected in increased willingness of participants to have someone with schizophrenia move next door or marry into the family, schizophrenia continued to be associated with greater stigma than depres- sion. Although, the third assumption, that those trained in mental health literacy will express less stigma and prejudice towards others experiencing mental ill health, was supported by the research reported in this paper, mental health literacy initia- tives may require specifi c focus to address the preju- dice directed toward those experiencing psychosis.

The fourth assumption, that those trained in mental health literacy will use their newly acquired skills to help others who are experiencing mental ill health, is more problematic. From the existing

41%) reported, prior to training, that they had offered help to someone with a mental health prob- lem. Following training more participants (N = 29, 75%), provided help, z = −1.31, p = 0.19. Change in behaviour among some participants may be con- trasted with focus group fi ndings, with participants’ reporting expectation of providing help to those in need that was not necessarily readily fulfi lled.

I would have thought my personal view is they might have come to someone like us because I think they would have had confi dence that we have done the training. (Participant JL)

However, this expectation was not always trans- lated into practice in post-training experience.

No, no I didn’t use any of it at the Club I sup- pose it can only be used when someone needs the help and when someone approaches you and these kinds of things and we didn’t really have anything happening at the Club or no one came to me for support or anything like that as well. (Participant SD)

DISCUSSION Poor mental health literacy has been identifi ed as a signifi cant health issue especially in rural com- munities (Griffi ths et al., 2009). The research reported in this paper supports the view that participants, as individuals, benefi t from mental health literacy training through enhanced knowl- edge and confi dence. The question of benefi t to others from mental health literacy training requires further consideration.

The fi ndings of phase 1 and 2 of the community mental health literacy program reported in this paper are consistent with the existing literature, (Jorm et al., 2004; Lam, Jorm, & Wong, 2010; Pierce et al., 2010) that those completing the training increase their knowledge of mental ill health. Pre–post (training) measures suggest an increased capacity to recognise common mental health problems, specifi - cally depression and psychosis, from a brief clinical vignette. Participants’ knowledge of evidence sup- ported treatments for depression and psychosis also improved. The fi rst assumption, that those undertak- ing mental health literacy training will increase their knowledge of mental ill health, especially depression and psychosis, was supported by this research.

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students increasing their understanding of mental ill health, but may not necessarily increase teach- ers’ individual support for students experiencing mental health problems (Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010). In this study the stu- dents gained mental health information through their teachers suggesting that a passive transfer of knowledge occurred, but it did not translate into active help for individual students experiencing mental health problems (Jorm, Kitchener, Sawyer, et al., 2010). For others, not in the obvious lead- ership role of a teacher, opportunities to share knowledge and the benefi ts of increased confi dence may only come with a more purposeful approach to their social interactions. Individuals trained in mental health literacy can actively or passively share the benefi t of their training to others. This may in a be structured or unstructured setting, see Table 3.

The interaction between a person trained in Mental Health Literacy and another person may vary and include two distinct types, active and pas- sive. In addition the context of that interaction may be in a structured or unstructured environment.

Variations in potential transfer of training benefi t to others Transfer of the benefi t of mental health literacy training to others can be passive or active and occur in structured or unstructured social interactions. The least formal transfer of benefi t may occur as knowledge and/or expression of confi dence and less stigmatising attitudes are communicated to others by the trained individual during day-to-day social interactions that do not exist for the specifi c purpose of sharing the benefi ts of training.

literature and the research reported in this paper there is limited evidence to support this assump- tion. Therefore, it is not as well established as the other three assumptions. Transfer to others of the benefi t from mental health literacy training may occur through communication of newly acquired knowledge, sharing of changed attitudes or assis- tance to support a person experiencing mental ill health. Evidence to support the fourth assumption is diffi cult to obtain. Ideally it should include infor- mation from those who come into contact with trained individuals and determine if they received benefi t or not. Participant (trained individuals) self-report data may also be valuable. The fi rst three assumptions may be regarded as refl ecting change that is internal to participants, their skills, their confi dence and their attitudes especially stigma and prejudice. The potential benefi t of mental health literacy training identifi ed in the fourth assumption may start as an internal change in those completing training, but if this internal change is to result in benefi t to others, it needs to operate beyond the individual who has received mental health literacy training. Benefi t to others may be passed on passively (e.g., as part of routine social interaction) or actively (e.g., as part of a purpose- ful interaction). Identifying such a benefi t requires measures that are external to the trained individual. Some leaders, such as teachers, sports club coaches, community leaders and workplace leaders may have more opportunity than others within their profes- sional role to apply newly acquired knowledge and demonstrate increased confi dence (Bapat, Jorm, & Lawrence, 2009; Hossain et al., 2010). Educating teachers in mental health literacy may result in

