Do no harm: can school mental health interventions cause iatrogenic harm? [pdf]
cambridge.org
cambridge.org
Anecdotally, this isn’t limited to adolescents. There is a weird trend toward over-diagnosing common life struggles as major clinical health issues requiring intervention. I think this comes from a place of good intentions, where people don’t want to miss anyone who might have a major mental health issue that will benefit from treatment. However, over-diagnosing mental health conditions and convincing kids they even common struggles are actually mental health issues that require advanced treatment techniques has the opposite effect of amplifying common struggles into something much bigger.
There’s a secondary phenomenon in some demographics wherein having a mental health diagnosis is perceived as providing some social advantage, as weird as that sounds. This isn’t just conjecture, it’s actual policy in some schools. It’s well-known among kids that having an ADHD diagnosis will grant people extra time to take tests in some schools, which becomes a cheat code for getting a leg up. I’ve also witnessed young adults swapping tips on how to say the right things to get certain mental health diagnoses and get specific drugs: Xanax for anxiety, etc. They were even swapping names of doctors and notes about who was more lenient about prescribing certain drugs in a Slack community. Coming up with rules to stop that behavior without triggering complaints about stigmatizing mental illness was a challenge.
Not just to children, just in general, the narratives we use to interpret the things that happen to us can actually cause more harm than the event itself.
Simplistic example, but take a culture where scars are a mark of pride, say from surviving battle, compared to one where they are seen as ugly and so shameful. The physical harm in each case is the same, but the mental impact is very different.
We even see this in trauma, like with sexual assault. Being pitied and told something that happened to you was the worst thing that can possibly happen to someone, it makes a far worse mental impact than it otherwise might have made without that framing.
There are a number of reasons for this, but I think in general, disempowering people by removing their sense of control and the notion that they're resilient becomes something of a self-fulfilling prophecy.
Sometimes, some people really are less resilient or lose their sense of control in some circumstances, and then they do need that help, but that should probably not be the default approach. We've had a bit too much of an over correction to the old, "suck it up and walk it off" mentality.
You’d get a diagnosis, get a drug that had value for sale or you could take it, and the reasonable accommodation for ADHD was taking a test in a private room with open book.
I was pissed when I found out as tests were usually graded in a curve, and these idiots broke the curve for the rest of us.
Taking longer can help your career, but there's a limit. Test times were always very generous for people ahead of the curve, short for people below, and just about right for everyone else, because that's how they're designed.
Ancedotal, but when i was in school i remember people top of the class were often last to finish their test (i guess because they double checked things more).
My subjective unprofessional opinion is that this tendency is also an over-compensation in trying to destigmatize mental illness, and to treat mental illness as illness and sufferers thereof as victims, rather than blaming them for lacking motivation or whatever unempathetic BS people used to think.
Hopefully this is a short-lived trend and things will balance somewhere a little more sensible.
> There’s a secondary phenomenon in some demographics wherein having a mental health diagnosis is perceived as providing some social advantage,
Mental illness had some degree of social gravity (not necessarily clout or advantage) when I was a teenager back in the "emo" and "scene" days of the 00s. The phenomenon has clearly evolved somewhat, but I don't think it's entirely new. What is new is its reach.
Not surprising, because they don't address the fundamental issues. Why would mindfulness help with depression, better than teaching these kids how to grieve in an effective, healthy way?
CBT can be helpful, but it 'intellectualizes' problems too much. How about teaching these kids how to increase their self-confidence? How to identify their emotional needs? How to build their social skills, resolve conflicts in relationships, and assert their personal boundaries? Most sure aren't learning that from their parents.
