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Mental Health in Schools

‘I feel the book should be compulsory reading for everyone who
works with young people, but especially pastoral heads and senior
teachers with responsibilities in this area.’
Janine Phillips, Class Teacher

Mental health is an important component of the PSHE (Personal, Social and

Health Education) curriculum. This practical guide for teachers looks at how
mental health issues affect children's behaviour, self-esteem, motivation and
achievement and what the school can do about this.

Suitable for senior staff, teachers, all those with pastoral care responsibilities
and teachers and coordinators of PSHE, the book explains the difference
between counselling and counselling skills and covers issues such as:

• mental health and behaviour

Prever
• the causes and range of mental health problems experienced
by young people

Mental Health
• how schools can make a difference
• the idea of a 'mentally healthy' school
• information on listening skills, counselling and talking therapies
• how to set up and run counselling provision in a school
• multi-agency working and referral
•
•
•
peer support
lesson ideas and plans for PSHE lessons
activities for staff to use in INSET

Mark Prever has been the Manager of a school-based Student Support

in Schools
A Guide to Pastoral and Curriculum Provision
Centre for young people with social and emotional problems. He is
currently Student Development Leader at Yardleys School and Counselling
Development Officer at the Open Door Youth Counselling Service,
Birmingham. He is a former chair of Counselling Children and Young People
CCYP, a division of the British Association for Counselling and
Psychotherapy (BACP).
Mark Prever
cover design: wendy scott
cover image © photolibrary

ISBN 1-4129-2331-X
PAUL CHAPMAN PUBLISHING
A S A G E P U B L I C AT I O N S C O M PA N Y
London • Thousand Oaks • New Delhi
w w w. p a u l c h a p m a n p u bl i s h i n g . c o. u k
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10143 PRELIMS.QXD 15/9/06 11:39 Page i

M ENTAL HEALTH IN SCHOOLS

10143 PRELIMS.QXD 15/9/06 11:39 Page ii
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M ENTAL HEALTH IN SCHOOLS

A Guide to Pastoral and Curriculum Provision

Mark Prever

Paul Chapman
Publishing
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© British Association for Counselling and Psychotherapy 2006

First published 2006

Apart from any fair dealing for the purposes of research or

private study, or criticism or review, as permitted under the
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Paul Chapman Publishing

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10143 PRELIMS.QXD 15/9/06 11:39 Page v

C ONTENTS

Dedication vii

Acknowledgements ix
About the author xi
Preface xiii

1 Introduction 1

Schools and Mental Health

2 Mental health and young people 8

Defining mental health
How many young people in our schools suffer from a mental health
problem?
How do we know if a pupil has a mental health problem?

3 Risk and resilience 19

Risk factors
Resilience

4 What are the causes of mental illness in young people? 29

Biological factors
Psychological factors
Environmental factors
Child abuse and
mental health
How domestic violence affects the mental health of a young person

The emotional impact of divorce and separation on young people
Bullying and mental health

Academic pressure and exam stress
Examples of young people at additional risk
Looked-

after children
Bereaved children
The mental health of gifted and talented pupils
Gay and
lesbian pupils

5 Specific mental health problems in children and young people: how schools can help 44
Asperger’s syndrome
Attachment disorder
Attention-deficit and hyperactivity disorder

Bipolar disorder
Conduct disorder
Depression
Eating disorders
Generalised anxiety

disorder (GAD) and other anxiety disorders
Obsessive-compulsive disorder
Post-traumatic

stress disorder
Schizophrenia
School refusal
Self-harm
Suicide and attempted suicide

6 A whole-school and multiagency approach 70

Schools are emotional places
A whole-school approach to mental health
What can schools
do to promote mental health and support young people?
Combating stigma
A multiagency
approach
Child and Adolescent Mental Health Services (CAMHS)
Mental health professionals
and services
Intelligent referral

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MENTAL HEALTH IN SCHOOLS

7 The mental health curriculum 86

Resources for use with pupils

8 The listening school 111

Listening skills and counselling
Peer-support schemes
Employing a counsellor in your school

9 Useful organisations and resources 128

References 147

Index 151

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This book is dedicated to my daughter Miriam

and all young people

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A CKNOWLEDGEMENTS

I would like to recognise the importance of all the people I have worked with in numerous set-
tings over the last 30 years or so and whose influence has been real and lasting. In particular, I
wish to acknowledge all the children and young people who have worked with me and who
have shared many of their hopes, fears, sadness, loss and distress. It really is quite special when
young people let you into their life, trusting you with their thoughts and deepest feelings –
things that are potentially so hidden and private.

Many thanks to the British Association for Counselling and Psychotherapy for commissioning
me to write this book and, in particular, to Lewis Edwards, Marketing and Communications
Manager, for keeping me on task and strictly to deadlines.

I also wish to thank all those professionals who have influenced me throughout my career; in
particular, Carmel Mullen-Hartley at the Open Door Youth Counselling Service in Birmingham.

I am grateful to my family for their support through difficult times and particularly to my part-
ner Ruth.

Finally, and certainly not least, is my daughter Miriam, who remains special to me in so many
ways. Miriam has highlighted the importance of good parenting, security and love in young
people’s development and in their emotional health and well-being.

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A BOUT THE AUTHOR

Mark Prever was born in Hackney, East London, in 1953 and has been involved in education
for over 30 years. He is an experienced teacher but has substantial experience also of youth and
community work and social work with young people at risk. For many years he has held formal
pastoral roles, including Head of Year and Personal Social and Health Education Co-ordinator
in a range of secondary schools across Birmingham.

Over the last 16 years, Mark has developed a substantial interest in counselling and is currently
Counselling Development Officer at the Open Door Youth Counselling Service in Birmingham
where he has previously held the roles of clinical supervisor and Chair of the Agency.

Up until recently, Mark was the manager of a school-based Student Support Centre for young
people with social, emotional and behavioural problems as well as holding responsibility for
child protection at the school. His current role at the school is Student Development Leader.

Mark has also held the role of Chair of Counselling Children and Young People (CCYP), a divi-
sion of the British Association for Counselling and Psychotherapy. He maintains a particular
interest in counselling and therapeutic work with young people, mental health and emotional lit-
eracy in educational settings, and is a trainer and writer in these fields. He has written for a range
of journals on related matters and has contributed to radio and the production of TV programmes.

Mark lives in Worcestershire and has a daughter aged 11.

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P REFACE

Why write this book?

In writing this book, I have more than a desire to disseminate information about mental health
in the context of schooling. I want it to be a useful resource, but I am aware also of a campaign-
ing edge. The book is designed to raise the issues and possibilities of a comprehensive approach
to mental health in schools. A concern for the mental health needs of young people, and the
school’s awareness of these, remains largely hidden. Schools are trying their hardest, often with
success, to support young people in difficulty, and many hours are spent with parents and
pupils trying to address problems. However, many professionals working in schools will recog-
nise that they feel helpless and deskilled when confronted with young people who are
self-harming, socially isolated and withdrawn, or behaving in a way that causes distress at home
and school. These outward expressions of sadness, unhappiness or difficulty ultimately affect
the learning and well-being of other pupils with whom they come into contact.

I believe that unless education places mental health and well-being at the forefront of planning,
schools will remain purely reactive institutions with a ‘fire-fighting’ model of pastoral care.
What is advocated here is a more proactive approach, where problems are anticipated and pre-
empted, and where prevention and early intervention are keenly held concepts that influence
policy and planning. This book seeks to raise awareness of mental health in schools and chal-
lenge schools with a new way of thinking.

Who is it for?
This book is for all adults who work in schools and who come into contact with young people in
distress or difficulty. This includes teachers with a pastoral role, whether as form tutor or at the
level of middle management. However, I would be pleased if it also appealed to all classroom
teachers and assistants and those with newly created pastoral roles as a result of workforce reform.
Clearly, these pages will be of use to other staff working in schools, such as learning mentors, spe-
cial needs teachers and the school special educational needs coordinator. In addition, I hope that
the book is read and discussed by school head teachers, other members of the senior leadership
team and governors, in particular those with the influence to effect change.

The book is also relevant to the many other professionals working in schools, such as behaviour
support, education social workers, educational psychologists and Connexions workers.

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MENTAL HEALTH IN SCHOOLS

In fact, I hope this book will be of interest to anyone who sees schooling as more than an
opportunity to pass on knowledge and help pupils achieve in the formal sense, important as
these goals may be. It is for all professionals who wish to highlight the importance of promot-
ing the mental health and emotional well-being of young people in our schools.

Importantly, this book is also about working with parents, family and friends whose lives are
entwined with the child in distress – or become so. My aim is that the content and ideas
explored in the book will open up purposeful and sensitive communication with families, and
facilitate the kind of dialogue and sense of working together in partnership that is so necessary
for quality support, intelligent home–school contracts and – hopefully – successful outcomes.

How should the book be used?

I want this to be an intensely practical book, written with a passion born out of many years of
experience. As indicated above, I also hope that the book will challenge and offer new perspec-
tives on the practice of pastoral care.

The book should be read in full because it is important that the arguments presented are under-
stood. The book can later be returned to for reference and discussion. I would be delighted if the
book were used for training and professional development. For this reason, I have included a
number of ‘reflection boxes’ throughout the text at appropriate points. These can be used for self-
reflection or in discussion with others. Where a page is headed ‘photocopiable’, please feel free to
reproduce it for work with colleagues. Where material has been designed for pupils to work with,
you may make multiple copies for classroom use. In addition, the text is interspersed with a
number of ‘key points k ’ that attempt to capture the essence of the following pages.

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C HAPTER 1

Introduction

This chapter will show that:

Young people in difficulty may have underlying mental health issues. Schools need to
look beyond the behaviour to understand what might be going on for that young person.
Narrow behavioural approaches are sometimes limited and may make matters worse.

Perhaps the best place to begin is with the following case studies, which introduce us to some
of the main issues to be explored throughout this book. These young people do not of course
exist, but they represent an amalgam of some of the young people I have known during the last
30 years. While reading, you may recognise elements of some of the pupils you already work
with. If I have learnt anything in my years’ working with young people, it is the complexity of
their lives, the stresses they face, the loss they experience, the violence they encounter.
Sometimes I ask myself: how would I cope in their situation? Do I really understand? Can I
even begin to feel what they are feeling now?

Carl
Carl is a Year 8 pupil, small for his age. His junior school transfer information shows that
he has had problems with his behaviour since Year 4 when his mother and father’s rela-
tionship reached an all-time low and domestic violence became a feature of the
relationship – violence which Carl witnessed daily. Carl has attention-deficit and hyper-
activity disorder (ADHD), but his doctors find it difficult to judge the correct levels of
medication to enable him to negotiate successfully the school day. There are problems at
school, and he has spent many hours in the school’s ‘time-out’ facility, offering respite to
his teachers and classmates. His mother and father are now separated, and Carl feels let
down by his dad, who rarely agrees to see him and often cancels at the last moment. Carl
feels rejected and takes this frustration to school. He is aware of his ‘condition’ and is will-
ing to talk about it; indeed, he is keen to do so. The school is aware of his special needs
and has made real efforts to take them into account. However, the situation is deteriorat-
ing, and some of his teachers feel he is ‘getting away’ with too much. They have questioned

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MENTAL HEALTH IN SCHOOLS

how much of his difficult behaviour is due to his ADHD, and therefore understandable,
and how much is simply bad behaviour. This has introduced inconsistency into their
approaches to him, and Carl is now confused and resentful of any intervention that is part
of the school’s behaviour code. Carl has been allocated a mentor, who meets with him reg-
ularly, and SMART targets for ‘negotiated’ behavioural improvement. To redress the
school’s apparently lenient approach to him, Carl has recently received a number of fixed-
term exclusions so that he understands where the line is drawn. He has problems relating
to other pupils and is consequently the subject of bullying, as other pupils react to his
aggression and anger. They also resent the way teachers treat him differently and that he
appears to be handled more sympathetically by his head of year.

Sunita
Sunita is a diminutive 11-year-old pupil who has struggled throughout Year 7. Her mother
despairs over Sunita’s refusal to go to school. Her attendance at junior school is just about
satisfactory, although some concern had been expressed. Sunita’s mother brings her to
school, but the terrified child clings to the gate and cries. She begs her mother to take her
home, promising to go to school ‘tomorrow’. The learning mentor at the school has
encouraged Sunita to enter the school on occasion, assuring her that she can spend the day
alongside her, but the mentor knows this is not a long-term solution. When encouraged to
go to lessons, albeit on a limited timetable, Sunita cries loudly, and her desperate appeals
disturb others. When in school, she inevitably complains of stomach pains and headaches,
and occasionally she has to be escorted to the toilet to be sick. The head of year is under
pressure to improve Sunita’s attendance, and the education social worker has been
involved. Everything has been tried: encouragement and rewards, threats of court action,
and the possibility of transfer to another school. Sunita has a very close relationship with
her mother, and Sunita’s crying has made it hard for her mother to maintain firm bound-
aries. At times, it is easier to allow Sunita to stay at home. Her mother is herself depressed
and feels guilty about her role, as she had been hospitalised for a good part of Sunita’s first
few years of life. She remains intermittently unwell, and Sunita is worried that her mother
will die as her aunt did.

Zoe
Zoe does not appear to be interested in school at all. Her Years 7 and 8 end-of-year reports
showed an average student whose behaviour was within the normal range. Now, in Year 10,
Zoe’s coursework is non-existent. Constant phone calls home do not appear to make a dif-
ference. Her teachers are frustrated because they feel she is ‘wasting her ability’. They are also
concerned that her aggressive behaviour toward teachers and dinner supervisors is a bad
example to others. Other students look up to Zoe and she occupies a position of power
within her peer group. She has sometimes resorted to punishing those who challenge her
superiority and status, by excluding them from the friendship group. Zoe spent just over a

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1  INTRODUCTION

year on the child protection register when her 20-year-old brother interfered with her sister.
While there was no suggestion that he had touched Zoe, social services established the risk.
This affected the family in acute and profound ways. For Zoe, there were issues about her
parents’ failure to protect her sister and their defence of her brother, which hurt her deeply.
The situation at home has reached crisis point and Zoe does not want to stay there. She
habitually runs away. Zoe is self-harming and recently was hospitalised briefly after taking
10 paracetamol tablets in the playground, an event that caused great anxiety in the school.
Periodically, Zoe goes a whole day without eating, causing her friends concern. Zoe is often
in detention at school because of her ‘attitude’ and occasional rudeness. School uniform
remains an issue, and the school is determined that she should dress the same as others.
She has been excluded on three separate occasions for fighting and smoking. There is a sug-
gestion, but no evidence, that she is smoking illegal substances.

Mohammed
Mohammed comes from what appears to be a very settled and caring home. He has two
brothers who successfully attended his school without incident. Both gained good A levels,
went to university and now have excellent jobs. Mohammed’s parents show a great deal of
interest in Mohammed, always attend parent consultation evenings, and comment in his
‘school planner’. At school, Mohammed’s behaviour is exemplary. He receives many ‘cred-
its’ but rarely collects them. His attendance is faultless and he is often commended for the
quality and accuracy of his uniform and preparedness for school, evidenced by his bulging
pencil case. Mohammed is difficult to engage, although staff know he is highly articulate.
He told his concerned form tutor that he has lots of friends, but he is rarely seen with
them, preferring to sit alone in lessons and occupy the library at lunchtime. No one bullies
him – he rarely attracts the attention of any adults or pupils in the school. He mostly goes
unnoticed, although his teachers have high hopes that he will attain at least eight grade
A–Cs. Mohammed is an asset to the school and his parents are proud of him and commu-
nicate their high expectations of him.

These four case studies represent the kinds of issues faced by schools every day. In all parts of
the country, not just in the inner city, school staff grapple gallantly with young people whose
behaviour is causing concern in various ways. To a large extent, the school’s response is a behav-
ioural one, because schools have traditionally operated in a behaviourist way, emphasising
behavioural and cognitive approaches over models that place feelings at the fore. This may have
a lot to do with the way we train teachers now, with less emphasis on philosophy and psychol-
ogy, and more on practice and learning from experienced teachers in schools. We would do well
to question the distinct lack of the ‘pastoral’ in the development of our teachers – a strange phe-
nomenon when we consider the inherently human nature of teaching.

Reward and punishment, the bedrock of behavioural approaches, leads teachers sometimes to
address a pupil’s behaviour without really understanding the causes. The caring teacher who
puts pressure on the underachieving pupil by establishing targets and offering rewards may, in

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MENTAL HEALTH IN SCHOOLS

fact, be adding to the stress and anxiety of that child. If we concern ourselves with the overt
behaviour of young people, we end up punishing the sad pupil whose depression manifests
itself as aggression. We may end up dealing with Carl in incoherent ways because we do not
quite understand what is happening to him in the classroom and corridor, and fail to support
him with the confusion, rejection or shame he may be feeling. We caringly put pressure on
Sunita to get into school because we know ‘what is best for her’ without recognising the under-
lying causes of her fear, thereby exacerbating her anxiety all the more. We become frustrated and
then angry with Zoe, whose behaviour challenges our own professional sense of worth. In
doing so, we fail to support her through her understandable anger and her need to control her
immediate environment and relationships. We focus on her violence without really under-
standing her pain and hurt. When she deliberately harms herself and threatens to take her life,
she generates fear in the adults who care for her, and this leads to a belief that she ‘needs help’
of a kind that is beyond the resources of the school. The reality is that Zoe will indeed need
additional support from other professionals, but she remains a student at the school until she is
permanently excluded – the most likely outcome.

Mohammed represents the many students who may be experiencing a mental health difficulty
but whose behaviour does not cause concern or, if it does, it remains a lower priority for an
overstretched pastoral system. It would be difficult to guess what might be happening for
Mohammed, but his withdrawn and isolated behaviour should be a concern for the vigilant
teacher and the school that recognizes that early intervention prevents the development of
more serious consequences in subsequent years.

Reflection box ?

 Thinking about the young people you currently work with, do you recognise any dimen-
sions of the pupils described in these case studies?
 Looking beyond the behaviour, can you identify what might be happening for Carl,
Sunita, Zoe and Mohammed?
 What might each young person be feeling?
 When reading the case studies, what were you feeling? Did you feel sympathetic to
each pupil?
 Think about a time when you were at school and you felt confused, unhappy, anxious or
even despairing. What did you need from your teachers and the adults with whom you
came into contact?

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1  INTRODUCTION

Schools and mental health

Key points
k
Schools have an essential role to play in promoting young people’s mental health, and
teachers and other professionals working in schools are often in the front line. Schools
should embrace these new responsibilities because attending to mental health and
well-being will have a positive and profound effect on learning and pupil behaviour.

There is nothing new in the idea of being concerned about the mental health and emotional
well-being of young people in schools. Teachers have always understood that young people
bring a multiplicity of problems into the classroom, and that this affects their ability to engage
with the curriculum in a purposeful way. The converse to this idea – that mental health difficul-
ties act as a barrier to learning – is that mental health and well-being are a prerequisite for
academic success. However, positive terms such as ‘mental health’ have not always been
employed by school-based professionals, who traditionally have worked from a different frame
of reference, using the currency of ‘behaviour problem’, ‘disaffection’ and ‘dysfunctional’.

This is understandable: teachers and mental health professionals undergo completely different
training and their role is differently defined. Katherine Weare (2003) has highlighted the differ-
ences between these two spheres of activity, seeing mental health professionals as being
concerned with individual troubled, troublesome and ‘special needs’ students, while teachers have
mostly been concerned with developing a student’s intellectual, logical, technical and sometimes cre-
ative powers, but rarely their emotional capacity. She continues: Those in education have tended to
view what happens in the black box of ‘mental health’ as at best mysterious and medical, and at worst
rather frightening and off-putting.

Schools, of course, have a long history of trying to support teachers and help pupils in difficulty,
and the roles of the educational psychologist, behaviour support teacher, social worker and,
more recently, the learning mentor are testimony to these efforts.

There are those who argue strongly that it is the role of the school to educate. They insist that
teachers and other school-based staff are not in the mental health business and that these con-
cerns should be left to properly trained professionals with experience in the field. Schools, they
assert, are there to teach our children and to facilitate learning. However, I believe it is impor-
tant to see education as more than the passing on of knowledge and skills through a
subject-based curriculum. In the push toward a greater emphasis on teaching and learning –
however much that is to be applauded – it is important that we do not neglect what is at the
core of education: a concern for a child’s development in the widest sense.

This book celebrates a multiagency approach and collaboration between schools and mental
health workers, but it also wishes to suggest that a concern for mental health and well-being is
not incompatible with the traditional aims of the school, notably academic outcomes. Indeed,
it is strongly argued here that any failure to address mental health issues in school will affect
pupils’ capacity to learn effectively. When young people feel supported, valued and secure, and

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MENTAL HEALTH IN SCHOOLS

have a sense of belonging, they learn better. When young people feel more robust and resilient,
they are better prepared to cope with the problems they encounter. Put simply, happy pupils
learn best. Also, where mental health difficulties are not addressed, there are consequences for
young people and their families. The learning of other students, and sometimes the health and
well-being of the child’s teachers, can also be adversely affected.

The role of the school in exacerbating problems should not be overlooked. Students who per-
sistently experience a lack of academic success due to an inappropriate curriculum are punished
for their poor behaviour, which results from the unfortunate cocktail of emotional problems
and school failure. The argument extends into a concern for the community in general, as
young people with mental health problems are more likely to get into trouble with the police,
cause difficulty in the neighbourhood and be users of mental health and social services in the
future, with significant cost to all. The question, therefore, is not whether, but how schools
should become more actively involved in mental health promotion and intervention.

The importance of the school in prevention of, and supporting pupils with, mental health
problems was most recently brought to the fore with the publication of the guidelines,
Promoting Children’s Mental Health Within Early Years and School Settings (Department for
Education and Skills (DfES), 2001). However, it appears that, for many schools, the school’s
influence was never substantial enough to effect change (Ofsted, 2005). Organisations such as
the Mental Health Foundation, YoungMinds, the Samaritans, ChildLine, the British Association
for Counselling and Psychotherapy (BACP) and other like-minded organisations have kept the
cause alive.

This has not been easy, for despite a growing recognition of the importance of mental health
and emotional well-being, secondary schools still appear, at the time of writing, to be preoccu-
pied by fear of Ofsted inspections and the publication of formal academic outcomes such as
GCSE results. These statistics bring teachers into competition with neighbouring schools and
signal danger if a school appears to be failing, relatively, in these more measurable outcomes.

On a more optimistic note, the impact of Every Child Matters (DfES, 2004), and government leg-
islation that places emotional health and safety as two of the five desired outcomes, could give
impetus toward lasting awareness and change.

In her exploration of the rift between the worlds of mental health and education, Weare (2003)
recognises that some the difficulties alluded to here may have to do with language. She writes:
In order for other professionals to feel more comfortable with what they often see as the frightening and
rather medicalized world and terminology of ‘mental health’, there needs to be some mind-shifts about
what mental health involves.

She goes on to suggest that mental health has traditionally been used as a ‘synonym for mental
illness’ and thus the preserve of mental health professionals. This may be referred to as the
‘pathogenic’ model. She also refers to the work of Antonovsky (1987), who advances a more
positive concept, that is, a ‘salutogenic’ or wellness model that emphasises mental health pro-
motion and emotional wellness. A whole-school approach that focuses on the creation of an
emotionally healthy environment and a concern for the promotion of mental health is strongly
advocated here and will be explored later in the book. However, such an approach may be
insufficient alone. Whilst we recognise the importance of prevention, it is important also to
recognise the high and increasing incidence of mental health difficulties among young people

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1  INTRODUCTION

in our secondary schools. These are discussed below. What I am putting forward is a balanced
approach, concerned with prevention but also showing a preparedness to support young people
in difficulty, especially through early intervention.

Schools across the country are already doing a substantial amount of creative work with regard
to mental health and well-being, although they probably will not refer to it as such. However, it
may only be by recognising the nature and scale of the problem, and actually naming it, that we
can move toward more coherent ways of working, both within schools and in genuine partner-
ship with professionals drawn from other disciplines.

Reflection box ?

 At this stage in your reading, what mental health difficulties can you think of which
might act as a barrier to learning?
 What words do you find yourself using for pupils who have difficulties in their home,
school and personal lives?
 What do you think of when you read the words ‘mental health’?
 What might be the consequences of not addressing mental health problems in young
people – for the school, the home, the community?
 What does the word ‘education’ mean to you?
 What is your school already doing to promote mental health and support pupils with
mental health difficulties? Make a list.

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C HAPTER 2

Mental health and young people

Defining mental health

This chapter discusses how:

Mental health and mental illness are difficult to define accurately, but a school needs to be
operating at a variety of levels if it is to prevent and respond to mental health problems.

The task of defining mental health and mental illness is a notoriously difficult one. The Mental
Health Foundation, in Bright Futures: Promoting Children and Young People’s Mental Health
(1999), recorded:

If our views of children are ambiguous, our thinking on mental health is even more confused. The
media feeds us images of ‘the mentally ill’ as unpredictable and dangerous maniacs who need to
be locked up. At the same time Prozac, a drug intended to treat clinical depression, is deemed
suitable by some as an aid to tackling the stresses of everyday life. (p. 5)

Part of the problem lies in our historic use of the word ‘mental’, which has negative associa-
tions. Indeed, the word is used by both adults and children as a term of abuse. The link between
the language of mental health and mental illness is explored later in this book when we look at
the concept of ‘stigma’.

