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.

Students, Pupils and Learners

I've been looking at www.juniorcycle.ie instead of getting a life and enjoying the holidays. I mean, I am enjoying the holidays but feel compelled to season this enjoyment with the piquant sting of looking at where Irish education is headed. I blame the Twitter. We really should have a gentleman's agreement to suspend school-related content, at least for August.


One thing -  among many - that strikes me about juniorcycle.ie is the recurring reference to students as "learners".  For example:
-"learners' overall well-being must be supported alongside their intellectual development."
-"This skill [working with others] helps learners develop good relationships and to appreciate the value of cooperating"
-"The learner's junior cycle programme builds on their learning to date and actively supports their progress in learning"


I've been asking myself where I stand on this. On the one hand, I'm all for it. It's not ungrammatical and it reinforces the idea that that's what school is for: learning stuff. Learning is also something students do for themselves, so the emphasis on learning and learners should, in principle, recognise the responsibility of students for their own effort.


So far, so positive. A little doubt niggles away at me that the intended benefits of renaming students as "learners" may soon be lost. I'd say it'll be lost the day they start referring to themselves as "learners". For example we might soon hear "We, the learners, demand that our individuality be recognised and catered for through personalised learning" or more likely "We, the learners, object to the removal of Lucozade from the vending machines".  When we make "learner" a synonym for "student" the word no longer implies that the learner is doing any learning. Soon all you will have to do to be a learner is enrol in, and perhaps attend, a secondary school. I can think of a few pupils I've had, particularly early in my career, whose school life was unfortunately not characterised by learning but by other activities.


You might say the same about "student", which implies that the person does some studying. Again, this term is presumptive but nowhere nearly as much as "learner". You can study without learning anything, if you study badly. For example you could read a chapter of "Discover History" ten times the night before a test. You'd have studied but it's unlikely you'd have committed anything to your long-term memory.  I would say, in fairness, that all those in secondary school do some study, at some point. If you're studying you know you're studying but if you're learning you don't necessarily know you're learning. I don't mean this in an "I'm having so much fun in this engaging, group activity that I didn't notice the stealth fact-attack". I mean learning happens at a subsensory level and we only really know we learned something when we try to remember and succeed. "Trying to remember" itself could be a sign of partial, or imminent, forgetting.
Learning is hard. It takes a lot more than just showing up for school (though that's a start that far too many are failing to make).


When I was in school "students" attended third level. We were "pupils" as we were still in prison at school. As far as I know that's how children in primary school are still referred to. I can see why we've moved on from there as the term, at least to my mind, does not recognise the input a person should, by the time they're a teenager, be able to put into their own education. I'm sure there was an analogy in "First Aid in English" that said "Teacher is to pupil as shepherd is to sheep", or "Pupil is to teacher what shrub is to gardener". So I'm fine with "student" as long as it means secondary student and not "young adult who's entitled to wander in with a take-away coffee and take an à la carte approach to the timetable".
I've noticed that I've begun to use "learning" quite a bit, especially in language classes where methods of  acquiring and practicing new vocabulary are taught as a matter of course. I talk about becoming an "effective language learner", as acquiring another language requires effort and technique. But the key word here is "becoming".  MFL is one of the few areas that the phrase "learning to learn" has meaning. The skills of language-learning are almost infinitely transferable, a reason why there's absolutely no need to worry if a student chooses a language other than their parents' preferred option.

Really though, "learning to learn" is a misused aphorism that confuses "learning to drive" and "learning to swim" with what students do in school. Students in school learn  (hopefully) and the more you know, the easier it is to learn new things. "When it comes to knowledge, those who have more gain more" Daniel Willingham writes in "Why Don't Students Like School"  There are more and less effective ways of studying but learning itself, thankfully, is an innate ability of the human brain. You don't need to learn to learn, any more than you need to learn to think
"Learning to learn", if interpreted as it is here by former Minister Ruairi Quinn at 2 minutes in, has the potential to seriously damage education. The phrase can be used to suggest that it doesn't matter what students learn in school as long as they're learning the skills of learning. Quinn for example states that "learning to learn" has taken over from "learning to remember". This new definition of learning does not seem to involve memory, which is extraordinary. Students can leave school with no knowledge as long as they have acquired the skills of learning. Of course, as teachers, we know this is nonsense as you can't acquire the skills of learning by any other method than practice and if you've learned something you remember it. Nevertheless the concept of learning without remembering persists.  Take today's call from the ESRI, for " a greater use of project and team work to equip young people with the type of skills they need for lifelong learning and the labour market". Whether it's Chinese or Klingon, programming or origami, European geography or the Enneagram- so what? School is really only an apprenticeship for the adventure that is life-long learning. As such it doesn't really matter what learners do or if they do it badly. We'll allow for false starts and abortive attempts. If a child does a project on earthquakes and still can't tell the Richter scale from the Beaufort, does it really matter once he or she has selected an area of interest, done some collaborative research and produced a nice multi-media presentation? After all, we don't have teenagers in charge of monitoring these things.