These interventions are far too superficial to obtain the intended results. I'll be pointlessly provocative now: they almost seem intended so that teachers/interveners can avoid having to deal head-on, one-on-one, with their students' "messy" emotions. No need for school adults to have empathic, difficult conversations with kids whose parents are undergoing a divorce. Instead, just teach the kids (as a group) how to intellectualize their emotions, or distance themselves from them. It minimizes the role of teachers and other trusted adults as a social support system, it places the onus on kids to "fix themselves", and it downplays the importance of emotions in causing these problems in the first place. It makes things very impersonal. Imagine if sex-ed classes were founded on Victorian notions of decency, would they be of any help? It concerns me that so many intelligent, thoughtful scientists are barking up the wrong trees. If they refocused their efforts, they could be far more effective.
All the things you listed are already directly addressed within CBT.
I'm not rejecting CBT's usefulness. It's a good tool. But I found it better at improving symptom management than at addressing underlying problems.
Most of us have thought patterns because we experience the world around us. Our actual experience of the world might as well just be our thought patterns. If those thought patterns lead to negative thoughts, that doesn't imply I am inherently the problem.
Mindfulness chooses a line and tells the patient it's their problem to deal with. It's merely convenient (and profitable) that we are as individuals able to affect our own thoughts to a significant degree. It is a course in training you to deal with the pain of your own self-awareness without requiring an actual change to those conditions.
If mindfulness told us our job was to affect actual change in our world, it'd be nothing more than a completely irrelevant set of practices.
It doesn't cover underlying causes there. CBT doesn't work by alone. It needs other therapies to complete the cycle.
I like and have benefitted from some of these frameworks, but none of them is a silver bullet.
Well, I'd say that based on what I know about CBT and mindfulness, both of those are well supported methods for accomplishing all that, CBT especially because of its emphasis on reframing situations and recognizing negative thought patterns.
On a personal level I find positive reframing to be a super power that CBT and others reinforce. It's helped me with all kinds of problems.
They refer to mental health issues but don't give any concrete examples. The most specific they get is depression and anxiety; but aren't depression and anxiety symptoms of underlying problems?
Why? Because both parents and teachers have more load than they can bear with kids already which also strains their ability to give emotional availability to the deeply irrational stage of being a human being with little intellectual capacity developed to cope.
I'd rather that instead of accusing "scientists" (which?) of being worthy of deep concern when you yourself have not taken into consideration this context as if the authorities in question are purely malicious.
Fun fact: abstinence-only sex education actually increases the rate of teen pregnancies, not just compared to comprehensive sex ed but to no sex ed at all.
So of course if you tell kids not to fuck and they have a million outlets to help burden the consequence then it’s a non-functional system not in coherence with todays reality. Living in the past is useless. But it doesn’t mean the values of the past are bad. Just incompatible with modern society.
And I didn’t say it’s a solution because it’s not. It’s good advice for various reasons but it needs to be supplemented with lots of knowledge on how to protect yourself too.
Your argument would be better[1] if you supplied the numbers instead of assuming them and then arguing from the consequence.
1. ie: work
But frankly married couples regularly having 10+ kids wasn’t something to celebrate.
Really though these are the kinds of statistics people love to mess with. Do you count rates of pregnancy for unmarried adult women, or rates of unmarried pregnancy out of the adult/total population, or even rates of unmarried pregnancy out of the total number of pregnancies? Why not look at them all and pick whichever one supports the point you’re trying to make…
What on earth? When did you last check that? Percent of births to unmarried women has gone from 5% in the early 1900s to 15% by 1980 and then ballooned to 40% this decade
https://www.statista.com/statistics/276025/us-percentage-of-...
Again, that doesn’t mean the rate of unmarried women having children has increased because the rate of married women having children has declined. Similarly the percentage of married women has fallen dramatically. And of course the US in 1900 is hardly the beginning of time.
I think you'll find that most experienced one or the other, and probably both. Being supported by your parents and other authority figures is the exception, not the norm.
It's all about perspective.
In my limited and probably too absolute opinion (there's more nuance than what I have here), schools seem to either be about checking boxes to say "see we did everything!" or have some naive administration with a savior complex.
Most people don't care about getting to the root issues, or are blinded by their biases. I feel like there's no real community left and no real hope for many. It's hard to give a damn about the future when you know your's is fucked but everyone is still putting on the pressure to be successful.
