Talking to someone about self-injury can be difficult and overwhelming. Remember that the person you are approaching is trying the best they can to manage their situation, and probably feel bad about what they have done, and worried about other people’s reactions. In the clip, Debbie’s Coach notices her move to conceal fresh injuries and responds immediately. If you think someone is injuring themselves, and that you are the right person to approach them, it’s important to ask directly. The Coach asks “Is everything ok? Have you hurt yourself? I can take a look if you like?” Debbie responds plainly and simply, “it’s nothing.” Just as plainly, the coach responds that he only wants to help and is concerned. An important thing to note is his use of “I” statements instead of “You” statements. “I’m not meaning to make you feel uncomfortable Debbie,” he says. Debbie’s response, “It’s ok”, allows him further opportunity to express his concerns. “It’s just, some of those scars look fresh… It’s my job to make sure you’re ok Debbie. I’m not just a laugh-a-minute super talented footie Coach y’know? I’m also an employee of the Universe, and I have a duty of care to you.” Thanks to the comfortable and non-judgmental tone that has been struck by the Coach, Debbie laughs and seems to relax (Make sure to be aware of what body language is saying and whether the other person is comfortable for you to continue). MHFA Tip for approaching someone about NSSI  You should discuss your concerns with the person in a private place. Be supportive without being permissive of the behaviour. Use a calm voice when you are talking and try not to express anger or a desire to punish the person for self-injuring. Take all self-injury seriously, let the person know you are concerned and want to help them to reduce their distress. Be considerate of cultural differences and context and support the person to make their own decisions to stay safe in a way that they are comfortable with.

Now feeling like she’s in a safe environment to talk, Debbie opens up about how she’s been feeling.

“I guess I haven’t been feeling myself lately. I don’t know what it is, but it’s like I feel disconnected from stuff – like I’m on the outside looking in – it’s hard to explain.”

Keep in mind that ‘stopping self-injury’ is not the focus of the Coach’s follow-ups. Instead, he goes on to ask questions about what can be done to make Debbie’s life more manageable and find out how her environment can be made less stressful in a way that fits for her.

“When was the last time you went back home?”, the Coach asks.

“To Country? Not for months… It’s like, the longer I stay away from family the less connected I feel to community,” Debbie says.

The Coach proceeds, “Have you thought about joining any Indigenous groups on campus?”

“I went a couple of times with my girlfriend, but it’s not the same you know? It’s not family.”

“Yeah, it must be tough… Have you spoken to your girlfriend about how you’re feeling?

“She’s got enough to worry about, I don’t want to add to that.”

Hearing what she has said, the Coach asks Debbie if she thinks all the feelings she’s been hiding have contributed to her self-harm.

“Do you think that’s why you cut yourself… because you haven’t been home. Because you feel so isolated at the moment?”, he asks.

“I don’t know, it makes me feel in control y’know. Like, if I can’t control anything in my life right now. At least I can control this,” Debbie admits.

The Coach then supports Debbie by most importantly not expressing any judgement, but in fact agreeing that her emotions are appropriate and valid, “Makes sense.”

MHFA Tips for what to avoid when talking with someone about NSSI

• Minimising their feelings or problems
• Using statements that don’t take the person’s pain seriously, e.g “But you’ve got a great life!” or “Things aren’t that bad”
• Offering drugs, prescription pills or alcohol to the person
• Accusing the person of attention-seeking
• Giving the person ultimatums, e.g. “If you don’t stop self-injuring you’ll have to move out”
• Using terms such as ‘cutter’, or ‘self-injurer’ to refer to the person
• Gossip or talking to others about the person’s self-injury without their permission
• Trying to solve the person’s problems for them
• Making the person feel guilty about the effect their self-injury is having on others