Peter Wilson, former director of YoungMinds, addresses this problem, bringing a sense of clarity
to the discussion. In his book, Mental Health in your School: A Guide for Teachers and Others
Working in Schools (YoungMinds, 1996), he writes:

Mental health is often confused with mental illness, and as such quickly passed over to
psychiatrists and other specialists to sort out. But in fact, mental health is simply what it says it is. It
is about the health of the mind – that is, the way we feel, think, perceive and make sense of the
world. (p. 15)

Here, Peter Wilson is referring to mental health as a positive quality, reflecting a young person’s
capacity to live a full and rewarding life with confidence and sociability.

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These sentiments echo the words of the World Health Organisation, which made an inspired
early attempt to redefine mental health in positive terms way back in 1946. Health was
described as a complete state of physical, mental and social well-being, and not merely the absence of
disease or infirmity.

These ideas have been taken up by the Mental Health Foundation (1999), which sought to
equate the definition of physical health as the absence of physical disease to the idea that
mental health should be seen as more than a narrow quasi-medical definition of the absence of
diagnosable problems. They emphasise the importance of mental health promotion for everyone.
For a child, this means being able to grow and develop emotionally, intellectually and spiritually in
ways appropriate for that child’s age (p. 5).

A different perspective on our attempts to define mental health is to begin by identifying what
actually constitutes mental health and emotional well-being. The DfES (2001) adopted the
Mental Health Foundation’s definition of children’s mental health, which it had drawn from an
NHS Health Advisory Service publication (1995), and saw the mentally healthy child as one
who has the ability to:

develop psychologically, emotionally, intellectually and spiritually

initiate, develop and sustain mutually satisfying personal relationships

use and enjoy solitude

become aware of others and empathise with them

play and learn

develop a sense of right and wrong

resolve (face) problems and setbacks and learn from them.

In the United States, the Surgeon General’s Report on Mental Health (2000) defined mental
health as the successful performance of mental functioning resulting in productive activities, fulfilling
relationships with other people and the ability to adapt to change and cope with diversity.

Our list of mentally healthy characteristics is augmented by Helpguide, an organisation concerned

with providing information on mental health (www.helpguide.org/mental_emotional_health.htm).
The list includes:

a sense of well-being and contentment

a zest for living – the ability to enjoy life, laugh and have fun

resilience – being able to deal with life’s stresses and bounce back from
adversity

self-realisation – participating in life to the fullest extent possible, through
meaningful activities and positive relationships

flexibility – the ability to change, grow, and experience a range of feelings, as
life’s circumstances change

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a sense of balance in one’s life – between solitude and sociability, work and
play, sleep and wakefulness, and rest and exercise

a sense of well-roundedness – with attention to mind, body and spirit

creativity and intellectual development

the ability to care for oneself and others

self-confidence and self-esteem.

Some of the ideas may seem a little simplistic and too general to mean much, but I suspect that
you may have already begun to consider them in relation to your own life and will begin to
relate these characteristics to the young people you come into contact with in school. They are
also useful indicators when we consider their opposites – an activity that may give us some
insight into the meaning of mental health problems and mental illness.

A discussion as to the meaning of the words ‘mental health problem’ or ‘mental illness’ is
equally important. A recent article in the New York Times (2005) by Benedict Carey explored the
question as to where mental health ends and mental illness begins. He refers to two ‘viscerally
opposed camps’. These include doctors, who suggest a broad definition to include mild condi-
tions, which can make people miserable and often lead to more severe problems later, and, on the
opposing side, experts who say that the current definitions should be tightened to ensure that limited
resources go to those who need them the most and to preserve the profession’s credibility.

Case Study
Harvinder’s behaviour is a cause for concern. His father was diagnosed with a severe
mental illness three years ago and has been hospitalised on a number of occasions. The
father does not live with Harvinder, his mother and his two brothers any more, although
he still exerts a considerable influence over family affairs in a negative sense. His mother
says that Harvinder is ‘out of control’ at home and has on occasion been violent toward
her and his younger siblings. He has twice seriously damaged his home, and has ripped
furniture and broken windows. At school, Harvinder is regularly removed from lessons for
disruption but appears to show little remorse – even when his English teacher left the
room in tears after one particular lesson. The school SENCO is at the point of beginning
the statementing process but knows that this will take time. Harvinder is in Year 9, it is
September, and his form tutor feels that he will not reach the end of the year.

In the preceding case study, does Harvinder have a mental health problem? Could he be suffer-
ing from a conduct disorder? Is he depressed and angry? Is he acting out his pain and
confusion? Is this simply a classroom management issue? Should he be referred to an educa-
tional psychologist or CAMHS through his GP? Are there child protection issues? Schools
around the country ask the same questions every day about young people in their care, and
related discussions often have a feeling of helplessness and desperation about them.

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Reference to the literature on ‘abnormality’ is often not helpful in attempting to define metal
illness. Rosenhan and Seligman (1989) refer to elements of abnormality such as the ‘violation
of moral codes’ and ‘unconventionality’, and they recognise that such definitions are social
judgements. Similarly, Richard Gross and Rob McIlveen (1996) have concerns about such
‘ideals’, seeing them as ‘value judgements’ and ‘bound by culture’.

Perhaps a more helpful concept is that of a continuum, with mental health at one end and
severe mental illness at the other. Attempting to distinguish between what Katherine Weare
refers to in her book Promoting Mental, Emotional and Social Health: A Whole School Approach
(1999) as ‘the well and the ill’, we may feel more confident in understanding what might be
found at these two extremes but less confident about what is in between. At one end might be
normal anxiety, often regarded as necessary for everyday functioning, and at the other end,
panic disorder that prevents patients from leaving their homes.

Harvinder’s behaviour, which causes so much concern at home and school, is somewhere on
that continuum. His anger and aggression are neither pathological nor seen as acceptable by the
adults who come into contact with him. However, in many respects, his behaviour is under-
standable given his difficult circumstances.

In advocating the advancement of schools with a concern for the mental health of pupils and
staff, the least desirable outcome is an organisation that is quick to label young people as
having mental health problems – or one that is too quick to assume that behaviour is within
the normal range for the period of adolescence, taking into account the additional stresses that
young people experience from time to time.

It is important to see that we are all somewhere on that continuum, and there have been and
will be points in our lives when we might require additional help. At one level, this might be
provided by our close friends and family, but there may also be times when we ask for addi-
tional help from recognised professionals, such as a counsellor, psychiatric nurse or GP. If we
apply this concept to our schools, the model fits well. It may be that Harvinder can be helped
most effectively by the involvement of a caring teacher he has a relationship with and with
whom he feels able to talk openly. There may be a mentor in school that he trusts. It may also
be that a referral to social services will provide additional family support and perhaps offer fur-
ther referral to a voluntary agency offering family work.

Harvinder’s difficulty does represent a mental health issue, but it does not necessarily follow
that he has a mental health problem or the beginning of a mental illness. Hasty referrals
remove responsibility from individuals to professionals, and that is not always desirable.

A school that places mental health and well-being at the core of its aims can support Harvinder
and his family at a variety of levels. It would provide the kind of healthy school environment
where Harvinder feels safe and can thrive against adversity. It will be a school which recognises
his difficulty and intervenes early, offering the kind of quality support which addresses some of
his underlying issues whilst setting appropriate boundaries – so important when a young
person’s life appears to be spiralling out of control. However, this would also be a school that
looks beyond his behaviour and recognises when outside help is necessary and understands
what constitutes an ‘intelligent’ referral to other professionals, a matter which is addressed later
in this book.

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These ideas relate directly to the work of Tones (1981) as presented by Weare (1999), which
offers a three-level model: the ‘tertiary level’, where a severe and recognisable mental illness has
been diagnosed; the ‘secondary level’, which may be characterised by temporary mental illness
or difficulty from which the person will probably recover; and the ‘primary level’, which may be
seen as the wellness level.

Understanding that Harvinder’s difficulties may be a mental health issue for the school and his
family, affects our response to him. To focus on his behaviour alone is unhelpful.

Reflection box ?

 If Harvinder said he wanted to talk to you about home and school, what would you say?
 Can you add to the list of criteria that indicate that a person has good mental health?
 When you first read the criteria, did you find yourself reflecting on yourself or those
close to you? What were you feeling?
 What do you consider to be ‘abnormal’ behaviour in a young person?
 Where are you on the mental health continuum? Has it been different at various times
in the past?

How many young people in our schools suffer from a mental health
problem?

Key points
k
There are a significant number of young people in the UK who are suffering from a
mental health problem or illness. Most of these are also pupils in our schools.

In 1999, the Office for National Statistics estimated the population of the UK at just under 60
million. Children up to the end of Year 11 would represent over 20% of the population. The
Mental Health Foundation (1999) suggests that at any particular time, up to 20% of children
and adolescents may be experiencing psychological problems. Based on epidemiological stud-
ies of young people, the following figures are put forward as the possible incidence of mental
health problems in young people:

12% anxiety disorders

10% disruptive disorders

5% attention-deficit disorders

6% specific developmental disorders, enuresis and substance abuse.

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A lower figure, only 1%, is recorded for psychotic and pervasive developmental disorders such
as autism.

Quoting the Office for National Statistics (2000), YoungMinds notes that over 10% of children
and young people aged 5–15 years are affected by a significant mental health disorder. The fig-
ures for children of statutory secondary school age rise to 11.2%.

YoungMinds also records the following statistics drawn from a variety of sources:

Attempts at suicide are made by 2–4% of adolescents, of whom over 7.6 per
100,000 young people aged 15–19 years succeed.

Some 2–8% of adolescents experience significant depression.

Some 1.9% have obsessive-compulsive disorders.

Up to 2% have either anorexia nervosa or bulimia nervosa.

Similar figures are recorded by the organisation Mind (2001), which adds that self-harm affects
3% of adolescents and that the suicide rate in young men has risen significantly, by up to 75%,
since 1982. YoungMinds argues that these distressing statistics may have risen to well over 100%
in the last decade. It is also recognised that the incidence of conduct disorders is twice as
common in boys as in girls, and for hyperkinetic disorders, such as attention-deficit and hyperac-
tivity disorder (ADHD), the rate is even more significant, possibly up to four times as common.

Translating some of these figures into meaningful information for teachers and other profes-
sionals, YoungMinds calculates that in the average secondary school of 1000 pupils there are
likely to be:

50 pupils who are seriously depressed

100 who are suffering significant distress

10–20 pupils with obsessive-compulsive disorder

5–10 girls with an eating disorder.

In addition, various other writers suggest that up to 100 young people in a similar school may
be suffering from anxiety, while the figures for those abusing drugs or alcohol could be simi-
larly large in inner-city areas.

Despite the legitimate concern that these figures may represent a medicalisation of behaviour
problems and a tendency to label children in distress, they remain significant. My own experi-
ence suggests that in reality the figures could be higher, especially in relation to self-harm,
eating distress, anxiety and depression.

This, then, is the task faced by schools. Wherever possible, we need to find ways to prevent these
problems in young people from developing. We need to act early with our own school-based
support systems and refer on to – and work directly with – mental health professionals where
this is felt necessary and desirable.

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Of course, any discussion of the incidence of mental health problems in young people belies the
pain, suffering and despair that each brings to those young people and their parents or carers. We
should also remember that it is not only diagnosable mental illness that invites us to be respon-
sible about promoting mental health and emotional well-being in our schools; there are many
young pupils experiencing a range of difficulties, often associated with the normal tasks of ado-
lescence and growing up, that might also need our support. This is particularly so where normal
development is potentially hindered or thrown off course by exceptional home circumstances.

Reflection box ?

 What were your thoughts as you read these statistics?

 Did any current or past pupils come to mind?

How do we know if a pupil has a mental health problem?

Key points
k
It is possible to identify a range of ‘warning signs’ that might help us to judge whether a
young person has a mental health problem. These should be used with caution but
nonetheless are indicators of concern.

For some, the period of adolescence represents the smooth transition from childhood to adult-
hood; for others, it is characterised by confusion, distress and conflict with friends and family.
Those who parent, teach or come into contact with a teenager are often confronted by rebel-
liousness, irritability, moodiness and arguments. Sometimes adolescents can be aggressive and
challenge authority. If we bear this in mind, it is not surprising that those who work with young
people in schools sometimes find the job stressful: assembling up to 1500 adolescents in a
single building in an attempt to teach and encourage them to learn can sometimes seem a
bizarre idea.

Difficult behaviours are a ‘normal’ part of the process of growing up, becoming pubescent, seek-
ing independence and reflecting on one’s future. However, schools have a responsibility to
support young people through this minefield as part of a wider commitment to the social edu-
cation and emotional development of their pupils. In view of the kinds of statistics set out
above, the reality is that some pupils in our schools may begin to develop mental health prob-
lems that, if left untreated, could develop into longer-lasting mental illnesses. The earlier a
mental health problem is identified, the better the chance that the pupil can be supported and,
if necessary, referred for treatment.

So how is it possible to distinguish between normal adolescence and the early stages of a
mental health problem? The answer has something to do with how many warning signs are

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present, how persistent they are over a period of time, and the degree to which they are affecting
the young person’s individual and social functioning and the capacity to engage with learning.

Peter Wilson (YoungMinds, 1996) suggests that we ask ourselves the following questions when
concerned about a pupil’s emotional well-being:

How extreme is the behaviour or attitude?

How prolonged or persistent is it?

Are there sudden changes in behaviour?

How driven or out of control is the child?

Is there a marked contrast in the way the child behaves at home and at school?

How is the behaviour affecting other members of the school community?

It is important to remember that the presence of a variety of warning signs may not indicate a
mental illness but may be a pointer to the need for additional support and intervention.

The comprehensive list of warning signs (see page 16) is included for your reference.

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Warning signs of mental health problems in young people at school

Feelings

persistent sadness or depression

pervasive feelings of hopelessness or despair

often feeling anxious or afraid

feelings of shame or guilt

being irritable and angry for much of the time

frightened that their mind is no longer under control

marked frequent swings between negative and positive feelings

significant mood swings that appear to be unrelated to events

feeling bad about themselves or their appearance

lacking in energy to do things and feeling tired much of the time

feeling overwhelmed and troubled by their feelings.

Thoughts

preoccupation with death and dying

thoughts about suicide or hurting themselves

overly rapid thoughts and ideas

delusionary thoughts

feeling of being another person

paranoia – the belief that someone is watching them or seeking to harm them

unexplained voices or hallucinations

the belief that their lives are controlled by mystical or unreal beings or objects

finding it difficult to make decisions

limited understanding and difficulty with conceptual thinking

thinking of themselves as bad or evil.
Behaviour

being overly isolated or withdrawn

avoiding social situations

© British Association for Counselling and Psychotherapy 2006 (BACP)

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crying a lot, sometimes for no apparent reason

having fears or phobias that affect ability to function normally

showing loss of interest in leisure activities and inability to enjoy themselves

experiencing sleep difficulties, including insomnia, sleeping too much and regular
nightmares

beginning to act in a sexually provocative manner

drug use, alcohol abuse, crime or other undue risk taking

speaking too quickly in a way that makes it difficult to understand them

constantly dieting, missing meals and refusing to eat when others are around

undergoing significant or rapid weight loss or gain

making themselves sick or abusing laxatives

playing with and/or starting fires

communicating in ways that appear to be incomprehensible or not make sense

lacking in energy, bored and lethargic

often complaining of headaches, tummy aches or general illness

attention seeking, hyperactive or restless

behaving in a regressive way – starting to act in ways more common in younger
children

deliberate self-harming, including cutting, burning, hair pulling, head banging or
biting nails until they bleed

talking about suicide and periodically taking small quantities of pills, prescribed or
otherwise

being accident prone; often hurting themselves

evidence of mutilating or hurting animals

odd behaviours such as rocking or masturbating in public

often starting fights with other pupils

aggression toward adults and other pupils

neglecting their appearance or personal hygiene

adopting ritualistic, routine or repetitive behaviours that appear to be irrational

regularly breaking the law with little regard for the feelings of others.


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Specifically in relation to school

constantly worrying about academic pressure and school failure

overly obsessive about their work

having little motivation or sense of direction

showing decline in school performance that fails to improve

loss of interest in lessons or activities previously enjoyed

becoming a workaholic

avoiding making or maintaining friendships

daydreaming and often off task

difficulty concentrating; fidgeting and restless

very low self-esteem and sense of personal worth; constant self-criticism, putting
themselves down or making negative statements such as I’m thick; no one likes me;
I’m stupid

other teachers or pupils expressing concern about them

significant decline in attendance

refusing to go to school despite threats or encouragement

appearing to be frightened of school

often being the victim of bullying and appearing to place themselves at risk despite
advice

bullying others

very demanding of teachers’ time and attention.

© British Association for Counselling and Psychotherapy 2006 (BACP)

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C HAPTER 3

Risk and resilience

This chapter looks at:

Risk factors, those situations and events in a young person’s life that increase their
chances of developing a mental health problem. Resilience or protective factors are
those that help a young person cope and survive in adversity.

As teachers and professionals working in schools, we sometimes find ourselves making compar-
isons among young people and their ability to cope with difficult situations in their lives. We
may ask, how is it that two young people, both faced with similar problems in their lives,
appear to cope so differently? One pupil seems to ‘bounce back’, whilst another seems to spiral
into depression or anxiety, or appears out of control.

‘Resilience’ is an important consideration for those concerned with the mental health of young
people in schools. Similarly, it is important for schools to be aware of those ‘risk’ factors that
contribute to the likelihood of pupils developing a mental health problem or illness. The task
of the school, therefore, is to find ways in which to minimise the negative effect of risk factors
and build resilience in young people. The related concepts of risk and resiliency provide a fresh
perspective on much of the work that good schools have been doing for many years. However,
making these ideas explicit sets out a way of understanding our pupils and their difficulties with
greater clarity and proposes an agenda for intervention with individuals.

The Mental Health Foundation (1999) suggests that a young person is more likely to cope with
difficulty if there is a balance between risk and resilience. Where risk factors outweigh protective
or resilience factors, a young person’s life may become unmanageable. The Mental Health
Foundation also attempts to explore the relationship between risk and protective factors, sug-
gesting that it may be possible to:

reduce the risk itself

alter the exposure to the risk

reduce the likelihood of a ‘negative chain reaction’ initiated by the risk factor

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promote self-esteem and self-efficacy in the young person

create ‘new and positive opportunities’ and offer ‘turning points’ where a risk
path may be ‘rerouted’.

Risk factors
Risk factors will be considered in more detail in the next chapter, which sets out to explore the
causes of mental health problems in young people. However, it is important to consider them
here in relation to resilience, for, as the following pages will show, there is an obvious interplay
and correlation between the two concepts. It has been suggested by the DfES (2001) that risk
factors are ‘cumulative’; that is, where there are more risks affecting a young person, there is a
greater likelihood of difficulties developing. A similar negative indicator will, of course, be the
‘severity’ of the risk factor. Drawing upon the evidence submitted to the Mental Health
Foundation Inquiry, Bright Futures, by Professor Peter Hill at the Hospital for Sick Children,
Great Ormond Street, London, the final report offers the following broad statistics and
informed calculations:

If a child has only one risk factor in their life, their probability of developing a mental health
problem has been defined as being 1–2%. However, with three factors it is thought that the
likelihood increases to 8%; and with four or more risk factors in their life the likelihood of the
child developing a mental health problem is increased by 20%. We know, therefore, that the
greater the number of risks, and the more severe the risks, the greater the likelihood of the child
developing a mental health problem. (pp. 7–8)

It would be useful here to consider risk factors under three headings, such as those identified by
the Mental Health Foundation (1999). Inevitably, there will be overlaps.

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Risk factors

Factors within the child

genetic factors, although these alone are unlikely to cause mental health problems

sensory impairment

learning disabilities

communication and language difficulties

chronic illness

low self-esteem

religion, race and culture, including confusion as to personal identity

confusion over sexual identity

school failure

developmental delay that might include autism or Asperger’s syndrome

early behaviour problems.

Factors within the family

parental mental illness, especially of an acute kind, such as schizophrenia, or of a
chronic kind, as in a mother with long-term depression

family size; for example, having numerous siblings

family discord, conflict and disorganisation

family breakdown

violent or aggressive relationships where this leads to the child’s experiencing fear or
rejection

poor parenting resulting in inconsistent discipline, which might be considered as
lacking in boundaries or being oppressive

abuse – where the young person has experienced physical, sexual, emotional abuse
or neglect

parent criminality

parental drug misuse or alcoholism

bereavement and loss

parent education difficulties, such as school failure or learning difficulties


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lack of mutual attachment and nurturing during the early years

low expectations leading to a lack of motivation and challenge

too high expectations, leading to undue pressure and stress.

Community and environmental factors

socio-economic disadvantage

unemployment affecting family income and parental emotional well-being

housing problems, including overcrowding or homelessness

poor neighbourhood, including living in an environment of decay or inner-city
decline

racism and discrimination

peer factors, including negative peer influences associated with crime, anti-social
behaviour or drug misuse, or social isolation as a result of peer rejection

membership of an at-risk group, as in looked-after children, young carers and refugees

bullying resulting in fear, isolation and possibly self-hatred

experiencing a traumatic event, perhaps being involved in war, an accident or
terrorism, or being the victim of a crime or violence.

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Resilience
For some time, researchers have been interested in learning about resilience, believing that if we
can understand more about such protective factors, we might be able more effectively to pre-
vent mental health problems developing in young people – or at least reduce their impact.

An understanding of resilience and protective factors is important because it suggests ways in

which interventions can be made by the school and other professionals to increase pupils’ abil-
ity to cope with change and survive adversity. The key task for schools is to find ways to
translate these concepts and ideas into practical action and intervention.

An excellent representation of the nature of the concept of resilience is provided by Julia

Vellacott (2005), a psychotherapist working in London:

Resilience is not a matter of absolute strength. Like a tree that bends in the wind but does not
break, resilience involves the ability to return to shape; to suffer but not to shatter, not to become
so stuck in a defensive position where there is an impoverishment of personality. Indeed, the
struggle involved in hardship may lead to growth created out of that hardship. (p. 18)

As adults, we often value life experience in another person, and it is sometimes argued that it is
a necessary part of growth and development. In some way, life experience contributes to the
growth of maturity and better prepares us for life’s challenges. It is important to note, however,
that in some cases where a child has experienced significant trauma – as in the case of chronic
abuse – ‘resilience’ alone may not be sufficient, and additional care may be needed as part of
the recovery process. In a similar way, it should be understood that resilience does not ‘inocu-
late’ a young person from the effects of severe trauma, and in many situations there may be
deep and long-lasting scars, sometimes continuing into adulthood.

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Resilience factors

Factors within the child

being a girl

having a good vocabulary and use of language

having normal cognitive development

emotional literacy

being a ‘good’ baby

ability to maintain attention and concentrate

secure early attachments

being attractive to others by appearance, temperament or personality

high self-esteem and sense of worth

a sense of humour

empathy

developed problem-solving skills including the ability to think clearly, make plans and
ask for help when necessary

an internal locus of control and a belief in one’s own ability and self-efficacy

positivity in the face of adversity

ability to establish and maintain friendships

a sense of meaning in life, including goals and direction

self-awareness and a positive sense of self

developed social skills and competency

a sense of autonomy and the desire and ability to carry through tasks alone

flexibility and the ability to adapt

ability to cope with change

ability to move successfully between different cultures

good resistance skills, where the young person develops the ability to resist peer
pressure and risk-taking behaviour

a sense of sexual identity

awareness of the needs of others.

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Factors within the family

a strong relationship with at least one competent, loving and caring parent

parents who have sought pre- and postnatal care

regular family income and employment

continuity of parenting, where there has been no long separation from a parent

a family where anger, conflict and stress is managed well

child receiving quality time from parents and other family members, as in working
and playing together

not having to compete with more than four siblings

having older siblings whom they can turn to

clear boundaries set and expectations about behaviour expressed clearly

avoidance of personal criticism; discipline focusing on the behaviour rather than the
young person

an extended family including grandparents, uncles and cousins

a family where love, compassion and affection are demonstrated

positive and mature family communication

education valued and supported

child involved in family decision making

reading at home encouraged

safe and healthy home environment

having access to a positive familial role model

the young person’s skills, assets and qualities noticed and explicitly valued with
encouragement to build on these

strong family faith, religion or belief system.

Factors within the community and environment

good housing

a good neighbourhood where the young person is not overexposed to drug misuse
or violence

positive peer influences, especially those that reject anti-social behaviour


© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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MENTAL HEALTH IN SCHOOLS

the community provision of opportunities for good health and social care,
employment, recreation and childcare

community recognition the achievement of young people locally and nationally.

School protective factors

at least one significant and caring relationship with an adult in school

high expectations of academic success

high behavioural expectations and firm and clear boundaries

positive school climate and high morale among staff and pupils

extensive extra-curricular programme including sports

opportunity for active participation in the life of the school

curriculum that is structured, thematic and experiential

curriculum that recognises that children learn in different ways

concern for promoting the self-esteem, independence and self-efficacy of pupils

teachers offering time and space to listen

school providing welfare, mentoring and counselling as part of the formal pastoral
system

teachers and other adults in school model caring relationships and communication

school encouraging young people to have a sense of connectedness and belonging

pupils valued equally regardless of difference

school demonstrating commitment to physical and emotional health, and healthy
lifestyles and sexual attitudes encouraged

conflict managed well

pupils’ achievements valued and celebrated

clear policies on anti-bullying and drug misuse

well-established programmes in personal and social education and citizenship

active sex education policy and programme for personal relationships and sex
education

caring, empathic teachers and support staff

teachers showing genuine interest in and concern for pupils’ learning and well-being

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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RISK AND RESILIENCE

school providing professional development opportunities for staff

teacher encouragement of the development of pro-social behaviour

school encouraging parental involvement

school making opposition to injustice and discrimination explicitly clear.

