Breaking down barriers

Schools are becoming ever-more responsible for schooling students in a far wider sense than education. When it comes to mental health we've moved from tentative awareness-raising to proactively tackling stigma. We're empowering the next generation to be unafraid of mental illness in themselves or others and to seek help as needed – often directly through school.

School-based mental health approaches can broadly split into three categories: curriculum-based, pastoral and whole school.

Curriculum-based approaches

A broad and balanced curriculum that prepares pupils for life and not just for exams is being increasingly embraced by schools, parents, pupils and policy-makers. Many schools now include lessons aimed at boosting resilience, promoting wellbeing and giving pupils an understanding of mental health issues. Developing and delivering appropriate curriculums is being done both from the bottom up, with teachers creating their own resources, and top down, with the Department for Education commissioned 'Guidance on preparing to teach about mental health and emotional wellbeing' for key stages 1 to 4 having been freely available since 2015. A government-funded RCT is currently underway of a range of programmes aimed at pupils aged 5 to 16, from brief mindfulness exercises through to longer programmes – notably 'The Guide', a multi-session programme aimed at improving mental health literacy of teens which has gained a solid evidence base in Canada and is being adapted for use in the UK.

A key issue with regards to delivering curriculum-based approaches in the past has been a lack of time – academic subjects tend to take precedence. This is set to change though, as the Department for Education recently shared plans to make many elements of PSHE (Personal Social Health and Economic Education) compulsory from September 2020 with the introduction of statutory 'Health Education' – which includes both physical and mental health. There is an important role for psychologists here, helping schools to determine what shape their health education curriculum should take to meet the needs of their pupils and how best to deliver this. There is also a knowledge gap that we can help to fill – school staff will be expected to deliver this new curriculum despite no background knowledge about mental health.

Pastoral approaches

Whilst the school curriculum is largely about awareness raising and promoting wellbeing, schools are also becoming increasingly involved with recognising and responding to mental ill health in pupils. Schools are encouraged to train at least one staff member in Mental Health First Aid through both local and national initiatives, and many schools choose to train their whole staff in basic mental health literacy. As well as recognising pupils in need of support, school staff are increasingly providing support to pupils who aren't reaching the thresholds of over-stretched CAMHS services through services like Place2Be, which places teams of counsellors in schools. The Department for Education first provided guidance for schools about the role school counsellors can play in 2015 and has updated this since, in 'Counselling in Schools: A Blueprint for the Future'.  

There has also been a movement towards breaking down the barriers traditionally found between health and education, with many schools now choosing to employ specialist staff or developing stronger links to CAMHS services. Through a government 'mental health services and schools link pilot', now in its second phase, schools have been encouraged to develop a single point of access with CAMHS to better enable collaboration between schools and mental health services. This commonly sees a primary mental health worker placed in schools for all or part of the week; supporting pupil mental health and developing staff skills and supporting the referral process where young people require more significant input.

This idea is built on by a new government Green Paper, Transforming children and young people's mental health provision, produced jointly by the departments for Health and social care and for Education. This calls for mental health support teams which will straddle between schools and education, made up of staff specifically recruited and trained for this role. The first wave of trainees commenced their training in January 2019 and will work in trailblazer areas across the UK to provide mental health support to school pupils and decrease mental health wait times. The role of psychologists here can be to help schools understand the local landscape and rapidly changing referral pathways. We can also help schools to make the best choices for students in need of therapeutic input. There is no 'one size fits all' solution, but school staff are often unaware of the range of options available.  

Whole school approaches

Increasingly, schools are moving towards a whole school approach to mental health. This encompasses both the pastoral and curriculum elements as well as considering staff wellbeing and the school culture and ethos. Schools are drawing on lessons learned from improving safeguarding practices, and many now have a lead governor for mental health as well as a staff member who takes the lead on mental health or wellbeing. Government research has shown that more than half of schools have a mental health lead already in place. The new Green Paper looks to build on this by encouraging all schools to appoint a mental health lead who will be provided with funded training.

