Friday, 25 April 2014

We Need to Talk About Mental Health

Next month is May, mental health awareness month. Already green ribbons are appearing in my Twitter feed and my blood pressure is starting to rise.  I originally called this post "why I won't be wearing the green ribbon"  but then I looked at the website and thought, if all you're looking for is people to talk about mental health, then I'm up for the challenge. I think we do need to think about mental health, but we need to think critically about what we're told, and we need to be scrutinise how the mental health agenda is promoted in schools and to young people generally.
At least they remembered the apostrophe

I can't understand how so many people, including people whose views I normally admire, are so gung-ho on the notion of mental health and the need for mental health awareness campaigns. How can I be so wrong and so out-of-step? Don't I care about how many people are dying by suicide? Don't I care about the numbers of children in adult psychiatric care? What about stigma: don't I want to reduce the stigma around mental illness? Aren't these all important issues? I do care, what I don't do is share the conviction that mental health awareness campaigns are the answer to any of these issues.

Suicide, adult units and stigma
Reducing the number of people who die by suicide is a hugely complex area, as the reasons people take their own lives are myriad and all these reasons are have to be dealt with separately. I am not an expert in this area so will confine my comments to suicide among psychiatric patients and recent psychiatric patients as this was the category I fell into at the time of my own suicide attempts. Better services are key, and by better I don't mean "more". In fact less is often more; in particular the practice of prescribing anti-depressants to those aged under twenty-five must be curtailed as much as possible.  By better services I meant services whose goal is to minimise the long-term contact the patient has with mental health services over his or her lifetime. A real recovery where patients leave the system altogether, rather than a recovery approach that orients them to a lifetime of patienthood. It is good to see DBT being rolled-out nationally and this, I believe, is a step in the right direction. I take issue of course with the Irish Times' inaccurate description of DBT as a "new treatment". It has existed, in more or less its current form, for the past twenty years. Imagine if the HSE suddenly made a life-saving drug available to Irish patients after it has been on the market and proved to be safe and efficacious in other countries for twenty years. Would we call that drug a "new drug"?

While the admission of children to adult psychiatric units is certainly a problem, we have to avoid the simplistic conclusion that the country needs a raft of dedicated child-and-adolescent inpatient psychiatric facilities. Hospitalisation should be a last resort and if it is decided there is need for such a facility I would favour a national centre of excellence rather than have children treated in small, paediatric units in adult facilities.

What about the stigma surrounding "mental health"? I don't like the word "stigma" in this context as it suggests something attached to the sufferer. "Prejudice" might be a better word, as in the public are prejudiced against people with mental health problems. I certainly experienced prejudice, most notably from the college radio station who told me I couldn't volunteer there any more because I was "a psycho". I would call them from the locked psychiatric ward several times a day, begging them to take me back. I can see that my enthusiasm seemed bizarre under the circumstances and also that the fact I was heavily medicated and locked up was all the proof they needed to confirm their fears.  In my own experience the more educated people believe themselves to be in relation to mental health, the more prejudiced they were towards me, and the most prejudiced of all were the health-care professionals tasked with looking after me. To me, improving services is the most vital step in combating stigma. There is no point in Kathleen Lynch giving out about how we should be nice to the mentally ill when her own department denies "voluntary" patients the right to sign out AMA,  and insists on the right to administer ECT to patients  "able but unwilling" to give consent.

What about educating the public? Mental health campaigners put great store on this. We are all familiar with "facts" about mental health such as that one in four of us has a mental health problem, that everyone is vulnerable to mental health problems, that mental illnesses are all real illnesses the same as cancer and heart disease, that your GP is your first port of call if you suspect you have a mental health problem and that there is an epidemic of mental illness among young people. You may also know that there are safe and effective treatments for most mental illnesses, that will not cure you, but will make life more manageable and that help is always available. But are these facts beyond dispute or do they just reflect current, dominant thinking among journalists and health professionals? To me, the science of mental health is not yet advanced or conclusive enough to warrant the attention and column inches it receives. Take for example, the role of self-esteem in mental health. Raising self-esteem continues to be a key objective of mental health promotion and the phrase features heavily in last year's Well-Being in Post-Primary Schools Guidelines. But there are some psychologists- such as Kristen Neff in the video below - who argue that our obsession with raising self-esteem  is partly to blame for the continued prevalence of bullying in our schools.

