The theme of this year’s #WorldMentalHealthDay (10 Oct) is ‘Mental Health for All.’ While such an aspiration is admirable, one has to question if it is too ambitious a vision at a globally bleak time.
The pandemic has laid bare many of the inequalities in our society.
As British writer Damien Barr put it:
"We are all in the same storm but we are not all in the same boat. Some are on super-yachts. Some have just the one oar."
This is a fitting description of the fundamental disparities between communities, which contribute to enormous and potentially catastrophic impacts on both physical and mental health.
Prior to the pandemic, there was increasing awareness of the differences between schools, colleges and universities and the ways people are effectively segregated by socioeconomic or academic advantage. Post COVID-19, these differences will be far greater.
Young people affected by serious socioeconomic disadvantage are less able to devote time and attention to academic study. They often have little or no access to extra support or to digital technology. They face higher risk of violence, disruption or distress at home. As a consequence, they are more likely to demonstrate behavioural and emotional issues, affecting both them and those around them. Falling behind at school or college can lead to further stigma. Education inequality then carries through to work, resulting in income inequality.
All of these can contribute to poor mental health. All mental health care, whether it relates to prevention or treatment, is responsive to both the strengths and needs of individuals and their community’s identity and culture.
High levels of inequality in access to, and experience of, mental health care are evident in a number of population groups. They include girls and women; people in poverty, unemployed people (especially young people not in education or employment or training (NEET); Black, Asian and Minority Ethnic (BAME) communities; children and young people; homeless people; lesbian, gay, bisexual, transgender and / or queer / questioning ‘plus’ (LGBTQ+) people; looked after children; and people living with physical or learning disabilities.
Health outcome research (National Collaborating Mental Health Centre for Mental Health, 2019) indicates that marginalised groups are affected in three different ways: their experience of accessing treatment; their experience of treatment and the outcomes they can expect.
These three areas are the same we need to focus on in education:
1. Access to Treatment:
Access to health care and experiences of it will influence the outcome of a person’s recovery. For example, people in BAME communities are more likely to be detained under the Mental Health Act (CQC, 2018) rather than be diagnosed with a mental health issue. Certain groups, for example refugees and transgender people are also less able to access the care they need. They may not receive the right type of help or get it too late.
Similarly, access to the right schools, colleges and universities and relevant educational support will influence the outcome of a student’s engagement, involvement, learning and motivation. Children and young people from lower socio-economic backgrounds are twice as likely to display learning-related behaviour problems. The influential Coleman Report (1966) concluded that schools themselves did little to affect a student’s academic outcomes over and above what the students themselves brought with them to school or college. They note that ‘the inequalities imposed on children by their home, neighbourhood and peer environment are carried along to become the inequalities with which they confront adult life at the end of school.’
3. Experience and outcomes of education or treatment:
When it comes to mental health there is evidence that people’s experience of care and treatment is different, especially if they are from marginalised communities, affecting both their interaction with health services and their recovery. To be relevant, the culture of an individual will need to be considered and services will also consider cultural differences, religious beliefs and social stigma as part of mental health support. Difficulties in treatment experiences for certain parts of the community include people who are LGBTQ+ who are more likely to experience stigma accessing mental health care even though mental ill health and suicide rates are higher in this group. (RaRE research report, 2015).
BAME communities may also experience disadvantage receiving appropriate professional services. Cultural stigma and distrust about the concept of mental health can mean people are not willing to share experiences or raise issues. There may also be cultural and language barriers.
There has been a notable increase in the proportion of death by suicide in females aged five to 19 years (Office of National Statistics, 2018). Supporting the mental health needs of girls, young females and women needs urgent focus. The same inequalities exist in education. Two thirds of women and girls globally are illiterate with a significant proportion out of school. Socioeconomic status, disability and ethnicity also impact on the experience of education ― often as a result of unintentional, institutional bias.
The pandemic has both brought to the fore pre-existing problems and created new ones. The consequences of a crisis continue to unfold long after it is over. It is therefore even more important that we re-structure our systems of education and health so that they become responsive, and provide a resiliency framework for young people to thrive.
Authorities must therefore make strong efforts to re-enrol and re-engage young people in education and be vigilant to drop-out rates when schools and colleges re-open. Many households will recede further into poverty, often resulting in dropping out of education and to poor mental health. This will further impact on student difficulties in re-engaging with education, and those who return to school will need extra academic support to catch up on lost learning. The availability of extra remedial lessons is essential to allow all students to reach their expected basic levels of learning. Other necessary measures include a reconsideration of exam or assessment expectations, accessible pastoral support, relevant mental ill health treatment access and initiatives to engage potentially distressed families in supporting their young people in the best possible way.
A proposed framework for both health and education to address should include:
- Addressing the mental health needs of the population
- Identifying positive measures to support education and the mental health or young people
- Exploring who is and who isn’t accessing education and mental health support and why
- Having a forum to address education and treatment experiences
- Monitoring outcomes
There are of course moral, legal and economic imperatives for advancing equality. Moreover, learning and collaborating with all sections of society provide a valuable opportunity to innovate and enhance the way we provide both education and healthcare.
This means getting to know different groups and their views and needs, and working collaboratively. What is offered should be youth-centred and incorporate choice. Families and carers need to be engaged in how to identify needs and challenge stigma.
With more waves of the pandemic likely, is essential that we future-proof our young people (as well as education and health providers) to deal with future challenges in a comprehensive, cohesive and resilient manner. Together, we can face the storm whatever vessel we might be in, if we know there is a shared view and support on getting to the same shore.
Dr Nihara Krause, Consultant Clinical Psychologist and Founder stem4