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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MENTAL HEALTH IN SCHOOLS

Simply ‘being a girl’ may seem an odd factor in measuring resilience. Generally, girls may be
stronger emotionally, and this may result from the fact that girls share their feelings with family
and friends, more readily than boys. There may even be inherited or genetic differences between
boys and girls.

The list, of course, is endless and highlights all those ideas and practices that constitute a caring
and effective school. However, the list also highlights opportunities for action with regard to
mental health promotion. These will be discussed more fully in a later chapter. It should be
noted that the potential for school intervention is not confined to this final (school) section.
Teachers and other school-based professionals are in a position to encourage, develop and sup-
port many other protective factors within the child, family or school. We are not in a position to
change a child’s gender, effect change with regard to inadequate early attachments, change the
early nurturing experience, find jobs for unemployed adults in the family or even encourage
parents to have fewer children! We can, however, build self-esteem, and help pupils develop
friendship skills, develop a sense of autonomy and learn to resist negative peer pressure. In the
context of family and community, we can support families in distress, advise on behaviour
management, encourage parents to recognise their child’s achievements where these are hidden,
and generally encourage a good working relationship with the school. With regard to the com-
munity we can counterbalance negative peer influence and either directly, or in association with
other statutory and voluntary agencies, support families facing practical problems in relation to
housing or health problems within the neighbourhood. Of course, this is nothing new; schools
have been supporting and encouraging parents and pupils for many years. However, under-
standing these actions in the context of mental health promotion and intervention points the
way to a more coherent and comprehensive whole-school approach.

Reflection box ?

 Can you identify from your experience a pupil who appears to thrive against all
adversity?
 Consider a number of risk factors mentioned in this chapter. How might the risk be
reduced? Can we affect exposure to that risk or prevent a ‘negative chain reaction’?
 In what ways is your school already working to increase resiliency in its pupils?
 Think of a pupil you know. How might the school increase or improve his or her protective
resilience?
 Reflect upon those protective factors which may have contributed to your own resilience.

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C HAPTER 4

What are the causes of mental illness in

young people?

This chapter looks at:

The causes of mental illness in young people. The causes are complex and often the
result of a number of interrelated factors. Some of these are of direct interest to
schools, struggling to understand and work with the young people in their care. Some
groups of young people are particularly at risk due to specific circumstances.

There is, of course, no simple answer to this question. It is likely that a mental illness in a young
person is caused by a complex interplay of biological, psychological and environmental factors.
Mental illness rarely has one cause; it is more likely to be multifactorial. What is clear is that
mental illness should not be seen simply as a weakness of character or the result of poor nur-
turing. Similarly, recovery from a mental illness cannot be viewed as a matter of being strong
willed or of young people ‘pulling themselves together’.

Biological factors
Here, mental illness is seen as a sign of a physical or organic disorder. Biological abnormality
can arise in a variety of ways. Observation and studies of some mental illnesses suggest that
mental health problems appear to have a genetic origin and run in families. In this sense,
mental illness is seen as a matter of inheritance, whereby some DNA material containing our
genetic code is passed on from generation to generation. Whilst it is unlikely that ideas and
images are inherited, it is believed that parents’ genes contain ‘instructions’ to future genera-
tions, determining not only looks and a tendency toward physical illness but also the way we
think and feel. Genes alone rarely cause mental illness; more likely, genetic factors are triggered
by trauma or environmental factors. In other words, it does not necessarily follow that, simply
because there is mental illness in the parent, the child will inevitably inherit that problem; it
just makes it statistically more likely.

Some mental illness can be attributed to chemical imbalances. Neurotransmitters are the body’s
chemical messengers that convey information from neuron to neuron and facilitate communication

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MENTAL HEALTH IN SCHOOLS

in the brain. Where these chemicals are out of balance, we may see signs of mental illness. It is
well known that deficiencies in serotonin can affect moods, precipitate anxiety and alter sleep
patterns.

Other biological causes include infection of the nervous system, damage to the brain as a result of
drugs or alcohol, and pollutants such as lead and other toxic chemicals. The brain can also be
affected by severe physical trauma such as head injury, metabolic disorders affecting chemical bal-
ance, endocrine and hormonal problems, dietary deficiencies and the ill effects of medication.

Psychological factors
Psychological factors include those concerned with personality and temperament. These may
predispose a young person to a mental health problem. For example, a child with an anxious
disposition may be more likely to develop an anxiety disorder, be a school refuser or suffer
from depression. Some mental illness is associated with early attachment problems. Mental ill-
ness may also be triggered by acute or chronic trauma, such as physical, emotional or sexual
abuse or neglect, domestic violence and bullying. Inevitably, the loss of a parent, family
member or close friend can have a profound effect on a young person’s mental health and well-
being. Other psychological factors include those associated with self-image, ideal self, actual self
and subsequently self-esteem.

Environmental factors
These might include:

living in poverty

divorce or separation of parents

school-related factors such as academic pressure or exam stress

sexual or racial harassment

dysfunctional families

transitions and life changes such as moving schools

drug and alcohol misuse.

In fact, many of the risk factors discussed in the previous chapter are, by definition; contribu-
tory factors in mental illness.

Space does not permit me to explore all the factors that might affect a pupil’s mental health, but
below I wish to look in a little more detail at those which may be of direct concern to schools in
particular. These include:

child abuse

domestic violence

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WHAT ARE THE CAUSES OF MENTAL ILLNESS IN YOUNG PEOPLE?

divorce and separation

bullying

academic and exam stress.

Also, there are a number of pupils who may belong to ‘vulnerable’ groups whose circumstances
may be contributory to or exacerbating factors in the mental health of young people. These
include pupils from black and other ethnic minority groups, refugees and asylum seekers, pupils
with learning difficulties, young people who have experienced chronic childhood illness, and
children with alcoholic or drug-dependent parents. By way of example, I consider below the fol-
lowing groups of pupils who may face additional and complicated risk:

children whose parent suffers from a mental illness

looked-after children

bereaved children

gifted and talented pupils

gay and lesbian pupils.

Child abuse and mental health

Child abuse, whether sexual, physical or emotional, is a major mental health issue. My own
experience of working with young adults who were abused as children has shown that the effects
can be debilitating, pervasive and long-lasting – a view that is supported by many studies.

It is not unusual for schools to make periodic referrals to social services where there is evidence
of physical abuse. Physically abused pupils are more likely to become anxious, as they live in
fear of a recurrence of the violence. Such anxiety may result in stress, often leading to depres-
sion. Physically abused children may become overly aggressive toward adults in the school, and
their peers. This may eventually lead to more serious emotional and behavioural problems and
school failure.

Emotional abuse includes adult behaviours such as rejecting, isolating, insulting, humiliating,
constantly criticising, threatening and belittling. It may also involve the lack of, or withdrawal of,
love and affection and the necessary conditions for normal social and emotional development.

Emotional abuse serves to devalue children’s self-esteem, inducing feelings of inferiority and
poor self-worth that leave children with a negative outlook on life. They may come to view
themselves as useless and blameworthy. Emotionally abused pupils may also display signs of
overt or passive aggression or may become shy, withdrawn or overly compliant. They may
become highly dependent on or demanding of adult attention, with significant consequences
for relationships at school. The pupil who is abused emotionally may develop compulsions,
obsessions and irrational fears, and may show cruelty to others. It could be argued that the
cumulative effect of long-lasting and persistent emotional abuse upon a child can be more dan-
gerous to that child’s mental health than periodic physical abuse or even sexual assault.

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Many people have written about the effects on young people who have been sexually abused,
including Draucker (1992) and Sanderson (1995). Some of the effects may be immediate,
whilst there may also be a legacy later in life, particularly if there has been absence of quality
support.

A young person who has been sexually abused may experience a deep sense of shame. Shame is
a powerful emotion that can have a deeply corrosive effect in the long term. The pupil may
experience a number of powerful feelings such as guilt, confusion, denial, grief and anger.
Other effects of sexual abuse might include the onset of depression and anxiety, as young vic-
tims struggle to make sense of their shattered world.

Young people who have been sexually abused are more likely to engage in deliberate self-harm
and attempt suicide, whilst the development of eating disorders and drug abuse is also
common in abused children. One of the most significant and alarming effects of abuse is that
the young person may suffer from post-traumatic stress disorder, characterised by flashbacks,
nightmares and compulsive thoughts, which may last for years if left untreated.

Sexual abuse will often have a profound effect on the pupil’s interpersonal relationships, which
may become disturbed and dysfunctional. Relationships with close family members and friends
become strained, especially if the abuse occurred within the family itself. In the long term,
abuse may interfere with the pupil’s ability to form warm and trusting relationships with a part-
ner and there may be a fear of intimacy. It is a recognised phenomenon that there is an
increased likelihood of the young person forming similarly abusive relationships into adult-
hood. Needless to say, there may be subsequent problems with engaging in sexual activity with
a partner and there are links with promiscuity, prostitution and other forms of sexual exploita-
tion. The abuse may have a distorting effect should the victims of abuse later become parents
themselves, and for many young people there remains the fear that they might repeat the
behaviour of those that have abused them.

Finally, there may be associated cognitive effects on the young person. In school, they may
begin to fall behind with their work, lose motivation and behave more erratically, either with-
drawing into isolation or acting out in a confrontational or aggressive way.

How domestic violence affects the mental health of a young person

Domestic violence occurs where physical, sexual or emotional abuse is inflicted on a partner. In
most cases, this is the woman, although there is increasing evidence that men may also be vic-
tims of domestic violence. It would be incorrect to assume that all domestic violence involves
actual physical assault. Often it begins with more subtle forms of emotional violence and neg-
lect, including threats, put-downs, and comments and actions designed to embarrass, demean
or humiliate. There may be a variety of forms of verbal aggression and attempts to control the
victim’s environment and relationships, before gaining momentum toward violence against
property and subsequently against the person, in the form of pushing, shoving, slapping,
punching, biting and kicking. In some cases, weapons may be used. Domestic violence may
also be associated with sexual violence where one of the adults is coerced, pressured or forced
into sexual activity with the other partner. Domestic violence often leads to serious injury and
sometimes death. The Royal College of Psychiatrists (1999) notes that as many as one in four

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women are abused by their partner. They also suggest that violence is more likely where there
are children in the family, and often begins during pregnancy and after the birth of the child.

Children and adolescents in our schools who witness domestic violence can be deeply affected
by their exposure, and the effects may continue into adulthood, compromising future mental
health and well-being. Clearly, the effects of the violence will depend upon a number of factors,
such as the nature and severity of the violence, how long the young person has been exposed to
it, and the child’s age and degree of resilience. There may be additional complicating factors if
the children have been victims of abuse themselves by the same adult, or if they have been
involved directly in the abuse of the same parent. There may be secondary consequences of the
abuse, including the diminished ability of the abused parent to offer the child support and the
use of alcohol or drugs as coping mechanisms.

Pupils who have been exposed to domestic violence are sometimes in a constant state of anxi-
ety, fear or even terror. They may experience continuous psychological pain, feeling sadness and
a profound sense of the loss of the family and relationships they feel they should have. They
may begin to feel helpless and without a sense of hope or purpose. They may fear their own
mortality or become concerned for the life of the abused parent. There may be contrasting emo-
tions of guilt – expressing a sense of responsibility for the violence and anger – and fury at one
or both of the parents involved. There may be some ambivalence about relationships, and the
pupils may feel ‘in the middle’ – torn both ways and unsure about where loyalties lie. They may
begin to hold contrasting feelings simultaneously, such as dependency and need at the same
time as fury and rage.

Sleep may be affected as the young person is woken by the violence or by nightmares. Such
pupils begin to view the world as unsafe, and they find it hard to trust, having been let down by
the adults in their lives. Their world now becomes threatening, all-consuming, hostile and
unpredictable. Nothing seems the same any more; their world is turned upside down.

Boys often cope more aggressively, acting out their pain and confusion. Girls may also be aggres-
sive, and their behaviour may become a cause for concern, but they are equally likely to internalise
the problem, becoming more depressed and anxious. Both boys and girls may develop difficulties
in resolving disputes with siblings and friends – conflict being the inevitable result.

The pupils may exhibit regressive behaviours, retreating into the ways of a younger child.
Conversely, they may take on an adult, caring role, seeing themselves as the protector of the
abused or violated parent and responsible for the safety of younger siblings.

The Royal College of Psychiatrists (1999) also refers to complications in later life, including the
idea that the children may become abusers or victims themselves. They argue that children
learn from the example set by their parents; boys may learn to be violent to women, and girls
may come to see that violence is inevitable and something you just have to put up with.

The emotional impact of divorce and separation on young people

The Royal College of Psychiatrists (1999) estimates that up to 50% of all children in the UK will
see their parents divorce or separate. This means 150,000 children of school age will be sepa-
rated from one parent. When these figures are translated to the school setting, the implications
are significant.

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Pupils whose parents divorce or separate are more likely to experience difficulties at school.
Behaviour is affected, with the pupil possibly becoming more aggressive; work suffers; and there
may be changes in attendance patterns, through an increase in either condoned absence or tru-
ancy. The school’s disciplinary machinery comes into play, as it struggles to manage the young
person’s behaviour that threatens to spiral out of control.

There are very practical consequences of a marriage break-up, including financial constraint as
parents sometimes have to cope with reduced income. There may be house moves involved and a
general lowering in the standard of living of the remaining family. Families might be torn apart
and siblings split between former partners. There are also, statistically, likely to be issues typical of
reconstituted families, as parents find new partners and a former parent may be replaced by a step-
parent in law or simply by way of cohabitation. All of these significant life changes can happen
within a short period of time, leaving the pupil disoriented, confused and insecure.

The Times Educational Supplement (2003) explored the impact of ‘parents at war’ in their series
‘The Issue’. They noted how pupils may be affected prior to, during and after the split, leaving
some young people with emotional and behavioural problems. They also alerted us to the
potential difficulties when the split is not managed in an amicable way with both parents keep-
ing an eye on the emotional needs of the children affected:

And if the separation is adversarial, the effect can be even more devastating and long term.
Children can get caught in the middle, often used by one parent to get at the other … . When it is
adversarial, the child may be drawn into the conflict, forced to hear endless criticism and hostility
from each parent about the other or be asked to take sides or find fault.

It follows that the mental health of a young person can be affected by parents becoming con-
sumed by the split themselves and consequently being less emotionally available to the
children involved. At school, a pupil may become more dependent, attention seeking or needy.
It may well be that the child who experiences divorce experiences the same range of emotions
as a child who has lost a parent through death.

Children of separating parents will experience a wide range of emotions. These include denial,
as the children shut down their feelings in an attempt to avoid the acute feelings of grief and
loss. This may lead to silence in the child that can be mistaken by parents and schools as accept-
ance, resulting in children being denied the kind of emotional support they need. Feelings
‘bottled-up’ are more likely to show themselves in other ways, as through angry outbursts and
the bullying of other pupils.

Family break-up often results in feelings of shame and guilt. The pupil may feel different from
and inferior to other young people where the family remains intact. Guilt comes on account of
the mistaken belief that they have caused the split-up. There may well be anger too, directed at
the parent whom they feel is responsible, or both. There may be emotional confusion as the
young person faces decisions around loyalty and betrayal, leaving the young person torn apart.

Children may have feelings of deep insecurity as they enter a period of rapid change, as rela-
tionships and routines become disturbed and no longer predictable. Children may also fear
abandonment, believing that having lost one parent, they may lose the other. However, linked
to this may be feelings of rejection, one parent appearing to walk away from them. This may
raise questions of self-worth and value, with inevitable consequences for the child in school, as

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confidence is lost and alternative ways of feeling good are sought. This may take the form of
looking out for other pupils whose behaviour suggests that they, too, might be in pain –
making the young person feel less judged and more accepted.

Pupils may lose a sense of direction and become disaffected from school. They may become
isolated and the victims of bullying themselves. They may worry about the future and what
might happen to them, or become consumed by beliefs that their warring parents will be recon-
ciled and reunite, returning to the status quo. The pupil may also develop signs of anxiety, and
younger children may start to become ill, complaining of stomach-aches and headaches and
generally feeling unwell. Some young people may experience panic and be physically sick, with
many trips to see the school nurse.

As with any discussion about the mental health consequences of life events, the reality is often
complex and affected by other risk and resiliency factors, and some children appear to cope
better than others. It should also be noted that separation or divorce may be preferable to
unhappy parents living together ‘for the sake of the children’ or because economic factors pro-
hibit living apart. Swan-Jackson (1997) notes how, for some of the young people in our
schools, divorce or separation may be a relief, especially where continuous conflict or domestic
violence may be involved.

Bullying and mental health

Bullying remains a persistent and high-profile concern of most schools. It may be seen as:

hurtful behaviour where harm is intended

occurring over a period of time, possibly of a repetitive or serial nature

involving an imbalance of power where victims are often unable to defend
themselves.

Bullying takes a variety of forms. It can be physical, involving hitting, punching, tripping up,
pushing, hair pulling, kicking, spitting or throwing objects at another person. The physical ele-
ment may be indirect, taking the form of inducing other, more confident and powerful pupils
to assault the victim. Bullying may be verbal and include insults, name calling, spreading false
and malicious rumours, and talking about family members in rude or offensive ways. Verbal
bullying may also take the form of malicious phone calls and attempts to extort money or pos-
sessions. Bullying can of course be non-verbal, such as excluding people from the group, or
taking their belongings and hiding them. Non-verbal bullying also takes the form of ‘dirty
looks’, or implying physical threat by gesture. It may include racial or sexual harassment. More
recently, cyberbullying has involved the use of computers and mobile phones. Unfortunately,
there are almost unlimited ways in which young persons may use their powers and relation-
ships to bully others.

For most young people in our schools, bullying is a transient experience. In terms of mental
health consequences, these are more likely to be significant if the bullying is severe and persist-
ent over a long period of time.

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Most profoundly, bullying is an attack upon a pupil’s self-esteem. This may have been a signifi-
cant factor in why the young person was initially targeted for victimisation by potential bullies,
and now is compounded by the negative attention. Pupils who are bullied may begin to feel
worthless and ashamed, seeing themselves as a failure, inferior to others and valueless. They
may begin to feel incompetent and unattractive or even ugly, questioning their looks and
acceptability to others.

Pupils may begin to feel anxious or panicky; they may start refusing to go to school. They begin
to live in fear of the bullying and hide themselves away. This constant emotional strain may
cause physical symptoms, and health may suffer as a consequence. Sleep patterns may become
disrupted, and the pupil may begin to experience bad dreams or nightmares.

Bullying often has severe repercussions for social relationships; victims of bullying report feel-
ing excluded and isolated. This affects their ability to form trusting friendships with other pupils.
At school, victims may find it hard to concentrate and they may become moody or irritable.
Sometimes, displaced anger is directed toward other ‘less powerful’ pupils or adults in the school.
Constant anxiety, low self-esteem and social isolation sometimes lead to depression in young
people. They may come to question their reason for living, contemplate their own death and
develop suicidal ideas. They may begin to harm themselves. The media often report the ultimate
effect on the mental health of a victim of bullying, when victims attempt to take their own life or
succeed in doing so – possibly the most devastating tragedy for both schools and parents.

Academic pressure and exam stress

It is a discomforting thought that schools, as well as doing their best to support pupils’ emo-
tional development and well-being, may in fact be a contributing factor to the mental ill health
of the young people in their care. A key area where schools could usefully examine their own
curriculum, policies and procedures is that of academic outcomes, particularly formal attain-
ment, as measured by exam success. As government piles the pressure on schools, these targets
and expectations are transmitted to our pupils via teachers who themselves feel the pressure to
achieve the targets set by school leadership teams – who perhaps feel the pressure themselves
most acutely.
There is growing concern about the effects of academic and exam pressure on our young. The
National Institute for Clinical Excellence has ranked exam pressure alongside other problems,
such as bullying, bereavement and abuse, as a cause of mental health problems in young
people. This itself has been triggered by concern about the increasing prescription of antidepres-
sants for young people. Such a concern is reiterated by Smith in her article ‘Britain: Teenagers
Driven to Depression and Suicide by Exam Pressures’ (2004), which refers to evidence that
appears to link exam stress with the use of psychiatric drugs and teenage suicide. She also
records how the children’s charity ChildLine has reported significant increases in the number of
young people using its website or calling to complain of exam pressure. In an article in the
Guardian (13 September 2004), Madeleine Bunting, also asks us to consider the idea that we’re
raising kids to pass exams, but not face the world, adding that they are now paying for their lack of
emotional resilience.
Many studies about stress argue that a little stress is a good thing, serving to motivate our young
and helping them to concentrate their energies on academic goals. But, clearly, too much stress

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can have negative effects on a pupil’s emotional well-being. Continuous assessment has been
recognised as taking the pressure off final exams, but it places new stresses on our pupils, par-
ticularly on those who are conscientious and who are taking the full range of examination
subjects at GCSE level or above.

Young people may not consciously recognise stress in themselves, and they may show the pres-
sure in other ways. They may become irritable and experience eating distress or sleep
disturbance. They may become obsessional about routines and develop a concern for perfec-
tionism. They may begin to overwork, lose a sense of life balance and become emotionally
exhausted. Pupils under pressure may not know how to ask for help or even recognise the pres-
sure they are under. They may become nervous and agitated, and develop many of the
physiological symptoms of stress, including ulcers, digestion problems and increased heart
rates. The young person’s mind may begin to race, and memory may become impaired. They
may find decision making harder, as their concentration is affected. They become moody and
on edge much of the time.

At the heart of the pupil’s anxiety is the fear of failure. They are concerned about letting other
people down, particularly parents, but they also fear the humiliation they feel would come with
not achieving their goals. Stress and anxiety, unceasing over long periods of time, is linked
directly with depression and, as we have seen above, with suicide.

Exam pressure itself may not be the only cause of mental ill health in pupils in our schools.
Competition, pupils not being able to achieve academically, banding, setting, streaming, work-
load and homework may all be areas a school needs to consider in any discussion of creating a
mentally healthy school environment.

Examples of young people at additional risk

Children who have a parent suffering from a mental illness
Growing up in a family can be difficult at the best of times, but it is particularly challenging for
those pupils in our schools who have a parent at home suffering from a mental illness. Of
course, mental health issues are not new to most families, and many young people experience
times when one or both parents may be depressed, anxious or more stressed than usual. In
most situations, these phases are short-lived, and with the help of the GP or a specialist, diffi-
culties can be overcome and more normal functioning resumed. However, some young people
have a parent whose illness extends over a long period of time and is severe and debilitating.
The problems may be most complicated when a parent is suffering from a diagnosed psychotic
illness, such as schizophrenia, with long periods of separation due to the hospitalisation of the
parent. In these circumstances, children in the family face additional risk.
Of course, in some cases, the risk may already be present in a biological sense, with some
mental illness – or inclinations to it – already proven to be carried on from one generation to
another via genes. There is a greater likelihood that a young person will suffer from ADHD,
depression, schizophrenia, and bipolar and other personality disorders when these have been
diagnosed in a parent.

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A young person whose parent has a mental illness may face a number of additional practical prob-
lems that need to be negotiated, each with an emotional consequence. Additional responsibilities
beyond those that might be expected of an adolescent may emerge, including caring for the parent
who is unwell or the partner. Younger brothers and sisters may have to be protected and cared for
to compensate for the under-functioning parent. Children themselves may be neglected or even
physically abused. This is most likely where drugs and alcohol present mental health issues in
themselves, or where they are associated factors. Indeed, parental mental health remains a signifi-
cant factor in the number and type of referrals made to social services under child protection
guidelines. In the most extreme circumstances, young people have been seriously injured by a
mentally ill parent; in rare cases, they have died from the violence inflicted upon them.

Returning to the idea of neglect, it follows that parents who are clinically depressed or have an
obsessive-compulsive disorder or a more serious personality disorder are unlikely to be able to
support a child’s own emotional development. Parents consumed by their own mental health
issues may be less available for their own growing child and less able to support them psychologi-
cally and practically. The parent may display unpredictable or disconcerting behaviours, leaving
the child frightened and confused. Young persons who see their parents hearing voices, experienc-
ing an episode of paranoia, or saying things that appear to be incomprehensible and without logic
or reason, may become terrified at what they cannot make sense of. If a young person witnesses a
parent’s suicide attempt at first hand, the sense of terror and insecurity could be all-consuming.

Fortunately, the chances of a child dying at the hands of a mentally ill parent remain small, but
more significant is the potential long-term damage to a child’s psychological health and emo-
tional well-being. Pupils in school whose parents are suffering from a mental illness may find it
particularly difficult to seek help, as they may be infused with a sense of responsibility or guilt.
They probably will feel a sense of shame; in particular, young persons may be ashamed of their
parents’ behaviour, perhaps when they visit their school or when friends call. Parents’ behav-
iour may cause embarrassment if it takes the form of bizarre and unpredictable actions. Pupils
may also be concerned about their own mental health, fearing that they may end up with the
same difficulties. This can take the form of anxiety or more acute panic attacks that may serve to
confirm to the young person their belief that they are losing control of their mind. The per-
ceived instability of the parent may also cause pupils to reflect upon themselves, and they may
face confusion and an identity crisis of their own. They also become more vulnerable to any
minor crisis or life difficulty, the children’s reduced resources rendering them impotent and
unable to make decisions.