TABLE 3: BENEFITS OF TRAINING TO OTHERS FROM THOSE TRAINED IN MENTAL HEALTH LITERACY PROGRAMS

Type of interaction Context of interaction

Structured Unstructured

Active Providing information and support to those experiencing mental health diffi culties through organized pathways, (e.g., organised pathway to obtain mental health assistance)

The trained individual empowers others experiencing mental health diffi culties to seek professional support (e.g., promotes behaviour change in social contacts)

Passive Providing and or promoting information/ positive attitudes through structured meetings, (e.g., workshop promoting mental health issues)

Providing information (knowledge) and positive attitudes in normal social interactions, (e.g., sharing information of what was learned in MH training with friends)

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been reported with MHFA training (Pierce et al., 2010). This study noted the sense of empower- ment experienced by those undertaking training. This might be seen as a key component in promot- ing support of others following training.

Developing approaches during mental health literacy training to assist others after completion of that training, may enable greater opportunity to assess the impact of such assistance thereby making it possible to validate assumption four. Future research in this area following training with a well established mental health literacy approach such as MHFA is desirable. This would require not only consideration of relevant approaches for the communities in which those trained are active but also methods to assess the experience of individuals that the trained come in contact with. Structured contacts will be more readily investigated than unstructured and may be an appropriate starting point for such research.

Study limitations This study was undertaken in a rural and regional area and its fi ndings may not be immediately applicable to other areas. In addition, the study was limited by the low return rate of the post training questionnaires. It was not possible to ascertain the reasons for the low return rate. Similar diffi culties in the return rate of question- naires have been reported by other researchers in this fi eld (Kelly et al., 2011). However, as noted above no clear demographic differences were found between those responding to the follow-up questionnaire and those not responding.

CONCLUSIONS In this paper the underlying assumptions behind mental health literacy programs, have been con- sidered in the context of a rural program. The assumptions that mental health literacy training will increase participant mental health knowl- edge, increase confi dence in responding to mental ill health in others and diminish stigmatizing atti- tudes towards those experiencing mental ill health were supported. The assumption that those who interact with individuals trained in mental health literacy readily benefi t from this training, is not strongly supported. An approach to understand the mechanism that may enhance the benefi t in

More formal transfer of benefi t from training may occur if similar sharing of knowledge or atti- tudes occurs in a more structured setting such as a mental health information meeting. Whilst the setting is structured, this interaction might be regarded as passive refl ecting the recipient’s posi- tion as a listener without necessarily having direct interaction with the person trained in mental health literacy. A comparable situation may be when the interaction is active but the setting unstructured such as when a trained individual feels enthused by their new knowledge and changed attitudes and purposefully seeks to communicate these in common day-to-day life settings that are not set up specifi cally for the purpose. Individuals have been reported to engage differently with those experiencing mental ill health following mental health literacy training (Hossain et al., 2010).

The most formal transfer of benefi t may occur when the setting is structured and the interac- tion active such as when an individual trained in mental health literacy directly engages with oth- ers in need of mental health assistance through a structure designed for that purpose. This might include providing support for a person to seek professional help following contact through an identifi ed trained person, who is the mental health contact in an organization.

Promoting the development, during mental health literacy training, of mechanisms to facilitate transfer of benefi t to others after completion of training may enhance the impact of such programs. Selections from the range of mechanisms described in Table 3 that are applicable to participants’ cir- cumstances should be encouraged. In most situ- ations the least formal approach of sharing new knowledge and changed attitudes in normal social interaction is likely to be appropriate. For organisa- tions, the most formal approach including setting up a structure to promote support of those experi- encing mental health diffi culties by those trained may be more appropriate. Following mental health literacy training this might include non-trained members of the organization being made aware both of those trained and/or of a pathway to seek help and support that minimizes the barriers of embarrassment and potential lack of anonymity. Limited use of a number of these approaches has

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Jorm, A., Kitchener, B., Sawyer, M., Scales, H., & Cvetkovski, S. (2010). Mental health fi rst aid training for high school teachers: A cluster randomized trial. Bio Medical Central Psychiatry, 10, 51.

Judd, F., Cooper, A., Fraser, C., & Davis, J. (2006). Rural suicide – People or place effects? Australian & New Zealand Journal of Psychiatry, 40, 208–216.

Judd, F., Jackson, H., Komiti, A., Murray, G., Hodgins, G., & Fraser, C. (2002). High prevalence disorders in urban and rural communities. Australian & New Zealand Journal of Psychiatry, 36, 104–113.

Kelly, C., Mithen, J., Fischer, J., Kitchener, B., Jorm, A., Lowe, A., et al. (2011). Youth mental health fi rst aid: A description of the program and an initial evaluation. International Journal of Mental Health Systems, 5, 4.