In 2015 Public Health England commissioned a 'Promoting children and young people's emotional health and wellbeing' framework for schools and colleges wishing to implement a whole organisation approach to mental health. This drew on NICE guidance and what was found to be working well in schools who had been earlier to respond to pupil mental health needs. This guidance is due to be updated in line with current research and government recommendations, but is still widely accepted as a good starting point for schools. It also forms the basis of The Carnegie School of Mental Health's 'Mental Health in Schools Award'; a process for developing and recognising best practice currently being undertaken by over 300 schools across the UK.  

Many schools are developing wellbeing or mental health teams to oversee the implementation of a whole school approach – psychologists can form an important part of these teams, acting as a critical, questioning friend and helping to identify and fill skills and knowledge gaps.

Are schools the right place?

It has been suggested that schools are increasingly expected to fulfil basic parenting requirements: Ofsted's chief inspector Amanda Spielman recently highlighted the increasing number of children starting school without basic self-care skills such as toileting. She said it should not be the responsibility of schools to fill the gap. Is the same true of wellbeing and mental health? Should it really be the role of schools to fulfil what would once have been considered a parenting task? In many instances, schools are both providing this input for pupils and also providing input for parents through programmes like Family Links and Parent Gym.  

A benefit of a school-based approach is that with the right support, schools can choose and deliver universal evidence-based approaches in a way that parents cannot. Schools can also work to meet the needs of every child, including those who do not have consistent trusted adults in their lives and who are most likely to miss out on this input, but arguably are in most need of it.  

Even if we accept that schools provide a good vehicle for universal interventions, are they the right place for targeted interventions for pupils with diagnosable mental health issues? The government's move towards the development of school-based mental health support teams has been met with a mixed response, with critics suggesting that a year of training is far too little to enable skilled delivery of mental health interventions and that schools are not the right place for these interventions to be delivered. But with CAMHS over-stretched to the point that (according to NHS England's 2018 figures) only one in four children with a diagnosable mental health issue is receiving professional input, something, somewhere, has to change.  

What about the teachers? Our teachers are highly stressed and over-stretched – with figures from the Education Support Partnership's 'Teacher Wellbeing Index' suggesting more than half have considered leaving the profession due to health pressures, with one in three quitting within five years of starting. Are they appropriate role models for pupil mental health? Does loading more responsibility onto them risk further fuelling the current issues? Arguably a whole school approach to mental health should promote the wellbeing of both staff and students; but care must be taken to ensure staff mental health needs are recognised and met and that they are given appropriate guidance and supervision in order to enable them to best support their pupils, and protect their own wellbeing too. Supervision is something that schools are only just beginning to recognise a need for – psychologists can play a key role in helping schools to develop and implement supervision and reflective practice for key staff.

The agony of choice

A marketplace that was once bereft of options is now flooded with programmes designed to spot, support, measure or otherwise impact on pupil mental health. We encourage school leaders to be critical consumers; but working far from their area of expertise and keen for results, with a genuine passion for supporting their pupils, they can be easy prey for canny marketeers.  

Psychologists can help here as schools need clear signposting towards what works. Beyond being provided with the skills to tell a good or safe programme or resource from one that should be avoided, teachers are asking for concrete advice. Help them to become more critical consumers, and if you're aware of evidence-based resources or programmes that have a positive impact, then share the good news. Time-poor and worried that they may do more harm than good, teachers welcome initiatives like the Royal Foundation-funded Mentally Healthy Schools website, which signposts quality-assured resources that teachers can use with confidence. This plea was made anew at a recent Ministerial roundtable, with the Association of School and College Leaders welcoming the introduction of statutory PSHE but stating that teachers need training and quality-assured resources if they are to confidently teach about topics like mental health.

What next?

The change of pace is fast and schools need our support if they are not to crumble under the pressure, or risk harm because they are working beyond their area of expertise. But our children are in crisis; more input is needed. With the right guidance and support, schools and school staff are well placed to make a difference; but we need to work together. We need to actively break down the barriers between health and education; between us and them. We must work collaboratively to find new ways forward, with our children at the heart.

- Pooky Knightsmith has a PhD in child mental health from the Institute of Psychiatry, is the author of five books and is the current vice chair of the Children and Young People's Mental Health Coalition. [email protected]

Note: This article is part of a forthcoming collection, 'Schooling the good citizen', from the September edition and due to appear online by 22 August.

Illustration: Ana Rosa Louis  www.destroymodernart.com