The crucial need for a whole-school approach to mental health

Steve Mallen, Chairman, The MindEd Trust, writes…

With psychological disorder and associated behavioural and learning challenges escalating throughout the education system, adolescent mental health has become a mainstream social and political issue. Schools are central to the wellbeing and life-formation of young people, so the education environment is inevitably a crucial focus for mental health literacy programmes and policymakers.

In my extensive research following the tragic loss of my son two years ago, I have yet to encounter a school in any setting anywhere in the country which does not have pupils’ mental health high on its list of priorities.

But schools are caught in a perfect storm on this issue. On the one hand, psychological disorder is growing in prevalence at a population level. NHS data shows that A&E admissions for self-harm increased by a staggering 93% between 2009/10 and 2013/14 for girls aged 10-14, and by 45% for boys. There is now deep debate on the causes of adolescent psychological trauma: family issues, academic pressure, bullying and social media are frequently cited as key drivers. Just as with most physical illness and with my son, there is also strong evidence in support of a genetic basis for mental illness, regardless of the strength of the home and school environment. Nobody is immune.

The problem is growing rapidly and is approaching ‘epidemic’ proportions, according to many of the teachers and school leaders with whom I have spoken. The fact that 75% of all mental illness in the population at large predates the end of higher education in origin only compounds the urgency and magnitude of the problem.

Problems rising, but resources declining

Yet, while the incidence of mental illness is rising, the care, support and treatment pathways open to schools are diminishing. Since April 2013, public health directorates within local authorities have had a statutory responsibility for prevention and early intervention with regard to mental health. In the first instance, with mild psychological conditions, schools and families would naturally turn to local authority and community services for guidance and pupil care.

However, as is well documented, local authority expenditure on mental health is in a parlous and declining state, against a backdrop of stringent public spending cuts. A freedom of information (FOI) request from the charity Mind in 2016 revealed that local authorities spend less than 1% of their public health budget on mental health; indeed several jurisdictions recorded zero expenditure. This renders public health directorates systemically incapable of meeting their statutory requirement to safeguard young people from a mental health perspective.

In turn, schools have a shrinking range of options for supporting young people with psychological difficulties. This inevitably impacts heavily on classroom behaviours, teachers’ time and school resources.

Further, as many schools and families are only too well aware, public health resources for treating young people with mental trauma are simply not fit for purpose throughout much of the country. GPs are poorly trained in mental illness, and the thresholds for accessing secondary care are getting ever higher in the face of burgeoning demand and wholly inadequate service resources. At least 40,000 children a year are refused treatment in specialist mental health facilities despite being referred by their GPs. And while at least 150,000 are successfully referred, only too frequently they find themselves on absurdly long waiting lists.

At least 40,000 children a year are refused specialist mental health treatment, despite GP referral

The net impact of these trends is placing an intolerable and mounting burden on the education system, as by default schools become the custodians of adolescent mental health problems. The education system is ill-equipped to deal with both the scale and technical challenges presented by adolescent psychological disorder.

The MindEd Trust, together with many other charities, is now agitating for urgent reform. Progress is being made – witness recent pronouncements from the prime minister and the convening of a select committee on mental health in education involving, unusually, the departments of both health and education. But very little is yet happening in schools; and the problems are growing.

What are schools to do? What can be done to improve the emotional resilience and mental health literacy of pupils and staff? Schools are not hospitals and we must avoid the medicalisation of childhood. But mentally robust and contented pupils will obviously produce enhanced academic performance, creating successful schools and a younger generation with better life chances.

The vast majority of schools are already deploying a wide range of tactical measures to help students and staff. Many schools have instigated ‘wellbeing’ or ‘mindfulness’ programmes; some teachers are receiving mental health first aid (MHFA) training; school and community based counsellors are playing a bigger role; and extra-curricular programmes are being developed to improve and broaden pupil psyche.

However, our research shows that most of the current interventions and innovations are deficient, on two levels.

Firstly, the vast majority lack a substantive evidence base, which calls into question their credibility and outcomes. A whole ‘wellbeing’ industry has emerged in recent years which is all too ready to sell programmes and methods into schools. Under the marketing and anecdotal collateral of these programmes however, there is frequently little or no independently verified proof of effectiveness. At best, this means that schools are sometimes wasting money on ineffective methods. At worst, some programmes may actually be exacerbating the very problems they are seeking to solve. In other words, they are dangerous. This is especially the case with self-harm and eating disorder interventions. Similarly, many schools are engaging counsellors who, although well intentioned, have little or no formal qualifications or accreditations, deploying techniques with questionable scientific veracity.

The second, crucially important, deficiency of current approaches is their sporadic and selective application. They are often limited to isolated initiatives reaching only a segment of the school population.

