3. DO THE RIGHT THING - The Logic of Using Non-specialists to Deal with Mental Health

This week is “Mental Health Awareness Week” and in the school where I work this was marked by the launch of a new student-led initiative for “Wellbeing Ambassadors”; one for physical health, and one for mental health. The idea is that these would be responsible students, carefully selected, who would be approachable and knowledgeable about those issues and be a listening ear for students with wellbeing difficulties, able to point them in the right direction for help and support. As with most schools, we already have the essentials in place - a school counsellor, a school nurse, learning support, etc. - but the idea of the ambassadors is to take these things out of the shadows; normalise and publicise the various ways in which we, as a school, offer support for struggling students and make these further options for wellbeing an everyday part of a student’s life.

But it did concern me, as I listened to the proposal, and it concerned several members of my classes taught later in the day, that theoretically we were going to be telling students with potentially serious mental or physical health problems to seek help from a fellow student, rather than simply telling them to speak first to a fully trained, experienced professional. While the school plans on training the student up for the role, there is no way their training will equal that of our actual school counsellor, or equivalent, and there are seemingly, therefore, only two ways the conversation can go:

The ambassador always tells the student to seek advice from a professional (in which case, why the ambassador at all?)
The ambassador will, themselves, give at least some advice to the student seeking help (in which case we are advocating, as feared, students to seek inexpert help on serious issues from a random and unqualified student).

Neither option seems great, until we consider (A) again: for (A) to be the aim (that all students needing help go to the right place and get it) we need a way for students to feel comfortable seeking out help from a professional, and this is often an obstacle to student wellbeing as the idea of “seeing a counsellor” or even “seeing the school nurse” seems a little daunting, especially in the area of mental health where, until social stigmas are lifted, seeing such a professional feels like an admission of some sort of defect. We already have (A) in place without the ambassador element and we know there are students in our school who currently don’t take advantage of what we offer for exactly that reason. And there are some who simply don’t realise the help is there.

So given a version of (A) is already the current situation, and has its flaws, consider then what might be currently happening now without the addition of (B):

C) Students keep their problems to themselves and suffer in silence

or,

D) If they do speak to someone about their problems, they speak to a close friend or family member, themselves an unqualified and inexpert individual without at least even the basic ambassador training.

So while (B) might be imperfect, it remains better than (C) or (D), and enhances the likelihood of (A) being achieved, so (B) still adds more good to the school overall than is found in its absence.

This is the same logic that sees me and my many colleagues across the country, as professional teachers in England, despite holding absolutely no qualifications in mental or physical health, frequently put in the position of delivering lessons and advice on these important wellbeing issues as if we were experts under the umbrella of schools’ PSHE (Personal, Social, Health and Economic) programmes.

The idea of PSHE is that students need more than the academic curriculum to leave school well-informed and healthy citizens; they need life-lessons and moral guidance. The problem is not the existence of PSHE - the principle behind it seems right - but in its execution. It is not an examined subject, so in the market-culture of school-funding is low priority for investment compared to other elements of the curriculum which will impact the league tables. Therefore there is little money for qualified experts to come in and give informed guidance on these issues, and very little priority given to PSHE in terms of CPD training or timetabling. There are, for example, only rare instances where a dedicated salary payment is given over to a specialist teacher of the subject. Instead, in many schools, it is the job of a form tutor to deliver PSHE, usually with no specific training or time set aside for planning and preparation. So what tends to happen is someone - usually a Head of Year or similar - is charged with putting together a programme, which they do, usually as a box-ticking exercise, and then that programme is delivered by their colleagues. That delivery can either be “off the rack”, literally reading what is there and following instructions as written, or tailored by the teacher and adapted according to their own personal teaching styles. Either way though, the question of expertise and subject knowledge - essential in all other curriculum areas - doesn’t really come into it. If you’re working in a school, you’re expected to be a form tutor. And if you’re a form tutor, you’re expected to deliver PSHE. And among the topics the PSHE curriculum requires you to teach are mental and physical health, with no basic checks done first to see if you are either comfortable or capable addressing these issues with students.