Does this change in language matter? I'm not sure. I know that teaching in a single-sex school obviates the need for a term for our charges as we universally refer to them as "the girls", and our counterparts in the other-gender school across the road refer to "the boys" or"the lads". Colleagues at mixed schools do tend to use "students" more often. Very few use "pupils". Will "the learners" catch on, outside of official literature? I think it could be case of the Department attempting to make something so, by saying it is so.  If we phrase things so it sounds like children are taking responsibility for their own education, they'll step up to the plate. And if we call all the young people enrolled in our schools "learners", well they must be learning something.

Reading as a Factor, or Reading as a Product?

We have been told for a few years now that "teaching" is a bit of an old-fashioned idea. It was a kind of custom prevalent in less civilised times, but will soon be relegated to its rightful place. It won't be eradicated but will exist beside the much more important "learning". Like many teachers, I've had the pleasure of a Whole-School Inspection. Ours, which took place last year, was of the MLL variety. That is it looked at the quality of management and teaching in the school, and also at the quality of "learning" that was going on. I have sat at a conference where a school principal asked everyone in the room to consider, then pair n' share, what we felt good learning looked like. I've attended a Learning Schools Project event where the chairman of The Teaching Council admitted that he doesn't like talking about "teachers" and how in the future, we will distance ourselves even further from this arcane idea. "Teaching" to "teaching and learning" was only the first step and in future we will refer to "learning and teaching". I think there will be a fourth step and can guess what it is.
Talking about learning is important, and the more we know about the subjective experience of learners, the more it appears we are mistaken in our belief that they hear what we think we're saying. Recategorising pupils and students as "learners" is welcome if it in recognition that their own efforts are as crucial to their achievement as the is the quality of teaching they receive. But sometimes I feel this focus on "learning" is less about student behaviour and more about a profession that is gradually assimilating public opinion that sees teachers as irrelevant and possibily obsolete.
I bring this up because I've been reminded lately of a thought I had following an inschool talk ( you know the ones) that informed us that we needed to stop thinking we knew more than the learners did, and that we had to move towards being "guides on the side", that everything now was on google anyway and that we would need to be developing twenty-first century skills. Imagine if a UFO landed outside a bingo hall and that was the aliens' first experience of human society. Well this was our first experience of EduSpeak Bingo and we didn't even recognise it, let alone have our cards and markers ready.
 "Wow" I said after the speaker had departed, "Now I know where I'm going wrong with my Ordinary Level fifth years."  I didn't really think I was going wrong at all. My OL fifth years were a lovely group of co-operative individuals whom I taught in the library for want of a free classroom. While good-natured and diligent, self-starters they weren't and motivating and inspiring them could be a challenge. "Wow," I went on " I know now that I should just stay in the staff room. In no time at all they'd be tearing the books off the library shelves, eager to teach themselves all about poetry, and then they'd be so excited they'd start writing essays comparing the books they'd read".
Now we did use the library, and I'm a huge believer in school libraries. They are a fantastic resource and should be funded, supported and used. Every few weeks the students would take out books. We used to spend time in class reading silently, me along with them and I'd try to get a discussion going about which books they liked and which they'd recommend to the others. It was a struggle but a worthwhile struggle and I wasn't overly bothered that the first chapters of all the books were much more dog-eared than the final chapters. The library was for pleasure, and I wasn't going to dilute that pleasure with admonitions about finishing what you'd started or seeing things through to the end.
Now I learn that my school is to introduce "library classes" across the school from next September (as we teachers are fond of calling the third week of August).  We are not alone in this: I know of at least two other schools in the area that are introducing, or have introduced, such classes. Students will be obliged to keep a log of their reading and it is yet to be decided if further proof of finishing the books will be required. The students will be supervised during this time in the library by a teacher. The rationalisation is that by being invited to read for pleasure during the school-day, students will become hooked on reading and will read for pleasure at home as well. The motivation for the initiative is to promote reading, to raise standards of literacy and by doing so raise academic standards because we all know the French got it right when they said "Un enfant qui lit, est un enfant qui réussit" (a child who reads is a child who succeeds).