Whole-school approach essential

While tactical interventions can produce positive results in the short term, for some of the school community, there is now overwhelming scientific and academic evidence to suggest that mental health literacy and outcomes can only be properly addressed via a ‘whole-school’ approach. To be effective, emotional resilience and wellbeing programmes have to embedded into the consciousness and curriculum of the school in a sustainable model which includes all year groups and students, teachers, parents, governors and community stakeholders.

The stigma and fear which surround mental illness, and which prevent so many young people coming forward for help, can only be eroded by a system level change in attitudes which recognises that mental illness is no different from physical illness. Everyone experiencing difficulty, whether students or staff, should be able to seek help in an open, empathetic and nurturing environment. Hundreds of thousands will then be prevented from reaching crisis, and the whole school community will benefit from a happier and healthier cohort.

Prevention is better than cure and we should be aiming to give the NHS less to do in the first place, averting the descent of young people into trauma and crisis – trauma which can destroy families, undermine schools and weaken society.

There are three pillars in a successful whole-school approach: implementation, content and outcomes.

Implementation

Implementation is best addressed by a change management model supported by the governing body, owned by the staff, and with dedicated and accountable leadership. It is essential that baselines are established, the scale of existing issues understood and quantified, and all parts of the school community are consulted. This should take place against the backdrop of an audit of existing resources and programmes, making the most of good practice and dispensing with ineffective methods. The literature on mental health literacy in schools stresses the need for effective implementation; many seemingly good programmes have faltered as a result of poor implementation and weak oversight.

Content

The issue of programme content is challenging but surmountable. It is imperative that emotional resilience programmes are multi-faceted. They should include traditional learning, peer-to-peer methods, digital formats and a cross-curriculum approach which makes full use of music, drama, sport and community learnings. And of course, the trainings, methods, resources and materials deployed must be evidence based. Schools will need to carefully research this theme. Fortunately, a wide range of signpost resources are now available from organisations such as Public Health England, the Department of Education, the National Children’s Bureau and many charities, including The MindEd Trust.

Emotional resilience programmes should include traditional learning, peer-to-peer methods, digital formats and a cross-curriculum approach

Critically, successful programmes depend on a continuous learning and repeatable culture, wherein mental health literacy is woven into staff CPD and deployed in every year of the school, using age-sensitive methods. Research also indicates that successful programmes must be locality and cohort customised – what is best in one school may not be best in another, owing to variations in location, age, gender, ethnicity and other cohort characteristics. Whole-school programmes need to be created, owned and administered by the school in direct response to specific needs and local circumstances.

Outcomes

At present, thousands of schools are running a myriad of tactics and programmes, but gaining little or no data or information about their effectiveness. This means that schools are unable to quantify progress (positive or negative) beyond the realm of anecdote. This mitigates against continuous learning, programme evolution and the establishment of best practice which could benefit the education sector as a whole. It is essential that schools record and measure progress and outcomes. Here again, extensive resources are now available to help schools adopt the right systems.

One of the main outcomes of a successful whole-school approach to mental health is an increase in pupils and staff presenting with psychological disorders. This may sound a negative and counter-intuitive outcome of programmes designed to reduce mental illness. However, an increase in incidence is to be welcomed because it is associated with the early surfacing of mental difficulties. Early detection permits timely, relatively easy and cost-effective remediation and prevents descent into mental crisis. At present, many young people reach crisis before their problems are recognised or help is sought. At this point, the road to recovery is long, the chance of recurrence is high, families suffer and the school is beset by persistent and protracted problem situations which can severely impair progress.

In these circumstances, if the number of students and staff asking for help is increasing, that is a good thing. A very good thing: safeguarding the next generation and reducing the societal burden of mental illness while reducing a hindrance to school performance.

Many current initiatives in schools are impaired by patchy and inconsistent pathways for those requiring help.

It is obviously imperative that students and staff seeking help with psychological problems are able to access care and support, both within school and in their locality. A whole-school approach must also therefore include multiple and permanent care and treatment pathways. Ideally, a school counsellor with dedicated resources should be on hand. The school must establish good connections with external therapists, public health resources, local GP practices and its local NHS mental health trust. Good access to and relations with local charities and education support services are crucial. Schools can also access digital and online resources, including social media support communities, online therapy and self-help programmes, many of which have negligible associated costs.

Much of the work schools are doing to improve mental health is valuable; but unfortunately, there is also much that is ill-conceived, despite laudable intentions. Successful interventions and emotional learnings will ease suffering and, quite literally, save lives. However, the challenge before us is to create a system-level improvement in mental illness, right across the school community.

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The MindEd Trust was established following the tragic death by suicide of 18-year-old Edward Mallen in 2015. The Trust is developing a fully funded national pilot study which will support schools in creating a whole-school approach to mental health. If your school might be interested in participating in this study, contact Steve Mallen.

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