We Have Hard Choices To Make On Children's Mental Health

As ever, we should look for cause and remedy in what we do, what we fail to do, or what we could do differently. Our children are too precious for us to do other than make children's wellbeing the highest priority.
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Today, on World Mental Health Day, the issue of mental health, and children's mental health in particular, has possibly never been higher on the agenda. A recent, major national survey on mental health in England confirmed very real trends showing alarmingly high levels of distress, with young women at particular risk: one in four women aged between 16 and 24 reported having harmed themselves. Coming out in the same week, the Royal College of Nursing conducted a survey that found seven out of 10 specialist nurses caring for the growing number of young people struggling with mental health problems believe that NHS services are insufficient.

So, we are faced with the classic dilemma - increasing need running into a lack of sufficient support. The response requires some hard choices - the only humane and pragmatic next step is to consider what we can do to make a meaningful difference, based on what we know works. And what we know is that the two main therapy avenues for mental health disorders are psychological and medication-based are both effective. However, it is crucial that we do not see our hard choice as being about favouring one or the other. It is tempting to opt for medication as it is easier to grasp and seems to offer the comfort of apparently straightforward cause and effect.

As ever, the truth is more complicated. Generally speaking, both interventions can complement one another, although psychological therapies should be considered a first-line option given that medical interventions are less likely to have long-term benefits, and their side effects are many. But at the same time, not every therapy will work equally well for each individual or for each condition and neither intervention avenue should be expected to be a magic bullet, able to definitively make the distress go away. Any treatment needs to be tailored to each individual's needs.

A key question raised is how does just talking in psychological therapies bring about change? Of course, we can learn new ways of looking at things in the therapy, practice new ways of coping etc. But is it all just to do with the therapist and the consulting room? In unpicking what makes psychological therapies effective, we can learn a lot about what the human mind needs in general to stay well - not just how to stop being ill. In other words, it has some bearing on that Holy Grail of mental health policy: psychological resilience. What really makes therapy work also and perhaps mostly takes place outside therapy. It is in the physical and social spaces beyond the therapy room where learning and applying new ways of being, new ways of coping, start to unfold: the extent to which a therapy works is measured by whether the person can take and use their learned skills in new settings. And this translation to real life is most easily done early on in disorder histories and during childhood: it is one of the many reasons why access to treatment as early as possible is such a vital - as yet too often unmet - imperative. If you allow things to go on for a long-time it will be much more difficult to change, but there are windows that open to change in childhood and adolescence. The child's brain is more open to experience, for good or ill; it's why it easier to pick up a foreign language during school years than in adult life.

The child's developmental task of growing their mind evolved as a highly social, interactive business. To be able to make sense of one's own or other people's minds - the fundamental underpinning of mental health - one needs, in the first instance, to have experienced having one's own mind being held in mind by someone else. That someone else - and in most ordinary circumstances this would to be a child's primary caregiver or caregivers - in their day to day care, without even thinking about it, is showing curiosity in and recognition of the infant's needs, thoughts and feelings. Long before a baby has learnt to understand their own thought processes, let alone appreciate that other people have their own, entirely separate minds, a caregiver responds to their baby's actions as if they have a separate, independent mind. It is through this constant process of teaching through interaction (as in a tennis game: 'serve and return') that the human mind is incubated by the minds around it.

When an individual's capacity to makes sense of their own or other people's minds in a robust and balanced way is damaged or lost, the world rapidly becomes a dangerous and lonely place. We all experience such moments, often - thankfully - in relatively fleeting way, when we have a terrible day, or when we are hurt or vulnerable or grieving. But sometimes we need another mind to help us regain our hold on what might be going on in other people's thoughts, or in making sense of our own mind. Nowadays, we often call this way of benefitting from other people's minds to support our own psychological therapy, but it is something that humans have done for one another in a myriad of ways for as long as we have had language: we have always sought out other people's thoughts and feelings and ideas, and let other people have access to ours, as a way of achieving stability, safety, and learning how best to get navigate the challenges thrown at us.

In the particular case of psychological therapy, this process does not finish with the therapist. In fact, any treatment that does simply end at the consulting room door, is by definition not an effective one. An effective therapy session is one that will help the patient "try out" their minds in relation to other people's. Too often, resilience is conceptualised as an isolated trait in the individual - something that one has or does not have. In fact resilience is a never-ending social process. Effective treatment does not "give" an individual resilience. What it does is enable the individual to access and support, find inspiration and consolation, from a whole range of other people. That leads us back to the actual hard choice we have to make when it comes to tackling increased need and finite resources in children's mental health.

The human mind is a social thing: this is what makes it both so vulnerable, and so powerful. In a modern world which pushes us towards isolation, suspicion, hostility and rivalry, there is perhaps a greater need than ever for us to articulate the fundamental social needs of the human mind if we are to take mental health seriously. The hard choice is for us as a society is to look at the bigger picture of our children's wellbeing and look at the role every aspect of our society can play in increasing that wellbeing. As ever, we should look for cause and remedy in what we do, what we fail to do, or what we could do differently. Our children are too precious for us to do other than make children's wellbeing the highest priority.

You can hear the latest Child in Mind podcast from Anna Freud National Centre for Children and Families on iTunes and Soundcloud.


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