I'm delighted with this, as it means I will no longer have to give up precious English class time down in the library. But I wonder if we might have  a bigger impact on the literacy of our students by adding not a library class to the timetable slot - that has become available due to the withdrawal of a one-class-a-week subject from the curriculum - but a regular class. A class where they would learn about a subject, under the expert guidance of a specialist teacher in that subject. It could have meant an extra Maths class, or an extra Modern Foreign Languages class or a History or Geography class. I would love an extra English class of course, but the school is thankfully already generous in our allocation.  There was a time when schools could include study classes on the timetable; a time for students to get ahead on their homework and benefit from an extra  forty minutes of evening freedom in which to watch television, walk the dog, chat to their siblings or even read.
Study classes are now verboten, as all students must be gainfully engaged in active learning for the entire school day. So why is it okay for students to go the library and read books? It is because of the belief that reading books is an important factor in academic achievement.
Last year a colleague and I attended the first round of in-service training linked to Junior Cycle English. The facilitator was adamant that silent reading, and the promotion of "reading for pleasure", was worthwhile and should be a priority for schools.  Her rationale was that studies had shown that children who read a lot of books for pleasure are likely to achieve more academically than children who don't do much reading. She didn't have any of these studies to hand. (I have noticed that, as humanities graduates, English teachers are expected to believe anything if it's prefaced by an authoritative "research shows....".) A few present tried to argue that there all sorts of reasons that  reading and academic achievement go hand-in-hand. Their reasoning was that correlation is not causation and having lots of books at home, fewer televisions and more interested parents was likely to lead to both more reading and more learning. They got nowhere as promotion of reading as a strategy to raise literacy and facilitate achievement is now Policy. The Specification for Junior Cycle English has a specific Learning Outcome that students will "engage in sustained private reading as a pleasurable and purposeful activity".
I remained silent because I couldn't formulate my own objection. On the one hand, I believe part of the appeal of reading promotion stems from the covert realisation that the Specification for Junior Cycle English does not cater for the able student. I don't mean students on the G&T spectrum, I mean any student of even slightly above-average ability. An emphasis on private reading allows these students to make progress at their own rate as they can read books more suited to their reading age and interests in addition to the material covered in class. They can read whole books rather than excerpts, and can read long novels. (I'm not suggesting that long novels are better or harder than short ones, just that texts read in class will now be short novels only as the stipulation is to read so many).  By making the teacher responsible for the private reading for pleasure that students do at home, it appears that these students are being challenged and developed.
However, my greater objection is that my friends may have been mistaken in their insistence that "correlation is not causation". What if there actually was a causative link between reading and academic achievement? But what if that link were in the opposite direction than that supposed by the SLSS and the NCCA? What if those children were good readers because they had learnt lots of stuff, including the meaning of lots of words and how words work? How then does private reading for pleasure foster academic achievement? Might it be the other way around? As I listened to the facilitator enthuse how private reading would expand the horizons and aspirations of unmotivated students and how reading would lift children who had more electronic devices than books in their bedrooms into the realms of the "word-rich", I got a funny feeling in my stomach. Somewhere, something was missing. I had been an avid reader as a child. and as a young adult and I was able to read hard books because I knew enough words and I'd learnt enough about history and other subjects to make sense of what I was reading.
I knew from reading Doug Lemov's "Teach Like a Champion" that enthusiasm for reading as a panacea for low achievement was not universal. It was this blog-post by David Didau however, that articulated and shed light on my misgivings.
On the blog, and again in his practical book, "The Secret of Literacy",  Didau writes the following about silent reading as a school practice:

...Pupils who are good readers experience more success, which makes them want to read more. As they read more, they become even more successful at reading. their vocabulary and comprehensions grows. Hey presto! a virtuous circle. Readers who struggle with decoding or who have poor vocabularies are unlikely to want to expose these weaknesses by picking up a book. they get much less practice and the gap opens and widens. Silent reading is a lovely experience for the word-rich...For the word-poor it becomes an exercise in trying to disguise the fact that they're holding the book upside down....Silent reading looks like a good idea because it gives pupils the space and time needed to read. What it doesn't do is help poor readers become more fluent, and is therefore doomed to failure."

"Doomed to failure" seems a bit strong but is justified if the promotion of private reading is considered a device to lift literacy across the board. I have heard reading classes credited with increasing vocabulary but Didau claims elsewhere that a reader must understand at least 95% of the surrounding content to be able to infer the meaning of an unfamiliar word. Thus reading becomes a vehicle for the Matthew effect, whereby the rich become richer and the poor become poorer.

So how far do the library classes, wherein students choose their own books and read them under the supervision of a teacher who may or not be a teacher of English enforce the Matthew effect? Let me say first of all that the wealth and poverty alluded to in the Matthew effect are not quite analogous to economic wealth and poverty. Vocabulary is not a commodity. If  a class encounter a new word and only three students learn its meaning, their learning is not tenfold what it would be were the whole class of thirty to learn it.
However, if we say that the most capable students learn the most in library class, is this at the expense of their classmates? It is at the expense of some, who would be better served having a normal class. And the learning in library class is at the expense of students who are find reading exceedingly difficult. Being given free rein in the library is an experience of confirmation that reading's too hard and not for them. It comes down to proportions and how confident we can be that a significant number of students has reached a reading level where they can benefit.
I am not against library classes, along as certain caveats be observed. One is that the teacher in charge of the class is there not just in a supervisory capacity but encourages the readers and when necessary, nudges students towards books that are hard enough to challenge or easy enough not intimidate. The other is that these classes be targeted as opportunities for Resource or Learning Support provision where appropriate. And lastly, library classes should not be a given on the timetable but should be reviewed annually and revert to normal classes if appropriate.
School management everywhere are under pressure to max out teachers' timetables before another teacher can receive as much as a minute's employment. Cuts to the pupil-teacher ratio and the abolition of allocations for most special programmes mean that principals and deputies have less and less wriggle-room. Library classes, or any class where a teacher can be deployed regardless of subject speciality, can make things slightly easier.
Do we view reading  as a factor of achievement, rather an achievement in itself? A factor that has been weighed and valued, along with background and motivation, and now it seems to be ranked above teacher instruction. I prefer to think of reading as a product. I don't mean "product" in its industrial sense, but in the sense of the eventual outcome of our endeavours. I want my students to achieve academically, I'm in favour of the retention of an exam system and I want my students to do well in their exams. I do not, however, see encouraging reading as a factor in their success. I see what they've learned in the process of studying for exams as a factor in their reading development, a development that can continue long after they have left school.
So when students go the library, as they will be doing for forty minutes every week, I don't want them to see what they're doing as an academic supplement. I'd rather they see it as a taster for the freedom they will have, after school, from the constraints of  lists of prescribed texts and enslavement to the teacher's preferences.  And I wish we'd stop telling children, and their parents, how important reading is. "Important" is taken to mean "important to learning" when really it is learning that is important to reading.
Reading, at least to my biased English teacher's mind, is important to life. And life is much, much more important than exams.

We Need to Talk About Mental Health

Next month is May, mental health awareness month. Already green ribbons are appearing in my Twitter feed and my blood pressure is starting to rise.  I originally called this post "why I won't be wearing the green ribbon"  but then I looked at the website www.greenribbon.ie and thought, if all you're looking for is people to talk about mental health, then I'm up for the challenge. I think we do need to think about mental health, but we need to think critically about what we're told, and we need to be scrutinise how the mental health agenda is promoted in schools and to young people generally.

At least they remembered the apostrophe

I can't understand how so many people, including people whose views I normally admire, are so gung-ho on the notion of mental health and the need for mental health awareness campaigns. How can I be so wrong and so out-of-step? Don't I care about how many people are dying by suicide? Don't I care about the numbers of children in adult psychiatric care? What about stigma: don't I want to reduce the stigma around mental illness? Aren't these all important issues? I do care, what I don't do is share the conviction that mental health awareness campaigns are the answer to any of these issues.

Suicide, adult units and stigma
Reducing the number of people who die by suicide is a hugely complex area, as the reasons people take their own lives are myriad and all these reasons are have to be dealt with separately. I am not an expert in this area so will confine my comments to suicide among psychiatric patients and recent psychiatric patients as this was the category I fell into at the time of my own suicide attempts. Better services are key, and by better I don't mean "more". In fact less is often more; in particular the practice of prescribing anti-depressants to those aged under twenty-five must be curtailed as much as possible.  By better services I meant services whose goal is to minimise the long-term contact the patient has with mental health services over his or her lifetime. A real recovery where patients leave the system altogether, rather than a recovery approach that orients them to a lifetime of patienthood. It is good to see DBT being rolled-out nationally and this, I believe, is a step in the right direction. I take issue of course with the Irish Times' inaccurate description of DBT as a "new treatment". It has existed, in more or less its current form, for the past twenty years. Imagine if the HSE suddenly made a life-saving drug available to Irish patients after it has been on the market and proved to be safe and efficacious in other countries for twenty years. Would we call that drug a "new drug"?

While the admission of children to adult psychiatric units is certainly a problem, we have to avoid the simplistic conclusion that the country needs a raft of dedicated child-and-adolescent inpatient psychiatric facilities. Hospitalisation should be a last resort and if it is decided there is need for such a facility I would favour a national centre of excellence rather than have children treated in small, paediatric units in adult facilities.

What about the stigma surrounding "mental health"? I don't like the word "stigma" in this context as it suggests something attached to the sufferer. "Prejudice" might be a better word, as in the public are prejudiced against people with mental health problems. I certainly experienced prejudice, most notably from the college radio station who told me I couldn't volunteer there any more because I was "a psycho". I would call them from the locked psychiatric ward several times a day, begging them to take me back. I can see that my enthusiasm seemed bizarre under the circumstances and also that the fact I was heavily medicated and locked up was all the proof they needed to confirm their fears.  In my own experience the more educated people believe themselves to be in relation to mental health, the more prejudiced they were towards me, and the most prejudiced of all were the health-care professionals tasked with looking after me. To me, improving services is the most vital step in combating stigma. There is no point in Kathleen Lynch giving out about how we should be nice to the mentally ill when her own department denies "voluntary" patients the right to sign out AMA,  and insists on the right to administer ECT to patients  "able but unwilling" to give consent.