Pupils may develop a range of relationship difficulties, often ending up withdrawn or separated
from others in the school and outside. They may find it difficult to establish and maintain last-
ing friendships, hindered by suspicion, lack of trust and low self-worth.
At school, pupils may become absorbed by their work in an attempt to divert feelings from the real-
ity they face each day. They may become aggressive as they unsuccessfully deal with their anger. If
the pupils are unable to understand the nature and extent of the parent’s illness, they may be less
than sympathetic, and overt or repressed anger may be the expression of fear and resentment.

Looked-after children
The term ‘looked-after children’ specifically refers to those young people who are ‘accommo-
dated’ by the local authority and therefore under its ‘protection’. Sometimes this is with the

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WHAT ARE THE CAUSES OF MENTAL ILLNESS IN YOUNG PEOPLE?

consent of parents or carers. Some children may be subject to care orders and placed in residen-
tial accommodation. Young people may be placed in foster care, and in some cases be subject to
a care order but still spend significant time at home. According to the Times Educational
Supplement, on 31 March 2003, just under 70,000 young people were being looked after by local
authorities – which represents around 0.5% of young people up to 18 years of age. There are
normally more boys than girls who are ‘looked after’. The numbers are rising particularly in the
under-10s.

Almost by definition, young people who find themselves in care will already have experienced a
wide range of difficulties, including the loss of a parent or abuse of some kind, and many will
come from dysfunctional homes. In addition, it is clear that the emotional effects of moving from
home into one or more new environments and having to establish relationships with unknown
adults is quite substantial. The Mental Health Foundation (2002a) tells us that looked-after chil-
dren are far more likely to develop mental health problems than those young people living in
‘settled’ homes. They also suggest that these problems often go unnoticed and help is not given.
They refer to the ‘traumatic upheaval’ of being moved from their own homes, under whatever cir-
cumstances. They also mention that some young people fail to settle in their new environment
and may experience mixed feelings about what has brought them to this point:

Some young people, especially if they have been moved from their own home, may find it hard to
settle and may feel torn or even guilty at being removed from their family, however abusive or
neglectful (although some may feel a sense of relief because of their changed circumstances). (p. 2)

The link between being looked after and the incidence of mental health problems is made clear
by the Office for National Statistics (2003). In a survey report, they suggest that among young
people aged 5–17 years who are in local authority care, up to 45% may be suffering from a
mental health disorder. The report found that among young people aged 11–15 years, the
prevalence of mental disorders for children looked after by local authorities, compared with
children from the private household survey, were as follows:

emotional disorders: 21% compared with 6%

conduct disorders: 40% compared with 6%

hyperkinetic disorders: 7% compared with 1%

any childhood mental disorder: 49% compared with 11%.

According to the Times Educational Supplement (18 June 2004a), more than one in four children
in residential care for a year or more have a Statement of Special Educational Needs; this com-
pares with 3% nationally. They also added that such children are up to 10 times more likely to
be excluded from school than their peers.

Children in the care of their local authority are more likely to have health-related problems and
are more likely to smoke, drink alcohol and abuse drugs, and be the perpetrator or the victim of
bullying at school. They often experience difficulties with the curriculum at school and gener-
ally do less well in their GCSEs, and many will leave school with almost no formal
qualifications.

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The feelings of a young person in local authority care will be confused and complex. Often they
will experience a cocktail of rejection, insecurity, anger, shame and loss. These and other emo-
tions can contribute to depression and aggression. They may also feel the stigma of no longer
living at home. This may lead to a sense of embarrassment and low self-esteem.

My own experience of working with looked-after young people is that their feelings sometimes
appear to get out of control, and peers become especially important, as if they offer some kind
of attachment to others. These pupils can be overwhelmed by feelings that remain raw and cur-
rent. The pupil sometimes begins to truant from school and engage in risky behaviours. School
becomes less important except for the social contact it provides. In some cases, schools fail to
recognise the tension and upheaval in the young person’s life and ‘will’ them to find routine
and security in school. The young person’s perspective may be different, and, rather than devel-
oping a sense of belonging, the pupil becomes alienated and disaffected.

Bereaved children
In my work in schools, I am often surprised and saddened at the number of young people who
have lost a parent through death. Sometimes we tend to see death as occurring in older age and
forget that parents in their 30s and 40s may lose their life through illness, accident or suicide.

Bereavement is a normal part of life; all of us will experience the grief associated with the death
of a loved one at some point in our lives. By the time pupils get to secondary school, they may
already have had such an experience, most probably through the death of a grandparent but
sometimes a parent or sibling. Sometimes friends die prematurely and the tragedy is felt by
pupils who knew the young person and by the whole school community.

Attempts have been made to make sense of the bereavement process and identify the ‘stages’ of
grief. The loss of a loved one is normally described by words such as shock, denial, anger, guilt
and sadness. Eventually, we expect a young person to move through a number of stages toward
‘acceptance’ and a return to normal life.

When adults experience the death of a loved one, it is believed that they will already have expe-
rienced the feelings associated with loss and may be better able to cope with the bereavement.
For a young person losing a parent, this may be their first taste of the many emotions associated
with grief, and they may well be unprepared.

Of course, everybody will react differently to a death and, as the Royal College of Psychiatrists
(2002b) notes, children often react differently from adults. They also cite a range of other fac-
tors that might affect a young person’s response to the loss of a significant person in their lives.
These include the child’s age and level of understanding and the particular circumstances of the
death. They suggest that a traumatic or sudden death may be harder for a young person to cope
with than a death that brought relief from prolonged suffering. They also imply that there may
be other family factors such as the impact of the death on other family members, and how this
might impair the quality of support offered to the child. In some families, the death may not be
discussed and children may therefore be unable to express their feelings. They may even
attempt to protect the feelings of remaining family members by remaining silent. Such deep,
unresolved emotion may begin to manifest itself in unexpected ways, and these behaviours may
not be linked by the school to the original loss.

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WHAT ARE THE CAUSES OF MENTAL ILLNESS IN YOUNG PEOPLE?

Loss of this kind can never be explained in simple, theoretical terms. In my experience, the
death cannot be considered in isolation from the child’s relationships, past, present and future.
For example, a young person in conflict with a parent who dies may be filled with a deep sense
of guilt, with matters unresolved and little prospect of these being worked through to a point of
resolution or reconciliation. Adolescence is a difficult time for many young people, and the loss
of a parent at the time of seeking independence can appear to derail normal change and growth.

Most of the young people in our schools, with appropriate care and unhurried support, will
negotiate the mourning process successfully, reaching a point where they have ‘come to terms’
with their loss. Whilst feelings may persist into adulthood, they begin to fade and become pro-
portionate and probably end up as a sense of ‘missing out’ on the relationship that would have
been. They may also have treasured memories of the lost loved one and always have a reposi-
tory of sadness deep within them that emerges when another person experiences bereavement
or when they read a book or watch a film.

However, unresolved or complicated grief can cause mental health problems in young people
that can persist into adulthood, with serious consequences for future relationships and social
functioning.

Some young people are not able to grieve, or start but do not carry on, and feelings of denial
and disbelief can continue for long periods of time. Depression is a direct consequence of
mourning that did not begin or was cut short. Chronic depression may begin to pervade all
aspects of the young person’s life during the daytime at school, at evenings and weekends at
home, and at night in the form of disturbed sleep patterns. Eating routines may be affected, and
eating disorders may be triggered as the young person seeks to regain control of a life that has
lost its shape and focus. Depression may be evidenced by the physical appearance of sadness in
the young person, apathy and unwillingness to engage with life and others. Appearance may
suffer, too, with little concern for what others think about them. Pupils may become overly con-
cerned about their own mortality or fear for the lives of other loved ones. In this way, the young
person enters a destructive period of consuming anxiety – and physical symptoms such as feel-
ing sick, or having a headache or stomach-ache may soon follow.

The pupil’s behaviour may take a downward turn, and school performance may slip below the
norm expected for that young person. Encouragement, reward, sympathy and coercion may serve
only to heighten some of the feelings already being experienced. Some behaviours may appear to
be regressive and child-like. Prolonged sadness may take the form of withdrawal from the social
world, and children may appear ‘stuck’, possibly still believing that their loved one will return at
some time in the future; that they have not really died. Long-term depression may become debili-
tating and hard to recover from without professional help. Sometimes children’s grief may
become distorted, and they become incapacitated by acute anger, self-blame or guilt – emotions
that will affect current and future relationships and the young person’s sense of self. Young per-
sons may also consider taking their own life in a vain attempt to be with the lost person again.

The mental health of gifted and talented pupils

Pupils in schools who have been identified as having additional gifts and talents are, of course,
ordinary young people, and their developmental needs are the same as those of other children.

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It also follows that gifted and talented young people are equally susceptible to the risk factors
discussed in an earlier chapter. The gifted and talented pupil may have an alcoholic parent,
suffer abuse or have parents who divorce or separate.

There is some discussion of whether gifted and talented pupils are more likely to demonstrate
greater resilience because they share some of the skills and qualities associated with resilient
people, such as the ability to solve problems. High intelligence is also seen as a protective factor.
However, much of the literature relating to gifted and talented children highlights the particular
social and emotional needs of these young people, and the potential for mental health difficul-
ties if their needs are not addressed. Some of these are discussed below.

Gifted and talented pupils are often perfectionists and have a strong ideal self that they strive
incessantly to become. They can be overly self-critical if they do not meet the standards they
have set for themselves. Paradoxically, their abilities become less of a cause for self-congratula-
tion and more often the beginnings of low self-esteem and self-criticism. Academically, such
pupils may be plagued by a fear of failure, a fear made real by the impossible goals set by the
young persons.

Gifted and talented pupils live and work under the constant pressure to be extraordinary. This
may cause stress and anxiety as they experience the need to demonstrate how able they are.
They may also be under pressure real or imagined, from parents and family, but equally stress-
ful. This sometimes results in these young persons dominating classroom activity and
sometimes even putting other children down by their display of brilliance, or, more directly, in
the form of derogatory comments. Within friendship groups, they may attempt to take control
and organise others. Such behaviours will generate resentment among peers and friends.

The pupil may also be seen as a loner by others, because work, study and the development of
given talents removes them from the peer group and leaves less time for social interaction and
behaviours normally associated with adolescence.

An inappropriate and undemanding curriculum can lead to boredom in school and behaviour
problems, and underachievement may be the consequence. These pupils may develop special
learning needs, as when cognitive ability outstrips their ability to communicate their thoughts
and ideas in writing. Such advanced thinking, hindered by a lack of motor skills, may lead to a
degree of frustration and irritability. Matters may be further complicated if the pupil is at differ-
ent stages of development, not only intellectually, but also physically and emotionally.

The young persons may also fail to find like-minded friends and may become isolated. They
may begin to experience the tension between being comfortable with their identity and their
desire to fit in and conform. The school may begin to identify ‘problems’ in non-conformist
behaviours that represent the pupil’s need to feel distinct and different. There is evidence also
that in order to ‘fit in’ and avoid isolation or bullying, gifted and talented pupils may deliber-
ately fail to achieve in an attempt to keep their qualities hidden and therefore make themselves
more palatable to their peers.

Most gifted and talented young people are well adjusted and go on to thrive socially and aca-
demically, but some do not, and begin to present with emotional problems such as depression
and anxiety, leaving parents and the school confused, disappointed and helpless.

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Gay and lesbian pupils

As most of us are aware, the task of growing up in the modern world is filled with difficulty, and
the period of adolescence is a particularly difficult time for many young people as they strive
toward adulthood. During this time, teenagers begin to develop a sense of their sexual selves,
and for many this can be a difficult process. For gay and lesbian pupils in schools, this can be a
very stressful journey. Many gay and lesbian young people are fortunate to have the support of
family and friends and perhaps a sympathetic adult in school, and they may also have devel-
oped an inner resilience that will sustain them through this difficult time. For others, this may
not be the case, and the school years can have a profound and devastating effect on their mental
health and well-being. It is likely that lesbian and gay young people are statistically more likely
to experience depression and anxiety and are overrepresented in groups that self-harm or
attempt suicide. These mental health problems are to do not with sexual identity but with the
reactions of other and wider societal attitudes. Homophobia can lead to the hurtful use of lan-
guage and sometimes even threats or actual violence. It remains difficult for these pupils to
express openly their sexual feelings without fear of ridicule or, worse still, actual bullying. The
result is that, in schools today, gay and lesbian young people often feel isolated and fearful, and
often carry a deep sense of guilt or shame. Often schools make the assumption of heterosexual-
ity, and many aspects of the curriculum, including, of course sex education, serve to heighten
feelings of not belonging, or rejection.

Reflection box ?

 Consider other ‘vulnerable’ groups such as black and ethnic minority pupils, and
refugees and asylum seekers. What additional factors may contribute to mental health
problems in these young people?
 Take one of the vulnerable groups discussed in this chapter, namely, children with a
mentally ill parent, looked-after children, the bereaved child, and gifted and talented
pupils. How can your school reduce risk and build resilience in these young people?
 Apart from academic pressure and exam stress, how else might a school contribute to
mental health problems in young people?
 Mental health problems may develop as a result of the complex interplay between bio-
logical, psychological and environmental factors. Do you see mental health problems in
young people as the result of nature or nurture?

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C HAPTER 5

Specific mental health problems

and young people: how schools can help

This chapter looks at how the:

Many myths and inaccuracies about mental illness affect our behaviour toward young
people. These need to be challenged. Young people are affected by the full range of
mental health problems, many of which require specialist professional intervention.
However, these young people most often attend our schools each day, and there are a
variety of ways in which we can support them.

Misconceptions about mental health are widespread and are found even among professionals
working with young people in schools and related settings. It is important to be aware of the
facts and to separate these from the fiction in order to end discrimination and treat young
people with the respect and dignity they deserve. Sound information also helps teachers and
other school professionals to avoid the consequences of mental health problems going
unrecognised. It also avoids the kind of misunderstandings that result in poor decision making
about the correct course of action to take.

This chapter serves as an introduction to the many kinds of mental health problems encoun-
tered in schools. Some are rare. The average member of staff is unlikely to come into contact
many times with a young person suffering from, for example, psychotic illness. Others are more
common and strike fear into pastoral staff, who feel deskilled and out of their depth – and
equally frustrated by what they perceive to be too few routes for referral and access to profes-
sional advice.

What follows is a brief look at some of the mental health problems affecting young people.
Clearly, each can be touched on only in summary form, and the reader may wish to refer to spe-
cialist books for more information. However, I have given more weighting to the following
mental health problems, believing them to be among the most common in secondary schools
and to cause most concern to teaching and pastoral staff:

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Asperger’s syndrome

attention-deficit and hyperactivity disorder (ADHD)

conduct disorder

depression

eating disorders

school refusal

self-harm

suicide and attempted suicide.

For each of these mental health problems, I provide a brief description, some of the ways in
which it can be recognised and how it is usually treated. This section also includes ways in
which the school can manage the young person’s problems more effectively and offer help and
support. The problems are addressed alphabetically. Certain identified pages may be photo-
copied for training and information purposes.

Asperger’s syndrome
What is it?
Asperger’s syndrome is a neurobiological developmental disorder sharing some of the same
characteristics as autism. It is more common than autism, but remains relatively rare. The symp-
toms are less severe than those of autism and appear to affect boys more than girls. Children
with classic autism are likely to be educated in special schools or units, whereas those with
Asperger’s syndrome are often successfully taught in mainstream schools. However, educating a
pupil with this disorder in secondary school presents significant difficulties. (See photocopiable
pages 46–7)

Attachment disorder
It is often stated that the first few years of a child’s life are the most critical in terms of social and
emotional development. These are the bonding years when young children form an emotional
attachment to their primary caregiver. It follows that the quality of parenting at this time in the
child’s life will determine future development. During these years, the child has needs and the
parent’s or carer’s ability to recognise and meet these needs is very important.

Sometimes things go wrong. If a child’s bonding with a significant adult is interrupted or

absent, attachment disorders may develop. Abuse or neglect, extended separation due to hospi-
talisation, post-natal depression and major changes in family life, as well as the caregiver’s own
unmet attachment needs in childhood, may disrupt this process of bonding and lead to prob-
lems later in the child’s life.

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Photocopiable

How do you know if a pupil has Asperger’s syndrome?

Pupils with Asperger’s syndrome will have particular difficulties with social interaction
and communication. They may:

be viewed as eccentric by their peers

say things which appear to be inappropriate

take comments literally, leading to misunderstandings and arguments

have difficulty with language, as with the social context of speech and in the style
of delivery

have difficulty understanding the ‘rules’ of conversation and interrupt or end
conversations inappropriately

make comments which are deemed too personal or offensive

be reluctant to accept change

exhibit rigidity of thought and obsessional behaviour, often carrying out ritualistic
actions

have a preoccupation with a particular interest or topic that appears abnormal

find it difficult to work collaboratively with others

have problems with imaginative play

not understand social ‘rules’ or ‘cues’, sometimes misinterpreting situations and
causing offence

have difficulty reading emotions in others and display little empathy

have difficulty interpreting non-verbal behaviours, including the facial expression and
body language necessary for good social interaction

be above average in intelligence and hold a great deal of knowledge about a
subject but may have difficulties with concepts, ideas and comprehension

have difficulty concentrating on some tasks and be easily distracted

have difficulty with transferable skills.

What can the school do to help?

Here are some ways in which a school can manage and support a pupil with
Asperger’s syndrome:

Keep the classroom a consistent and predictable learning environment.

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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Have clearly established classroom routines.

Connect with the pupil’s area of interest and try to relate this to the curriculum.

Make use of visual materials which aid the pupil’s understanding.

Keep the classroom an orderly place with clearly established rules and expectations
of appropriate and inappropriate behaviour.

Apply consequences consistently.

Express rules in positive terms.

Offer a place of ‘safety’ at break and lunchtimes as these can cause anxiety.

Be aware of the possibility of bullying.

Avoid the stress induced by change by preparing the pupil.

Involve the young person’s peers so that they have a better understanding of the
condition.

Teach social skills to the pupil.

Keep spoken language simple, concrete, precise, clear and literal, avoiding double
meanings, sarcasm and too much use of metaphor.

Encourage and reward each attempt to communicate effectively.

Recognise that homework is a problem and offer in-school support.

Avoid demonstration of anger and authority, which can lead to stubbornness and
conflict.

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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The attachment-disordered pupils may find it hard to form loving intimate relationships. They
may become mistrustful of other people and learn to manipulate relationships by acting in a
charming but superficial way. The young person may become indiscriminately familiar with
strangers and clingy. Other features of the disorder include lying, despite ample evidence of the
truth; being destructive to self and property; and sometimes cruelty to other children and ani-
mals. The pupil may be controlling, hypervigilant, attention seeking, lacking in affection or
empathy, and blaming of others, and have difficulty with authority. Such pupils may believe
that they are unworthy of love and affection and have low self-esteem. They may be less able to
cope with stress and frustration and act in defiant or aggressive ways toward adults and peers.
They are more likely to engage in anti-social activity, risky behaviours and addictions.

Attention-deficit and hyperactivity disorder (ADHD)

ADHD is characterised by persistent difficulties in paying attention and impulse control, and
hyperactivity. Affecting 3–5% of the school population, it is one of the most common of the
childhood behaviour disorders. ADHD is a chronic disorder that begins in infancy and persists
into adulthood. It can have a profound effect on the child’s family, the school and the wider
society. It is linked to school failure, exclusion and poor vocational outlook. ADHD remains
controversial: some question whether it can be effectively diagnosed or treated, and claim there
is little evidence of neurological differences. (See photocopiable pages 49–50)

Bipolar disorder
Known more commonly as manic-depressive illness, bipolar disorder is a serious mental health
problem characterised by abnormal shifts in mood. In contrast with everyday changes in emo-
tion, the young person suffering from bipolar disorder experiences larger mood swings, and
euphoric feelings are disproportionate and appear to be unrelated to events in that young
person’s life. Bipolar disorder is one of the few mental health problems which can be harder to
treat in children and adolescents than it is in adults. The illness can sometimes be difficult to
detect, bearing in mind the topsy-turvy world of adolescence and the range of emotions experi-
enced at this time. However, bipolar disorder can have devastating effects on children’s lives at
home, school and with their peers.

Manic symptoms include inflated self-esteem, elated moods, excessive energy and grandiosity,
decreased need for sleep (patients often go for days with little or no sleep), talking incessantly
and loudly with frequent changes in topic and theme, inattention, hyperactivity, distraction,
uncontrolled thoughts and ideas, engaging in risky behaviours likely to cause physical harm,
and over-attention to sexual matters by way of thoughts, feelings and behaviour.

Depressive episodes may include periods of deep sadness and irritability. Other symptoms asso-
ciated with such depression include loss of interest in activities once enjoyed, disturbed sleep
patterns, low self-esteem and feelings of worthlessness, over- or undereating and thoughts
about suicide.

All this represents serious implications for schools, who will obviously find it hard to manage
mood swings and teach a pupil who is extremely high or low at any given time.

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Photocopiable
How do I know if a pupil has ADHD?

The following are some of the main characteristics of ADHD. Pupils may:

become bored after a few minutes

be easily distracted

become restless, fidget and have difficulty sitting for long periods of time

be selective about what they concentrate on, often giving most attention to
activities they enjoy

have difficulty with taking turns and may dominate some activities, such as the use
of a computer or games

have difficulty with giving close attention to detail

have difficulty following verbal instructions

have difficulty listening when spoken to

be distracted by normal stimuli

be forgetful and disorganised

leave tasks incomplete

talk incessantly, sometimes mistiming interruptions

like to climb and run about inappropriately, sometimes engaging in risky behaviours

act without considering consequences

blurt out answers before the question is completed

display tantrums, including slamming doors and throwing furniture.

How is ADHD treated?

ADHD is normally treated by drugs known as stimulants, including methylphenidate
(also known as Ritalin), dextroamphetamin (Dexedrine or Dextrosat) and pemoline
(Cylert). It may appear strange that drugs designed to stimulate brain activity should
be administered to a young person when more calming drugs would seem to be
needed. This is because these drugs are designed to affect those parts of the brain that
control behaviour and regulate activity. Parents I have worked with report significant
improvements in behaviour, but the drugs are not a cure. Concern has been expressed
that these and other related drugs have been used with children displaying general
behaviour problems not necessarily associated with ADHD. Drugs are often used
alongside behavioural and more holistic therapies.


© British Association for Counselling and Psychotherapy 2006 (BACP)

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ADHD: What can the school do to help?

Seat pupils at the front of the room with their back to the rest of the class, but do
not exclude them from their peers.

Arrange for medication to be taken safely and regularly in school but avoid drawing
attention to this.

Encourage self-monitoring of behaviour.

Be patient and avoid being overly critical.

Offer regular praise and encouragement, recognising success and achievement.

Make work interesting, new and highly motivating to increase attention.

Establish clear rules and consequences that are frequently reinforced verbally and
visually.

Minimise unnecessary distractions and be aware of sounds in the room which might
affect the pupil.

Include variety in the lesson, especially incorporating more kinaesthetic-style lessons.

Give calm, specific and clear instructions, maintaining eye contact.

Check for understanding.

Establish routines and keep changes and alterations to a minimum.

Negotiate clear achievable targets for work and behaviour and celebrate success at
whatever level.

Use teacher attention as a reward for positive behaviour.

Move around the classroom and be clearly visible to the pupil.

Make sure all resources and equipment are readily available to the pupil.

Be warm and empathic, and attempt to look beyond the behaviour to connect with
children trying desperately to control their behaviour, win approval and find success.

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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Conduct disorder
Conduct disorder is a complex group of behavioural and emotional problems found in children
and adolescents. Pupils with these disorders may have difficulty following rules and behaving in
the socially acceptable ways normally expected of their peer group. Often, their problems are per-
ceived by parents, schools and peers as wilfully bad or delinquent behaviour and treated as such.
Negative reactions from adults to the young person’s behaviour fuel the difficulties. The causes of
conduct disorder appear to relate to susceptibility to genetic factors and a range of genetic influ-
ences such as inconsistent behavioural expectations at home. These might include overzealous
discipline, abusive relationships between parents, loss or grief, physical or emotional abuse,
criminal behaviour of parents or siblings, and the negative influence of the peer group. It is often
associated with oppositional defiant disorder, which is seen as the precursor to later and more
difficult conduct disorders in adolescence. (See photocopiable pages 52–3)

Depression
Most of us would like to think of childhood as being a carefree time. However, the truth is
often very different. At one time, we thought that depression largely affected only adults and
that ‘feeling down’ or ‘sad’ was an inevitable part of the growing-up process. There is now a
huge literature contradicting this view, and it is generally accepted that young people do suffer
from depression, a potentially serious mental health problem that affects how young persons
think, feel and behave. Depression is more than just ‘the blues’ and, left untreated, can lead to
school failure, alcohol or substance abuse, and even suicide. The Royal College of Psychiatrists
(2002d) estimates that depression affects two to three of every 100 teenagers. My own experi-
ence of working with young people in a variety of settings suggests that the figures may now be
even higher. (See photocopiable pages 54–5)

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Photocopiable
What are the signs and symptoms of conduct disorder?

bullying, threatening and intimidating behaviour

fighting, sometimes using weapons (bricks, bottles, sticks) without regard to the
danger of causing injury

rude and unacceptable language

cruelty to helpless animals and pets

vandalising property

forcing someone into unwanted sexual activity, including sexual assault and rape

setting fires for excitement and with the intention of destroying property

theft, including shoplifting; theft possibly involving face-to-face contact with the
victim but also burglary or breaking into cars

uncooperativeness and disregard of rules set by parents and the school

mistrust and fear of adults

truanting from school

running away from home for prolonged periods

lying as a natural reaction to criticism, to avoid blame or to manipulate and influence
friends, family and the school.