Promoting Positive Mental Health
My past life, as a psychiatric patient, and my current existence as a teacher converge on the issue of mental health education in schools. To many people this is a no-brainer. Surely if we can get in there, into schools where young people are, after all, a captive audience and educate the hell out of them around mental health, all will be resolved. I mean, on the one hand they can learn the scientific facts around mental illness and decrease their prejudice. We can expose them to real life stories or even class visits by sufferers of mental illness, thereby increasing their empathy and reducing stigma. We can educate them about the importance of doing things to protect their mental health, like eating well, exercising and reducing stress and also instil the importance of help-seeking behaviours. If we could only improve their emotional literacy, teach them how to look out for each other and how there's no need to fear mental illness, or the mentally ill.

I've always felt queasy about this sort of thing. Firstly I agree with Daisy Christodoulou that before we commit content to the curriculum we need to be careful that there is consensus among experts that the information is correct. To me, almost all of the discourse around mental health is not there yet. That's not to say that this theory or that theory is right or wrong, just that I would far rather students spent more time studying biology and chemistry, and that they would develop empathy through the time-honoured practice of reading fiction. Also, we have to ask questions about who is delivering this content. Recently there has been much justified scrutiny of what kind of groups are delivering sex education to Irish teens. I think similar scrutiny must also be applied to the many groups, voluntary and otherwise, who are giving mental health presentations in Irish schools every week. For example, World Mental Health Day is celebrated every year in Cork by a conference where in recent years students have received lectures such as one on nutrition by Patrick Holford.

Much mental health promotion is indistinguishable from health promotion generally. Activities like sleeping, exercising and eating healthily might be promoted as part of looking after your mental health. But why would we believe the students will do these things to protect their mental health but not be motivated to do them to protect their physical health? If we really believed mens sana in copore sano why bother with mental health promotion at all? I would argue that we don't need the mental health tagline and it is enough to educate students about how their bodies work, including the need for sleep and the benefits of exercise.

The Fear
Mental health promotion goes beyond this and promotes what I can only call fear. The fear is the idea that your own mind is probably faulty and not at all to be trusted. Your emotions are not a guide to your situation but instead are alien things that must be managed and suppressed in the case of anger or vented in the case of sadness. Students are still being taught about "negative" and "positive" thoughts, even though one of the first interventions of mindfulness and DBT programmes is to encourage patients to stop labelling thoughts and feelings as negative or positive.  Mental health promotion often calls itself "positive" as in positive mental health. But this adjective is misplaced. Their view of the human subject is anything but positive. In fact they believe in what Ecclestone and Hayes call "the diminished human subject."

Young people are actively encouraged to see aspects of their own personality as maladaptive and possible pathological. Take this campaign for , entitled "Ditch the Monkey". The monkey in this case is the young person's own negativity. Negativity which is wrong. We must all be happy! We're sure that all teenagers invite all their friends to parties, just like in junior infants. No teenager ever has to sit at home on a Saturday night because being a teenager is all about having fun, fun and more fun.

They also learn that a healthy teen is a confident teen. Better iron out those insecurities and develop a healthy body-image and high self-esteem. This is despite research, as referenced here by Kelly McGonigal that "stress, anxiety and self-doubt are not necessarily a barrier to your ability to succeed." In fact, they're not even a problem. What about exam stress? Again according to McGonigal, not a problem. "You don't need to get rid of it and it's not a sign that something's going wrong". In fact academic pressure is only a problem when it is fear-driven and the biggest fear driving students is fear of letting down their parents. The problem stressing out students is not lack of mental health awareness. The problem is unrealistic and/or unhelpful parental expectations. Another fear students have is not getting into a particular course. I think all teachers are familiar with students who become fixated on courses for which the points are beyond what the student will realistically achieve.  This is a harsh lesson for a young person to learn, particularly a young person raised on positive, cheerleading messages like "if you believe it, you can achieve it", "you can if you think you can" and "no negative thoughts allowed".