I have lost a lot of weight in the last two years due to diet changes and an increase in exercise, but back when I was considerably overweight and objectively unhealthy I would stand there telling my students about how to eat right and stay healthy and see them rolling their eyes at the blatantly hypocritical advice. I have never done drugs, or drunk a drop of alcohol in my life due to straightedge beliefs I developed as a teenage punk rocker, yet I have had to speak authoritatively to teenagers on the pros and cons of both, and explain to the young people in my charge how to have a healthy relationship with alcohol as if I actually know what I am talking about. And I have had to sit there suffering from my own mental health issues - grief, anxiety, stress - whilst doing my best to offer my classes meaningful advice in how to deal with all three.

In all of these cases each year I think I do pretty well. As an experienced teacher, and a teacher of philosophy and RE, I know how to conduct a good classroom discussion around controversial or contested ideas and don’t shy away from such things. I regularly have to discuss ideas I don’t agree with or feel uncomfortable about. Other colleagues forced to teach the same things, however, can be far less equipped from their daily pedagogy, depending on their subject specialism. Even I can only give advice or information to the best of my knowledge, and on each of these issues my knowledge is, at best, inexpert and amateur. If I can’t control my own eating behaviours, who am I to tell my students what to do? If I’ve never drunk alcohol or bowed to the peer pressure to do drugs, am I best placed to give advice on these things? If I had to leave a crowded shop just the day before because I was having a panic attack, am I really the person these young people need to hear telling them about how to look after their own mental wellbeing?

So let us consolidate all this information into some working principles I think it is fair to say schools are operating on:

i. We genuinely want our students to get help for issues with their physical or mental wellbeing from relevant professionals and have mechanisms in place for them to access that professional help.

ii. However, in order to educate students about the best available help it requires us sometimes use non-experts and amateurs to disseminate that information.

Furthermore, due to the pastoral elements of being a form tutor, we can add a third principle:

iii. Sometimes these non-experts and amateurs will not only disseminate information but be used

in a listening role and to give advice to individuals who seek their help on related wellbeing

issues. While the non-experts and amateurs still have a duty to point the students in the

direction of relevant professionals, it is acknowledged that not all students will take that

advice, so help that can be safely given at this earlier stage should be given to the best of

one’s ability, where possible.

These three principles must be uncontroversial, as they are embedded into the pastoral system of most schools in the country. While they do not mitigate against the fears expressed regarding student ambassadors and the downside of route (B), they do demonstrate that the same things we worry could be problematic about inexpert students advising other students in need of advice, already exist within the pastoral system, through the similarly unqualified and inexpert givers of physical and mental health advice we find in non-specialist teachers. If (B) makes a genuine case against student ambassadors, therefore, then the same case can be made against non-specialist PSHE teachers: we are advocating, as feared, students to seek inexpert help on serious issues from a random and unqualified person.

But, as we have already seen, though (B) may be imperfect, it is better than options (C) or (D). If physical and mental health were never discussed in school, and key information not disseminated, no matter how imperfectly, students would be left with the same two options:

C) Students keep their problems to themselves and suffer in silence

or,

So, again, on balance, (B) still adds more good to the school overall than is found in its absence, as it contributes to the greater likelihood of principle (i) being met than the default positions of (C) or (D).