Kitchener, B., & Jorm, A. (2002). Mental health fi rst aid training for the public: Evaluation of effects on knowledge, attitudes and helping behavior. Bio Medical Central Psychiatry, 2, 10.

others from training individuals in mental health literacy, such as through MHFA, has been dis- cussed along with the diffi culties in measuring any such benefi ts. Further research should be under- taken to determine the most effective approaches to support and measure potential benefi t in others from mental health literacy programs undertaken by individuals.

ACKNOWLEDGEMENT The funding support of beyondblue for this research is gratefully acknowledged.

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Received 11 January 2012 Accepted 09 April 2012

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N O W A V A I L A B L E RURAL MENTAL HEALTH

A special issue of Rural Society – Volume 19 Issue 4 – ii+94 pages – ISBN 978-1-921348-22-8 – December 2009 Editors: Darryl Maybery (Monash University, VIC), Grace Brown (Monash University, VIC), Richard Pugh

(Keele University, UK) and Emilia E Martinez-Brawley (Arizona State University, USA)

Editorial: Rural mental health: Published in collaboration with the Australian Association of Social Workers – Darryl Maybery, Grace Brown, Emilia E Martinez-Brawley and Richard Pugh Commentaries The future for rural social work in China – Bin Xu Social work and rural mental health in the UK – Richard Pugh ‘The World is Flat’: Is rural social work fl attening too? – Emilia E Martinez-Brawley The future for social work and mental health in rural and northern Canada – Ralph Bodor Ensuring the future of rural social work in Australia – Grace Brown and Rosemary Green Research reports Improving the mental health of drought affected communities: An Australian model – Anne Tonna, Brian Kelly, Judith Crockett, Richard Buss, Russell Roberts, Murray Wright and Julie Greig

Families on the fringe: Mental health implications of the movement of young families to non-metropolitan areas – Margot Rawsthorne, Wendy Hillman and Karen Healy Understanding resilience in South Australian farm families – Jennene Greenhill, Debra King, Anna Lane and Colin MacDougall Resilience and wellbeing of small inland communities: Community assets as key determinants – Darryl Maybery, Rodney Pope, Gene Hodgins, Yvonne Hitchenor and Amanda Shepherd Enduring drought then coping with climate change: Lived experience and local resolve in rural mental health – Deb Anderson Conceptualising the mental health of rural women: A social work and health promotion perspective – Desley Harvey Practice note: Using the media to enhance wellbeing and mental health – Sarah Melinda Dobie Buila Epilogue: Rural mental health and rural social work – Bob Lonne Book review: The house on the hill: The transformation of Australia’s farming communities – Neil Barr – Reviewed by Ingrid Muenstermann

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MENTAL HEALTH AND ILLNESS: PRACTICE AND SERVICE ISSUES A special issue of Health Sociology Review – Volume 20 Issue 2 – 144 pages – ISBN 978‐1‐921348‐57‐0 – June 2011

Editors: Anne-Maree Sawyer, Pauline Savy and Katy Richmond (La Trobe University, Melbourne VIC) Introduction: Translating mental health policy into practice: Ongoing challenges and frustrations – Anne-Maree Sawyer The hegemony of cognitive-behaviour therapy in modern mental health care – David Pilgrim Towards an integrated model of practice evaluation balancing accountability, critical knowledge and developmental perspectives – Paul Stepney and Ilmari Rostila The dodo bird verdict and the elephant in the room: A service user-led investigation of crisis resolution and home treatment – Hugh Middleton, Rebecca Shaw, Ron Collier, Aimie Purser and Brian Ferguson The slide to pragmatism: A values-based understanding of ‘dangerous’ personality disorders – Susie Scott, Debbie Jones, Rachel Ballinger, Gillian Bendelow and Bill Fulford Encounters with the ‘dark side’: New graduate nurses’ experiences in a mental health service – Michael Hazelton, Rachel Rossiter, Ellen Sinclair and Peter Morrall

‘Having those conversations’: The politics of risk in peer support practice – Anne Scott, Carolyn Doughty and Kahi Hamuera Medicalisation or under-treatment? Psychotropic medication use by elderly people in New Zealand – Pauline Norris, Simon Horsburgh, Kirsten Lovelock, Gordon Becket, Shirley Keown, Bruce Arroll, Jackie Cumming, Peter Herbison and Peter Crampton The origins of a New Zealand suicidal cohort: 1970-2007 – Cate Curtis and Bruce Curtis

Summary: Broadening the evidence base of mental health policy and practice – Lisa Brophy, Pauline Savy

Book review: The Autism Matrix – Gil Eyal, Brendan Hart, Emine Onculer, Neta Oren, and Natasha Rossi – Reviewed by M Ariel Cascio

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