How is it treated?
In some cases, conduct disorder may coexist with other childhood mental health
problems such as ADHD and depression, and these may need to be addressed
simultaneously, perhaps with the use of medication. Sometimes the child is offered
anger management and other cognitive-behavioural therapies designed to improve
communication, problem-solving skills and impulse control. Where there are associated
learning difficulties, special needs input may be appropriate. Where resources exist,
family therapy or parenting education may be offered to help with management of the
young person within the home.

What can schools do to help?

Understand this condition and focus on the child, not the challenging behaviour.

Avoid power struggles; remain calm and avoid becoming overly angry with the
pupil.

Focus on the pupil’s good behaviours, not the negative ones.

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Offer choice.

Offer constructive feedback about behaviour within the context of an
established relationship.

Use classroom approaches which focus on activity.

Model effective communication and conflict-resolution skills.

Set clear expectations for behaviour and make consequences fair, proportional and
consistent.

In the classroom, set clear and achievable goals and reward any movement along the
continuum.

Use behaviour-modification schemes designed to motivate, such as ‘token
economies’ and reward-linked behavioural contracts.

Build trust, show interest and listen.

Build self-esteem.

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Photocopiable
What are the signs and symptoms of depression in young people?

persistent sadness that will not go away

feeling irritable, worthless, guilty, hopeless and empty

under- or overeating

irregular sleep patterns and frequent tiredness

difficulties with concentration

recurrent thoughts of death or committing suicide

boredom

wanting to be alone much of the time

friendship difficulties

extreme sensitivity to criticism, failure or rejection

inability to find interest in activities previously enjoyed

using alcohol or drugs to control moods

lack of energy; fatigue

regular complaints of symptoms such as headache, backache and stomach-ache that
have no physical cause

low self-esteem

falling off in school performance

poor school attendance

volatility, aggression, tantrums, anger and rage

talking about and actually running away from home

crying a lot.

How is it treated?
The good news is that depression is, more often than not, treatable, especially where
there is early diagnosis, treatment and support. Sometimes doctors prescribe medications
such as antidepressants. Their use remains controversial, but it often appears to relieve
symptoms by affecting brain chemistry. Young people may also be offered counselling or
psychotherapy in order to provide a safe place to talk about underlying issues.
Cognitive-behavioural therapy may also be arranged, offering the young person the
chance to challenge some of the negative, self-deprecating and erroneous thoughts that
may be at the root of their sadness.

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How can schools help?

Develop a warm, caring and supportive school environment.

Recognise that depression can be very real – not a sign of weakness but a
potentially serious mental health problem.

Ensure that symptoms of depression are not mistaken for laziness or poor behaviour.
This emphasises the importance of effective listening and attempts to understand the
pupil in context.

Be a good listener, making time and space to talk with young persons and
encouraging them to express their feelings.

Be non-judgemental, warm and empathic.

Encourage the reluctant pupil to seek help.

Introduce programmes into the curriculum designed to encourage pupils to learn
about and express their emotions more effectively.

Monitor pupils closely.

Deal with bullying swiftly and effectively.

Ensure that every pupil in the school has at least one adult who knows them well.

Observe pupils closely and be alert to signs of depression, especially changes in
mood and behaviour.

Encourage and facilitate friendships in pupils who appear isolated.

Encourage participation.

Be alert to any talk of suicide; take these comments seriously. This means contacting
parents and the pupil’s GP.

Know your limitations and those of the school and refer on, as appropriate, to
mental health professionals.

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Eating disorders
Eating disorders are associated with eating problems and an overwhelming obsession with
weight. These emotional disorders take a variety of forms, but the most common are those con-
cerned with anorexia nervosa, which involves depriving oneself of food in order to become or
remain thin. It often involves a degree of distortion about body image. Not eating may also be
associated with the abuse of laxatives and a tendency to over-exercising. Bulimia nervosa
involves binge eating and a loss of control followed by feelings of guilt and the need to purge
the body of food consumed. This may involve laxatives or, more commonly, induced vomiting
or the abuse of diuretics. Compulsive or binge eating is similar to bulimia, but the young
person becomes overweight, not attempting to avoid excess calories. As many as 10% of school-
aged girls (the figure is lower for boys) may experience eating distress, and some of these may
go on to develop a full-blown eating disorder. Eating disorders can have serious medical conse-
quences, but they are seen as the physical expression of emotional distress and turmoil. In some
ways, they may be seen as a means of coping with distressing or unacceptable feelings that
threaten loss of control. (See photocopiable pages 57–8)

Generalised anxiety disorder (GAD) and other anxiety disorders

GAD is a mental health problem affecting many young people and adults. A degree of anxiety
or worry is normal and helps us plan our lives and avoid doing things that might harm us.
However, GAD is excessive, exaggerated and unrealistic anxiety that is more persistent than ordi-
nary worry. Young people with GAD worry about everything and anticipate disaster. It leaves
them feeling out of control. GAD is ‘general’ in the sense that it does not focus on one particu-
lar aspect of the young person’s life but is all encompassing and pervasive. Its many physical
symptoms include insomnia, gastrointestinal problems, headaches and high blood pressure. It
can have profound effects on the sufferer’s personal and social life, sometimes becoming so dis-
abling and debilitating that the young person ceases to function effectively, and relationships
and schooling begin to break down.

GAD is one of a number of anxiety disorders, including social phobia, which denotes anxiety
about social situations that appear to the sufferer to increase the risk of embarrassment or
humiliation, especially where they might find themselves the centre of attention; panic disorder,
which involves a loss of control and disturbing physical symptoms triggered by conscious or
unconscious thoughts that imply a threat to health and security; and separation anxiety, which
may be normal in infants and toddlers but is likely to be developmentally inappropriate in ado-
lescents and young adults. Somatoform disorders, such as hypochondriasis, involve fear of having a
serious or fatal disease, despite evidence to the contrary. It may be seen in the many, often
younger, pupils who present in school with physical symptoms, such as stomach-ache,
headache or nausea, for which no medical cause can be found. Young people are also prone to
develop the full range of phobias that represent a powerful but irrational fear of an object, living
thing or situation. These can sometimes be so debilitating that they interfere with the young
person’s capacity to lead a normal life. Obsessive compulsive disorder (OCD) and school phobia are
discussed on page 59.

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Photocopiable
What are the signs and symptoms of eating disorders?

continual refusal to eat or maintain normal body weight

noticeable weight loss

wanting to be left alone

preferring to eat alone or in secret

hiding food

excessive or unnecessary exercising, often bound by rigid and ritualistic regimes

irregular menstrual periods

obsession with parts of the body such as the size of buttocks, waist or stomach

expressed fear of gaining weight or becoming fat

excessive dieting

fussiness about food

dehydrated or poor skin condition

lack of interest in food

regular sore throats, mouth infections or swollen glands

overeating

sleep problems

the need for perfection

frequent denial of being hungry

dishonesty and lying, especially about food

becoming manipulative

often going to the toilet during and after meals

tooth decay, sore mouth and gums

overinterest in food, cooking and calorific values

dizziness

problems with concentration

need to feel ‘in control’

skipping lunch at school and missing meals at home

abdominal pains or constipation


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difficulty in maintaining body heat and often feeling cold

distorted body image; fear of being fat when the evidence is to the contrary

depression.

How are eating disorders treated?

Eating disorders can be treated by ‘talking therapies’ such as counselling or psychotherapy.
Medication may be prescribed if there are associated problems such as depression or
anxiety. Doctors may also offer medical treatment to deal with any of the physical
consequences of the eating disorder. Nutritional counselling can support the young person
in achieving normal eating patterns as part of the recovery process. In some cases, family
work may be suggested to address issues within the family, or self-help groups to prevent
isolation and to facilitate mutual support. Serious eating disorders may result in
hospitalisation in order to initiate weight gain to prevent death from malnutrition or suicide.

How can the school help?

Understand more about these conditions – their causes, symptoms and treatment.

Recognise how powerful emotions are for a young person suffering from an eating
disorder; these may include shame, guilt, self-disgust or a sense that life is out of control.

Be vigilant for the signs of eating distress and be prepared to refer students on.
Early intervention is crucial to full recovery.

Support the young person emotionally and practically beyond the referral to health
specialists.

Use PSE/citizenship time to explore the social, cultural and emotional factors
associated with food and eating. Be aware of the influence of the media, which
emphasise unrealistic images of beauty and physical attractiveness.

Become a ‘healthy school’, promoting healthy eating and exercise.

Look beyond the diagnosis and connect with pupils and their distress.

Be aware of the values and attitudes promoted by the school, which might be
contributing to the problem, as in attitudes toward health and fitness.

Offer genuine caring and non-judgemental listening.

Be prepared to act as an advocate.

Intervene early where there is bullying and teasing about weight and appearance.

Build self-esteem.

Be patient: eating disorders affect school work and relationships.

Ask pupils what help they would like.

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Obsessive-compulsive disorder
Young people with OCD are plagued by recurring and unwanted thoughts (obsessions) or the
need to perform repetitive, ritualistic behaviours (compulsions) that dominate their life and
normal functioning. Young people with OCD are aware that their thoughts and behaviours are
irrational but may have only fleeting control over them. Rituals such as excessive washing,
cleaning, checking, touching and ordering are performed in an attempt to bring relief from
obsessive thoughts about dirt, germs and infestation; the fear of committing a violent act;
sexual or blasphemous thoughts likely to provoke retribution from a higher being; or anxiety
about lack of orderliness, exactness or symmetry. Rituals often bring only temporary respite
from the pain and frustration, and when they are not performed, anxiety may rise to unbear-
able levels. OCD most often begins in childhood and will present itself in a variety of forms
and degrees in every secondary school.

Post-traumatic stress disorder (PTSD)

PTSD results from a young person’s exposure, either directly or indirectly, to an exceptional or
catastrophic event or situation that involved actual or threatened serious injury or death,
including murder, rape, domestic violence, car accidents, terrorism, violent street crime, suicide
or abuse. There may also have been the direct experience of natural disasters such as floods or
tornadoes. For young people coming from abroad, the trauma may have been caused by war or
torture. PTSD can have devastating effects on the mental health of a young person. Recurrent
and intrusive memories and images of what happened and the fear of its recurence can cause
extreme psychological distress. Relationships may become disturbed as emotions are thrown
into disarray. Attempts to avoid the feelings and thoughts linked with the trauma may well dis-
rupt life, and anxiety and depression may soon become evident. Hyperarousal, in other words,
the constant sense of being under threat, will affect peace of mind and concentration and lead
to angry or explosive outbursts. All these symptoms will affect the pupil at home and at school.
If left untreated, they may develop into more serious psychiatric illness.

Schizophrenia
Schizophrenia is a serious and complex mental illness largely affecting adults and rare in chil-
dren. However, a very small number of children, perhaps one or two in every 10,000, may be
affected, and such adult psychotic illness may begin to manifest itself in a child as young as
seven years of age. The symptoms of childhood and adolescent schizophrenia are similar to
those in adults, and include social withdrawal, unnatural and irrational fears, and suspicion of
others – for example, patients believe that they are being watched or that people are plotting
against them (paranoia). The pupil may have difficulty separating fantasy from reality and
might experience sensations such as the voices of people who are not present (hallucinations).
They may hold a series of false beliefs; for example, they believe that they have been visited by
aliens (delusions). Other characteristics of schizophrenia include odd or eccentric behaviour,
such as laughing at sad happenings; disordered or disorganised speech resulting in incoherence;
impaired memory; poor social skills; and flat affect, showing little or no emotion and showing

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little body language or facial expression. Behaviours can include sudden and unpredictable
aggression, and catatonic behaviours, such as staring and becoming motionless. Schizophrenia
is a difficult mental illness to treat and will inevitably cause not only distress and unhappiness
to the young person but much heartbreak and anguish to those around them.

School refusal
What is it?
In school refusal, a pupil does not want to go to school or refuses to do so. In some cases, the
young person is brought to school but refuses to stay there. This is very distressing for the
pupil’s parents and family as well as being a difficult time for children and their school. In my
experience, school refusal is a growing problem. School refusal as a description is preferred to
the idea of school phobia, because school refusal is often caused by a number of problems, some
not directly related to school, and it would not meet the criteria usually used to describe phobia.
School refusal most often occurs at transitions, such as between junior and secondary school,
and at times of stress, such as exam periods. Sometimes it begins after a prolonged period of
legitimate absence such as during illness. Pupils may suffer from anxiety about attending school
for a number of family reasons, including arguments at home and fears that parents may split
up, and separation anxiety, especially where there is an overprotective parenting style or where
the young person fears for the parent’s welfare or health. School-related causes include fear of a
particular teacher, dislike of changing for PE, being picked on by older pupils or their peers,
having learning difficulties and experiences of failure, and not having friends. Young people
will be reluctant to attend school if they perceive it to be unstructured, chaotic and, conse-
quently, unsafe. Boys and girls are affected equally – 1–5% of the school population. School
refusal is different from truancy because often the child stays at home and becomes emotion-
ally distressed, and the parent is usually aware of the problem. Truancy mostly involves an
attempt to hide non-attendance at school. (See photocopiable pages 61–2)

Self-harm
Deliberate self-harm, also known as self-injury, self-inflicted violence or self-mutilation, is one of
the more distressing mental health problems encountered by adults in school. The Times
Educational Supplement (18 March 2005) records that the national inquiry into self-harm found
that 10% of young people aged 15–16 years have deliberately hurt themselves, and that as many
as 24,000 under-18s are treated in casualty departments for self-harm each year. Traditionally,
self-harm has been seen as injuring oneself by cutting wtih blades, glass or other sharp objects;
burning with direct flame, a hot object or chemicals such as aerosols; scratching or rubbing the
skin until it bleeds; punching oneself or hard objects; picking at wounds, spots or skin blem-
ishes; and pulling one’s own hair. However, taking overdoses, abusing drugs, self-starvation
through excessive dieting, and abusing drugs may also be seen as kinds of self-harm. In extreme
situations, self-harm may involve taking poisons, jumping in front of cars and jumping from
buildings. Considerably more girls self-harm than boys. (See photocopiable pages 63–4)

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Photocopiable
How does school refusal show itself?

Pupils may:

be fearful, overly anxious and distressed at the thought of going to school or
whilst there

display physical symptoms associated with anxiety, such as sweating, increased
heartbeat, palpitations or panic attacks

have recurring headaches

complain of stomach-ache or nausea

cry a lot, sometimes in quite distressing ways

display temper when told they have to go to school

have problems with sleep and eating patterns

be clingy and insecure at home

become markedly less anxious when told they do not have to go to school

fail to respond to rewards and encouragement to attend school, threats and
consequences having equally minimal effect

threaten to harm themselves if forced to go to school

become depressed.

How is it treated?
It is important for a doctor to rule out all possible medical causes for non-attendance.
The best interventions are often those that are multidisciplinary, involving a number of
different professionals. School refusal may coexist with related psychological problems
such as depression and anxiety, and these may be treated with a combination of
psychiatric drugs and or psychotherapy. It would be unusual for medication to be used
to deal with school refusal exclusively. Behavioural interventions may be introduced,
such as training in relaxation techniques, assertiveness and social skills. In some cases,
approaches such as systematic desensitisation may be tried. This involves gradually
exposing young persons to school, in stages, hopefully convincing them that they have
nothing to fear. Sometimes family work may be the most productive intervention.

How can the school help?

Early intervention is crucial. Be prepared to involve an educational psychologist and
education social worker at an early stage. A referral to the pupil’s GP may result in
the involvement of Child and Adolescent Mental Health Services (CAMHS).


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Look for underlying causes; anxiety about attending school may be masking other
fears such as fear of being away from a caring parent.

Talk with pupils, at home if necessary, asking them to write down their feelings
about school. Help them to express their anxieties and concerns. Show that you
understand.

Work closely with parents and carers, possibly setting up positive reinforcement
schemes or asking parents to supervise children on their way to school.

Offer pupils reassurance and acknowledge just how difficult it is for them to attend
school.

Be consistent and firm, avoiding unnecessary changes to your expectations of the
young person.

Empower pupils and help them to make changes. Encourage them to develop
strategies to solve their problem.

Involve other pupils; they may be prepared to offer friendship, security and
support.

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Photocopiable
Why do young people self-harm?

The reasons why young people self-harm are usually complex and deep-rooted but
probably involve inability to express difficult or distressing feelings in less harmful ways.
Self-harm may be seen as an escape from unpleasant emotions such as anger, loss, guilt
and shame, and as a way to maintain control over life. It may also represent a form of
self-punishment. Some young people report that it helps relieve feelings of numbness
and depersonalisation. It has been argued that self-harm is a coping mechanism that
lessens the desire to commit suicide, although counter to this is the observation that in
some situations deliberate self-harm has led to death when this was not the original
intention. Young people sometimes go to great lengths to cover their injuries, especially
with clothes. They may also regularly give ordinary reasons for extraordinary injuries.
Self-injury can result in infection, scarring and permanent disfigurement.

How is it treated?
Counselling and psychotherapy may be offered alongside drug treatments where there
are associated mental health problems such as depression and anxiety. Sometimes a GP
will make a referral to CAMHS, and psychiatrists and specialist nurses may become
involved. Joining a support or therapeutic group may be recommended. Sometimes
creative art therapies can help. Hospitalisation may be a last resort.

How can the school help?

Make time to listen to the pupil and try to understand.

Try to connect with the young person behind the self-harm or injury.

Look for the physical and emotional signs of self-harm and find a sensitive way of
initiating a conversation.

Avoid being judgemental. Do not look shocked, upset, disgusted or anxious,
despite how you may be feeling.

Recognise that self-harm is rarely attention seeking or an attempt to manipulate
others. Often it remains hidden.

Ensure that school personnel receive training.

Use the school curriculum to explore many of the issues surrounding self-harm in
ways that help young people understand self-harm and what causes it, and suggest
ways in which they can cope in more positive, less self-destructive ways.

Build a school community which is caring, supportive and open, and which makes it
less likely that a young person will self-harm when faced with difficult feelings.

Encourage pupils to tell an adult if they know that a pupil in school is self-harming.


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Seek out support if you are affected by what you have seen and heard.

Understand that self-harm offers young persons a way of coping and that they may
be terrified of giving up harming themselves. They may need time to cope in a less
harmful way.

Be prepared to make a referral to obtain specialist help for the pupil. Where
immediate life-saving action is needed, act promptly and call for an ambulance.

Do not exclude pupils; they are probably safer at school.

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Suicide and attempted suicide

A variety of statistics can be found about suicide among young people, but what is clear is that
it represents a serious and growing problem. It has been suggested that the estimated suicide
rate among young people is higher than the figures published, as some deaths are attributed to
other causes such as accidents. Many schools have experienced a suicide attempt or what might
be referred to as parasuicide, which is a form of self-harm that appears to threaten life but in
which victims do not intend actually to kill themselves. Such parasuicide might be seen as a
form of communication – an expression of despair and hopelessness. The victims may feel that
these acts are the only way of telling others how they really feel.

Suicide is the third leading cause of death in young people, after illness and accidents. Girls
attempt suicide more often than boys, but young men are often more successful in completing
the task. Whilst figures for adults have remained static, the suicide rate among young people
continues to rise. In addition to those who commit or attempt suicide, a number of surveys and
my own experience of working with young people suggest that a high proportion of teenagers
have considered or had ideas about taking their own life.

There are very few more tragic events than the death of a child by their own hand, and it can
have profound and distressing effects on loved ones and the young person’s school. Suicide
among young people can be avoided by effective prevention, early recognition and treatment,
and the secondary school can play a role in all three areas. (See photocopiable pages 66-8)

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Photocopiable
Suicide: warning signs

recognisable and significant mood changes

unexplained changes in personality

social withdrawal, especially from friends and family

deep and apparently unending depression

changes in weight, eating behaviours, sleep patterns or interest in personal
appearance

low self-esteem

giving away personal and prized possessions

loss of interest in life, low levels of motivation, and tiredness and fatigue

talking about wanting to die or saying that they or other people would be better
off if they were dead

saying that they would not be missed if they were gone

turning to the misuse of drugs and alcohol (Drugs can be both an indicator and
risk factor in the sense that their use may reduce impulse control, or heighten or
depress emotions.)

behavioural changes including uncharacteristic anger and aggression toward peers and
adults

preoccupation with death and dying

a marked and sudden decline in performance and achievement at school

gathering information about suicide and its methods

expression of deep feelings such as despair, hopelessness, shame, guilt, grief, anger
and emptiness

themes of death and sadness in writing, poetry and art, and in the selection of
reading material or illustrations

intentional self-harm such as cutting

verbalising suicide intent

previous suicide attempts

sudden recovery from depression – possibly indicating that a peace has been found
with the young person’s decision to commit suicide

current issues of loss in the young person’s life through, for example, the death of a
parent, divorce, or someone significant to the pupil committing suicide.

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How is it treated?
If surrounded by secure family and peer relationships, young persons may be offered
only brief interventions. However, if young persons have communicated a serious
intent to take their own life, or if appropriate support is lacking and there is
associated mental illness, the young persons may be hospitalised after a
comprehensive assessment. It has been argued frequently that young people who
arrive in casualty after a suicide attempt are sometimes treated unsympathetically by
doctors. This may have once been the case, but government-initiated guidance has
attempted to change attitudes in this area of care. Many of the feelings associated
with suicide ideation are linked with depression and are thus treatable with
appropriate interventions such as counselling and medication.

How schools can help

Treat the pupil’s problems with care and treat all suicide threats as serious; no talk
of suicide should be dismissed as attention seeking or taken lightly. Suicidal
verbalisation and ‘minor’ suicide attempts such as taking a small number of painkillers
often precede more serious attempts.

Train staff to detect the signs of depression and potential suicide, and be prepared
to make immediate and appropriate referrals to social services and health
professionals, such as the school nurse or GP. If in doubt, seek professional advice.

Suicide-prevention programmes remain controversial, some people believing that they
may increase risk. However, a comprehensive approach to emotional literacy may
enable young people to learn the vocabulary and skills to express difficult and
deep-rooted feelings. Schools may also teach problem-solving skills.

Be aware of individual students at risk due to particular circumstances; at-risk groups
such as pregnant schoolgirls, gifted and talented young people, and children with a
family history of suicide; and complicating mental health issues affecting children or
their family.

Notice when a pupil appears to be low or sad.

Offer non-judgemental listening, but no single adult in the school should be
supporting a depressed pupil alone.

Listen to the pupil’s words, but also to what is being communicated covertly.
Listen also to what is not being said: does the young person fail to express a sense
of future?

The school should have a named individual, known to staff, that will receive and
respond to concerns.

Where an adult is supporting an unhappy pupil, remember to let the pupil know
that there are limits to the confidentiality a school can offer.


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The school should not wait for a crisis but intervene early, supporting pupils who
have experienced a difficult event or period in their lives before more acute
behaviours begin to cause concern.

If a referral has been made and the pupil remains in school, continue to offer
support and to work closely with other agencies involved.

Build self-esteem.

Intervention with a suicidal pupil

If suicide has been attempted, offer appropriate first aid and seek immediate medical
attention.

Calm the situation and avoid the involvement of too many adults. Where
appropriate, a close friend of the pupil can be encouraged to offer support. If
possible, remove the young person to a quiet place and encourage talking. Be
prepared for silence and be patient.

Encourage the pupil to give up any dangerous objects or medications, but do not
use force.

Observe the pupil whilst talking. Listen intently and reflect back how the young
person is feeling.

Avoid interrogation and intrusive questioning.

Contact parents or carers. Seek advice from social services and health professionals.

© British Association for Counselling and Psychotherapy 2006 (BACP)

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Reflection box ?

 Mental health issues affect us all, directly or indirectly. As you read this chapter, which of
the problems described could you identify with for personal reasons? Which affected
you emotionally? Did you recognise any aspects of yourself?
 Which kinds of mental illness do you have most ‘sympathy’ with. What moral, political
or ethical questions were raised for you?
 Which mental health problems were you most informed about? Which do you need to
understand more?
 How sensitive is your school to the kinds of problems described here?
 Which ‘signs and symptoms’ or specific mental health problems could most easily be
missed or misinterpreted, leading to inappropriate behavioural interventions?

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C HAPTER 6

A whole-school and multiagency approach

This chapter will show:

The emotional side of school often remains hidden, yet it has powerful influences on
all that happens there. Mental health is best addressed by a whole-school approach,
and this can be achieved in quite creative ways. Key to a whole-school approach is the
issue of addressing stigma, which can have debilitating effects. Working closely with
outside agencies is crucial if we are to ensure effective prevention, early intervention
and support for young people with mental health problems in our schools.