What about educating the public? Mental health campaigners put great store on this. We are all familiar with "facts" about mental health such as that one in four of us has a mental health problem, that everyone is vulnerable to mental health problems, that mental illnesses are all real illnesses the same as cancer and heart disease, that your GP is your first port of call if you suspect you have a mental health problem and that there is an epidemic of mental illness among young people. You may also know that there are safe and effective treatments for most mental illnesses, that will not cure you, but will make life more manageable and that help is always available. But are these facts beyond dispute or do they just reflect current, dominant thinking among journalists and health professionals? To me, the science of mental health is not yet advanced or conclusive enough to warrant the attention and column inches it receives. Take for example, the role of self-esteem in mental health. Raising self-esteem continues to be a key objective of mental health promotion and the phrase features heavily in last year's Well-Being in Post-Primary Schools Guidelines. But there are some psychologists- such as Kristen Neff in the video below - who argue that our obsession with raising self-esteem  is partly to blame for the continued prevalence of bullying in our schools.

Promoting Positive Mental Health
My past life, as a psychiatric patient, and my current existence as a teacher converge on the issue of mental health education in schools. To many people this is a no-brainer. Surely if we can get in there, into schools where young people are, after all, a captive audience and educate the hell out of them around mental health, all will be resolved. I mean, on the one hand they can learn the scientific facts around mental illness and decrease their prejudice. We can expose them to real life stories or even class visits by sufferers of mental illness, thereby increasing their empathy and reducing stigma. We can educate them about the importance of doing things to protect their mental health, like eating well, exercising and reducing stress and also instil the importance of help-seeking behaviours. If we could only improve their emotional literacy, teach them how to look out for each other and how there's no need to fear mental illness, or the mentally ill.

I've always felt queasy about this sort of thing. Firstly I agree with Daisy Christodoulou that before we commit content to the curriculum we need to be careful that there is consensus among experts that the information is correct. To me, almost all of the discourse around mental health is not there yet. That's not to say that this theory or that theory is right or wrong, just that I would far rather students spent more time studying biology and chemistry, and that they would develop empathy through the time-honoured practice of reading fiction. Also, we have to ask questions about who is delivering this content. Recently there has been much justified scrutiny of what kind of groups are delivering sex education to Irish teens. I think similar scrutiny must also be applied to the many groups, voluntary and otherwise, who are giving mental health presentations in Irish schools every week. For example, World Mental Health Day is celebrated every year in Cork by a conference where in recent years students have received lectures such as one on nutrition by Patrick Holford.

Much mental health promotion is indistinguishable from health promotion generally. Activities like sleeping, exercising and eating healthily might be promoted as part of looking after your mental health. But why would we believe the students will do these things to protect their mental health but not be motivated to do them to protect their physical health? If we really believed mens sana in copore sano why bother with mental health promotion at all? I would argue that we don't need the mental health tagline and it is enough to educate students about how their bodies work, including the need for sleep and the benefits of exercise.

The Fear
Mental health promotion goes beyond this and promotes what I can only call fear. The fear is the idea that your own mind is probably faulty and not at all to be trusted. Your emotions are not a guide to your situation but instead are alien things that must be managed and suppressed in the case of anger or vented in the case of sadness. Students are still being taught about "negative" and "positive" thoughts, even though one of the first interventions of mindfulness and DBT programmes is to encourage patients to stop labelling thoughts and feelings as negative or positive.  Mental health promotion often calls itself "positive" as in positive mental health. But this adjective is misplaced. Their view of the human subject is anything but positive. In fact they believe in what Ecclestone and Hayes call "the diminished human subject."

Young people are actively encouraged to see aspects of their own personality as maladaptive and possible pathological. Take this campaign for SpunOut.ie , entitled "Ditch the Monkey". The monkey in this case is the young person's own negativity. Negativity which is wrong. We must all be happy! We're sure that all teenagers invite all their friends to parties, just like in junior infants. No teenager ever has to sit at home on a Saturday night because being a teenager is all about having fun, fun and more fun.

They also learn that a healthy teen is a confident teen. Better iron out those insecurities and develop a healthy body-image and high self-esteem. This is despite research, as referenced here by Kelly McGonigal that "stress, anxiety and self-doubt are not necessarily a barrier to your ability to succeed." In fact, they're not even a problem. What about exam stress? Again according to McGonigal, not a problem. "You don't need to get rid of it and it's not a sign that something's going wrong". In fact academic pressure is only a problem when it is fear-driven and the biggest fear driving students is fear of letting down their parents. The problem stressing out students is not lack of mental health awareness. The problem is unrealistic and/or unhelpful parental expectations. Another fear students have is not getting into a particular course. I think all teachers are familiar with students who become fixated on courses for which the points are beyond what the student will realistically achieve.  This is a harsh lesson for a young person to learn, particularly a young person raised on positive, cheerleading messages like "if you believe it, you can achieve it", "you can if you think you can" and "no negative thoughts allowed".

