Tuesday, 23 September 2014

Side Effects

It was my best friend's fortieth birthday. My own is fast approaching. We were walking through our local department store, looking at the fancy face creams. I am a product junkie and spend far too much money on jars of gunk that never live up to the promises on the lovely, embossed cardboard boxes.
My friend is a pharmacist and in a successful effort to avoid temptation I asked her "Is it true that if any of these worked they'd be on prescription?".
"Absolutely" was the reply. "If they did what the claim to do [reverse skin damage, slow cell degeneration] that'd be a medical effect and there are no effects without side effects."

When we think about psychotherapeutic interventions in education, we shouldn't seek reassurance in studies showing that this therapy or that therapy is effective in a clinical setting. Rather any such effectiveness should be taken as a warning that such an intervention is probably unsuitable in schools. School is not, and never will be, a clinical setting. If something is potent enough to have a measurable and  predictable effect, then its effects on the general population (who are fine) may be, on balance, negative. Its effects on the vulnerable, when administered outside a clinical setting by people whose training is in an entirely different discipline, may be catastrophic.
Nick Rose (@turnfordblog) has written recently on proposals to utilise Mindfulness Based Cognitive Therapy on a widescale basis in UK schools. Rose writes on his http://evidenceintopractice.wordpress.com blog that:

" My concern is that CBT and mindfulness are forms of psychotherapy which are being gently scaled into schools in the name of developing ‘resilience’ or ‘well-being’....Part of the push towards psychological interventions in schools (I’d include ‘Growth Mindset interventions in this list) is to develop children’s self-regulation strategies and improve attainment. If the suggestion was to offer low doses of a therapeutic drug to help children in school, teachers would be up in arms – yet, we appear remarkably blasé when low doses of ‘talking therapy’ are being offered. If the aim is to improve well-being, then there are still important questions to answer. Do all children need psychotherapy to maintain their well-being within school? How do we screen for the children who would benefit from a psychological intervention and which children would not – and most importantly, children for whom it might have a negative effect?"

I don't have experience of MBCT but to me it seems entirely sensible. I have never found the traditional CBT description of thoughts as "negative" convincing. I have met people in hospital and elsewhere plagued with the conviction that if only they could control and eliminate these negative thoughts then they would be restored to health. Except such control and elimination are impossible.
My own experience is with Dialectical Behaviour Therapy, a forerunner of MBCT. It is currently being rolled out around Ireland within a mental health care setting, a move which I wholeheartedly welcome. I was dismayed, however, to hear Marsha Linehan, speaking at UCC last year, refer blithely to plans to extend DBT "into the schools".
Those who work in mental health promotion, like those who work for campaigns for sexual health, road safety and drug-abstinence often see schools as a golden opportunity. All those malleable young minds with nothing else to be doing all day besides absorbing healthy messages like "just say no to drugs/ binge-drinking/ unsafe sex/burning fossil fuels". Nothing new here.
The move to embed mindfulness in the curriculum is a new departure, one that sees the lines between education and mental health-care provision blur to obscurity. This is not psychotherapy in schools for well-being, this is psychotherapy in school for learning. Learning and well-being are increasingly seen as one and the same thing. The highlight of this year's Feilte Irish Festival of Education is touted as a panel discussion of Well-being featuring educationalists and teachers such as Bressie and Eoghan McDermott. It's the Mind, Body, Spirit Festival brought to you by the Voice of Ireland and sponsored by the Teaching Council.

Interventions like mindfulness are seen as entirely benign, to be rolled out in school by teachers with little or no training or else by outside facilitators. A private enterprise, Bright Sparks Coaching, is offering a two-hour course that will allow teachers to "understand [mindfulness'] application in the classroom". The work of this company is supported by education centres and they have conducted "mindfulness training" in schools. Their website states
"The ability of children to be able to self regulate has a profound impact on their ability to learn. It has been proven that negative & destructive emotions inhibit our ability to learn and hold information. It is therefore an invaluable asset to teach our children the ability to recognise and manage their emotional lives. Furthermore it is now understood that our brains are elastic and continues to grow, develop and shape itself throughout our childhood and adolescents. During the process of growth, our brain has the capacity to be shaped and wired in a way that supports the development and activation of Pre Frontal Cortex, which is responsible for the integration of all areas of the brain that create optimal health."

Brain words and neuroscience aside, the idea that this intervention can sort out children's pesky emotional complexity and "negative emotions" so they can learn better and faster is naïve in the extreme. The reference to "negative and destructive emotions" is also a red flag to anyone even slightly acquainted with mindfulness, as one of the primary aims of the practice is to not judge emotional states or classify them as harmful. The first item on a list of the benefits of mindfulness training in schools is that it "saves time". Yes, it's annoying how much time and patience goes into teaching and learning. How convenient it would be to have a class of thirty little Zen masters with rapid-growth mindsets and bullet-proof resilience.
For most students the worst outcome of mindfulness training in school-time is the opportunity cost of educational time. Some may even derive modest benefits, but those benefits have to be weighed against the potential harms. What about students who could benefit the most from mindfulness training? Shouldn't they get the training in school, where their lack of mindfulness is having an undeniable impact on their education? Not if you consider the reasons that children come to school with a mindfulness deficit serious enough to be interfering with their learning.
If we look at where mindfulness interventions have been successful clinically, we can see that a mindfulness deficit is associated with trauma, depression, eating disorders and other serious issues. Linehan's "Skills Training Manual for Borderline Personality Disorder" reports that approximately 75% of the patients who met the criteria for the original intervention had been sexually abused. Emma Seppala at Stanford University recently reported meditation as a successful intervention for combat trauma. This is potent, serious stuff and we should, as Rose, suggests, no more think of applying it in schools than we would hand out psychoactive drugs in the canteen.
Linehan writes "Mindfulness to current emotions means experiencing emotions without judging them or trying to inhibit them, block them, or distract from them. The basic idea here is that exposure to painful or distressing emotions, without association to negative consequences, will extinguish their ability to stimulate secondary negative emotions". Eliciting painful emotions while protecting vulnerable people from their negative consequences is a hard task for a trained psychotherapist. Eliciting painful emotions in an SPHE discussion, or encouraging them to surface in an RE guided meditation, and sending a child off to Maths when the bell rings borders on cruelty. Allowing mindfulness trainers (no matter how vetted and qualified) into schools to offer psychotherapy in a whole-class setting is irresponsible. We must remember, always, that the students we know are at risk are not the only students who are at risk.

As my friend pointed out, if things work they need to used judiciously and their supply controlled. I believe that mindfulness based interventions can offer much to young people who need them, and that an important benefit is that it can enable them to be present (physically and psychologically) enough in school to gain an education that will give them the same life chances as their peers. But teachers are not the people to do this, and school probably isn't the place to do it in. Mindfulness for teachers themselves is probably a good thing and I don't doubt that a mindful approach to teaching can be as useful as a mindful approach to any job. But implicitly fostering mindfulness in the classroom is quite different from didactically teaching its precepts as scientific fact, or attempting lift-all-boats interventions that are ultimately amateur, unstandardized and potentially harmful.

Postscript: I wrote the above post before Feilte 2014 which featured Ann-Marie Ireland from www.chilloutireland.ie. ChillOutIreland appears to be a similar business to Bright Sparks Coaching, but has achieved much greater influence and acceptance within Irish education.

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