Schools are emotional places

Schools are infinitely emotional places, yet this dimension to schooling is sometimes not recog-
nised. Imagine for a moment an average secondary school of around 1000 pupils with over 100
teaching and non-teaching staff. Each person enters that school daily, infused with a multitude
of emotions, multiplied and compounded by the process of teaching and learning, and the rela-
tionships that underpin this endeavour. Thoughts, feelings and behaviours ricochet like a
pinball machine, forming almost infinite permutations. Among those 1000 pupils, adolescent
hormones pump around the body causing frustration, anger and confusion. Questions about
identity and sexuality abound. If we take all this into account, it is hardly surprising that things
happen in school: pupils fight or feel themselves attracted to each other; teachers shout,
become upset or work in fear of someone seeing that they cannot cope; friendships emerge but
then fail, leaving winners and losers; pupils exert power over others, who fall victim. The list is
endless and remarkably complex. In the light of the above, I sometimes question the whole
idea of schooling; the idea of 1100 or more people in a cauldron of emotion trying to teach and
learn makes schools seem an odd invention!

Of course, it has been increasingly documented that emotions affect learning. In a positive
sense, we remember best when what we learn has an emotional context – when what we are
asked to retain or learn to do is infused with personal meaning. The key moments I can recol-
lect from my school days are those associated with fear, pride, disappointment, excitement,
shame and a sense of being part of something.

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Undoubtedly, too, difficult emotions and raw feelings can act as a barrier to learning. A pupil who
is stressed because of home conflict may find it hard to focus on algebra; a young person grieving
for a loved grandparent may find it difficult to concentrate on Henry VIII; a child deep in depres-
sion may find it hard to find the energy to participate in games or other physical activity. A child
who has problems with establishing a normal eating pattern may think primarily of food and
weight, and the pupil who is terrified of being in school may think only of going home.
Experience tells me that motivation is the prime mover in achievement, and it is most energised
when pupils have a sense of future and direction, and least evident where they strive hopelessly
to find meaning. I believe that no young person sets out to fail, but some behave in a way that
suggests they do not care.
As professionals in schools, we sometimes are unaware of, or less tuned in to, the emotional
dimension and, in particular, our own feelings. We, too, may be having difficulties in our own
lives, which inevitably affect our performance and relationships. Sometimes professionals in
school see pupils primarily as learners in a narrow sense, and the increasing focus on teaching
and learning often recognises how our brains work but says little about the part emotions play.
Learning is never an emotionally neutral experience, and it will serve to enhance or diminish
self-esteem. Pupils develop a whole range of defences to defend vigorously their fragile self-
esteem. As adults, we are no different.
A mentally healthy school recognises this parallel dimension and its impact. A school that is
sensitive to the emotional needs of young people and which places mental health at the core of
its aims is likely to be more successful than that which has identified achievement in narrow
academic terms. Such a school seeks to promote healthy minds whilst at the same time being
aware of the role the school can play in supporting those with emerging difficulties. It is also
aware of its capacity to contribute to or exacerbate the kinds of mental health problems that
young people carry through the school gates with their school bags.

A whole-school approach to mental health

Whilst it is hoped that the home and family are the prime source of nurturing and support, it is
recognised that this may not always be the case. Schools, too, may contribute to the stress and
unhappiness in a young person’s life, but they can also be places of growth where mental health
is promoted and young people supported. Young people spend significant amounts of time in
school, and this can make a real difference to their current and future lives. It is recognised that
this can truly be achieved only by a whole-school approach.
A whole-school approach to mental health will not simply happen – any more than a language
or science curriculum will be delivered by chance. It needs to be thought out and planned for. A
mentally healthy school does not delve into the emotional world of young people in some
token way that allows boxes to be ticked on school self-evaluation forms. It takes mental health
matters seriously, possibly seeing them as the most important factor in school success, under-
pinning everything else that happens within its walls and beyond.
Mental health is seen as all-encompassing and operating on many fronts simultaneously, and
not confined to a single dimension. The school places mental health and emotional well-being
at the forefront of its thinking and central to its aims. This all-embracing aspect of school is
seen as connected, and not fragmented, and each aspect of school life is both affected and influ-
enced by its ideas and philosophy. Mental health is made explicit, not hidden, and is high on
the agenda of change and development. It is seen as being part of long-term development, and

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is not short term or transitory. It needs to be sustainable and not likely to fade. A mental health
approach ensures that it is resilient and not cast aside by future centrally enforced initiatives,
but has a word to say on their introduction.
Mental health should permeate all aspects of school life and learning. Everybody is involved
regardless of role or status. Mental health should be seen as everyone’s business, and not con-
fined to school-based specialists or merely the concern of outside agencies and mental health
professionals. Mental health affects our approach to the curriculum; it is there in every relation-
ship and every interaction between adult and child. Mental health is part of teaching and
learning, in leadership and management at all levels from classroom to senior leadership team.
Mental health should be there in our staff development programmes, sometimes explicitly and
sometimes simply as a perspective. It should be identifiable in school policy and most impor-
tantly in our pastoral care systems and relationships with parents and carers.
Mental health in a secondary school may be seen as operating on three levels. The first is con-
cerned with school ethos, climate, organisation and curriculum. This is about our school
environment and its capacity to promote and support – or undermine – mental health. This
level is about prevention and awareness. The second level is concerned with early intervention,
seeking to reduce risk and increase resilience. The third stage represents the school’s capacity to
respond swiftly and intelligently to expressed need. This level is concerned with the school’s
ability to offer individualised and intensive support, and also recognise when referral to other
agencies and professionals is needed.
Perhaps most significant in mental health is a concern for the culture and climate of the school.
These are difficult concepts to define but are of profound importance. Anyone entering a sec-
ondary school will soon get a feel for it. A positive school climate will be seen in the faces of the
young people and the adults who work there. A mentally healthy school would seek to uphold
and pass on to others a variety of beliefs, values, norms and shared traditions that promote a
feeling of caring, collegiality, cooperation, connectedness, inclusion and belonging.
Relationships would show evidence of mutual respect, trust, warmth and openness. This will be
there in the type of language used between all adults and young people and in the friendships
that emerge. It would also be there in how men and women and boys and girls relate to each
other, and in the friendships that form between young people of different faiths, beliefs and
ethnicity. In contrast, a negative school culture is characterised by power, exclusion, conflict,
separateness and harassment.
It is not possible to state how important it is to recognise the role schools play in the promo-
tion of mental health. Some argue that mental health is not the concern of schools. In response,
it must be said that mental health is already happening in our schools, regardless of preference
and beliefs about the purpose of education. The task of the school is to ensure that this is a pos-
itive, comprehensive and coherent process.

What can schools do to promote mental health and support

young people?
Good schools will already be health-promoting schools, and many of the ideas set out below
simply represent good practice. However, it is worth highlighting some of these to enable schools
to evaluate themselves and focus some of their energies in this direction. The ideas below will
contribute to some understanding as to what might constitute a mentally healthy school.

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Photocopiable
The mentally healthy school

Ethos and organisation

Work to create a school environment in which pupils feel psychologically safe and
secure. This should be a priority in line with the government papers, Healthy
Schools and Every Child Matters.

Foster a sense of belonging, as by the use of first names or welcoming pupils into
school and classroom. The need to belong goes back to the child in all of us.

Regard each young person as of equal status. This aim is easily stated but difficult to
deliver. This means valuing those students who are not likely to contribute to
measurable outcomes and may themselves appear to be a drain on time and resources.

Help pupils adapt to change and establish routines around school and classroom.
Provide consistency and continuity. Young people can react negatively to change,
and this can result in stress and anxiety.

Be a school which challenges the stigma of mental illness and teaches tolerance
and understanding. Display posters, include stigma in the curriculum and address
it in assembly.

Locate a whole-school approach to mental health in the context of a wider concern
for the creation of a healthy school. This may include associated areas such as
healthy eating and fitness.

Give pupils a voice, as through a school council. This will offset disaffection and
alienation and give pupils a sense of power to effect change. A school council also
provides a listening device, enabling the school to gain a sense of what school is
really like for the pupils who attend there.

Respect confidentiality. Have clear policies on who can share what information with
whom. Make clear the limits to confidentiality from the start.

Ensure that the school has a clear, fair and consistent behaviour policy. Young
people thrive best when they know where boundaries are, and when they feel safe
from physical or psychological harm. Poor discipline increases stress and is an
additional risk factor, especially if young people are already experiencing problems in
their lives.

Deal quickly and effectively with racial, sexual and other forms of harassment. Ensure
the school has comprehensive and well-documented policies in these areas.

Make school interesting and stimulating. Work hard to prevent boredom and
disengagement.

Make school a safe place in which pupils can talk about feelings.


© British Association for Counselling and Psychotherapy 2006 (BACP)

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Awareness

Increase staff awareness and understanding of mental health issues through training
and experience. The school should be prepared to include mental health as part of
its professional development programme. Many of the major organisations listed at
the end of this book hold conferences and training events, and some will train staff
within the school. Many of the generalist training agencies now advertise courses
relating to mental health and emotional well-being. Information about specific mental
health problems is available on the internet, and specialist organisations often
produce excellent materials for professionals.

Understand the tasks of adolescence that need to be negotiated, and build this
awareness into your ideas and practice.

Recognise that you are working with young and developing minds; handle with
care.

Look at your own lifestyle and way of being. Be a positive role model.

Be aware of the effect of school on your own emotional health. Look after yourself.

Understand the importance of good mental health in the adults who work in
school. Ensure that staff are equally supported and valued.

Relationships

Watch what we say. Our words can be powerful and can build up young people
or undermine their confidence and sense of self.

Show patience. Adolescence is a time of challenge, independence and search
for identity.

Accentuate the positive. Encourage and support but do not attempt to coerce
pupils into feeling good. They may need to feel sad for a while.

Build on young people’s strengths and qualities.

Like adults, young people develop a range of defences. These may be necessary for
survival. Understand that a pupil’s behaviour or attitude may not be about you at all.

Treat pupils as young adults in the making, but offer and expect respect.

Build the kinds of relationships with young people that make for self-esteem and
increase resilience.

Find ways to help young people relate and learn the skills of friendship.

Be sensitive to anger and frustration. Accept that anger is OK as long as the angry
young persons do not hurt themselves, other people or property. Encourage pupils to
express their anger in meaningful ways that communicate without destroying relationships.

© British Association for Counselling and Psychotherapy 2006 (BACP)

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Curriculum

Promote emotional literacy. In particular, help pupils develop a sophisticated
emotional vocabulary.

All subjects contribute to the social and emotional development of pupils and
mental health – through both content and the process of teaching and learning.

Look closely at teaching and learning in the school. Recognise that we all learn in
different ways.

Ensure that the school offers mental health resources of all kinds and make these
readily available to parents and particularly young people.

Develop an extensive programme of extra-curricular activity and encourage the
positive use of leisure time.

Teach about mental health issues, such as bereavement and loss; be prepared to
address controversial and sensitive issues openly and honestly. Many of the
organisations listed in Chapter 9, ‘Useful Organisations and Resources’, provide
materials for young people that can be incorporated into the school’s PSE
programme. Some have published specific teaching packs for use in school. A
number of companies produce catalogues of materials relating to key areas such as
bullying, bereavement, self-esteem and working with emotions. A number of these
are listed in the useful website section of Chapter 9.

Be concerned about failure and its devastating impact on young, impressionable minds.

Intervention

Encourage staff to be observant, noticing those little changes in personality and behaviour
that might indicate that something is wrong, thereby facilitating early intervention. This is
about sensitivity and awareness amid the stress and activity of school life.

Teachers are not mental health professionals. We should not simply ‘double up’ as
psychologists, doctors or nurses but be clear about the part schools can play in
mental health promotion, prevention and intervention.

Recognise the school’s limitations and establish clear lines of referral.

Have systems in place to track vulnerable pupils, ensuring that no pupil is
overlooked or gets lost in the system.

Do not be a school that reacts. Be proactive and anticipate problems.


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Consider the appointment or designation of a mental health coordinator in the

school – someone who will maintain an essential overview and who can ensure that
mental health remains high on the agenda. This is most likely to be a member of the
senior leadership team who will also have oversight of Healthy Schools and Every
Child Matters. A really committed school could appoint a professional with a
specific responsibility for mental health and emotional well being.

Ensure that mental health has an active and secure place in the school’s
improvement plan.

Be a listening school. Whilst there is an important place for advice and guidance,
adults should create the time and space to really listen to pupils.

Make it acceptable that a pupil can talk with an adult of their choice in school
when they feel the need.

Have clear policies and procedures for offering help when a pupil experiences the
death of a loved one, is self-harming or has experienced trauma. It may also be a
good idea to establish a crisis response team.

Involve parents and families early and meaningfully as real partners, not just when
the problem becomes too deep-rooted or appears insurmountable.

Put in place effective procedures for child protection. The school needs to create
the kind of relationships and opportunities that make disclosure of abuse more
likely. Understand that support continues beyond referral to social services and
other agencies.

Watch keenly for the silent, hidden, lonely and isolated pupils in your school.

Take an active anti-bullying stance. Bullying can have a profound and lasting effect
on the psychological well-being of the victim. Have clear policies in place, make the
issue high profile, and encourage a clear anti-bullying ethos. LEAs offer written
guidance here, as do a number of organisations listed in Chapter 9.

An efficient and effective special educational needs department is essential if pupils
with social and emotional problems and learning difficulties are to be identified
early, and interventions planned and delivered. Unmet special needs will contribute
to mental health problems in the school.

Establish a place of silence in the school for pupils and adults where they really can
experience ‘time out’.

Make it a priority to develop close working relationships with mental health
professionals and those individuals and agencies who may be able to support pupils
in distress.

Be aware of mental health issues at times of transition, as when pupils transfer from
junior school. This is when some young people begin to fail and experience distress.

Never give up on a young person. Work to build meaning, hope and a sense
of future.

© British Association for Counselling and Psychotherapy 2006 (BACP)

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Combating stigma
Society has always felt uncomfortable with mental illness; indeed, there is a long history of
mystery, prejudice, fear and discrimination over many hundreds of years. However, we are now
in the early years of a new millennium in which such attitudes and beliefs are no longer accept-
able and should be challenged. Ideas about mental health are passed on by our family and
friends, but the school is the obvious place to challenge stereotypes and negative attitudes that
have an effect on those suffering from mental health problems – and all of us indirectly. Words
like ‘psycho’, ‘loony’, ‘schizo’, ‘crazy’, ‘nuts’, ‘insane’ and ‘mad’ are used frequently by adults and
children alike. The media influence us in significant ways, mentally ill people being portrayed
as unattractive, violent, dangerous, unpredictable, needing to be restrained by straitjackets, and
even as killers. In particular, newspapers are keen to highlight the mental health problems of
people who commit the most horrendous crimes. Misconceptions about mental illness are also
exploited by advertisers to improve sales and promote their clients’ products. All this fuels fear
and anxiety and can lead to further stereotyping and stigma. We are also exposed to the idea
that the mentally ill are there to be made fun of through jokes and humour. Moreover, despite
the advances in psychology, medicine and neuroscience over the last decade or so, the mentally
ill are portrayed as lazy, inadequate, weak, self-indulgent and incompetent.

Stigma is a sign of shame and disgrace that affects how others perceive you and how you see
yourself. By the time pupils start secondary school, they have already been exposed to many of
the negative ideas described here, and young, impressionable minds will absorb these to the
detriment of themselves and those around them. Mental health problems are not always visible
in the way that physical illnesses often are. Mental illness can be referred to as the invisible ill-
ness despite associated physiological causes and effects. Many people experience mental health
problems, to a lesser or greater degree, at some point in their lives.

It is these ideas which we should also be exposing pupils to in school through the curriculum. A
number of published programmes now expect pupils to explore the issue of stigma head on.
Clearly, exposing young people to the facts about mental illness is important if stigma is to be
eradicated. The Mental Health Awareness in Action project in London saw the charity Rethink
and the Institute of Psychiatry set out to address mental health stigma through raising aware-
ness in secondary school students (Pinfold, 2003). Among the concepts and ideas presented
were that mental health problems are common and affect everybody, that people can recover
from mental illness, that discrimination can seriously affect people with mental health prob-
lems, and that any link between mental illness and violent behaviour is a myth. The
programme showed that teaching about mental health could reduce stigma but that these ideas
needed to be reinforced. One way to do this is to ensure that mental health issues figure promi-
nently in the school curriculum, through both specific subjects and, more discretely, through
personal and social education/citizenship lessons. (See photocopiable page 78)

A multiagency approach
There are strong arguments to support the idea that schools should be the focus of child and
adolescent mental health provision. As stated earlier, young people spend many of their waking
hours in school, and teachers and other school-based professionals have traditionally provided

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Photocopiable
The effects of stigma

The stigma of mental illness can affect both adults and young people in a variety of
ways. Affected people might:

experience fear, ridicule and rejection by other people

not seek help when they need it, for fear of being devalued or labelled

hide their feelings, suffer in secrecy and disguise their symptoms

feel inferior and outside the ‘group’

become isolated from friends and family

develop low self-esteem and diminished confidence

experience discrimination; as adults, having difficulty with gaining insurance,
employment and finance

feel a deep sense of shame, guilt and hopelessness – possibly leading to self-harm
and suicidal behaviour

not recover from their illness as quickly as expected. People suffering from mental
illness often claim that the stigma and the negative attitudes of other people are as
distressing as the experience of the mental illness itself.
In establishing a whole-school approach to addressing stigma, it is important that we
begin with ourselves as professionals. It is desirable that we:

increase our knowledge and understanding of mental health and the range of mental
illness and its causes

explore and challenge our own attitudes to mental health and address any
stereotypes and misconceptions

be prepared to challenge comments made by colleagues, parents and pupils

ensure that the school is not discriminating against pupils and adults who may be
experiencing a mental health problem

encourage young people to seek support when they need it

do not refer to a pupil as ‘depressed’ but, rather, as having depression (This applies
to all diagnosed mental illnesses.)

be aware of the mental health issues in our own lives and how we need to be
understood and supported at that time.

© British Association for Counselling and Psychotherapy 2006 (BACP)

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support for pupils with social, emotional and behavioural problems; therefore, this way of
working, with education at the core, would seem appropriate. In the United States, school-
based mental health is more common and has brought some success. Schools would, I believe,
welcome the on-site involvement of mental health professionals – because it is more common
now to feel out of their depth with some of the young people they meet. School-based mental
health services would also reduce stigma in seeking and accessing mental health services, and
make services more widely available. The government paper Every Child Matters and subsequent
legislation, and the move toward extended schools, will encourage and compel schools and
other organisations to work more closely together, and this is to be welcomed.

Interagency collaboration will not come without its problems, and anecdotal evidence suggests
that whilst schools are very willing to cooperate, they currently face an inordinate amount of
pressure to reach targets and compete with other schools in league tables. Generally, practition-
ers across all disciplines may feel anxious about interagency collaboration. Each agency
working with young people brings its own aims, objectives and ways of working. They will have
professionally defined priorities that may also be influenced by local and central government
expectations. These differing perspectives will often be found in the different language that is
used and the different methodology. Schools may also feel that they cannot deliver what is nec-
essary, as time in school is scarce and initiatives and change abound.

The benefits of multiagency working will include improved communication, earlier interven-
tion, more effective referral routes and procedures, and, hopefully, increased understanding of
the roles which professionals play in the wider scheme of things. All this can only benefit young
people in difficulty and their parents, who often crave help and support. Multiagency working
requires clarity of roles and an understanding of what each agency and professional does. There
should be no threat here, as each has a unique contribution to make. A common sense of pur-
pose will not come easily and coordination both within the school and beyond will be
necessary – but is not impossible.

In the context of this book, I would encourage schools to widen their thinking and look beyond
passive referral to real joint working. The school will need to educate itself about what organisa-
tions are doing with young people and how they can link and work together more closely. I am
not talking here exclusively about the statutory sector, either. Schools traditionally have been less
confident in engaging with the voluntary sector, which has less of an ‘official feel’ and possibly
the image of less accountability, yet my own experience tells me that this is where some of the
most committed and targeted work can be found. Attitudes are changing, and voluntary agencies
are also equally keen to work in the school setting as previously uncharted territory. It would be
a good idea to find out what organisations exist locally and who may be able to provide appro-
priate services. Most authorities produce directories of this kind. Establish contact and form
relationships with specific individuals. Visit and find out what they do and how they can help.
However, the best interagency work comes with actual use and working alongside professionals
from other professions and disciplines. This can only be a desirable development.

Multiagency working means more than passing on young people to so-called specialists. It has
the potential for worthwhile collaboration and sharing of expertise, and fills me with excite-
ment and hope. Schools will need to find the time to make this happen, but the benefits in the
long term will be noticeable. Schools are powerful organisations and historically have been less
enthusiastic about changes encouraged or facilitated by those outside the sector. Changes in the

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way government departments themselves cooperate may also be necessary. However, if schools
have the desire and will, change can happen and there is significant evidence that the process
has begun.

It would seem appropriate at this point to consider how the present child and adolescent
mental health services operate and to consider the roles of mental health professionals who
might come into contact with schools directly.

Child and Adolescent Mental Health Services (CAMHS)

CAMHS may be seen as a model that sets out and contextualises all the services that promote
the mental health and psychological well-being of children and young people.

The CAMHS concept includes all services working with young people in a multiplicity of set-
tings. Some of these are directly concerned with mental health, whilst other more universal
services, such as education, are seen as part of the wider picture. This supports the ideas pre-
sented in this book, that mental health is the concern of all professionals who work with young
people, and is not just the preserve of mental health specialists. There are, of course, different
levels of mental health promotion, prevention, early intervention and specialist input, and the
CAMHS model recognises these differences within the wider concept of a comprehensive,
coordinated approach to the mental health needs of children and young people.

The tiered approach set out briefly below is not a statutory or centrally controlled system. It is
best seen as a helpful conceptual framework through which services can be commissioned and
needs identified and met most appropriately.

Tier 1
Tier 1 comprises front-line professionals who have little or no specialist mental health knowl-
edge but are often the adults most commonly exposed to young people in difficulty on a daily
basis. They include:

general practitioners (GPs)

teachers

generic social workers

children’s residential workers

youth workers

school nurses

health visitors

youth justice workers

voluntary agencies

the police.

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These non-specialists are in an excellent position to identify problems as soon as they begin,
and make referrals to more specialist services. They are also in a prime position to promote
mental health and prevent problems from developing. In some cases, experienced professionals
at this level may be in a position to offer advice to young people and their parents about the
less severe problems that sometimes present in young people.

Tier 2
Professionals working at tier 2 have some specialist knowledge and experience. They often work
in collaboratively with other services at this level but do not usually form part of an identified
team. They include:

clinical child psychologists

counsellors working in GP practices

educational psychologists

community psychiatric nurses

education welfare officers

Connexions workers

psychotherapists

behaviour support teams

community paediatricians

psychiatrists.

Specialists at this level may also operate in tiers 3 or 4. They may be involved in offering train-
ing to professionals at tier 1. However, much of their time is spent offering advice and
consultation to families and other professionals. They also have a pivotal role to play in the
assessment of more complex need that may require intervention at a higher level of expertise.

Tier 3
These professionals are normally working within a coordinated team based in a mental health
clinic or through child psychiatric outpatient services. They offer support to children, young
people and their families where more severe, complex and persistent mental health problems
have been identified. Tier 3 professionals include:

child and adolescent psychiatrists

clinical psychologists

community psychiatric nurses

child psychotherapists

occupational therapists

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art, play, music and drama therapists

specialist social workers.

Tier 4
This tier offers highly specialised interventions for young people with the most advanced, com-
plex and persistent mental illnesses that require considerable specialist knowledge, skills,
experience and of course resources. Tier 4 intervention includes in-patient psychiatric units for
adolescents, units for those with severe eating disorders, specialist neuropsychiatric teams, spe-
cialist facilities for young people with significant sensory disabilities, secure forensic adolescent
units and specialist teams working, for example, with victims of trauma and sexual abuse.

Intelligent referral
Achieving the right balance between school-based support and referral to an outside agency can be
difficult. In some cases, referral criteria have been clearly established, or at least there is an under-
standing between the school and other professionals as to when to refer. For example, an education
social worker normally becomes involved where there is poor or erratic attendance. Behaviour-sup-
port services work with pupils who do not appear to have responded to a range of school-based
interventions. A Connexions worker may receive a referral for a pupil who is disaffected and with
an uncertain future. Of course, the most clearly defined referrals are those to social services where a
young person is deemed to be at risk of physical, emotional or sexual abuse or neglect. Schools
have a regulated responsibility to refer such concerns within a short period of disclosure.
However, in my experience, schools either refer too early, before exhausting possible school
support, or delay until matters have got out of hand. An ‘intelligent’ referral is one that attempts
to identify the need and referral route. Many exclusion centres are full of pupils experiencing a
whole range of emotional problems that have been misinterpreted and left untreated.

It is important to see referral as a process rather than an action taken whereby responsibility for
a young person is passed to another agency. Normally, the pupil remains in the school and is
entitled to support alongside referral. The young persons need to be involved in this process, as
do their parents. The reasons for the referral should be made clear, and an opportunity to dis-
cuss feelings about the referral made available. A referral ‘imposed’ upon a child or family is less
likely to be successful, and professionals working in the statutory and voluntary sector become
frustrated when a young person appears at the door, at best with little understanding of what is
happening and at worst angry and resistant.