Which is likely why, on a larger social scale, certainly for issues of mental wellbeing, the use of unqualified non-specialists has also been widely advocated. While most of us have access to a doctor and understand the process by which we seek help for our physical wellbeing (and usually come into contact with our GP, or dentist, or optician, regularly enough for one reason or another that they will hopefully notice particular warning signs and point us in the right direction for treatment if needed) the stigma attached to mental health still leaves many unable or unwilling to get the help they need. And even if they do decide to seek help, the range of options surrounding that help can often be alienating. Unlike physical health, where the science can speak for itself on what the best treatment may be for a particular problem, with mental health there are literally competing narratives about what the problem even is before they begin to advocate their radically departing alternative approaches to treatment. Is the mental health problem biological, requiring pharmaceutical treatment? Is it a problem in the direction of your thinking, and therefore in need of some cognitive behavioural therapy to re-train the brain into making better choices? Are there external triggers to which your mental health problems are a legitimate response? Does it stem from a troubled childhood for which years of psychoanalysis are needed? Four different therapists could diagnose four different answers for the same problem and potentially none of their answers are correct. While in the UK the NHS advocates approaches that have an evidence-basis for their efficacy, if you are one of the many people for whom the pills, or the re-programming don’t work, then how do you decide what to do? And in some cases, how do you afford it? Not to mention that the baseline concept of “normal” mental health that we are judging ourselves to have failed to meet in the first place is, itself, deeply contested, often boiling down to the massively subjective idea of “normal” being anything at all so long as it doesn’t intrude on your daily functioning.

These many practical and epistemological barriers to mental wellbeing are what have led mental health charities to create things like Mental Health Awareness Week in the first place. Like similar mental health events, such as “Coffee and Chat” mornings, or high profile celebrity stories about mental health (this week a highly promoted television event is Prince William sitting in a locker room with a bunch of professional footballers and the group discussing their own grappling with mental health, not a single one of them a qualified mental health professional) the main drive seems to be just getting people talking. We don’t talk about mental health enough, they say. Mental health should be the same as physical health. We all have mental health, just as we all have physical health, and sometimes we need a health check. Don’t be afraid to talk - especially if you are a young man and in the most at-risk group for suicide. Talking to anyone is better than talking to no one. Talk to a friend, a colleague, even a complete stranger if you call the Samaritans or similar organisations. Talk!

And by raising awareness in this way, year by year, more and more, we do talk. There is a national conversation, ongoing, about mental health that is a world apart from the way mental health was discussed publicly just a decade ago. It is a significant accomplishment, and it is based, as I have suggested, on the same logic that sees inexpert and unqualified student ambassadors and PSHE teachers being recruited to talk about mental wellbeing in schools: because talking to someone is better than talking to no-one, and the more we talk then the more likely we will be pointed in the right direction for the help we need. Furthermore, the more frequently we all talk about mental health, the more likely it becomes that the random non-specialist you do talk to will at least know something about mental health rather than nothing, even if it simply the name of a group like Mind or the Samaritans to point you towards.

Both organisations, by the way, are largely volunteer-led charities. There is training, yes, but does that make these trained volunteers any more “expert” than our original student ambassadors or hastily up-skilled teachers? And in a world where psychological “expertise” is split between competing schools of thought (i.e. biological, structuralist, functionalist, behaviourist, cognitivist, psychoanalytical, Gestalt, humanist, etc.) what does it actually mean to be an expert in this field? Unless taking a strictly biological view of mind as brain, with medicines the only answer for anything, then “expertise” in mental health seems very different than the kind of “expertise” we are looking for in physical health. Perhaps the reason talking to strangers, no matter how inexpert, may, for some people, be just as helpful to their mental wellbeing as talking to a professional is because we’re all - professionals and amateurs alike - still trying to figure this thing out together and have yet to hit upon any unimpeachable, infallible, definitive answers about mental health in the way that we have about our physical health. And until we hit upon such definitive answers, any well-intentioned and well-reasoned speculation is as good as any other. The professional counsellor, the sincere student ambassador, the assiduous teacher of PSHE, the emotionally-open member of the royal family - we’re all just scrambling in the dark trying to find the tell-tale flicker of the light at the end of the tunnel and, until a better alternative comes along, a non-specialist who cares is better than nothing at all.

In society at large, as in their microcosm, the humble school, although imperfect, overall, our collective efforts to try and help add more good to the world than would exist in their absence, and so the continued struggle should be supported.

AUTHOR: D.McKee