Currently in the UK, young people who are struggling with mental ill health access support and treatment through the Child and Adolescent Mental Health Services (CAMHS).

In a recent review this service was described as:

…complex and fragmented. Mental health care is funded, commissioned and provided by many different organisations that do not always work together in a joined-up way. As a result, too many children and young people have a poor experience of care and some are unable to access timely and appropriate support.
– Care Quality Commission, 2017

Many of those referred to CAMHS struggle to access the care they need. There are a multitude of reasons why this might be, but not least because many young people:

…face significant barriers in accessing and maintaining contact with CAMHS because they lead unstable and chaotic lives.
– The Children’s Society, 2017

This has led many to suggest that offering CAMHS services in schools would ensure that those who need services would be able to access them more easily.

In the past, the role of school in providing mental health support and education has been relatively minor, but with the increased number of young people reporting long standing mental ill health (Pitchforth et al., 2018), this is changing. The government is offering incentives to get schools to do more to support young people’s mental health and suggesting that specialist provision should be available in schools. In their most recent report this was broadly welcomed:

Some children and young people thought the teams could be closely linked to young people’s lives and would therefore feel more relatable than the mental health services currently available. It was felt the proposed teams could also develop closer relationships with families, helping parents to support their children, which many young people found to be very important.
– Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps P.24

However, placing services in school so that they are practically more accessible will be pointless if the real barrier to access is stigma:

Other children and young people however, reported that some of their peers would not be willing or able to access support in school due to bullying, stigma, confidentiality concerns…
– Ibid.

In our culture, as in many others, mental health is stigmatised. Other elves before me (David Steele and Laura Hemmings) have blogged on this point and these are well worth a read. It is clear that stigma plays a role in whether or not people access services: firstly in a user’s ability to overcome stigma to seek services, secondly to utilise the services effectively and thirdly in the stigmatisation shown by some service practitioners themselves (see above blogs). Placing these services in schools, full of hormonal teenagers whose sole aim in life is not to be different in any way (and if your own life experience doesn’t bear this out I refer you to Sarah Jayne Blakemore’s excellent book ‘Inventing Ourselves: the secret life of the teenage brain’), may mean that the stigma of being different and having a ‘mental health problem’ may be too great a barrier for some to overcome.

This current paper considers how stigma might affect the accessibility of school based mental health interventions and how understanding this should inform the way such services are integrated in to schools to be as efficacious as possible (Gronholm et al, 2018). It asks two key research questions:

1. To what extent do students experience stigma due to screening positively for/participating in targeted school-based mental health interventions (TSMHIs)?
2. What are the consequences of the potential stigma for students engagement with TSMHIs and associated screening?

Methods

This systematic review used 8 studies that met inclusion criteria from a possible set of 3,463 found by literature searches. The studies were drawn from 5 electronic databases and citation and reference searches were also carried out. The reviewers also contacted study authors of the primary research for further recommendations about evidence to include in their review.

The inclusion criteria considered the:

• Domain studied (mental health related stigma reported by participants);
• Population (primary or secondary students in school who had been screened for or were participating in TSMHIs);
• Intervention (these had to be school-based and targeted, not universal);
• Study type (the reviewers selected articles reporting on data from peer-reviewed studies that used qualitative methods only).

The studies all used qualitative methods so the authors screened for methodological quality and no studies were excluded on this basis (all studies scored > 50%).

In order to accurately interpret the data in light of the research questions, established guidelines were used for thematic synthesis, creating an analytic framework. The lead author conducted the process but it was validated through consensus discussions with co-authors.

The systematic review complies with PRISMA guidelines and was registered with PROSPERO.

Results

The eight articles had a total of 219 participants, all of whom attended secondary school and most of the studies focussed on early interventions described as, for example ‘school mental health services’ or ‘school counselling services’. Two of the studies involved a cognitive behavioural intervention for students identified as at risk of depression.

The thematic synthesis identified 3 overarching themes that fitted with the research questions, each then divided into sub themes:

1. ‘Anticipated and experienced stigma’ (creating barriers to accessing support)

• Negative labelling: deviation from the norm and reflection of stereotyped attitudes
• Discriminatory reactions: peers reactions such as bullying, hostility and rejection
• Compromised confidentiality: concern that counsellors would divulge details.

2. ‘Consequences of stigma’ (creating a barrier to accessing and fully engaging in interventions)

• Anticipatory anxiety: fear about negative reactions such as labelling and discrimination
• Restricted disclosure: fear of negative consequences meant that on some occasions students were reluctant to ‘open up’
• Distancing from support: some students rejected support or downplayed their need for it.

3. ‘Mitigating strategies’ (ways that providers tried to overcome the stigma-related barriers)

• Applying alternative constructions for psychological support: there was evidence that students were more positive about interventions when they were framed as ‘practical coping’ strategies or as offering tools to cope, rather than more biomedical and mental health issues
• Increasing choice and control: when students were more proactive in their choices and control of help-seeking, their experiences were felt to be more positive and non-stigmatising
• Ensuring confidentiality and building trust: a variety of simple measures were described to build trust and ensure confidentiality, all of which helped to overcome stigma-related barriers.

Conclusions

In answer to the two research questions, the reviewers conclude that students do experience stigma due to screening positively for/participating in TSMHIs both from peers, others and self-stigmatisation. As a consequence of the potential stigmatisation, some students were reluctant to engage with TSMHIs, restricted how much they disclosed and distanced themselves from providers.

