Occasionally (not often) I tune in to commentary, whether on the radio, in a book, or on the telly etc., where I think ‘that’s precisely what I’ve been thinking for a while now’, and in some cases exploring and speaking about in my work. So it was when I listened to Radio 4’s Start the Week programme on Easter Monday. The topic was ‘Defining Mental Health‘. Andrew Marr hosted health researcher and psychologist Lucy Foulkes, the neurologist Suzanne O’Sullivan, and Sally Holland, the Children’s Commissioner for Wales, who I came across in work I did for the Welsh Government, that I have to say are making a good fist at transforming the education of children and young people in Wales in ways I approve of. Which is not something I say often when I look around and engage with the education system here in England.
The three discussed their work and thoughts in relation to the impact of COVID-19 on young people (a topic I have been keen on). The context was widespread reports of an epidemic of mental health problems among the young. Not that COVID was regarded the cause of these problems; the sense was that the pandemic has simply exacerbated issues that have existed for quite a while.
O’Sullivan started by reflecting on cases of illnesses she had researched for her book The Sleeping Beauties – And Other Stories of Mystery Illness. In one startling example, O’Sullivan describes refugee children in Sweden unable to wake up. What she uncovers are extreme psychosomatic disorders where, in this example, the children are so fearful of being sent back to the countries they had escaped from that they become paralysed into levels of inactivity verging on coma. This is called Resignation Syndrome, a complete withdrawal from society, activated by their social environment, in this case the realities of asylum-seeking. O’Sullivan is at pains to say that ‘psycho-somatic’ does not mean ‘putting things on’, these are very real responses to stress. The critical point is to recognise the influence of societal forces such as political decision-making. This introduction opens up a fascinating discussion about the wider context of mental health, and what lies behind the perceived crisis particularly among young people.
Certainly, in my own work with youth workers it is rare the subject of juvenile mental health doesn’t get mentioned. Sometimes it is all that is talked about. Listening repeatedly to this is when being an old kid on the block matters to me, having worked in the service of youth for more than thirty years. I want to value this experience as I can personally attest to the emergence of concerns amount young people’s mental health and what has happened since, to extent that sometimes at least appears to be the dominant paradigm for working with young people.
Allow me some reflection. Way, way, back, when I was a rookie, I can remember a colleague attending a one-day training course about adolescent mental health. I kid you not when I say from then on it was almost as if every young person they worked with had a mental health problem. Yes, I know, saying this makes me sound a bit flippant, cynical at best. Maybe I am, but believe me when I say I am trying to make a serious point, and it is precisely the point that the three commentators made on Start the Week. Namely, that sometimes these narratives take hold to such an extent as they seem applicable to everyone.
I first got interested in this many years ago when a pal who was a social worker, and who had been around even longer than me, spoke of the impact of child protection policies on her work. She described how, over time, the number of referrals had gone up and up and up, the consequence being that the amount of work needed to examine the veracity of these claims had also increased markedly, consuming the majority of her working hours. I was left with an image of a bulging in-tray on one side of her desk and just a few files on the other, cases that, on the basis of systematic review, had clear signs that something was wrong. But also so little time left in the week to get on with the business of social work, which for her, and me, was supporting people, not simply, as some media images would have us believe, working out which kids to take off their parents.
At the time I had had a hand in the writing of the International Guide on the Methodology of Street Work throughout the World in which I and colleagues from all continents had discussed the value of street work interventions that were ‘first and last’. The idea here was that there was great value in responding quickly to minor issues that might easily escalate into really significant problems. One story of practice seemed to sum this up perfectly, and I used it often in explaining what I meant.
In this, a boy making the transition from primary to secondary school is told by his father that he is ‘a big lad now’ and that he needed to walk to school without parental accompaniment. His mother resisted this on the basis of concerns that they lived in a crime-ridden neighbourhood and he could easily be preyed upon. An accommodation was reached where the boy was instructed to take a specific route to school judged safer than others. However, this included a narrow footpath between a house and a garden in which, unbeknown to the parents, a large dog roamed. The boy feared the dog greatly and did not want to pass it. But he feared more the wrath of his parents if they found out he had deviated from the route. So he played truant instead. A street worker present in the community discovered this quickly in conversation with the boy; and acted quickly in contacting the parents to negotiate a new route. Problem solved. The point of the story of course is that, as with the social worker, their work had also gone on to be more about crisis intervention and neither was able to do the kind of everyday pre-emptive community work described here. Rather, it was much more likely that they would be called upon when the situation escalated, such as when an Attendance Officer was alerted that the boy had been off school for a long time, by which time all manner of others problems had probably set in, which could easily include the suggestion that the boy was suffering some kind of trauma.
The story is relevant I think because, as with the conversation among the contributors to the radio programme, there was an agreement we need to act as soon as help is asked for. But the critical point is that this help is so very often nothing to do with mental health, these are just everyday issues that, more often than not, demand a practical, often simple, response.