There are attempts by mental health promoters (or "ambassadors") to square this circle with slogans like "it's okay not to be okay". The idea seems to be to worry young people about their mental health but not to really scare them.  Along with the checklist comes the assurance that if they don't make the mental health grade, help is available if they just "reach out". No-one seems to have any qualms about the effects on young people of entering into the mental health system. Even while those who work in the system complain that it is stretched to capacity, it still advertises for clients.  Any reluctance among young people to engage with services is attributed to "myths and stigma" rather than mistrust of the service or concerns about its quality or relevance.

I speak from my own experience of how easy it is to be side-tracked into a futile, expensive and traumatising quest for better mental health. I was a sucker for the kind of things now being taught in classrooms all over Ireland. Time and again when a crisis would hit my life I would turn to psychiatry, my GP, my counsellor-du-jour  and every time the approach was the same; I needed to fix myself. I needed to improve my mental well-being, normally either by taking medication o alter my neurotransmitters or by talking endlessly about my early life experiences, and then life would improve.  I know I was not alone in this experience. Others have told me they had similar experiences of seeking help and finding themselves mired in the quicksand of the mental health system. The only thing that actually worked for me was radical acceptance and mindfulness of what actually was and is. The less time I spent worrying about, and working on, my mental health the more I was able to achieve and do in my life. And the more I did, the better I felt.

But what about people who really are ill? I'm not denying that these people exist. The brain is an organ like any other in the body and must be susceptible to malfunction and disease. I can also appreciate that many people benefit from psychotherapy, particularly those who have suffered trauma and abuse. But the mental health agenda in schools does not deal with illnesses that will surface no matter how much we mind ourselves. Students, and the public, love inspirational happy endings and remain ignorant of lifelong struggles with psychiatric illness. Neither does mental health awareness tend to deal with the trauma and abuse that so many children suffer. From talking to the many people it has been my privilege to encounter in inpatient and outpatient units throughout the years, I can definitively say that mental health problems do indeed discriminate, despite what we're told, and are much more likely to affect individuals who were abused as children, neglected as children, were exposed to violence in the home and/or who grew up surrounded by addiction. No amount of mental health awareness can counter insufficiencies in our child protection system.

The Worried Well
So while mental health awareness does nothing for children who need help, it risks creating a cohort of the worried well. These are anxious students, or students going through a rough patch, who are encouraged to pathologise their experience and "seek help." For some students, being asked to think about their mental health leads them down a path of anxiety, where they miss out on the real education that would allow them to achieve academically and live independent, fulfilled lives. Mental health issues can seem like a get-out-of-jail free card to stressed teenagers but focusing on their mental health might be doing more help than good. Repeated attempts to "ditch the monkey" will fail if the monkey is an integral part of their personality. Here is another quote from McGonigal

If we put our attention on inner experiences..and we try to control these inner experiences it almost always backfires. It tends to strengthen those experiences and we feel even more self-doubt and more stressed and more anxious...energy gets pulled away from the energy we need to simply take action in the direction of our goals.

I have written about people who take the message of mental health awareness to heart and start to doubt their own mental health status. There are also students whose faith in their own mental health is bolstered by what they learn and whose already robust self-esteem is further enhanced. They also are susceptible to the idea inherent in Staying Well that mental health can be conserved if we only mind ourselves. I fear that this idea must inevitably lead to a lack of empathy with those who didn't follow the programme and didn't stay well.  I teach Senior Cycle English and one thing I have noticed in the last few years is pupils frequent lack of sympathy for the poet, Sylvia Plath, who took her own life. Why did she not just ask for help? they wonder. Why did she give in to her negative thoughts?

I would hope that the emotional development and well-being of students is important in all schools and to all teachers. I would also hope that where students develop mental illnesses they are treated with kindness and understanding by staff. I would hope that staff members are approachable and that listening support is available in schools. We can do all these things without putting mental health on the curriculum.

Kelly McGonigal addresses education-related stress at around seventeen minutes in.

Marsha Linehan at UCC. "Real Change is Possible"

Last Friday I attended Marsha Linehan's lecture at University College, Cork.  Dr. Linehan is Professor of Psychology at the University of Washington, Seattle and is best known as the originator of Dialectical Behaviour Therapy. She has recently opened up about her own struggles and how they led her to develop the therapy, which is largely based on mindfulness, acceptance and the facilitation of  change.

Professor Marsha Linehan

DBT and me
It's more than ten years ago that I came across the work of Dr Linehan. I had been hospitalised in St. Patrick's in Dublin and had been held for five days in the euphemistically titled "Special Care Unit". I took the opportunity that the nurses' station was unmanned to have a peek at my file, that was lying on the counter. I got the shock of my life when I saw that the box marked "diagnosis" was marked "borderline personality disorder". At this stage I had been a mental health patient for eleven years and a psychiatric patient for six years. This was the first I'd heard tell of borderline personality disorder. I was vaguely aware that such a diagnosis existed but knew little else.

