The woman who didn't see the angel

On the day Scottish Mental Health Minister Maureen Watt unveiled a new 10-year mental health strategy, I'm writing this article in my 'consulting room' which, perhaps unsurprisingly, has a number of meaningful artworks upon the walls. Right now I am looking at an Icelandic artwork called 'The woman who didn't see the angel,' by Karolina Larusdottir. This black and white etching depicts a forlorn woman staring blankly out of her window. Yet, if only she would get up off her chair and look out of the window, she would see a glorious angel waiting there to transform everything.

This consulting room is in a Scottish secondary school servicing almost 1,500 pupils. I am an Educational Psychologist with particular skills in CBT counselling, mental health, learning difficulties and autism, delivering a public service to this school (and others), its teachers, support specialists, pupils and families. I also collaborate with colleagues in the third sector, Social Work, Child Health and CAMHS.

Far be it from me to glorify my own profession by applying the unseen angel metaphor to educational psychologists (and heaven knows there is plenty of mental health work for all of our esteemed and hard pressed colleagues in other areas of applied psychology). But having recently attended a Public Policy Conference on the next steps for Scotland's mental health strategy, where the predominant concern coming from the floor was 'what are we going to do about the mental health of children and young people and those with additional support needs in schools?', it now seems obvious that more questions need to be asked. Why, with respect to mental health, does the hard working and accomplished profession of Educational Psychology appear to be, like the angel, invisible to Nicola Sturgeon and her current administration? Is there not a single policy maker who is wise enough to get up off that chair, look out of the window and discover the transformational power of an economically viable and already existing infrastructure of expertise, just outside the window of every family in the nation?

The ten year mental health strategy begins in the right place: early mental health intervention for children and young people in schools, evidence-based interventions, training, assessing risks, accessing 'counsellors' in schools, working with families in the community, multiagency collaboration, the mental health of children with disabilities, children in the looked after, child protection and criminal justice systems, building skills in teachers and so on. Whilst pages are dedicated to CAMHS funding and commissioning, the profession of educational psychology – which is at the forefront of all of these initiatives on a daily basis – gets a mention on one line within the whole document. It's on page 13: ensuring access to educational psychologist for schools. The last time I looked, the numbers of educational psychologists allocated to schools was reducing, the educational psychology courses were being diminished and having funding removed. In fact, they are on the brink of extinction in Scotland.

As a public service, Educational Psychology is one of the key professions that serve the needs of the nation's children, especially the most vulnerable. When something is being done well, it is easy to not notice it, and then to think, mistakenly, that it is no longer needed. Could it perhaps be this efficient invisibility that lies behind the Government's failure to consult the profession on mental health policy in schools, and also to neglect Educational Psychology training courses? Alongside the recent cuts in Education and the decrease in the availability of this expertise to the schools and communities, is it a surprise that the mental health of children and teenagers has become a rather pressing zeitgeist?

The Educational Psychology Service is here for a reason. It has evolved over many years in response to societal and human need. Attempting to replace this incredible infrastructure with more clinicians and ad hoc voluntary/private individuals in school settings could be likened to shutting down the nation's railway network and gradually replacing it with more buses and cars without ensuring that the vehicles are fit for purpose or that the drivers even have a licence. Removing funds from Educational Psychology and donating it to health may allow a few more children to climb up the CAMHS waitlist, but it will not stem the flood of children and young people getting there in the first place. It also scapegoats the children by medicalising their difficulties, difficulties and stresses that they themselves have no control over or responsibility for in their lives.

I have been developing my expertise in the mental health of children and young people in the educational and community context for many years. It is a privilege to do so and I am ably assisted by the unique and broad statutory role of my profession in Scotland. In 1946 the Education Act (Scotland) required Scottish educational psychologists to: work with children and their families; study them, intervene and assess them. In 2002, the Currie Report provided the profession with an infrastructure of core duties that include: consultation; assessment; training; research; policy and development work. This infrastructure is vast, far reaching, even to the furthest recesses of remote Scotland and, importantly, it is very economic. Every school in Scotland has a named Educational Psychologist with true psychological expertise who is able to work with staff and children in need. It has been well said by Tommy MacKay (2011) that:

'In terms of training, they (educational psychologists) are the most generic psychologists with more postgraduate training time devoted to the child and adolescent sphere than for any other branch of psychology. In terms of role, they are the most contextualised, working across the domains of home, school and community. In terms of background, their knowledge of educational settings is unparalleled'.  

So how does all of this translate into the everyday practice of a 'mental health efficient' Educational Psychology Service in Scotland?

A day in the life becomes a year…

Given the diversity of the profession's particular set of duties, these mental health activities sit alongside many other tasks. In any one day an EP could be conducting autism assessments, doing school consultations on supporting the behaviour of a distressed child of divorcing parents, writing reports, looking at mental health research data and editing papers for a professional journal. On another day the EP could be delivering training on Attachment and Nurture for schools, counselling a pupil with anxiety, advising a colleague on research design and evaluation and assessing learning difficulties. On yet another day the EP could be consulting with a parent at home who is reaching the end of their tether with the behaviour of learning disabled child, meeting parents whose anxiety is impacting on their child and helping a Headteacher to prioritise children for various stages of intervention.