I'm lucky enough to be in the same position but I don't think that's how it works for > 90% of the adult world.
One thing about being an adult is that if mindfulness increases your anxiety you can choose not to practice it. Children are often forced into mental health interventions by schools. Imagine being compelled into doing something that worsens your mental health by someone trying to improve your mental health. The authors are correct that we should be selective about which students get which treatments. Often these are applied more broadly than is appropriate. The authors make no claim about the size of the impact of this practice, or the number of students negatively impacted.
Note: I'm from the US, the paper specifically comments on the UK education system.
Basically: is it causing the very thing the intervention is intended to help.
Blinding a patient during eye surgery to remove a tumor is an iatrogenic outcome, for example.
Whats the iatrogenic rate for use of SSRI and other interventions?
"first do no harm" carries huge burdens. Sometimes, harm is unavoidable because doing nothing itself represents the potential for harm to emerge and if its a conscious choice, you did something: you decided not to do something else.
I had a particularly fraudulent school psychiatrist. When my IQ tested low enough, my IQ score was reported. When my IQ tested too high, it was censored on the grounds of being "misleading". Parental and teacher evidence was submitted to justify further mental health interventions which was grossly fraudulent (I was portrayed as unable to dress or feed myself) and a cursory 5 minute examination of me would have revealed this. One of the most disgusting things they did was pull me out of gym classes to spend more time sitting in a room with special needs teachers who occasionally nagged me to use a planner and do my homework. Exercise you know, being an extremely evidence based intervention for mental health, unlike whatever that shit was. Being treated as mentally ill and being perceived that way by myself and my peers did nothing to help me, especially since it only helped to reinforce the idea that the lifelong physical health problems which got worse during my school years were nothing but "anxiety" and that consequent declines in my mental health could be attributed to my earlier mental health issues and all the medical fraud helped to confuse the shit out of doctors.
I think the mental health system is a sham and that it doesn't have proof it treats the problems it claims to treat, and if anything the rise of suicidality over the last few decades as scholastic mental health has become more common as well as increases in self-reported, parent-reported, teacher-reported, and physician-reported mental health problems among students proves its somewhere between totally impotent and actively harmful. The final goal of increased mental health interventions is not getting to a point where nobody is sick anymore, it's to create more patients.
The biggest thing that pisses me off is that it's rarely measured if scholastic mental health interventions work, they are just ASSUMED to be positive without evidence. Nobody gives a crap about iatrogenic effects.
The episode of King of the Hill "No Bobby Left Behind" speaks to me: https://kingofthehill.fandom.com/wiki/No_Bobby_Left_Behind
Whether the harm outweighs the good is up for debate. In very affluent neighborhoods, lots of the kids are in therapy already. In lower-middle class or poor neighborhoods, the kids are probably resistant to it and it is, indeed, stigmatizing. So how much good can it possibly do?
https://help.welltory.com/en/articles/3973614-long-exhale-fo...
I was taught this method first at a Kempo Karate dojo in the late 1980s, it was also in Yoga books. It is associated with
https://en.wikipedia.org/wiki/Vagal_tone#Respiratory_sinus_a...
and well established scientifically today.
If you're having an asthma attack, then of course focusing on breathing won't help, because the breathing issues are what's stressing you out. Whenever I've seen focused breathing, literally never have I seen "and it's great for people having an asthma attack!"
Filling up your car with gas is normal and necessary. Would you still try to fill up your car with gas if it were on fire? And then complain that filling up one's car with gas is dangerous and didn't help that one time your car was on fire?
Even if you have an objective diagnosis and a rigorously developed treatment, you'd expect far less than 100% success; and you'd also expect side effects and other harm that happens with almost any treatment.
Given that mental health is much less rigorous than some other areas of medicine (because it's hard to make it rigorous), then its compounded by misdiagnosis and treatments where we don't understand the effects.
Afterall, people have choked to death on salads.
https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...