Using shame to change the person’s behaviour

When confronted with the idea of seeking outside help, Debbie responds “I feel shame alright.” Many people who engage in NSSI may choose not to seek help for fear of judgement and stigma. This fear is especially heightened for Aboriginal and Torres Strait Islander people who may feel ‘shame’. Taking in everything she has said about how she feels, the Coach does not put any pressure on Debbie to make a decision. Instead, he tells her that no matter what, she is in control. “I think if you talk to someone Debbie, you might just start to realise how much control you have over your life, even though I know it doesn’t feel like it right now,” he says. “I don’t know, I’ve never really been good about that y’know – Talking about my feelings…” But Debbie pauses and finally says “I’ll think about it.” The feeling of Shame (From Mental Health First Aid for Aboriginal and Torres Strait Islander People course) The feeling of ‘shame’ for an Aboriginal or Torres Strait Islander person is not easily defined and is different to the definition you might find in a dictionary. Shame can occur when a person is singled out or in a circumstance that directly targets a person’s dignity. Shame may be felt as a result of:

• Feeling disrespected by others
• Embarrassment
• Lack of respect or rudeness from others
• Being the focus of attention, even for positive achievements
• A breach of accepted ‘norms’ or taboos

A ‘shame job’ is an event that causes a person shame or embarrassment. The concept of shame is very important within many Aboriginal and Torres Strait Islander communities. Shame can be overwhelming, disempowering and can also act as a barrier to seeking support. Cultural context is important; Remember that your interpretation of what is happening for the person may be different to what is happening within their cultural context. Consider the potential for difference and have discussions in a respectful way.

At lunch Tom says he doesn’t have much of an appetite and that he “thinks [he’s] coming down with something.” 

Gav responds and says, “Well you’re tired, you’ve got a loss of appetite, maybe you should go see a doctor.” 

Tom immediately responds and says, “Doctors are useless,” as his most recent visit had sent him home with a simple prescription for “more vitamin D.” 

It’s not uncommon for those who experience mental health problems to have already seen a doctor and perhaps had a negative experience that has further frustrated their situation. 

Tom may have been unable to communicate his emotional and physical symptoms at the time or possibly downplayed the extent of how he’d been feeling.  

Gav doesn’t argue with Tom, he allows him to further voice his frustration.  

“It’s really frustrating, I know I’m late for work a lot but sometimes the thought of getting out of bed sort of paralyses me. I mean I’m afraid it’s actually gonna get to the point where I can’t leave the house to even be late for work,” Tom says. 

Anxiety at the thought of getting up can be an indication that someone is suffering from a mental health problem, and Gav doesn’t waste the opportunity to suggest a further visit to the GP. 

“Maybe you should see the Doctor again… Maybe it’s not something physical, maybe you’re depressed,” Gav says. 

At the mention of depression though, Tom shuts down and says he thinks they should go back to work. Gav doesn’t push the subject, but makes it clear he is “only trying to help” and accompanies Tom back to the office. 

A crucial element of providing Mental Health First Aid is knowing when to be gently persistent and when to step back from the conversation. As MHFAiders we respect a person’s right to talk and seek help on their own timeline – unless you believe they are at risk to themselves or others. 

Gav’s patience and understanding means he’s able to pick up the conversation again and Tom can feel safe knowing he won’t be forced to talk about anything he doesn’t want to. 

MHFA Tips for creating a safe space  When supporting a colleague, it’s important to consider who else might be around and to take measures to increase privacy. In this instance, Gav decides to take Tom out of the office, alleviating any stress that another co-worker could overhear, interrupt, or cause distractions. 

After allowing some time for Tom to feel more comfortable, Gav makes an opportunity to continue their conversation and asks to chat with him privately. Gav has also had time to think about ways he can provide further support and decides to share a story of lived experience from within his own family.  “Did I ever tell you about my brother Damian?… He suffered from depression” Gav says.  Tom replies, still guarded, “He seemed ok to me.”  “I mean he is now, but a few years ago his life was falling apart; his girlfriend left him, he didn’t pay rent and got kicked out of his house…  His life was falling apart, and it wasn’t because he wasn’t getting enough sun. He was diagnosed with depression.”  Tom continues to push back and says that Damian’s experiences aren’t relevant to him, but Gav gently persists and links back to what he has heard Tom say (drawing some direct parallels that can’t be ignored).  “Look Damian was feeling tired all the time too. He was having trouble concentrating, he wasn’t eating and kept making excuses for not getting things done,” he says.  Tom acknowledges the similarities in what Gav is saying and it starts to become clearer and easier for him to put his true feelings into words.  “Sounds like what’s happening to me,” Tom says.  MHFA Tips for providing ongoing Mental Health First Aid  Effective Mental Health First Aid conversations can happen in the span of 10-minutes, or they can occur over weeks and months of providing support.  If you are concerned about someone, it’s important to follow up any mental health first aid conversations you feel may be incomplete. 