Referrals are made when there is concern for a young person’s social, emotional or physical
well-being, and when intervention is seen to be beyond the expertise of the school. Schools are
quite experienced at recognising when a young person’s behaviour, thinking or emotions are
beyond the norm, causing concern both in school and at home. Most organisations and agen-
cies are more than willing to offer advice and to have a discussion about the young person
before a formal referral is made. Mental health referrals are normally made through the child’s
GP, the school nurse or the school medical officer. Such referrals should be made as early as
possible but particularly when the following concerns have been identified.

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Photocopiable
Mental health problems: when to refer on

Where there is evidence of:

persistent and debilitating low mood or depression

social isolation and withdrawal

severe anxiety or unnatural fears

self-harm, particularly self-mutilation

excessive use of alcohol or drugs

expression of suicidal thoughts or intent

the pupil appearing to hallucinate, hear voices, have delusions or be paranoid

obsessive-compulsive behaviour

problems with normal eating or purging or dieting excessively

the young person having significant difficulties in forming and maintaining peer
relationships

pupils expressing concerns about their own emotional health or ‘sanity’

the young person appearing out of control, having persistent anger or violent
tendencies or expressing concerns about harming another person

bizarre or inexplicable behaviour

the young person appearing stuck in grief or loss

attachment problems

developmental difficulties, such as bedwetting, soiling and sleep disturbance

very low self-esteem

marked mood swings

the pupil having experienced significant trauma, which appears to be affecting
thoughts, feelings and behaviour

the pupil appearing unable to function on a day-to-day basis.
Clearly, it is difficult in a book of this kind to be more specific about when to refer.
Each child is an individual with complex needs and circumstances. Intelligent referral
comes from knowing the pupil thoroughly and when the school can show that normal
interventions have failed. It is important to speak to colleagues in supporting professions
and seek their advice. If a young person’s mood and behaviour change rapidly or in


© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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unusual ways, or if they become a danger to themselves or others, particularly if there is

evidence of self-harm or suicidal thoughts or actions, a referral should be made as soon
as possible.

Making a referral
When one makes a referral, it is always useful to have the following kinds of information
available:

full name of the pupil being referred

address, including postcode

date of birth

parent/carer’s name and contact numbers, especially if these are different from the
child’s

known siblings, including those currently at the school

an up-to-date printout of the pupil’s attendance

why the young person is being referred

any familial history that may be relevant

school history including behaviour and achievement levels

a record of school-based interventions

any special educational needs

involvement of other agencies

details of any child-protection or social services involvement.

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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Reflection box ?

 What can you remember about school? Can you identify the emotional context of your
recollections?
 Look back at the section on ways in which schools can promote mental health and sup-
port young people. Use it as a kind of audit tool. What is your school already doing and
what needs more attention?
 How would you describe the ‘climate’ of your school?
 What attitudes to mental illness exist among pupils and staff in your school?
 What agencies is your school already working with?
 Consider the different emphasis, focus and language of each of the mental health agen-
cies and professionals mentioned in this chapter. How do these compare with your
school’s focus and objectives?

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C HAPTER 7

The mental health curriculum: resources

for use with pupils

This chapter looks at:

Issues around mental health should be raised with pupils directly through the taught
curriculum. This serves to raise awareness, increase knowledge, improve skills and
reduce stigma. The following classroom materials are designed for use during PSHE
time or for small group use.

Mental health is promoted through the ethos of the schools and should be enshrined in the
relationships, policies and procedures that exist there. However, mental health issues should
also form part of the curriculum. A number of subjects will, by their very nature, explore mat-
ters relating to feelings and matters of life and death. Indeed, it could be argued that every
subject on the school curriculum in some way contributes to this aspect of the development of
our pupils.

It is my belief that, through the PSE/citizenship curriculum, topics of direct importance to

mental health should be introduced, despite sometimes being controversial or of a sensitive
nature. Mental health problems are a reality for many of our pupils, directly or indirectly, and to
shy away from them is to deny young people the opportunity to explore these matters in ways
that help them deal with them if and when they happen.

The following resource materials are drawn from a BACP publication, Exploring Mental Health: A
Teaching Resource for Schools – for Work With Students Aged 14–16 (Prever, 2004). The resource is
for whole-class use but can be adapted for small groups. Having used these materials with older
pupils and even adults, I believe that they can be used beyond the originally stated 16-year
limit, which was always an arbitrary line dictated to some extent by the school curriculum. It is
the quality of the discussion which differentiates between ages and offers a potential resource
for use with older pupils.

A note of caution is necessary. In using these materials, we must recognise that some of the
issues and ideas may well touch some of our pupils more than others. It is important to check
at the end of each session that pupils are feeling OK, and that support structures are in place to

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help pupils who have been affected by content and discussion. The teacher should also ensure
that they have a colleague with whom to share strong feelings if necessary. This resource should
be used sensitively and with empathy. Please note that some activity pages are photocopiable
for class use.

1. Words, stereotypes and feelings

Activity guidance notes for teachers

These activities ask pupils to explore the language of mental health and the attitudes linked to
it. Pupils are also encouraged to look at stereotypes associated with mental health and to chal-
lenge these. Finally, pupils are asked to consider their own feelings and those of others in
relation to the language explored.

Time
50 minutes.

 What you will need

large sheets of paper

felt-tip pens.

How to do it
Split the pupils into groups of four. Hand them the pens and paper and ask them to carry out a
wordstorm around the idea of mental health. Remember, at this stage, all contributions are wel-
comed and not challenged. After five minutes, ask each group to display their results and share
with the whole group. Often the list of words will focus on mental illness and include a number
of slang words that are often seen as offensive or ill-informed, such as nutter, dimwit, mad,
schizo, not all there, odd, crazy or loony. How many words are seen to be positive or negative? Ask
the pupils if they have ever used words like these. What feelings are generated in the person
who uses these words: fear, superiority, separateness?
Explore with the group the possible origin of some of these words and the possible effect upon
our attitudes to people with mental health problems. What might they feel: isolation, shame,
anxiety, not belonging, inferiority, anger? Raise the idea that mental health is also about being
emotionally healthy and not exclusively about illness. Assess with the group the possible
impact on people with mental health problems, especially in terms of their sense of worth and
relationships.
Give out more paper. Now, ask the pupils, working with a partner, to draw the outline figure of
a ‘mentally ill person’. They should then label their visual representation. Allow ten minutes for
this. Ask them to share with another pair and look for similarities. Clearly, some pupils may

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resist creating the stereotype but encourage them to do so if only to highlight the attitudes that
persist in society.

Extension activities
Ask the group to think of how mental health is portrayed in film and on television. Are these
stereotypes?

2. Myth and reality

Activity guidance notes for teachers

There are many myths associated with mental illness, which have been adopted almost as
unquestionable truths. These activities encourage discussion around attitudes and knowledge.

Time
35 minutes.

 What you will need

a copy of the activity sheet, ‘Mental Illness: True or False’ (included in this
chapter) for each pupil

two sheets of A4 paper, one labelled TRUE and the other FALSE

Pens for pupils.

How to do it
Ask the pupils to complete the activity sheet ‘Mental Illness: True or False’. This should be done
by gut feeling rather than extensive deliberation. Allow five minutes for this before asking
pupils to pair up and compare responses. To what extent is there agreement? Where there is dis-
agreement, each pupil should try to explain the reasoning behind their choice. The following
information is reproduced for your use:

1. Only a very small proportion of people with mental illness are in danger of
harming others. Mental illness is more often associated with withdrawal and
silent suffering.

2. Mental health problems rarely affect intelligence. Some patients have lower
levels of intelligence and some are above average.

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3. Mental health problems affect many people either directly or indirectly

throughout their lives. Whilst most people do not suffer from a psychotic
illness, many people are affected by neurotic symptoms. Mental health
problems affect people regardless of race, religion, nationality or gender.

4. Children experience mental health problems, although these are often not
diagnosed or treated.

5. Self-harm is most often a secretive activity and a form of coping.

6. Many illnesses can be treated and managed, and often people will return to
normal functioning, but people with severe mental illness sometimes
experience difficulties throughout their lives.

7. Depression has nothing to do with being weak or lazy and is sometimes

associated with changes in brain chemistry. The causes of depression are
complex, and whilst all people have to take some responsibility for their
thoughts, feelings and behaviour, depression is not a choice, and we should
not apportion blame or withhold support.

8. Mental illness, while affecting other people around the sufferer, is not
contagious.

9. ‘Mental illness’ is a generic term that refers primarily to a group of illnesses of

the mind, in the same way that heart disease refers to a range of illnesses of the
heart and circulatory system.

10. Some tendencies to mental illness may be passed on between generations

biologically, and whilst poor parenting may be a significant risk factor, it is
unlikely to be the sole cause of severe mental illness.

Extension activities
As an alternative to pair work, consider placing your two TRUE/FALSE sheets at opposite ends
of the room and, on reading the statement, ask pupils to move to the side which represents
their opinion. They should be prepared to comment on their choice. Where there is a disagree-
ment and different views expressed, invite pupils at opposing ends of the room to change their
mind and join the opposite group.

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Photocopiable
Activity 2 Activity Sheet – Mental Illness: True or False

Decide which of the following statements are TRUE or FALSE. Circle your answer. Be prepared to
discuss your choices.

1. People with a mental illness are dangerous. TRUE FALSE

2. People suffering from a mental illness are often below average in intelligence. TRUE FALSE

3. Mental health problems affect most people at some point in their lives. TRUE FALSE

4. Children do not suffer from mental illness. TRUE FALSE

5. People who self-harm are seeking attention. TRUE FALSE

6. Mental illnesses can be treated and cured. TRUE FALSE

7. People who are depressed have weak personalities; they are often lazy and
should look at life more positively. TRUE FALSE

8. Mental illness can be ‘caught’. TRUE FALSE

9. Mental illness is just like any other illness such as heart disease or arthritis. TRUE FALSE

10. Mental illness is the result of poor parenting. TRUE FALSE

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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3. Stigma
Activity guidance notes for teachers

The word stigma is associated with feelings of shame or disgrace. For a person experiencing a
mental health problem, the views of others affect self-esteem and can last a lifetime. Stigma can
lead to discrimination, and affects relationships in potentially disastrous ways. Stigma is associ-
ated with prejudice and misunderstanding. This activity asks pupils to begin to experience what
this might be like.

Time
40 minutes.

 What you will need

No materials are required for the main activity, although art materials will be necessary for
extension activities.

How to do it
Firstly, explore the concept of stigma with pupils. What does the word mean? What might be the
origin of the word? The dictionary defines stigma as a mark of ‘social disgrace’, and of course it
is linked to the Crucifixion of Jesus and subsequent claims throughout history from individuals
who have claimed that wounds on their hands and feet appear to resemble those probably
experienced by Jesus himself.

Ask pupils to work with a partner. They should decide who will be A and who will be B. A
should talk for five minutes about the experience of having a mental health problem and being
treated differently by other people. Ask pupils not only to ‘tell their story’ but also express
thoughts and feelings. B should listen as carefully as possible, encouraging the partner to speak,
without challenging or judging. You should time-keep, and after the allotted five minutes, ask
the pupils to swap around. At the end of the activity, ask pupils what it felt like to be taking on
the roles of speaker and listener. In the role-plays, ask the pupils to consider incorporating
some of the following:

how stigma affects their relationships at home and at school

being treated as abnormal or ‘sick’

being afraid to tell anybody about the problem

feelings such as anger, fear, sadness, loneliness and isolation

effect on self-esteem

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being treated as an ‘illness’, and not a person

feeling rejected, worthless and less than human.

Extension activities
There are many opportunities to explore the experience of stigma through creative activities
such as poetry, stories, letter writing, poster work or art. Pupils can also be asked to explore ways
in which stigma can be challenged, as through education; seeing mental illness as simply,
another kind of illness; and challenging myths, misconceptions, stigmatising language and neg-
ative attitudes. They might also like to consider ways in which they can be more supportive of
friends and family who may be experiencing emotional difficulty in their lives.

4. What causes a mental health problem

Activity guidance notes for teachers

Some mental health problems are related to genetic and physiological factors and are seen as
having medical causes. However, many events and relationship problems might cause or maintain
a person’s emotional distress. This activity asks pupils to explore those factors that might have a
negative and sometimes debilitating effect on a person’s emotional health and well-being.

Time
50 minutes. The session can be extended to two sessions.

 What you will need

lots of newspapers and magazines

scissors

A3 paper

glue.

How to do it
Have plenty of newspapers and magazines available and prepare yourself for a mess! Ask the
pupils to make a collage based on the causes of mental health problems. Pictures and words
can be torn or cut out and stuck on the paper without any unnecessary focus on neatness, but in
a way that represents the factors that influence a person’s mental health. This could take around
30 minutes. Ask for volunteers to come to the front of the room and talk through their creation.

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Sometimes, there may be a tenuous link between the image and cause, but the collage is not
there as an accurate record but as a means of communicating ideas. Newspapers and magazines
contain pictures, images and headlines that refer to matters such as family breakdown, crime,
violence, substance abuse, death, poverty, parenting styles, illness, bullying and all kinds of
abuse. Make sure you leave enough time for clearing up. An alternative – and possibly more
controlled – activity would be to produce your own montage of images, which could be photo-
copied and discussed in small groups.

Extension activities
Pupils can be asked to keep a record of news items and storylines from soaps and dramas that
touch on the factors which might affect mental health.

5. Risk and resilience

Activity guidance notes for teachers

For a number of years, professionals have been interested in why some young people do not
develop mental health problems despite their exposure to a number of risk factors. Risk factors
merely increase the probability that a child will develop a mental health problem, and, clearly,
there is a complex interplay between these potentially negative influences and what are referred
to as protective or resilience factors. These activities help pupils to explore the concepts of risk and
resilience and perhaps privately relate them to their own experience.

Time
50 minutes.

 What you will need

Copies of the activity sheet ‘Risk and Resilience’ (page 95) for all pupils.

How to do it
The activity can be carried out in small groups or individually. Explain the concepts of risk and
resilience. Ask participitants why some young people face various issues in their lives but appear
to develop, thrive and progress, while the lives of others appear to fall apart, plunging them
into depression and self-destructive behaviours.

Then, ask the pupils to find different ways of grouping the risk and resilience factors, or offer
them the idea that they could be grouped under headings such as:

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factors within the child

factors within the family

factors within the community.

Now, ask the pupils to categorise both risk and resilience factors from the list provided.
Inevitably, there will be some overlap, and this should facilitate interesting discussion. You
could perhaps draw up a composite set of lists drawn from the pupils’ deliberations that repre-
sents a kind of consensus, if indeed this is possible.

Extension activities
Give the pupils two large pieces of paper and ask them to represent risk and resilience in sym-
bolic form. Ask pupils if factors can be ranked according to influence. This should initiate some
interesting discussion.

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Photocopiable
Activity 5 Activity Sheet – Risk and Resilience

Attempt to group all risk and resilience factors in a young person’s life. You may wish to use the
following categories or identify your own:

within the child

within the family

within the community.

Risk factors Resilience factors

Poor social skills Living in a close family
Hanging around with peers who get into trouble Attending a good school
A parent who suffers from a mental illness Following a religion
Being made homeless Being a girl
Overly strict parents A good sense of humour
Poverty Being a loveable baby
Being involved in a natural disaster Being clever
A rejecting mother or father A positive attitude to life
Being the victim of racism Taking part in sports
Lots of arguing at home Teachers have high expectations
Suffering from a long-term illness Lots of love and affection
Parents’ divorce or separation A high family income
The death of a parent or grandparent Good social skills
Parent in prison A drug-free family
Having a learning difficulty Respect for authority
Low self-esteem A large friendship group
Truancy from school Good housing
Being a refugee or asylum seeker A large extended family
Emotional abuse Quality time with parents
Witnessing violence on the streets Parental support for education

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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6. Emotional health and well-being

Activity guidance notes for teachers

Emotional health and well-being are important prerequisites for young persons to function at
an optimal level, achieve their full potential and enjoy life. This exercise encourages pupils to
explore what might constitute emotional health and its counterpart, unhealthy functioning.

Time
35 minutes.

 What you will need

flip-chart paper

felt-tip pens.

How to do it
Split the whole class into smaller sub-groups of around four pupils. Ask half of the groups to
explore emotional health and the other half emotional ill-health. Distribute the pens and paper
and ask the first half of the class to come up with a list of words that might describe somebody
who is ‘emotionally healthy’. Set aside ten minutes for this. Examples might include the following:

Enjoys life Positive outlook

Easygoing Has a clear sense of their future
Good at making decisions Lives in the present
Self-confident Has lots of energy
Happy Looks after their appearance
Good sense of humour Uses leisure time to the full
Sociable Has lots of friends
Warm personality Is a good listener

Ask the other half of the class to list words and ideas that might be associated with a person
who is ‘emotionally unhealthy’. For example:

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Often feels anxious or afraid Irritable or aggressive

Cries easily Neglects their appearance
Often sad or depressed Lethargic
Does not like eating in public Avoids social contact
Is often tired Displays a lot of anger
Is plagued by worrying thoughts Fears the future
Life appears to be out of control Bullies others
Talks about hurting themselves Feels that problems are insoluble

Finally, ask the groups to give feedback to the whole class.

Extension activities
When looking at some of the characteristics that define emotional health, it may be useful to
see them in terms of feelings, thoughts and behaviours. Ask the groups to reorder their lists
under these three headings.

7. Mental illness
Activity guidance notes for teachers

This activity invites pupils to begin to understand the range of mental health problems faced by
young people in particular.

Time
40 minutes.

 What you will need

a copy for each pupil of the activity sheet ‘Mental Illness and Young People’
(page 99)

flip-chart paper

felt-tip pens.

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How to do it
It is important to remember that some pupils in the class may be affected directly or indirectly
by the mental health problems described here. Special awareness and sensitivity is needed, and
where such a connection is known, the content of the session should be discussed with the
child concerned.

Ask the pupils, working in small groups, to list as many mental health problems as they can.
This should take around 15 minutes. Distribute copies of the activity sheet ‘Mental Illness and
Young People’. Pupils are asked to link the mental health problem with the descriptions in the
second column. Clearly, some generalisations are necessary, and there will inevitably be overlap
in some cases.

Pupils are also asked to record what they already know about these problems.

Extension activities
There is a great deal of material available on the internet concerning the mental health prob-
lems identified here. Groups of students could be asked to research different problems and at a
later stage give a presentation to the whole group. It should also be possible to use some of the
information contained in this book. Mental health problems often have self-help or interest
groups linked with them. These groups are a good source of information and will sometimes
supply speakers or a range of teaching materials.

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Photocopiable
Activity 7 Activity Sheet – Mental Illness and Young People

Young people sometimes experience a range of mental health difficulties. See if you can link the problem
with the description. What else do you know about these mental illnesses?

Schizophrenia Distressing thoughts and rituals, often necessitating repeating

behaviours such as checking and washing hands
Attention-deficit and hyperactivity Repeatedly hurting oneself, often by cutting
disorder
Asperger’s syndrome Deliberately, and often secretly, restricting food intake with the
intention of losing weight, often without the need to
Anorexia nervosa Finding it hard to settle down to a task and pay attention.
Sometimes disrupting others or damaging their possessions
Obsessive-compulsive disorder Strong feelings of sadness. A loss of pleasure or interest in things
once enjoyed. Feeling worthless and without hope
Post-traumatic stress disorder Seeing the world as threatening; inability to relax and excessive
worry
Anxiety Recurrent dreams and recollections of a past event; avoiding
specific activities, people and events
Conduct disorder Characterised by major abnormalities of thinking, beliefs and
perception. Sufferers often lose insight and contact with reality
Depression Often failing to use non-verbal expression or to recognise it in
others; sometimes engaging in repetitive and ritualistic activities;
often lacking empathy; difficulty in making friends
Self-harm Persistently unable to control behaviour and obey acceptable
rules. Characterised by defiance of authority and challenging,
sometimes destructive, behaviour

© British Association for Counselling and Psychotherapy 2006 (BACP)

P Mental Health in Schools by Mark Prever (2006). Paul Chapman Publishing

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8. Feelings and behaviour

Activity guidance notes for teachers

Clearly, there is a link between mental health and behaviour. This session asks pupils to begin
to explore this link by looking at their own feelings and how these might have a positive or neg-
ative effect on their schoolwork and relationships with others. This is a self-awareness exercise.
Explain that ‘behaviour’ here is not meant only in terms of conduct, but is more about what
pupils do and how they act in different situations and with different people. Pupils are then
asked to explore how mental health difficulties might affect a young person at school.

Time
50 minutes.

 What you will need

copies of the worksheet ‘Feelings and Behaviour’

pens

flip-chart paper.

How to do it
Working alone, pupils complete Section A of the following activity sheet, ‘Feelings and
Behaviour’. This should take approximately 15 minutes. It asks them to record a time when
they have experienced certain feelings. Pupils may want to retain confidentiality when com-
pleting this activity; therefore, responses could be recorded symbolically in a way only the
pupil will understand.

Pupils then complete Section B, which asks them to describe how having certain feelings might
affect their school work, friendships and relationships at home. Ask the pupils to return to the
last session, which explored mental illness. How might each of these mental health problems
affect a young person’s behaviour and relationships with adults and pupils in school? Ask
pupils to work in pairs and explore this idea in more detail.

Extension activities
Ask pupils to monitor and record their emotions over a number of days. How have these
affected their behaviour? What has been the effect on others?

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Photocopiable
Activity 8 Activity Sheet – Feelings and Behaviour

Section A
Try to remember a time from the recent or distant past when you have experienced the following feelings
and emotions. If you prefer, you may like to record your thoughts in a way that only you can
understand.

A TIME I FELT:
Really sad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Very angry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Left out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Happy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lonely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frightened . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Confident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stressed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Depressed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Friendly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ashamed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hopeless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Put down . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Section B
Draw up a chart that lists these feelings and any others that come to mind. Show how experiencing
these feelings might affect your behaviour:

at school

with your friends

at home.
How might your behaviour affect other people? How might it change their behaviour toward you?

© British Association for Counselling and Psychotherapy 2006 (BACP)

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9. Feelings, mental health and learning – the connection

Activity guidance notes for teachers

When pupils feel depressed or unhappy, or when they are anxious or scared, their capacity to
learn is adversely affected. They may withdraw or show aggression. Sometimes they act out.
When children feel unloved or neglected, they may seek attention or give up trying. As with
young people, our own ability to learn will be affected by our emotional health and well-being.
Learning involves risk, and when young persons feel that their sense of worth is in jeopardy, or
when they have come to expect failure, they will resist learning. These activities call upon pupils
to understand these concepts and relate them to personal experience.

Time
45 minutes.

 What you will need

copies of the following ‘Case Study’ activity sheet for all pupils

pens and paper.

How to do it
Explain the potential link between emotional health and learning. Ask pupils to work with a
partner. Distribute the ‘Case Study’ activity sheet and ask them to consider the two scenarios
and accompanying questions. They should record their responses in note form. After 10 min-
utes, ask them to join with another pair and share ideas.

Extension activities
This material could provide an opportunity for role-play. Ask the pupils to work in pairs and
each take on the role of parent/teacher and pupil whose underachievement is explored. The
pupils could be asked to consider, individually, times when they have avoided work at school or
when their learning has been impeded by strong thoughts and feelings.

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Photocopiable
Activity 9 Activity Sheet – Case Study

Case study 1
Until recently, Khalida has been a model pupil. She has had her coursework well under control and often
handed it in well in advance of due dates. She has always been popular and has a number of firm friends
who are also doing well. Since Year 7, her attendance and punctuality have always been exemplary, and
her only significant absence was when her parents split up when she was in Year 9, and she went to live
with her dad for a while. Her behaviour has always been very good, and apart from a couple of
detentions for minor offences, there have been few concerns. Her grandmother has been ill for some time,
and Khalida visits her regularly. Her mother has very high expectations of her academically, and she is
expected to go to university after completing her A levels. However, recently, Khalida’s form tutor has
noticed changes. She’s late once a week and seems irritable in lessons. Her English teacher has noted
that she has some coursework owing, a very unusual lapse. Khalida has spent more time in the library at
lunchtimes and appears to be only browsing. There was an incident last week when she was rude to a
member of staff and aggressive to a dinner supervisor who insisted that she could not eat her sandwiches
in the main dining hall. Importantly, Khalida seems to be bored in class and withdrawn, and she rarely
contributes to discussion. Her written work is correct but minimal.
1. In what ways has Khalida changed?
2. Can you suggest what might have caused these changes?
3. What feelings might Khalida be experiencing?
4. How has her learning been affected?

Case study 2
Dean has always had difficulties. His junior school report is littered with behaviour report forms, albeit of
a minor nature. He does little work in class and often remarks that the lesson is ‘boring’ or that it is ‘too
easy’. In lessons, Dean sits with three friends who are equally reluctant to engage with work most of the
time. Dean regularly forgets his equipment and rarely does any homework. Dean can be quite disruptive,
often engaging in activities that have no connection to his work. On some occasions, he prevents others
from working by taking their pen or hiding their belongings. He often gets into an argument with Tariq,
whom he regards as a ‘boffin’. Dean is in Year 8, but many of his teachers expect him to be excluded by
the end of Year 9.
1. What is going on for Dean?
2. Why does he find the work boring and too easy?
3. Why does he attempt to prevent others from working?
4. Why might learning be risky for Dean?
5. What is Dean feeling?

