Saturday, 22 February 2014

A Reply to "Psychiatric services for young people in need require drastic overhaul"

The comment page  of today's "Irish Times"  features two items about mental health. One is this humorous cartoon by Martyn Turner.
The other is a typically serious and well-intentioned piece by Breda O'Brien.
You might expect me to take exception to Turner's cartoon with its use of "psychiatric" as shorthand for crazy. But I won't. If anything I find it refreshingly un-PC.
But what about O'Brien's piece, which ties itself in knots about the lack of adequate provision for adolescent psychiatric patients? The article is a master-class in the use of euphemism. Take the invitation to "Imagine the impact on a 14-year-old of being confined in a psychiatric unit with very unwell adults. At the very least, she or he would be uneasy, and at worst, afraid and traumatised."
"Unwell adults" can here be read as psychos you wouldn't want near your child. The kind of people who'd make a child uneasy, or yourself uneasy. Who would put the fear of God into anyone sane and probably due something to leave you traumatised. O'Brien does not specify the kind of behaviour this might be. Psychiatric patients are scary people who do bad things to children.  We don't refer to psychiatric patients any more though, preferring to use the up-to-date official euphemism "service user."

In a way I am glad to see the article as I do believe that the impact of mental health on adolescents badly needs debating.  Just this week the Department of Education issued a press release saying that it is estimated that one in ten adolescents has a mental health problem. The press release doesn't say estimated by whom but provides a link to a framework for school mental health teams, which seems to confuse mental illness and bad behaviour. Mitching class and leaving the premises are now "symptoms", perhaps of drapetomania. This equation of unwanted behaviour and mental illness is inappropriate on two counts. Firstly, it is a slur on students with actual mental health issues. I can honestly say that in my own experience, students who "are in contact with CAMHS" are no more troublesome than their peers.  Moreover, this equation of bad behaviour with mental illness risks pathologising the many, many children who are deprived of appropriate parental care and guidance. Reframing a problem (especially inaccurately) in medical terms does not make that problem go away.

At least O'Brien, unlike the Department,  names her sources, writing that

 "....the Psychiatric Epidemiology Research across the Lifespan (PERL) Group Report found that one in five young Irish adults aged 19-24 and one in 6 young people aged 11-13 were experiencing a mental disorder at the time they took part in the research".
Now O'Brien is a teacher and as such these figures should have looked immediately suspect. Let's read them again. One in six young people aged eleven to thirteen. That's the upper end of primary school and into sixth class. That's five mentally ill children in a class of thirty. O'Brien does not give figures to the thirteen to nineteen age group. Those one in five young adults should be okay though, catered for as they are by our "much improved" adult psychiatric services.

Since no figures are provided we will assume that second-level students fall somewhere between the one in six and the one in five occurrence of mental illness. Or should we follow Quinn's more conservative estimate? Even that seems excessive to me.  Why do we have all these mentally ill children? The article states that  "Last October, research published by the Royal College of Surgeons in Ireland highlighted that young Irish people appear to have higher rates of mental health difficulties than their peers in the UK and US."

The phrase "appear to have" speaks volumes here. Because who's to say if they have or not? Is it one in five of them? One in ten of them? Is it most of them? All of them? Does it matter? Either Irish parents are doing something seriously wrong, the anti-fluoride people have a really good case,  or there's a whole lotta over-diagnosis going on.

I agree with O'Brien's premise that  too broad a definition of mental illness leads to a diversion of resources away from the few children who actually need them. I would follow this through to its logical conclusion and say that the Mental Health Problems for All project needs to stop. The whole-school mental health initiative, as well as the idea of using Youth Cafes for stealth psychiatry, needs to come to a halt. Not just because these things a waste of money, but because they are harming our young people.
I've nothing against Youth Cafes -  or a holistic educational ethos that includes pastoral care alongside knowledge acquisition and intellectual development -  as long as they don't purport to be healthcare facilities. It is disingenuous to lure young people in with pool tables and free coffee for the purposes of indoctrinating them in fashionable theories of mental well-being and psychopathology. As for the whole-school mental health guidelines these have been accepted by teachers with little quibble. Mental health is accepted as an unequivocal good and anything that promotes it and reinforces the concept can only enhance our lives.

In January 2013 Ruairi Quinn and his colleague, Kathleen Lynch, brought out a document called "Well-being in Schools". Well-being. The document focuses on mental health and suicide prevention, which is now all our business. We know already that Quinn has no interest in what is the real business of schools: education.
  
These are some excerpts from that document, all italics are mine:
·         Schools are in a unique position to promote mental health and emotional well-being. Boards of management, school leaders and teachers play a central role in providing leadership and direction in implementing a comprehensive and integrated approach to mental health promotion.
·         The needs and well-being of school staff need also to be considered and supported.
·         Education about mental health and well-being is an integral part of the school curriculum. It is especially important to address the myths and stigma surrounding mental health and suicide, whichfor many young people are barriers to seeking support.
Identifying and supporting students who may be vulnerable or at risk are key to successful mental health promotion and suicide prevention. These Guidelines provide a practical frameworkfor supporting schools in this challenging area

·         The Guidelines adopt a comprehensive, whole-school approach to mental health and well-being, focusing on the entire school community, not just individual young people with identified needs



·         For young people, mental health is part of their overall health and emotional well-being and is about how they feel, think, and behave

·         Protective factors in the school environment that help to build resilience in young people include

o    providing a positive school climate

o    having protocols and support systems in place that proactively support young people and their families, should mental health difficulties arise

o    fostering expectations of high achievement and providing opportunities for success

·         All school personnel should have high levels of awareness of the signals and messages young people send out when they are not coping 
 
  • Young people’s learning in SPHE can resonate with positive messages delivered throughout the school.
 

I wonder how much time will be left over for teaching, planning and extra-curricular activities when teachers (and all school staff) are done with the vital role of screening and identifying at-risk students, providing support to their families and looking after their own mental health. Mental health is not a neutral concept. It is already edging out the curriculum as seen in the Junior Cycle key skills of Staying Well and Managing Myself.

It may seem callous to disagree with the Mental Health Consensus. Who could be against such worthy concepts as emotional well-being or suicide prevention? I am, when I am being co-opted out of my own job, where the promotion of mental health is prioritised over the acquiring of real knowledge and where I'm expected to work in line with policies including such pseudoscience as "positive school climate".  In particular all talk of mental health promotion in schools is moot as long our ability to refer students to the only trained professionals in schools (guidance counsellors) is severely curtailed due to cuts. Training us all to "spot the signs of suicide" is no substitute. So I disagree with O'Brien that "these things are important, and should continue."

The article ends with the familiar decrying of the "stigma" of a mental health diagnosis, the author seeing no link with her earlier comments about "unwell adults".  As for young people who are unfortunate enough to have a genuine mental illness, there will be little empathy as long as statistics like "one in six children" and "one in four adults" make their condition sound like the common cold.