There are attempts by mental health promoters (or "ambassadors") to square this circle with slogans like "it's okay not to be okay". The idea seems to be to worry young people about their mental health but not to really scare them.  Along with the checklist comes the assurance that if they don't make the mental health grade, help is available if they just "reach out". No-one seems to have any qualms about the effects on young people of entering into the mental health system. Even while those who work in the system complain that it is stretched to capacity, it still advertises for clients.  Any reluctance among young people to engage with services is attributed to "myths and stigma" rather than mistrust of the service or concerns about its quality or relevance.

I speak from my own experience of how easy it is to be side-tracked into a futile, expensive and traumatising quest for better mental health. I was a sucker for the kind of things now being taught in classrooms all over Ireland. Time and again when a crisis would hit my life I would turn to psychiatry, my GP, my counsellor-du-jour  and every time the approach was the same; I needed to fix myself. I needed to improve my mental well-being, normally either by taking medication o alter my neurotransmitters or by talking endlessly about my early life experiences, and then life would improve.  I know I was not alone in this experience. Others have told me they had similar experiences of seeking help and finding themselves mired in the quicksand of the mental health system. The only thing that actually worked for me was radical acceptance and mindfulness of what actually was and is. The less time I spent worrying about, and working on, my mental health the more I was able to achieve and do in my life. And the more I did, the better I felt.

But what about people who really are ill? I'm not denying that these people exist. The brain is an organ like any other in the body and must be susceptible to malfunction and disease. I can also appreciate that many people benefit from psychotherapy, particularly those who have suffered trauma and abuse. But the mental health agenda in schools does not deal with illnesses that will surface no matter how much we mind ourselves. Students, and the public, love inspirational happy endings and remain ignorant of lifelong struggles with psychiatric illness. Neither does mental health awareness tend to deal with the trauma and abuse that so many children suffer. From talking to the many people it has been my privilege to encounter in inpatient and outpatient units throughout the years, I can definitively say that mental health problems do indeed discriminate, despite what we're told, and are much more likely to affect individuals who were abused as children, neglected as children, were exposed to violence in the home and/or who grew up surrounded by addiction. No amount of mental health awareness can counter insufficiencies in our child protection system.

The Worried Well
So while mental health awareness does nothing for children who need help, it risks creating a cohort of the worried well. These are anxious students, or students going through a rough patch, who are encouraged to pathologise their experience and "seek help." For some students, being asked to think about their mental health leads them down a path of anxiety, where they miss out on the real education that would allow them to achieve academically and live independent, fulfilled lives. Mental health issues can seem like a get-out-of-jail free card to stressed teenagers but focusing on their mental health might be doing more help than good. Repeated attempts to "ditch the monkey" will fail if the monkey is an integral part of their personality. Here is another quote from McGonigal
If we put our attention on inner experiences..and we try to control these inner experiences it almost always backfires. It tends to strengthen those experiences and we feel even more self-doubt and more stressed and more gets pulled away from the energy we need to simply take action in the direction of our goals.

I have written about people who take the message of mental health awareness to heart and start to doubt their own mental health status. There are also students whose faith in their own mental health is bolstered by what they learn and whose already robust self-esteem is further enhanced. They also are susceptible to the idea inherent in Staying Well that mental health can be conserved if we only mind ourselves. I fear that this idea must inevitably lead to a lack of empathy with those who didn't follow the programme and didn't stay well.  I teach Senior Cycle English and one thing I have noticed in the last few years is pupils frequent lack of sympathy for the poet, Sylvia Plath, who took her own life. Why did she not just ask for help? they wonder. Why did she give in to her negative thoughts?