To convey the breadth and depth of the mental health work we can do, it may help to reflect upon my year so far.

January is always time to deliver one of my introductory sessions on Cognitive Behaviour Therapy (CBT) approaches within schools to trainee educational psychologists at Strathclyde University. The trainees enjoy this part of the course – at heart, they all want to make the children better and this is a highly structured technique, grounded in psychological theory with a robust evidence base, demonstrating that it really does work. After my presentation, there is a queue of enthusiastic trainees seeking 'more please'. This is very rewarding and I can see a clear future pathway for course investment in CBT skills and capacity building for the profession of Educational Psychology. Why then, I wonder, is there a plan to dismantle the educational psychology training programmes? Funding is already removed, and the numbers entering the profession greatly diminished. Add to this the impact of austerity measures that lead to fewer educational psychologists on the ground…

At the start of the year, I joined a strategic group of mental health specialists from both Educational Psychology and Public Health working at Authority level. This Building Mentally Healthy Schools initiative is about supporting community services and schools with a culture change regarding their role in mental health support. It's about economically building knowledge, skills and capacities within the education system, to intervene with vulnerable young people at the earliest possible stage. As part of this service, we plan to roll out bespoke consultations with school management teams on supporting them to close the gaps in meeting the mental health needs of pupils. There is a high demand for this from Headteachers who report that, ten years ago, their biggest problem was behaviour. Today it is mental health (depression, anxiety, stress, anger, self-harm, suicidal ideation). Frontline staff are painfully aware of the gaps in meeting such needs within the school context for they already have many 'raising attainment' pressures upon them: indeed, most guidance staff have full teaching loads and are stressed as it is. A few teachers still struggle to see the relevance of mental health problems to learning. I find myself baffled that the powers that be cannot see how a stressed professional cannot support a stressed pupil, and that nobody is going to learn or attain much when under such pressures.

In March 2017, as part of my research, I examined the returned surveys of schools and educational psychology services on current strengths and difficulties in meeting mental health needs of children and young people. The school returns provide an illuminating snapshot of mental health practice in education. Most schools have no written policy for mental health and are uncertain about the existence of authority policy. They feel least informed about depression and similar actual diagnoses and are unlikely to monitor behaviour to screen for mental health risk or indicators. For the most part, they are also unlikely to have had specific training for the recognition and management of mental health issues. The agencies they rated as the most effective and supportive for mental health issues were Educational Psychologists and School Nurses. Least effective were Social Workers, CAMHS workers and Volunteer Counsellors. What then is so surprising, is that these weaker and less efficient systems is where the 'women that didn't see the angel' want to channel funding.

It is perhaps not so surprising, however, that schools are not that well organised, through no fault of their own, in terms of the mental health needs of its pupils. This is due to the historical fact that mental health was fully medicalised and interventions only came at a point of crisis in the GP surgeries and clinical psychology clinics. We have progressed greatly with our understanding and the normalisation of mental health issues for children and young people in recent decades, but critical systems around the child, like education, social services and child health, retain unreconstructed practices and beliefs about their role.  Perhaps it is even less surprising that schools perceive the biggest barriers to their ability to support pupils' mental health to be funding, staff capacity, the capacity of EPS to support them within schools and the capacity of CAMHS to take on new referrals of young people in actual crisis.

Plate spinning

All of this activity is, even at the best of times, an act of plate spinning. Yet this is something EPs are ably equipped to deal with. At times, when services are stretched, courses are under threat and austerity raises stresses in professionals, families and schools, it can be the perfect storm of spinning plates and inevitably, some can and do come crashing to the ground. Those it hurts most are the children and young people. Yet I firmly believe that this plate spinning is a core feature of the job that most EPs love. We can be the angels at the window.

Of course, there are things that only CAMHS can do. It is rightly an expensive, ring-fenced case load profession with highly specialised, intensive service for children and young people with complex mental health needs. Whilst they may do some family work, they do not work at systems levels building capacity, changing cultures and systems of entire organisations such as schools. This, however, is the bread and butter of Educational Psychology, who need their CAMHSs in the right place at the right time for the right pupils. CAMHSs need Educational Psychologists to support them in schools with sub referral threshold pupils, those crowding the waitlist and those approaching the waitlist.

This is about more than territoriality. There is easily enough mental health work for all professions. The skill is in having the right people, in the right place for the right task at the right time. If this is not done, we must ask: who is going to be left to clean up the mess when all the plates come crashing to the ground? Answer: the children, the young people, their future, the nation's future.

I conclude with a plea to all in charge of public policy nationwide. Invest in your Educational Psychology Service. Nurture this nurturing profession. Look after its wellbeing, for in doing so you remove pressure from your crisis services, build the wellbeing of children, families, schools and thereby create a mentally stronger nation. Please do not make the mistake of failing to see the economic and remarkable infrastructure and resource you already have in the profession of Educational Psychology. Your CAMHS teams need us, your teachers need us, your parents need us, your children and young people need us. Take a good look out of your office windows… don't be the woman who did not see the angel.