I came down to Cork that weekend and took myself to Q+2 and the medical section of the UCC's Boole library. I took a couple of books on borderline personality disorder and started to read up but it wasn;t until a second visit a couple of weeks later that I took out Linehan's book "Skills Training Manual for Borderline Personality Disorder".

This slim, A4 book, comprised mostly of photocopiable worksheet changed my life, as it has changed the life of thousands of others.  The change was twofold. On the one hand, for the first time ever, I felt some-one got me. Up until that time my diagnoses had been schizophrenia, anorexia or depression (although my last consultant in St. Patrick's did concede that he could find no evidence I suffered from any of these conditions). I had read books on all these conditions and while some of it fit, most of it didn't. Linehan's descriptions of the borderline patient struck a resounding chord. So did her discussion of the invalidating family. Looking back, I don't think I fit the prototype nearly as neatly as I thought I did, and of the three family types Linehan describes, I'd say mine fell mostly within the "Normal" parameters.

The essential was that here was some-one saying that the way I was acting was understandable and explicable, instead of merely deviant, mischievous or psychotic. And she offered hope that I could change. Change had never been a possibility within my treatment within the psychiatric system or from any counsellors I had attended, There was a polarity in their attitude towards me. On the one hand I was nuts, seriously ill and in need of constant medication and frequent hospitalisation. On the other, I was totally in control of myself and should just do what I was told and stop being such a nuisance. There was no future. There was no reality. The problem, as far as they were concerned, was my reluctance to obey, to concede and to comply.

DBT Venn diagram

Here, in DBT I found tools that I could use to make things better.  The whole thing was structured around four key skills : mindfulness, interpersonal effectiveness, emotional regulation and distress tolerance. I followed them as closely as I could. I made homework cards for myself and completed them, even though no-one ever corrected them. I photocopied all the worksheets and filled them out religiously. I copied sheets like "Cheerleading statements for Interpersonal Effectiveness" and pasted them on the inside of my bedroom door. I made myself do something daily from the Adult Pleasant Events Schedule.  I tried to practice willingness instead of wilfulness.

It's debatable how well I succeeded in all of this, given that I had no-one to guide me. It was hard but this was another benefit of the book; the book acknowledged that this was hard. Up until that time things I had been expected to do, or wanted to do, fell into two categories A) Easy, I should be able to do them, and B) Impossible, I should just give up. Living at home, staying away from certain people, giving up things I enjoyed, staying in hospital, being grateful: these were easy things. Going back to college, living independently, being medication-free, going back to the radio station where I had been a volunteer: these were impossible things that I should give up on.

DBT gave me a handle, a manual to do things that were hard but worth doing. The immediate impact on my quality of life was dramatic, although it would be some years before I actually moved out of home. Most of all was the inward comfort and confidence I gained from the knowledge that some-one, somewhere, even though it was half-way around the planet, understood my situation. Some-one knew that things other people found easy, I found hard, and that it was this difficulty and not some faulty wiring that made my life the mess it was.

I ordered Linehan's other book, "Cognitive-Behavioral Therapy of Borderline Personality" on-line and found even more comfort there. Take for example Linehan's debunking of the assumption that borderline behaviour is "manipulative."

"my own experience in working with suicidal borderline patients has been that the frequent interpretation of their suicidal behaviour as "manipulative" is a major source of invalidation and of being misunderstood. From their own point of view, suicidal behaviour is a reflection of serious and at times frantic suicide ideation and ambivalence over whether to continue life or not. Although the patients' communication of extreme ideas or enactment of extreme behaviours may be accompanied by the desire to be helped or rescued by the person s they are communicating with, this does not necessarily mean that they are acting in this manner in order to get help."

Somewhere else in the book (I can't find it but am sure it's there) is the line that has influenced me most of all. I'm paraphrasing because I can't find it but I'm fairly sure it goes something like. "All attempts by the patient to use "mental illness" to explain or justify her behaviour should be rejected".

UCC Lecture

So imagine my excitement when eleven years later I hear that Dr. Linehan's coming to UCC. I had to attend the morning session for "service users" rather than the afternoon session for mental health professionals. (I wonder if my consultant attended the afternoon session. He was the head consultant in the Cork hospital that I attended and at our last meeting in out-patients I told him I had found a new approach that was working. I said I was reading the work of Marsha Linehan. "Who's she?" he asked. "An American psychologist". "Hmmph".)

The title of Dr Linehan's lecture was "Real Change is Possible". Here is something that works. That takes people out of the psychiatric system. That builds lives worth saving. That if the HSE implemented properly would save hundreds of thousands of euro and potentially millions. In fact I will say millions as the saving involved in giving people effective treatment -  as opposed to prescriptions, out-patient appointments and infantilising OT - is threefold. Less is spent on inpatient stays, less of visits to A&E and less on medication.