After Tom admits to recognising himself in Damian’s behaviour, Gav re-introduces the thought of seeking professional help.  “It can be hard to let people know what’s going on. I’m glad you are talking to me now, I wonder if you just told the GP what you’ve told me,” he says.  “It’s important to let the GP know what has changed for you, and what is most hard at the moment.”  However, even after acknowledging the potential origin of his symptoms, Tom continues to be hesitant about seeking further help. It becomes clear that he is holding on to some stigmas surrounding mental health and fears the impact a diagnosis could have on his life.  “The minute I tell someone I’m suffering from a mental illness; I mean they’ll fire me. Why would they want someone depressed working for ‘em?…  I know what happens when people have thoughts like this, they just lock you up and they throw away the key,” Tom says.  Gav responds, and says “That’s not true, it’s different for every person. This is why you need to talk to a mental health professional, because they can help you and work out what you need. They can get you back to your old self.”  MHFA Tips for treating every Mental Health Conversation as unique  Re-examine the video from 1.34 onwards and see how Gav manages to use some humour to make Tom feel more comfortable.  He talks to him like a real friend, on his level, and uses language he knows Tom will respond to – “I mean you’re not crazy alright. You’re annoying, a bit arrogant. But you’re not crazy.”  Mental Health First Aid conversations are not “one size fits all.” While there are steps to follow, and best-practice advice for providing support, you are still supporting a human being.   We are all likely to respond to different things, such as humour, kindness, empathy, or information, and it’s important to take time and recognise what will work for you and the person you are supporting. 

When speaking to workmates or friends we’re not particularly close with, it may be harder to recognise and respond to signs of depression or mental health problems. Melissa notices an obvious change in Alicia’s attitude, but rather than dismissing her concerns, she encourages Alicia to talk and listens to what she has to say without passing judgement. When Alicia says she’s not hungry and hasn’t been eating much lately, Melissa asks, in a non-confrontational way, “This might be a weird question, but have you thought about seeing a doctor lately?” Alicia’s response, that her recent doctor visits were a disappointment, opens a dialogue that helps to connect her symptoms. “It’s hard. I don’t know what’s wrong with me,” Alicia says. Sensing her frustration, Melissa takes pause and doesn’t force any assumptions or diagnosis immediately, she allows time for Alicia to feel comfortable before continuing their conversation. MHFA Tip for supporting someone with depression: When a person is experiencing depression, it can be hard for them to have the motivation to engage in self-help strategies. Depression makes it hard to concentrate and focus. If someone is depressed, being forceful about self-help strategies can make them feel worse, because they may feel as though they’ve failed. Instead, support any efforts the person makes to feel better.

Throughout the day, Alicia continues to allude to her growing anxiety and stress. She notes a desire to break up with her partner Max, and even talks about dropping out of University.  After listening to Alicia’s and hearing how seriously she is considering some of these decisions, Melissa uses comparable lived experiences (those of her cousin) to alleviate some concerns.  “I don’t think breaking up with Max is the answer, or dropping out of uni… did you ever meet my Cousin Amber when she was visiting last year?” Melissa says.  She goes on, “When she was at School, she went through something very similar to what you’re describing.”  “Her relationship broke down, she thought about quitting uni, couldn’t concentrate and started getting anxious about every little thing – it started taking control of her whole life, and affecting the people around her.”  Alicia recognises a lot of herself in what Melissa is saying, “Yeah, I’m worried I’m starting to worry I’m pushing people away as well.”  MHFA Tip for giving support and information:   Support includes empathising with how the person is feeling and giving them hope for recovery. Offering consistent emotional support and understanding is an important part of providing mental health first aid – remember to use information and examples that they’re likely to understand.  The words Melissa uses when talking about her cousin Amber, to give hope for recovery, are a great example of how you can be supportive and informative…  “All she does is take care of herself; she treats her depression like any other medical illness.   She sees her doctor regularly, she speaks to her therapist when she needs to, and when she was diagnosed, she made sure she stayed on her meds.   And now, most of the time, she doesn’t even notice the symptoms, she doesn’t let the depression get in the way of doing stuff she wants to do.” 