I would hope that the emotional development and well-being of students is important in all schools and to all teachers. I would also hope that where students develop mental illnesses they are treated with kindness and understanding by staff. I would hope that staff members are approachable and that listening support is available in schools. We can do all these things without putting mental health on the curriculum.

Kelly McGonigal addresses education-related stress at around seventeen minutes in.

Monday, 21 April 2014

Stress, the Junior Cycle and Flight Mindset

 "Minding Me": a SPHE textbook
The SPHE Junior Cycle curriculum is soon to be defunct as the current, imperfect junior cycle is jettisoned in favour of honing twenty-first century skills, but at the same time its educational philosophy will soon be embedded across subject areas.  This excerpt deals with what students are expected to learn in third year, at which stage most of them will have been exposed to the SPHE curriculum for ten years:  

"Building on work done in second year, students are asked to identify the place of stress in
their own lives and the potential for too much stress at different times and stages of life.
Strategies for coping with stress are identified and promoted. Further work is done on the
handling of emotions and their appropriate expression"

The aims of this unit are to help the students to recognise the place of stress in day-to-day living, to help the students to recognise the effects of a high level of stress on themselves and others and to enable the students to identify factors that can reduce stress.

Learning outcomes for this unit include the aspirations that students will

appreciate the place of stress in their lives,  understand the effects of too much stress on themselves and others and  have identified stress-reducing factors.

This seems un objectionable and benign, if not very educational. Don't we all know that stress while a little stress is good for us, too much is bad news? A person who wants to be healthy and live a long life would be best advised to avoid excessive stress, and if that strategy fails, then at least make use of some factors that might mitigate its toxic effects. But what if our strategy of teaching students to fear stress (along with "negative emotions" such as sadness and anger) and mind their mental health has the potential to backfire?
The idea that stress is an avoidable toxin is common. Stress is up there with smoking, drinking, inactivity and poor diets in the list of things students must be advised against partaking in. The inclusion of stress on this list is unjustified, as the others are behaviours that on some level, the individual can control. This control might be limited by the addictive nature of substances such as nicotine. It can also be difficult to find the time and/or motivation to exercise. But for the most part, our exposure to cigarettes, burgers and vodka lies within our control. 

Flight Mindset
What about stress? How many of us choose stress or is stress, the really stressful kind, more likely to be a reaction to being in situations where our ability to choose freely is reduced. When we feel between a rock and a hard place, where we have to make the proverbial fight or flight choice.  My own experience would tell me that for me, stress is being in a situation where I realise fight is the better option. The better option, but not the one with which I'm more comfortable. I'm more of a flight person. And I worry that programmes that teach children that stress reduction is a worthwhile goal, that instil fear of "the effects of too much stress" and that prioritise coping with stress over coping with the world, promote a flight mindset.  

There may be situations where flight is the better option. It is also true that having a fight-over-flight predisposition may lead to as many problems for an individual. But I would argue that the way stress is taught in schools, along with the rest of mental health promotion, teaches a flight mindset. And when you flee, you lose. You trade your goal for your safety.  

The curriculum also aims to build self-confidence and self-esteem, and assertive communication features heavily on the SPHE syllabus. Let's say that both these strands are successful. On the one hand students have their confidence and their self-esteem boosted, so they are better able to assert their will, make their voices heard, and pursue their goals. On the other, all that they learn about stress and about their vulnerability to mental-health problems, instils the idea that the world is scary and that their own minds are unreliable.  Is anything going on here besides a completely pointless titration?  

The confidence-fear dialectic is to be further expanded until the proposed Junior Cycle. On the one hand, in my own subject, English, substantial amount of class time is to be expended in developing student's confidence in writing, but particularly speaking. On the other hand of the key skills that are proposed as the foundation of curriculum design, two are straight off the self-help shelf; Managing Myself and Staying Well.  