This is what I call ‘the flight from the social’, a product of a neoliberalising culture, that, just as with the pandemic, we fail to invest in preparedness. And, more broadly, fail to invest in a society that tries to do something about the social conditions that so often lie behind the stresses people experience. Therein, the authoritarian turn in Sweden has very real implications, including the triggering of Resignation Syndrome.
The point about the degradation of the welfare state is that it creates a reductive understanding of need. What happens is that many issues become conflated with the issue of mental health. This has a number of implications. As I suggested, there is a resource issue; the capacity to respond to serious cases is diminished as time and effort is consumed by a much wider population. And this population grows on the basis of ever more referrals from a wide range of people in contact with young people, but also from ever more self-referrals. Mental health starts to constitute a paradigm.
A critical question is to ask whether this expansion in numbers is evidence of an expansion in the issue itself; is it the case that there really is a crisis, an epidemic, a tsunami of child and adolescent mental health problems? The truth is we really don’t know, but what the radio programme offered was at least a critique that suggested other things might be happening.
First and foremost is the paradigm of language. Take the afore-mentioned ‘trauma’; listeners were enlightened to the fact that in the early use of this word it applied to individuals who had personal experience of very real harm. Consider for example when a clinician says the body had suffered trauma due to a severe injury. More recently however ‘trauma’ is often applied to someone observing another’s clinical trauma. A paramedic attending, say, a road traffic accident may be said to be suffering from trauma on the basis of what they witnessed, rather than personally suffered. Thereafter, ‘trauma’ has morphed into a colloquialism, applicable to almost anything; indeed, Post-Traumatic Stress Disorder (PTSD) now seems invoked on a daily basis.
For sure, a lot of psychological stress is real, but it is something different to call this trauma, and to use this terminology in response to all sorts of things. It is this process of expansion that we need to watch out for, as it can end up trivialising the very grave experiences of others.
It seems essential then to consider language, the terminology we use, and the effect it has on our thinking and behaviour as practitioners. And it seems reasonable to argue that when these terms become commonplace, used on a day-to-day basis, both those working with young people, and young people themselves, can become sensitised to a series of meanings distant from what these and other terms were actually designed to communicate.
Thinking about other words seems to consolidate the argument. Take ‘confidence’, or more pertinently the perceived absence of it in young people. When I listen to young people being interviewed on whatever media, about how, say, they benefitted from doing an activity. almost always they say “it’s helped me develop my confidence”. Likewise, the narratives of ‘confidence-building’ and ‘self-esteem’ seem omnipresent. I guess if you hear something all-day, everyday, you are eventually going to cut and paste it into your own language. Arguably, this is unproblematic, until that is there are behavioural consequences. I remember a neighbour telling me his infant daughter had repeatedly resisted going to school because, she said, she was worried about being bullied. With some gentle probing it transpired she had no experience of being bullied, but, given the fact that bullying was spoken about almost every day, she had developed the view it was inevitable. I figure this is another example of the socio-cultural roots of the issues that O’Sullivan writes about.
At the same time, young people are exposed to parallel and, arguably, conflicting narratives; schools provide ‘dealing with anxiety packs’ whilst at the same time extol the virtues of ‘resilience’, indeed often incorporate ‘being resilient’ into their values statements. ‘Grit’ is also popular.
It seems to me that telling young people they need to be resilient is to intimate the view that are not; it is degrading. How the vast majority have responded to COVID seems to suggest otherwise. Consider this in the absence of schools (and perhaps more pertinently politicians) reflecting on the culture of high-stakes testing they have created, the issue that heads the rankings when young people are asked what stresses them the most. And this applies to all young people; where the bulk are worried they are not going to get a ‘good pass’ the remainder fear not getting A*s. But worry not, as we have mental health services to support you; and a veritable industry of voluntary organisations only too willing to take on a contract or two to provide them.
If I was to let my cynicism run further, there’s money to be made from the promotion of these narratives; I worry about a culture of commercialisation in service provision. Some charities for example are accused of ‘poverty porn’, talking up issues to try to secure income. This aside, I fear something even more sinister; the child, the adolescent, becomes constructed, conceptualised, as having limited or no agency. Discussion of education for autonomy is relegated to philosophical circles. To my mind this is most insidious in terms of the language of vulnerability. Never will I forget listening to a conference presentation about vulnerable young people that led me to believe every last one of them could be counted in to the description given. When it came to questions I stuck my hand up and asked: “are you saying all young people are vulnerable?” The speaker mulled for a moment, then said “Yes”. I was staggered, but detected no similar reaction among the large audience. ‘Is this just me’, I thought. Again, I think this might be an age thing; it’s just a theory, but I figure many of my younger colleagues have grown up with these narratives; they were present in their own childhoods. And the education they were exposed to, including often at college, emphasised them too. Whereas old-timers like me read Crystal Eastman, the American civil rights activist who realised being ascribed the label of vulnerability ushered in, validated, the accompanying narrative of ‘protection’. Which for Eastman, especially in the context she was invested in, had an ulterior motive; “A good deal of tyranny goes by the name of protection”, she remarked. Thankfully we are not without more recent commentators, like Kate Brown, whose theory of ‘vulnerabilisation’ (in which the label vulnerable is often bandied around, but sometimes no used when it is very much needed) resonated with my own experiences. And my concerns about the policy-driven degradation of democratic practice, particularly in youth work. As ‘outcomes-driven’ work has become the norm, practice has shifted its emphasis from listening to what young people have to say, from discussing with them what their needs are, and from challenging them to participate in activities that meet those needs. Instead, we seem more inclined than ever to tell them what their needs are, or at least what the contracting and commissioning arrangements that pay our wages say their needs are. We are left then with having to seduce them in that direction, often baited by incentives. These are not autonomy-enhancing models, if anything they are disempowering; they seek to control young people and fashion their futures in ways determined by others. So I can see where Crystal Eastman was coming from.
