Teach Secondary Think Piece, November 2024

Unintended Consequences

Matilda Gosling looks at whether universal mental health interventions in schools may inadvertently contribute to the problem they are trying to solve

A fifth of children between the ages of eight and sixteen have a probable mental disorder, according to data from NHS England, and this has risen from a sixth since 2017. Popular theories attempting to explain this deterioration include social media, climate change anxiety, Covid and our expanding definitions of poor mental health, which increasingly capture normal human worry and sadness within them.

These statistics have put concerned adults and institutions on high alert. Mental health fluency is increasing among teenagers as messages filter through from social media, teachers and health professionals.

But is this awareness of mental health conditions and a resulting propensity to think about them at length actually part of the problem? There’s a risk of making teenagers feel vulnerable, which can erode their ability to feel able to cope with the problems life throws at them.

An NHS-endorsed resource for teachers, which is a ‘stress quiz’ aimed at fourteen- to eighteen-year-olds, asks those completing it: ‘Is there too much stress in your life?’. Students are asked how much various statements apply to them, including getting upset by quite trivial things, finding it hard to calm down after something has upset them, or getting impatient at traffic lights.

Most of these are arguably part of the human experience, especially during high-stakes exam periods. Those who get a high score are referred on to sources of external support, compounding their belief that there’s something wrong with them.

There’s increasing evidence, too, that universal mental health interventions in schools (those that are targeted at all students, not just those who have poor mental health) may sometimes create more problems than they solve.

While some have shown positive outcomes – especially when they’re delivered by mental health professionals, not teachers – others have not. A trial of dialectical behaviour therapy, which is a form of talking therapy, found that the mental health of students involved in the intervention got worse, unlike those in the control arm of the study. A mindfulness-based intervention has demonstrated higher levels of depression and depressed feelings in early adolescents who took part compared with those who did not.

Professor Willem Kuyken was lead researcher of a different trial of school-based mindfulness, which showed no significant positive or negative results. He has commented: 'Enthusiasm was ahead of the evidence.' He believes that the complexities of mental health research mean that we need to involve multi-disciplinary teams with different skills sets to solve difficult problems.

It’s not a stretch to argue that schools running their own mental health programmes, or implementing off-the-peg programmes developed by external providers, are going to miss that important element of multi-disciplinary expertise without which unforeseen, adverse consequences are far more likely.

For many people, it’s counterintuitive that universal mental health programmes are sometimes linked to worse student mental health. This makes it challenging to filter findings down to schools. Those unfamiliar with the research are distracted by easy messages about making students more aware of their mental health, intervening early and reducing stigma.

Beyond fostering feelings of vulnerability, why might we be seeing these sometimes negative effects? Doctors Lucy Foulkes and Jack Andrews, both from the Department of Experimental Psychology at the University of Oxford, have put forward a theory they’ve termed the ‘prevalence inflation hypothesis’. According to this theory, mental health awareness-raising efforts may be linked to teenagers recognising and over-interpreting symptoms, which then leads to higher levels of mental health problems.

A hypothetical example teenager – let’s call her Emma – might see, in class, a checklist of anxiety symptoms. She recognises items from the list. Perhaps she sometimes feels irritable, restless and tired, and sometimes finds it hard to concentrate.

These feelings are normal, but Emma doesn’t know this. She worries that she might have anxiety, and keeps an eye out for other listed symptoms. This makes her ruminate about her mental health, which leads her to feel down. It also stops her spending so much time on the things that are good for her well-being – connecting with friends, sleeping well, playing sport – as she’s looking inwards, not outwards. Her mental health starts to get worse. Emma now has diagnosable levels of anxiety.

The Government has committed to placing a mental health professional in every secondary school. ‘Early access to care, support and ongoing treatment is incredibly important,’ said the now Education Secretary Bridget Phillipson ahead of the summer’s General Election. ‘That’s why Labour would make sure mental health support is [offered] directly within our schools.’

For some teenagers – those who are already struggling with anxiety or depression, and who require professional support to alleviate their symptoms – this may be a helpful move.

But there are two important questions. Do all schools have enough pupils with serious mental health issues to require in-school provision? And, importantly, does placing even more attention on mental health in schools risk making those teenagers who are currently fine go inwards and start to over-interpret their symptoms?

Possible routes through the mental health quagmire include co-designing interventions with students, targeting them appropriately – there’s some evidence that interventions are less likely to cause harm when they’re targeted at older adolescents and adults – and ensuring that mental health programmes are delivered by trained professionals, not teachers.

Perhaps, though, we need to ask a more fundamental question. Should busy, resource-strapped schools be running mental health interventions for which evidence is, at best, mixed, or should they focus on teaching?

Leadership teams face a dilemma. Students learn better when they have good mental health. But teachers are not trained psychotherapists and, as we’ve seen, some programmes may cause more harm than good. We don’t yet have enough information to know in advance which these are, and the human mind is exceptionally complex. This means that any school running a universal mental health intervention is effectively rolling the dice with its students’ well-being.

Instead, schools may be better off focusing on what they do well – much of which we know, as a side effect, can prop up well-being. Students have better outcomes when they feel connected to their schools, when they experience a positive classroom climate (through, for example, high-quality interactions with teachers, routines and consistently applied rules) and when their schools are able to minimise physical aggression and bullying.

Focusing on these areas would also leave counselling and support services available to those with pre-existing, serious mental health problems. Diluting access to these services for all students makes them less available to those who really need them.

School leaders need to familiarise themselves with the evidence. So, too, does the Education Secretary.

Matilda Gosling is a social researcher and author. Teenagers: The Evidence Base is available to pre-order here.