Alicia recognises that she is experiencing similar symptoms to those experienced by Melissa’s cousin Amber, but she is defensive about whether the same treatment will help her.  “But I’m not Amber, what if the talking doesn’t help!? What if they think I’m crazy? What if they just lock me up in a hospital and forget about me!?” she says.  Melissa acknowledges Alicia’s concern and responds genuinely, explaining that there doesn’t have to be any pressure and that everyone’s experience is unique.  “Every situation is different, that’s why it’s really important to talk to a mental health professional as soon as possible. They ask you how you’re feeling and work out with you what’s best. You’re not crazy, and no one’s going to think you are...  Melissa’s mental health literacy and understanding of treatment options ultimately break through and puts Alicia on the road to seek professional help.  MHFA Tip for encouraging someone to seek professional help:   A common barrier people experience to seeking professional help is not believing it will work.  If this is the case let them know that professional help has worked for others, and it can work for them too. Encourage them to keep trying and remind them that it will be worth the effort. 

This MHFA conversation almost didn’t take place. Early on in their discussion Dave attempts to shut it down by saying “I’m not going to do anything stupid. I’m just… (sigh)… it doesn’t matter.” At this point it would have been easy for Carolyn to shift the conversation to something lighter, not wanting to pry or upset Dave. Instead, Carolyn knows from her training that it’s okay to ask clear and direct questions and then give the other person time to respond. Carolyn asks “No, go on… you’re just what?” This lets Dave know that it is okay to explain how he is feeling. He starts talking and the conversation reaches the next stage. If you’ve given someone an opportunity to talk, let them choose when to open up. However, if they do not initiate conversation about how they are feeling, you should say something. Speak openly and honestly about your concerns and respect their response and how they interpret their own symptoms. MHFA Tip for recognising a mental health problem in a young person:  It’s not always easy to tell the difference between normal adolescent mood changes and behaviour that indicates a mental health problem. Look for changes which prevent a young person from doing the things they want and need to do, negative emotions that are present most of the time (maybe even when something good has happened) and changes that persist for more than two weeks.

During the conversation Dave comments “I don’t like myself at all right now. I’m not normal.” Carolyn replies with “I don’t know about that, I think it’s very normal. I think lots of people have times in their life where they feel sad… hopeless.” She then takes this opportunity to go on and explain that it could be depression and suggests that Dave should talk to somebody who may know more about it.  MHFA Tips for supporting someone: 

• Treat the person with respect and dignity
• Offer consistent emotional support and understanding
• Encourage the person to talk to you
• Be a good listener
• Give the person hope for recovery
• If the person would like information, make sure the resources you provide are accurate and appropriate to their situation.

Towards the end of their conversation Carolyn suggests that Dave speaks to his parents about how he has been feeling. He is reluctant and feels that they won’t help and that they don’t listen to him. Carolyn then suggests meeting with the school counsellor, but Dave doesn’t want to do that either. Carolyn does not get disheartened; instead, she continues and suggest a visit to see his GP. Noticing that he is still unsure, she follows up this suggestion with the idea of looking at some online resources that might be a helpful first step. Dave responds well to this idea and we see him visibly relax and look hopeful. MHFA tips for when someone doesn’t want to seek help:

• You should find out if there are any specific reasons why they do not want to seek help. They may be based on mistaken beliefs. You may be able help the person overcome their worry about seeking help.
• If the person still doesn’t want help after you’ve explored their reasons, let them know that if they change their mind in the future they can contact you.
• You must respect the person’s right not to seek help unless you believe they are at risk of harming themselves or others.