One of the ironies of COVID is that many young people testify to actually feeling more in control of their lives, rather than less. For sure, their lives have been restricted, at least in terms of their mobilities, but otherwise many have had what they clamour for, more time with their parents. In this sense, their needs have been met, which equates to feeling in control. I watched my own son, in receipt of several teaching videos from his school, skip through some, and replay others several times. He had escaped from the clock-time, symbolically delineated by the school bell, which ordinarily dictated how much time he needed for this, and that.
I am not immune to other evidence; indeed I see it as a responsibility to engage widely. It’s true that suicide and self-harm has increased, but as the Start the Week commentators said this increase has not been dramatic, and certainly not to the extent that calling it an ‘epidemic’ or ‘tsunami’ suggests. So I figure there must be something more going on, some complexity; and that this complexity needs digging out. For the good of all.
I don’t doubt that some who read this will say I am heartless. My other son, who I discussed this with, warned me I might even by ‘cancelled’. But let me assure you what I want is the best for young people, and to my mind working in an autonomy-enhancing way is central to that. So I’d say we all have a responsibility to critique the ‘milieu’ in which we work, to ask searching questions as to whether we have created a climate in which young people can only ask for help, including for often pretty mundane things, by invoking the narrative of mental health. If this is so, this does them no good, nor does it do their peers (those who really need clinical and therapeutic support) any good, and nor does it do our practice any good.
As was said in this most important of discussions, “illness has become encoded in our politics”, such that the socio-cultural environments these politics shape tell us how to ask for help and what terms to use to secure it. In extremis, young people have to label themselves to get the everyday support that they should have by right. So it was refreshing to hear Sally Holland’s account of a cross-party mental health committee in Gwent in South Wales. Rather than every door opening on to a corridor that directs young people to mental health services what’s been put in place is a ‘no wrong door’ approach. In this, the widest range of services have been tasked to respond to all requests for help and to act in solidarity with young people as they navigate not just the challenges of adolescence, including the complex social realities of this period of their life, but the social realities of life per se.
Grief is part of this, and for sure COVID has dealt out plenty of that. But grief is not an illness; bereavement, like unhappiness, is part of life. My brother Trevor died in his early 40s and it his death hit me very, very hard. So much so that I responded to the suggestion that I visit my G.P. But I wasn’t prepared for being handed a script for drugs within minutes of opening up. That is, a culture of medicalisation does seem to be part of this story, or perhaps more accurately I should say ‘over-medicalising’ everyday life.
One culture seems to beget another; medicalisation provides a label, which I appreciate can be comforting. But sometimes people start to embody that label. Which is especially problematic when what’s being referred to is a grey area. ADHD is a case in point, a condition with no definitive test, just a series of symptoms that can lead to a situation where young people exhibit not one but many of these symptoms. It’s as if they accumulate evidence of the condition through their behaviour. This reminds me of studying ‘labelling theory’, which I suspect has fallen out of fashion. For sure labels can be pathologising, but what seems to happen now is that in order to help someone we have to give them a label, as it is only then that support services are activated, that resources flow in their direction. It is at least understandable then when those looking for support feel the need to self-label, as they rationalise this is necessary to receive help, which may also explain at least some of the rise in demand for services.
If any or all of this is of concern, the question becomes ‘what can we do about it?’ A point of entry for all who work with young people is to think critically and carefully about the language we use. This includes interrogating the political narratives that frame our work, and so often how we describe our work. Likewise the cultural language that inevitably flows from policy pronouncements, and the media that amplifies them. So too we might want to think about the language we use in our work with young people, and the manner in which we talk about life and what it is like. A discourse that wishes away life and all its realities is not going to help anyone. Rather, we might trust more to listening and questioning, as ways of demonstrating that we value what young people have to say, and their capacity to respond to the social and structural pressures that have their roots in politics rather than their own failings. And so they may realise that politics is for them also, a politics of creativity, collaboration, social action and solidarity where they can turn to those working with them to help them in often minor but no less important ways rather than having to label themselves as ill.