The challenges of youth mental health: showing the hero out of the panopticon
One of the challenges we all face – as researchers, clinicians, leaders and parents – in youth mental health is the dynamism and complexity of adolescence and early adulthood.
As McGorry et al1 allude to, one of greatest dangers is that this complexity and dynamism can itself become a reason for lack of self-confidence in professionals and an excuse for passivity and quietism. Young people can present for clinical support and yet professionals look to time and development (“he will grow out of it”; “it is just a phase”) as a response to help-seeking or look at the wider context of the young person's life, undercutting the distress he/she is reporting. We clinicians have to sail between Scylla and Charybdis: to remain optimistic, flexible, problem-focused and non-stigmatizing, yet realize the real clinical difficulties young people may be suffering, and the level of professional help and expertise that may be required2.
McGorry et al refer to “soft entries” to services, which are essential to limiting hurdles and thresholds for support. In the UK, many child and adolescent mental health services have operated from a distinct clinical base, with a system of referral and appointments and long waiting lists, which can make access for young people in education, or whose families have wider difficulties, problematic. Flexible, non-stigmatizing, blended models of access are crucially important. Alongside smoother access, we need to consider methods of “soft exit and re-entry”, so that services can respond and map onto the changing needs of young people and their families.
However, this optimistic and flexible approach to services should not be conflated with staff being less clinically skilled in the management of complex mental health problems. Many young people and families report that they have been seeing a certain service for a period of a few years but feel that they have not been helped, and that evidence-based interventions have not been offered.
Young people often see access to services and professionals as the end-point of their journey to seek care, and we need to make sure that, when they do access services, they find staff that are adequately skilled to assess and deliver the interventions which are required, and, as teams, have the clinical wisdom to pivot between different models of distress, and to move between the various levels of provision of care and support that a clinical staging approach requires, acknowledging the multimorbidity that young people often experience.
In the work of the University of Birmingham Policy Commission Investing in a Resilient Generation, the problem of a skilled workforce in youth mental health care became very clear3. The Commission calculated that scaling up mental health services so that every young person receives the help needed would require an investment in the UK of £1.77 billion. To meet this need would require an additional 23,800 clinical staff.
The report was published as Brexit was still progressing through government. With the UK having left the European Union, and considering the impact of the COVID-19 pandemic, these workforce challenges have now become even more pressing.
We are trying to increase capacity in the youth mental health workforce through implementing our own training programmes and supporting allied professional groups to develop expertise in mental health. These include primary care physicians4, members of the emergency services, and school staff, with evaluation of the government's Trailblazer programme underway5. We are also supporting peer-led initiatives and the use of digital health innovations.
Given this workforce issue, we are stressing the importance of implementing preventive strategies alongside improvement in services. Despite all innovations, we are unlikely to fully meet the mental health needs of young people, and hence it is important to try and address the increase in incidence of youth mental problems. The above-mentioned Commission identified several possible preventive strategies, including enhanced perinatal support, parenting programmes, reducing adverse childhood experiences (such as violence, bullying, victimization), mental health friendly education and employment, and supporting transitions between educational stages and employment. We have begun implementing some of these strategies in the University and City of Birmingham.
McGorry et al's use of Campbell's idea of the “Hero's Journey” myth seems an apt lens for thinking around youth mental health. Many of the young people we work with do themselves turn to a life-course perspective in their understanding of mental ill-health, looking to their past and to their future. One relevant theme is their often-mentioned claim that they feel they have experienced an “absence of adolescence”, i.e., a movement from childhood to adulthood, with no intervening period of safe experimentation. Our youth advisory group members mentioned having an awareness of almost being a “brand” defined by social media. A fear was that what had been captured online could not be erased or forgotten and hence there were less opportunities to make mistakes safely. The internalized panopticon of Foucault (i.e., a consciousness of constant surveillance) seems to be experienced.
The second theme of the Hero's Journey that seems relevant is the destination. McGorry et al mention the concern that young people have over climate change, and this can be linked to the feeling that prior generations have failed them, and the sense of responsibility they feel for the future. Relatedly, and echoing the point around increasing economic inequality and casualization of labour1, the neo-liberal social contract is one that often seems either unattractive or unattainable or both. Many of the young people we work with were children during the recession and periods of austerity in the UK: they talk about their parents’ struggles with employment, with debt, and the use of food banks. The idea of working hard, and getting one's own place and secure employment seems an unrealizable goal. Given this, a sense of meaning and purpose is important for us to engender in our politics and society, to offer a new Hero's Journey to young people. If one wanted to take a Keynesian approach to mental health, investing economically in young people to carry out volunteering and altruistic acts may have a benefit on their mental health, while at the same time contributing to create more equal and inclusive societies6.
A final point I want to make is the importance of co-production and having young people at the centre of mental health service developments. Many of us are aiming to move from participation and involvement to full equal co-production with those with lived experience of mental ill-health. Epistemic injustice is a term developed from feminist philosophy to describe someone's capacity as a knower being devalued or ignored due to factors such as gender, class or ethnicity. Young people with mental ill-health may be treated unjustly for multiple reasons7 (age, health, gender, ethnicity, social class) and, given the benefits they can bring to us in their knowledge of services and their personal experience, it is crucial for us all to do what we can to minimize injustice and scaffold and support full democratic and equal production. A first step towards this can be charting such injustices in real clinical and research contexts and developing steps to mitigate them.