Sandeep noticed that Ted’s behaviour had changed and looked for the right time to approach him and let him know his concerns. It took a few attempts before Sandeep was able to persuade Ted to go for a walk with him away from the office.  Sandeep initially invited Ted to join him at the gym. Ted replied with “I’m too tired, I think I’m going to go to the pub.” Sandeep knew that this would be the wrong environment for a mental health first aid conversation and, after pausing, asked “Hey Ted, how about we just get out of here and go for a walk?” Ted eventually agreed and they went for a walk in the park near their office where they had a mental health first aid conversation. MHFA Tips for approaching someone you are concerned about: 

• Give the person opportunities to talk. It can be helpful to let the person choose when to open up. However if they do not initiate conversation about how they are feeling, you should say something to them. Speak openly and honestly about your concerns.
• Choose a suitable time to talk in a space you both feel comfortable where there will be no interruptions, when you are both sober and in a calm frame of mind.
• Use ‘I’ statements such as ‘I have noticed… and feel concerned’ rather than ‘you’ statements.
• Let the person know you are concerned about them and are willing to help.
• Respect how the person interprets their symptoms.
• If the person doesn’t feel comfortable talking to you, encourage them to discuss how they are feeling with someone else.

While chatting on their walk, Ted makes a comment about wishing it was the end of the world and Sandeep realises Ted could be having suicidal thoughts. The pair sit down and Sandeep asks him directly “Ted, are you thinking about suicide?” Ted is a little surprised by how direct Sandeep’s questions is and quickly responds  “No…it’s just hard to think about tomorrow right now when I’m… I am just really struggling right now.”  Sandeep could have stopped there, but he goes on to say “Ted, if you’re thinking about suicide, it’s okay to talk about it.” Ted responds quietly with “Is it?” and Sandeep looks at him and replies in a slow and calm voice “Yes… are you?” Sandeep then remains quiet, giving Ted time and space to respond.  Ted pauses before saying “Yes… yes sometimes I am… I’m just wrecked at the moment.” They continue to talk, and Ted reveals that he has had thoughts on how he could kill himself and what would happen afterwards. Sandeep continues to talk to him in a supportive manner, without judgement, and their mental health first aid conversation continues.  MHFA Tips for talking to someone about suicide: Many people fear that asking someone if they are thinking about suicide could put the idea in their head. This isn’t true. Instead, it can make the person feel less alone with their thoughts, and more able to accept help. It’s important that the question is direct and unambiguous, and delivered without judgement. “Are you having thoughts of suicide?” or “Are you thinking about killing yourself?” are both good ways to ask. This lets the person know that you are not afraid to talk about suicide and they don’t need to be either. If the person doesn’t feel judged, they will almost always tell the truth. This is because most people don’t want to die. They want their pain to end and they can’t see another way out. You can help them find one.

Towards the end of their conversation Sandeep suggests that Ted speaks to his sister about how he is feeling. Ted does not want to involve his sister so Sandeep suggests a friend or even better his GP. Ted is visibly uncomfortable with the thought of talking to anyone else.  Sandeep convinces him that his GP is there to help and Ted calls and asks for an appointment for some time the following week. While Ted is on the phone, Sandeep nudges him and whispers that he should ask for an appointment today, which Ted does. Further tips for talking to someone about suicide:

• Suicide can be prevented. Most suicidal people do not want to die. They simply do not want to live with the pain.
• It is important to take suicidal thoughts and behaviours seriously.
• Openly talking about suicidal thoughts and feelings can save a life.
• It is important that you know the warning signs and risk factors for suicide, and the reasons why a person might have thoughts of suicide.

Helping a person who is suicidal is complex, however, there are three key actions to helping someone: 1) If you think someone may be suicidal, ask them directly. 2) If they say yes, do not leave them alone. 3) Link them with professional help.