It is clear that stigma creates barriers to service use at multiple points. The review highlights the need to understand where the barriers are and how best to intervene if efforts to increase access to services are going to be effective.

Strategies to mitigate stigma-related barriers

• Avoid biomedical language to describe interventions and frame support as ‘practical coping’ strategies
• Provide clear information about the interventions in advance;
• Personal agency is important, so support young people to be active agents in their care;
• Provide specific assurances around trust and confidentiality;
• Build strong trusting relationships with service providers.

The review raises some interesting issues around accessing services and the role that stigma plays, in particular the contradiction that whilst students are fearful of stigmatisation from peers they also cite peers as a good source of support.

The evidence used for this review is very lean and the authors conclude that more research needs to be done in this area to fully understand stigma-related barriers and enable them to be overcome when placing mental health services in a school setting. Not least so that we can compare how stigma may be different in schools to other service settings, and therefore if the barriers for school settings are greater or fewer than elsewhere (this would clearly strengthen or weaken the argument for placing services in schools).

Strengths and limitations

The authors are fully aware of the paucity of evidence and the consequences for analysis. Being based on only 8 papers and having 219 participants suggests that the review sample is not big enough to draw reliable conclusions. The number of studies included means that the authors were unable to make some important comparisons; for example the research only accesses secondary school age children, and of course barriers for primary schools may be different. The papers are all written in English and came from a variety of countries (New Zealand, Wales, Scotland, USA and Sweden) all of which the authors note are high-income Western countries. It is clear that this research may not be applicable to other contexts but it is also worth noting that even within high-income Western cultures there is a huge amount of cultural diversity around how mental health is viewed and it is arguable that these findings may not be applicable to sub-cultures within those studied (however such sub-groups could not be studied because of the small sample sizes).

In addition, the research is qualitative and therefore may contain bias, again the authors acknowledge these limitations. Although evaluated for quality, common limitations of the included studies were: “the influence of the researchers’ potential influence on study conduct and/results; a lack of information about reasons for non-participation…; and insufficient attention to contextual factors that might affect interpretation of the finding.” (p.20)

The strength of this paper lies not in the research it is drawn from, but in the questions that it raises:

• Why is there so little research into this area, particularly if we are about to plough money and scarce resources into school-based services?
• Will school-based services be effective if stigma is a barrier?
• If this is the case, how can we remove mental health stigma and encourage those who need these services to access them without shame?

Implications for practice

I think the question is not whether or not services are useful in school, the practical arguments for having these services in locations that are central to the community they serve are self-evident. The issue is wider – how do we remove the stigma related to ‘mental health’ (I use this advisedly as for most lay people this means mental-ill health, and has negative connotations). Rebranding, using more neutral language, and education is happening, but years and years of ingrained stereotyping will not be undone easily.

This review may be a first step in understanding what the stigma-related barriers are for young people regarding their mental health and how the can be overcome. Some schools are well on their way to doing this and in my work I see some great initiatives where schools are working with their whole community to better understand how to bring up a mentally healthy generation, working closely with other services to offer a comprehensive package of care. Other schools have yet to realise that there is an issue at all. So I would suggest that these barriers will not only vary from country to country but from school to school. Education around mental health and related services will need to be tailored to suit each individual context and with any luck, in time, using mental health services will be no different to using other health services.

But it will take time. Several years ago my son was diagnosed with Asperger’s/High Functioning Autism and Attention Deficit Hyperactivity Disorder. As parents, we spent a long time discussing the relevant merits of the labels: with them we got access to more support, we were able to better understand his behaviour and were able to guide others in the support they gave him outside of our home; on the downside – ‘stigma’ – that was it. These labels and associated stigma were and still can be a barrier. Children using Special Educational Needs (SEN) services in school are easy targets. Comments (in the staff room) like ‘ADHD is just an excuse for bad parenting’ are not helpful and they hurt. The same issues will be there for any young person wanting to access mental health services within a school setting.

It has taken years for the SEN stigma to be eroded and we are still not there. In 1982 Sally Tomlinson rewrote the rules for ‘Special Education’ this included a change to the language in an effort to destigmatise it, but sadly you now hear people using ‘special’ as a derogatory term, and so the stigma still exists 36 years on. We are only at the beginning of this journey for mental health, we have a long way to go.

Conflicts of interest

None.

Links

Primary paper

Gronholm PC, Nye E, Michelson D. (2018) Stigma related to targeted school-based mental health interventions: a systematic review of qualitative evidence. Journal of Affective Disorders 2018 Nov;240:17-26. doi: 10.1016/j.jad.2018.07.023. Epub 2018 Jul 10. [PubMed abstract]

Other references

Abdinasir, K (2017) Stick with us: Tackling missed appointments in  children’s mental health services, The Children’s Society.

Blakemore, S-J. (2018) Inventing Ourselves : The Secret Life of the Teenage Brain. Transworld Publishers Ltd.

Care Quality Commission: Review of children and young people’s mental health services: Phase one report (2017).

Department for Health and Social Care and Department for Education Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps (2018).

Pitchforth J, Fahy K, Ford T, Wolpert M, Viner RM, Hargreaves DS (2018). Mental health and well-being trends among children and young people in the UK, 1995–2014: analysis of repeated cross-sectional national health surveys. Psychological Medicine 1–11. https://doi.org/ 10.1017/S0033291718001757

Tomlinson, S. (1982). A Sociology of Special Education. London: Routledge & Kegan Paul.

How can we reduce mental health stigma and discrimination?

A hierarchy of stigma based on mental health diagnosis?

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