Staying Well

In addition to learning outcomes related to exercise and "healthy" eating, students will also learn how to "use a range of coping strategies to deal with personal problems and stress". There we have stress again, not something to be faced, something to be coped with. The phrase "staying well" implies a world of danger, where stress and unhealthy habits lurk behind every lamppost. It also implies that adolescence is a peak of mental and emotional well-being, after which humans must battle decline. Even though one study has found that by age 21, 81% of young people meet the criteria for at least one DSM-IV disorder. My own view is that it is unreasonable and unhelpful to hold adolescents to the same  standards of mental health as mature adults. Staying Well implies the only ways are down or maintenance, whereas I'm sure the experience of most of us is that we put the trauma  and experimentation of adolescence behind us and find healthy ways of being, just through our experience of being alive.  

Note how "stress" is aligned with "personal problems". It really is scary. Youth mental health website (to which students are actively directed in my school and many others) warns that stress can lead to infertility, obesity and most terrifying for their target market: skin conditions. But what if we didn't think of stress as a problem? What if we kept the self-help books off the curriculum and stuck with the biological facts? What if we equipped students with the knowledge of what happens in their bodies when they are under stress and left out the judgements about whether this is an evolutionary adaptation or a glitch in the system?


How Serious is the Threat Posed by Stress?

I was prompted to write this post by this TED talk by Stanford psychologist, Kelly McGonigal. The talk, given at TEDx Edinburgh, explains that the toxicity of stress is not a question of dosage (as popular wisdom and the SPHE curriculum assume) but of perception. McGonigal cites studies that far from helping us stay well, the fear of stress is itself a killer. On the other hand "when you choose to view your stress-response as helpful, you create the biology of courage". Far from needing to giving over a third of the secondary curriculum to self-management and self-surveillance, if we believe that our bodies do what they're supposed to do (unless we're sick) "[we] can trust [ourselves] to handle life's challenges".  

What I find most interesting is McGonigal's response to the question asked at the end of the talk. It's to do with deciding on a career and whether it's better to avoid those likely to be stressful. McGonigal replies that "chasing meaning is better for your health than trying to avoid discomfort" and advises us to "go after what it is that creates meaning in your life and then trust yourself to handle the stress that follows".  I can only speak for myself here, but I wish with all my heart that some-one had given me similar advice when I was a sixteen year old student, in fifth year and under ever-increasing pressure to choose a career that would at once do justice to my academic aptitude and at the same time be "safe". (And it was understood that as a girl, I'd be wise to choose a career that would in time be family-friendly). I didn't need strategies for coping with stress, I needed courage.

The problem with tips and strategies and thinking about ourselves and classroom discussion about motivation and coping and the teacher (extremely unlikely to have studied psychology at any level) explaining to students how their minds and emotions work is that all these things erode rather than develop resilience.  As Kathryn Ecclestone and Dennis Hayes argue in "The Dangerous Rise in Therapeutic Education" "therapeutic education inserts vulnerability". Ecclestone and Hayes do not mean the vulnerability celebrated by Brené Brown in her work, but the vulnerability of distrusting and pathologising your own thought-processes.

Positive Mental Health
Students are reminded over and over to be positive. Last year in my school posters were put up around the school with mantras such as "you'll never have a positive life with a negative mind" and "choose to be happy". Yet the positive mental health project is itself negative about the human mind and our human capacities. It is entirely negative on the view that the majority of young people can negotiate adolescence through the passage of time and the support, example and encouragement of the adults in their lives. Time and the presence of adult role models are no longer sufficient and students need explicit life-coaching, delivered to non-homogeneous groups of thirty students at a time. They need to learn to be confident, but not to trust themselves too much, to fear stress, to monitor their own mental health and the mental health of those around them ("mind your mates") and to adopt elaborate strategies for coping with life.
Perhaps McGonigal is overly positive and future research will show the truth to be even more complicated again. I am inclined to agree with her that evolution is progress and that the human body is a wonderful thing. Biology is something we should encourage young people to respect and admire instead of overloading them with precautionary tales and disease-mongering. The human heart, both literally and metaphorically, is wonderful. The human mind is amazingly resilient. If we want young people to value and trust themselves, we have to value them enough to give them a real, knowledge-rich education and trust them enough to spare them the psychobabble.