DBT costs more in the outset. Patients receive psychotherapy from a trained professional and also attend meetings where they are coached in the key skills. Having both individual and group sessions facilitates one of the dialectics of the therapy's title; the dialectic between being flexible and responding to what's going on at the moment and being consistent and following protocol. DBT also has a specific and prescriptive response to suicidal behaviour protocol, which rarely involves locking the patient in the nearest secure psychiatric ward.

The difference between Linehan's approach and the Irish model is striking. She said at one point "I wouldn't let fear rule my treatment" when I remember fear being a major driver in policy. Fear of us killing ourselves, fear of their being sued if we killed ourselves, fear of our committing criminal or quasi-criminal acts, fear of us, fear that we'd escape, fear that we'd stop taking our medication or object to taking our medication.

"I Have the Right to be on Earth"

Linehan defines this concept of having a right to be on Earth as "essential validity" and said that affirming it is of major importance. Again, when I think back, even though my psychiatric team were very strong on the idea that killing myself was a bold, inconsiderate thing to think of doing, their behaviour towards me did nothing to instil the feeling that I had a right to be on Earth. They didn't recognise my right to be free, my right to wear clothes, my right to autonomy over my body, my right to fresh air and the feel of sun on my skin.

In the original "Skills Training Manual" Linehan writes that DBT is not a suicide prevention programme but a life-enhancement programme. This distinction is crucial and linked, I feel, to the concept of essential validity. Suicide prevention sounds vaguely coercive. It's about stopping some-one doing something, forcing them back into a life that may not be worth living. A life where you don't feel you have the right to be on Earth is no life.

A part of the lecture I found particularly interesting was when she discussed suicidal thoughts. Thinking about suicide is extremely common, far more common than parasuicide or completed suicide. "Thinking about suicide" is a behaviour in and of itself. It's a behaviour that is practiced because it is soothing. It is soothing because it presents an alternative reality and also because while you're thinking about suicide, you're not thinking about your problems.  Linehan compares the practice of thinking about suicide to a drug. I can relate to this; when things get bad I find myself thinking about suicide. Not that I'd do it, just that thinking about it brings relief.

I didn't ask a question at the lecture but if I had, it would have been this, and I'd appreciate your views on this in the comments. Can we apply the idea of thinking about suicide being a displacement activity to society as a whole? Take the recent RTE coverage of suicide, something I've referred to in a previous post. This coverage was embarrassingly simplistic and made several unwarranted assumptions: that all suicides are calculated choices, that undiagnosed mental illness is a major factor, that there is plentiful "help" available were people not too feckless to bother asking for it.  Take also the plethora of voluntary organisations with suicide in the title. The awful radio ads urging us to choose life, not suicide as though one were Tesco and the other Lidl.  We have anti-suicide cycles and anti-suicide bumper stickers and are told frequently that we need to "break the silence" and have lots of chats about suicide.

But I wonder; when we talk about suicide are we putting off talking about our problems? When we shake our heads and mutter about how awful it is that so many young people don't just ask for help, or think of their families, are we avoiding asking the hard questions. When we put the entire responsibility for reducing suicide onto the shoulders of GPs and the psychiatric system, are we abdicating our own responsibility? I lost count of the number of tweets I received over Christmas telling me to call the Samaritans. That could be because of the type of tweeter I tend to follow, but still. 

Hard questions might include what is wrong with our psychiatric system when involvement with it is a factor in so many suicides? Other questions might be how we look after children in their infancy. Are we too quick to refer troubled teens to the GP? Might it be a good idea to reverse the cuts to school guidance counsellors? Is anyone ever going to come out and categorically say that children should not have televisions or internet access in their bedrooms? Why are we still so slow to acknowledge the scale of child sexual abuse? Why does our economic system leave so many able-bodied, capable young people surplus to requirements?

Success

The fundamental goal of DBT is not to prevent suicide but to build a life worth living. When you consider how much is involved in this, how long it takes, the costs involved you see that by side-stepping "suicide prevention" DBT faces up to some of the problems and indirectly, saves lives. It isn't a panacea of course and has had very limited success with, for example, Post Traumatic Stress Disorder.  There may also be patients for whom it will never replace medication, but can still help them lead a life worth living.  Its major successes, apart from the original borderline personality application have been in Substance Abuse (87% success rate), major depression (68%) and eating disorders (64%). Interestingly, Linehan sees depression mostly as a behavioural issue, like taking drugs or being anorexic, rather than a mysterious fog that descends for no apparent reason.

A pilot project is currently running in Cork and there is hope that DBT will be rolled out across the country. I would hope that it is not customised too much to fit in with current (mostly dreadful) practice. I hope it will not be adopted in a lacklustre fashion on the grounds that "nothing works with these people". The fact that so many clinical trials have been conducted will hopefully bring the medical people on board. This could be a huge shift in psychiatric policy. Let's hope so.