© British Association for Counselling and Psychotherapy 2006 (BACP)

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10. A little help

Activity guidance notes for teachers

While most people will not experience a diagnosed mental illness, many adults and young
people will feel low, depressed or anxious, and may display aspects of behaviour that, if more
long-lasting, persistent and severe, may be regarded as a mental health problem. It is clear that
adults and young people will need support at various points in their lives. These activities help
pupils explore possibilities.

Time
40 minutes.

 What you will need

copies for all pupils of the following activity sheet ‘Who Can Help?’

A4 paper

pens and felt-tip pens.

How to do it
Conduct a wordstorm with the whole group about who can help young people when they have
a problem. This might include:

Social workers Teachers Learning mentors

Head of Year Education social workers Parents
Friends Grandparents Special needs teachers
Family friends Neighbours Brothers and sisters
Doctors Nurses Psychologists
Psychiatrists Counsellors Behaviour support
Uncles and aunts

Give out copies of ‘Who Can Help?’ and ask pupils to complete it. After five minutes, ask the
pupils to share with one other person. Are any patterns discernible? What kinds of problems do
we share with different kinds of people?

Extension activities
Discuss with the pupils what would prevent young people from seeking help if they felt that
they might have a mental health problem? Ask pupils to interview an adult they know well to
explore how that person had found help when there was an emotional need.

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Photocopiable
Activty 10 Activity Sheet – Who Can Help?

Who might be able to help and support you if you were experiencing the following kinds of problems in
your life? If you prefer not to answer these personally, consider your responses as advice to a friend in need.

Problem Who can help?

You are being bullied at school. ......................

Your parents are splitting up and always arguing. ......................

Someone close to you has died and you can’t seem to stop crying. . . . . . . . . . . . . . . . . . . . . . .

You get headaches all the time. ......................

You are worried that you keep on losing your temper. ......................

You are frightened to go to school for no apparent reason. ......................

You are frightened to go home because of the violence. ......................

You know that your behaviour at home and school is getting

worse and you want to turn things around. ......................

You have fallen out with your best friend. ......................

Exams are looming and you are sick with worry. ......................

You are making yourself sick after meals. ......................

You have felt that taking lots of pills would solve all
your problems. ......................

You have felt sad and unhappy for many weeks and see no light
at the end of the tunnel. ......................

The work at school is too hard. ......................

© British Association for Counselling and Psychotherapy 2006 (BACP)

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11. A listening ear

Activity guidance notes for teachers

Many young people seek support from each other, and this is to be welcomed. Many schools
have attempted to formalise this process by introducing peer support and other similar
schemes. The reality is, however, that most emotional support on a personal level occurs
between friends. This session encourages pupils to develop the skills of helping and also to
understand when it may be necessary to involve an adult.

Time
55 minutes.

 What you will need

flip-chart paper

felt-tip pens

space!

How to do it
Working in small groups, ask the pupils to come up with the qualities of being a good helper
and listener and give feedback to the whole group. Such qualities might include:

Regard for non-verbal communication Asking open questions

Good eye contact Being approachable
Empathy Offering time
Being non-judgemental Trust
Confidentiality Focusing on feelings
Understanding Warmth

Ask pupils to practise some of these skills in a one-to-one situation. Pupils work in threes, each
taking the role of listener, talker and observer. Each talks about a real or imagined problem for
five minutes (you keep time). After each five minutes, ask the trio what it was like to talk, be lis-
tened to and to observe. This is not meant to be an exercise in counselling skills, but merely an
opportunity for pupils to focus on what a good helping relationship would look and feel like.

Talk to the class about the limits to confidentiality. Pupils should consider when they might
need to seek help from a caring adult and under what circumstances they might consider break-
ing confidentiality. This could take the form of a whole-class debate. Examples include:

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if the friend is at risk of harm in some way

if the friend is in danger of hurting another person

if the friend is self-harming

if the friend is contemplating suicide or has already made an attempt

if the friend has been or is likely to be abused, especially physically or sexually

if the friend is displaying unusual behaviours or having disturbing thoughts

if there is a risk of violence.

Extension activities
The group may wish to research and practise listening skills in more depth. Ask the group to
identify some of the qualities of a good friend.

12. Communicating what we feel

Activity guidance notes for teachers

There is a growing interest in what may be referred to as ‘emotional literacy’ and in particular,
how it can contribute to the emotional well-being of young people in schools. Key to emotional
literacy are principles such as self-awareness and the ability to understand our own emotions
and those of others. We also need to use these insights and understandings to make us more
effective in our own lives. Indeed, it can be argued that emotional literacy is an important lan-
guage. Put simply, the larger our vocabulary of feelings, the more able we are to express
ourselves in healthy ways. The following activities encourage pupils to develop an extended
feelings vocabulary and to use it in their daily lives.

Time
50 minutes.

 What you will need

flip-chart paper

pens

’feelings sheets’ (created by the teacher), listing the five key emotions
(shown below).

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How to do it
Split the class into five groups. Hand each group one of the ‘feelings sheets’. Alternatively, you
can give each pupil an individual sheet that is headed accordingly. Ask them to collectively
write down as many words as they can think of associated with that key emotion; for example,
anger, irritation, annoyance, fury, rage, aggression, violence and hate.

The five key emotions are

anger

happiness

fear

disgust

sadness.

Allow ten minutes for this. Now ask them to rank them according to intensity; for example,
ecstasy, joy, pleasure and amusement. Each group should present its results. Is everybody in
agreement with the rankings?

Ask the class to form pairs. Each pupil talks for five minutes about something important to
them in the past, present or future, using as many feeling words as possible. Pupils can take part
at the level they are most comfortable with.

Extension activities
Ask each pupil to choose a letter of the alphabet and come up with as many feeling words as
possible that begin with that letter. X, Y and Z could prove difficult!

Ask pupils to use feeling words consciously with family and friends for a couple of days. Do
they feel better understood? How did people react?

13. A mentally healthy school

Activity guidance notes for teachers

Schools have a responsibility to promote the social and emotional development of all pupils.
This activity asks pupils to identify ways in which schools already do this and how emotional
health can further be supported.

Time
1 hour.

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 What you will need

large sheets of paper

lots of coloured felt-tip pens or paints.

How to do it
Pupils should work in small groups. They should be asked to design a ‘mentally healthy school’.
This could be a visual representation or take the form of a large collection of illustrated ideas.
Suitable areas to include are as follows:

the building design and facilities

leisure areas

the canteen

the playground

teaching and learning

the curriculum

relationships between pupils

relationships between adults and young people

involvement with parents and carers

support staff for pupils

involvement of outside agencies

resources

policies, especially those relating to bullying, behaviour, drugs and sex education.

Each group could be asked to introduce their ‘ideal’ school to the whole group.

An alternative, which requires some confidence, is to ask pupils to begin their activity by identi-
fying the characteristics of a mentally ‘unhealthy’ school. On completion, these negatives can be
reversed to form the mentally healthy school.

Extension activities
Pupils can produce publicity with a computer to advertise the mentally healthy school. A TV or
radio advert could be written and recorded or performed.

Ideas for improvements in the school could be submitted to the school council.

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14. Questions in a box

Activity guidance notes for teachers

At the end of this course, pupils may be left with a whole range of feelings and issues that have
not been addressed or that have affected them more than expected. These final activities offer
the class an opportunity to ask questions and explore feelings. As with the rest of the course, it
is important to have suitable support systems in place to help pupils in need.

Time
25 minutes.

 What you will need

a medium-sized cardboard box

pieces of card or paper.

How to do it
Ask pupils to write down any comments, feelings or questions they might have about this
work on mental health. These can be anonymous, or the pupils may, if they wish, write their
name. The slips should all be placed in the box. The teacher should mix them up and read
them to the class. No pupils’ names should be read out. Pupils can ask for their card not to be
read out by marking it with a cross. In many ways, this is an opportunity for pupils to evaluate
and reflect upon the course. However, if pupils want further help, this is one way in which they
can ask for support.

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C HAPTER 8

The listening school

This chapter will show:

Really listening to young people is the most important way in which we can help pupils
with mental health problems and also promote emotional health and well-being in
schools. It is, of course, important to distinguish between the use of listening skills and
counselling, which is a more specialised activity. All young people should be able to
access counselling in schools as an entitlement, but the introduction of such a service
needs to be thought through and many issues and practicalities explored.

Listening skills and counselling

Experience has taught me that, regardless of the child and despite the young person’s present
predicament, real listening is the most profound way in which to help a young person. As pro-
fessionals we are often impotent when it comes to changing many of the difficulties that young
people experience. We cannot lift a family from poverty, remove a sibling with a severe disabil-
ity from the home, bring back a lost parent or stop parents from tearing each other apart, but
we can listen. Reference to our own experience will tell us that sometimes all we need to know
is that somebody really understands what we are experiencing. I do believe that teachers and
other adults in school are well placed to offer this kind of attention, and some do willingly. I
am also aware that sometimes we claim to be listening when what we are really doing is offer-
ing guidance and advice. These are valid interventions but they do not represent real listening.
Indeed, the very term ‘counselling’ is misused in schools and, at worst, can be entirely distorted
– as when we hear the suggestion that a pupil with behaviour problems needs ‘counselling’.

I believe that genuine non-judgemental listening in schools is rare – and beautiful where it is
found. The use of counselling skills should not be confused with counselling, which is a differ-
ent and more specialised activity with different boundaries and processes. Counselling involves
the setting up of a specific contract between a trained counsellor and persons who understand
that they are in the role of client. Good listening can occur at any appropriate time and often
where there is an available space. Counselling, by contrast, takes place in the same place,

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normally on a weekly basis for a fixed period of time. Depending upon the model used, the
counsellor will work in a particular way, using well-established theory and ideas attached to that
particular theoretical model. There will also be a clear understanding of the therapeutic nature
of the work. However, teachers and other school-based staff, whilst not normally trained coun-
sellors, can develop, refine and use counselling skills to good effect. Real listening cuts through
most things, and I believe it is possible to find the real child in every young person, despite the
behaviours that make them hard to reach or sometimes encourage us to reject or despise them.

What constitutes good listening?

Carl Rogers (1902–1987), a humanistic counsellor and psychotherapist, set out clearly what
he regarded as the ‘core conditions’ that are essential in any therapeutic relationship.
Rogers’s (1951) ideas have had a profound and long-lasting influence on the world of coun-
selling, but his ideas are equally applicable for use by non-specialists. They set out the basis
for good listening.

The three core conditions are the following:

congruence
This is the honest relationship between people’s inner feelings and their outer
display. Congruence may therefore be seen as not ‘playing a role’ but being real,
genuine and transparent.

unconditional positive regard
This means offering a person your full, caring attention without judgement or
evaluation.

empathy
This refers to seeing the world through another person’s eyes and accepting that
person’s perceptions and feelings ‘as if ’ they are your own without losing your
boundaries and separate sense of self.

These core conditions, Rogers believed, help people find their own way, identify their own solu-
tions and grow personally. They are easy to say, and even to write about, but these ideas
represent the most sophisticated of human interpersonal skills. Only when you have experi-
enced them is it possible really to understand what it feels like to be listened to. As teachers, we
rarely offer this kind of listening, but there is no reason why we cannot. The following list also
sets out what good listening might look like.

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Photocopiable
What constitutes good listening?

Understand the feelings, not only the content, of what is being said. Sometimes this may involve
looking beyond the stated word.

Acknowledge and identify what pupils might be feeling and offer this to them.

Recognise and communicate that talking about a problem may be difficult for the young person; it may
be especially and uniquely painful.

Be accepting. Work to receive genuinely what the young person is telling you, even if you are
thinking and feeling differently, have different values or see the situation from a position of experience.
Do not stop listening because you do not agree.

Be genuinely interested and demonstrate this. We can communicate interest by maintaining eye
contact, not fidgeting and not asking too many questions; our posture and minimal responses should
show we are trying to understand and want the young person to continue telling the story.

Offer as much confidentiality as you can within child-protection guidelines. Thoughts and feelings
about home and school do not always need to be shared. Explore with the pupil the limitations of
what can remain private from the outset and return to these periodically. This gives the young person
control over disclosure.

Be available. Let pupils know that it is OK to talk to you.

Listen patiently.

Make time and space for real listening to happen. Listen with your full attention, not whilst doing
something else.

Be aware of your own feelings and recognise when the pupil’s words or story resonate with your
own material or experience.

Be comfortable with anger as long as it is expressed in words and feelings, and not in physically
destructive ways. Anger represents feelings which are unexpressed or not heard.

Where appropriate, say what you are feeling. Model how to share emotions.

Believe what young persons say. This is how they see it at this moment in time.

Do not interrupt; your role is to facilitate talk.

Do not assume you know what the young person is saying.

Always remain calm when the pupil is sharing with you.

Ask few questions; those that you do ask should be open-ended in order to elicit more than a one-
word or ‘yes’ or ‘no’ answer.


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Rather than offer solutions, help the young person to identify options. Person-centred theory is based
upon the idea that ultimately we know what is best for us and given the right conditions we will find
our own way. Good listening will help pupils to identify options and decide a course of action.
Experience has taught me that solutions suggested or imposed are resisted, short-term or only agreed
to by the young person in order to maintain relationships or ‘please’ the helper. Solutions come from
a frame of reference based upon a range of experiences very different from those of the young person
being listened to.

Maintain good eye contact unless this is experienced as threatening.

Be comfortable with silence. It may be that the young person needs to think or feel.

Try to paraphrase what the pupil is telling you. This communicates that you are really listening.

Be an attentive listener. Use a variety of brief responses, such as nodding your head, or saying
’uh-huh’, ‘I see’, ‘go on’, ‘what happened next?’, and ‘how did it make you feel?’, to communicate
that you are listening and to encourage the pupil to continue.

Listen with your eyes. Facial expressions, body posture and arm movements tell what is really going
on for the young person.

Be prepared to admit your limitations and refer on when you feel young persons are at risk or that
what they are telling you makes you feel ‘out of your depth’. If you are concerned, be prepared to
say so. It is important to remember that when you support a pupil in this way you are part of a
wider pastoral system within the school, and other people should be aware of what you are doing.
For your own professional safety, it is important to listen to a pupil in a place which can be
overlooked by and is accessible to colleagues, but not by pupils’ peers.

© British Association for Counselling and Psychotherapy 2006 (BACP)

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Photocopiable
Barriers to effective listening

moralising or preaching, as if we are in a place of worship

lecturing, as if to a group of students

giving advice as a consultant might do

offering suggestions from our perspective

mind reading as in a theatre performance

filtering (hearing only what we want to hear)

being judgemental or critical because we know what is best

daydreaming or thinking about our evening meal or when to do the shopping

becoming preoccupied with what we are going to say next, thereby missing what the young person
is actually saying

interrupting or filling a silence when there is a natural pause or the need for reflection, mainly because
we are feeling uncomfortable

rescuing, reassuring, sympathising or praising to make pupils feel better without having an opportunity
to express what they are experiencing. (Actually what we may be doing is making ourselves feel
better, rather than staying with the pain and hurt.)

questioning or interrogating as if interviewing a suspected criminal

trying to please pupils because we have become dependent upon their approval

intellectualising (listening with the head and not the heart) (Intellectualisation releases us from the
need to experience the feelings within ourselves or those of the young person. Intellectualisation offers
safety but can prevent real listening and prevent the young persons from really experiencing what they
are saying.)

remembering our own life experiences as we listen (This can lead to over-identification and distort the
helping process.)

using humour or changing the subject when uncomfortable emotions or feelings are aroused (These
may be our own defence mechanisms in operation protecting our vulnerable or raw self.)

pseudo-listening (being preoccupied with what is happening inside our own head or in the room)

making notes as the young person talks (Notes can be written up afterward. Writing is distracting to
the listener and does not indicate attention to the young person telling their story.)

listening only for facts and becoming preoccupied with structure and chronology (Whilst these may
be important, the young person would rarely have experienced an opportunity to talk about their
feelings.).

© British Association for Counselling and Psychotherapy 2006 (BACP)

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Peer-support schemes
Schools have informally recognised the natural tendency for young people to offer each other
support and friendship, particularly in times of crisis or periods of transition. Indeed, it could
be argued that young people often seek out their peers first in times of difficulty, rather than
turning to parents and teachers. Peer-support schemes recognise these processes and seek to
harness this natural humanity found in young people. Space prohibits giving detailed proce-
dures for setting up a scheme, but a number of publications by ChildLine (2002; 2004) form
good starting points for schools seriously considering introducing a scheme of some kind.

Peer-support schemes take a number of forms, each with a different focus but equally valuable.
These include:

friendship, befriending or ‘buddying’

mentoring

conflict resolution or mediation

peer listening.

I have used the term peer listening in preference to the sometimes used peer counsellor, which I
believe is risky, in that it implies a specific professional role requiring significant training and
experience. To refer to peer supporters as ‘counsellors’ suggests an activity that has expectations
beyond maturity.

All of these contribute to the idea of a listening school. They often exist alongside and comple-
ment other listening ideas such as the school council and circle time.

Natalie Tormey (2005) sets out clearly some of the benefits of peer-support schemes. Pupils
benefit from non-judgemental listening and ‘help, comfort and guidance’ which arise from
wider social networks. Teachers see their school improve and appreciate the introduction of an
additional level of support that is often neglected through lack of time. Young people partici-
pating as peer supporters gain self-confidence, improve their communication skills, and
develop socially and personally themselves. Finally, Tormey sets out whole-school benefits of
such schemes, which include reduced levels of bullying, the approval of parents, better behav-
iour and improvements in educational attainment.

The following checklist represents some of the key questions and issues that will need to be
addressed if such a scheme is to be introduced. Cowie and Wallace (2000) set out the potential
of such undertakings but also highlight the possible dangers if such projects are not introduced
with care and considerable thought.

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Photocopiable
Setting up a peer-support programme: questions to consider

Has the school sufficient financial, staffing and spatial resources for such an undertaking? Would a special
budget be set aside? Clearly, there are implications for time and space, but the project needs a relatively
low budget, perhaps a few hundred pounds in the first instance, if only to signal to participants that the
scheme is valued and give peer supporters a say in the development of the scheme.

Is there firm support and encouragement from the senior leadership team for the scheme?

How would a peer-support scheme fit into the general school ethos? Are there compatible values
between the main school and the idea of empowering young people in this way? Certainly, a
number of the elements of the PSE/citizenship curriculum, the National Healthy Schools Award and
the Every Child Matters initiative can be addressed by a comprehensive peer-support programme.

How would such a scheme fit into the school’s wider pastoral care system? Pastoral managers need
to be supportive and kept informed. Preferably, they should be involved in the development and
implementation of the project. Involve them from the start.

Which kind of peer-support scheme best fits the needs of your school? It would be useful to have
some discussion as to where most support is needed. Is bullying an issue? Do new pupils feel safe
and secure? What other provision is made for pupils to share their problems? Answers to questions
such as these will help your school decide on the most appropriate model.

How will peer supporters be trained, and by whom? Do these persons need specialist experience
and qualifications? Could such expertise be brought in? In my experience, it is best to work with
other agencies, such as a youth-counselling organisation with experience of training. Because of the
nature of the work, a few days off-site training would be an excellent investment.

As peer helpers will need regular supervision, which has time implications, who is qualified and able
to offer this kind of support? Supervision is a necessary and important component in any successful
scheme and one sometimes neglected. Perhaps an experienced counselling supervisor could be brought
in to work with groups of peer supporters. Supervision should not be confused with daily monitoring
and the management of individuals within the project.

Where will this work take place? Are there rooms that offer a degree of privacy and are regularly
available? Peer supporters need a safe place in which to work. Pupils are unlikely to seek out support
in full view of their peers, who may see seeking help as a sign of weakness.

How will peer listeners be selected or recruited? What qualities are desirable? Should these young
people apply for these responsibilities or be approached directly? Peer supporters need to offer a
degree of maturity and confidence. They need to be good listeners and display empathy. They need
to be approachable, reliable and organised. As with counselling, peer supporters may not be able to
offer full attention to the needs of others if they are in crisis themselves. Sometimes pupils may be
approached directly or identified by staff, but I believe that these important roles carry more
credibility when the posts are advertised and full, often practical selection procedures are used.
Again, a local counselling agency, used to recruiting volunteers, may be more than willing to help.


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How might the scheme be viewed by other staff and parents? Might some professionals in school
find it threatening? Peer supporters need to feel valued, and staff need to be on board from the
start. The programme should be discussed with all staff after the decision has been made to explore
the possibilities of such a project. Some staff may feel that the project may take students away from
their main task of learning and achieving results; others may feel that it is open to manipulation by
pupils. Some staff may even fear that they might be the subject of discussion. However, in my
experience, adults in school are highly supportive of such ventures, and the more organised, defined
and transparent the scheme is, the better.

How should the scheme be advertised and made known to other pupils? Talks in assembly?
Photographs displayed around the school? Posters advertising the scheme? Sometimes, peer
supporters can introduce themselves during tutor time or with small groups of pupils.

Will the scheme focus on certain year groups, such as Year 7, or be targeted at specific vulnerable
groups, such as isolated or bullied pupils? Either way, it is important to be clear about this and
probably best to start small and build.

What sort of age gap is necessary between peer supporters and their ‘clients’? As stated above, a
degree of maturity is necessary for this role and age may be a factor. Younger pupils, say, Year 8,
could work with new intake pupils in September, but normally a suitable age difference is desirable.

How can we ensure that the expectations upon peer supporters will not adversely affect older pupils
working toward examinations? The role of pupil and peer listener can easily coexist but requires
commitment, personal effectiveness and organisation.

Would it be a good idea to attach to younger pupils peer supporters who have experienced similar
difficulties, such as behaviour problems? This may be appropriate but there should be realistic
expectations about outcomes, and pupils need to be carefully chosen.

Should access to peer supporters be open, by referral, or informal? The best kind of support is that
which is sought voluntarily, but it is sometimes possible to make pupils aware of the support on offer
and direct them as such.

Have issues of confidentiality and its limits been considered carefully? Training of peer listeners should
include information and procedures about child protection as well as an opportunity to explore
practice through role-plays. In actual fact, when there is any doubt, peer supporters should always
consult with their supervisor or manager of the project. We cannot expect young people to make
decisions about child abuse; this is our responsibility.

Has attention been paid to boundaries and to ensuring that participants in the scheme are aware of
the importance of firm boundaries? In particular, this is to protect the peer supporters, who may
become overwhelmed with the attention of pupils in need. Problems sometimes occur if young
persons become overattached to their helper or seek a friendship which is beyond the expectations of
the role. Such matters should be addressed in supervision or with the scheme manager. These
difficulties may have more to do with the peer supporter not maintaining boundaries than with the
supported pupil. The maintenance of boundaries remains the responsibility of the peer supporter, but
always with our support.

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Child protection is crucial – are those setting up such a scheme confident that peer supporters know
how to receive possible disclosures and know exactly what to do? It is advisable to give peer
supporters specific written guidance to refer to when in doubt. Peer supporters should be told to err
on the side of caution and discuss concerns with an appropriate adult in the school.

When will the scheme operate? Lunchtime? Before and after school? Might pupils be taken out of
normal lessons, especially where mediation may prevent problems from escalating? Most schools
operate schemes during out-of-lesson times so as to avoid any disruption to schooling. It is also a time
when pupils feel least conspicuous and are possibly most vulnerable.

How will the school keep peer supporters motivated after the initial enthusiasm has waned? The role
of peer listener can be exhausting and will make personal demands upon the young person. Like any
new initiative, morale needs to be maintained by praise, recognition, celebration and even additional
training and development opportunities.

Do interested staff have the time and energy to keep this endeavour going? No doubt, the points
made above apply equally to the adult in the school, who will probably have invested a great deal
of energy and commitment to the success of the peer project.

What sort of records of use will be kept? How will the scheme be monitored and evaluated? What
would constitute success criteria? At this level, only minimal records need to be kept. These may
include details about age, ethnicity, gender and presenting problems, identified by a code, which
later can be collated to provide evidence of the range, usage and value of the scheme.

What are the benefits for peer supporters and how might their commitment be formally recognised?
The peer supporters group should meet together regularly, and refreshments should be provided. They
may wish to have badges and their photographs displayed. Parents should be involved in any
recognition ceremonies, and records of pupils’ commitment should be passed on to future employers
and colleges.

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The above section can only raise questions and suggest ideas. Each school is different, and
therefore each peer-support scheme should be a good fit for each individual school, expressing
its ethos, climate, relationships and priorities.

Employing a counsellor in your school

Whilst pastoral care has a long tradition in UK schools, originating in our nineteenth-century
public school system, the idea of school counselling is a relatively new one. The late 1960s and
early 1970s saw a growing interest in counselling, due to ideas that had been imported from the
United States, and specialist training courses were set up in a number of universities, such as
Keele and Reading, to produce the counsellors to meet this growing demand. Fear and suspi-
cion of a new way of working with young people, therapeutic theory which was beyond the
experience of most people, and eventual financial cutbacks in the 1970s ensured that the new
profession would not reach maturity. However, in recent years, there has been a sharp rise in the
number of schools offering counselling either directly or through contracts with other agencies
such as the NSPCC.

This is not surprising, as the idea of counselling for young people has increasingly become part
of the language of government, and schools have increasingly recognised that more traditional
forms of pastoral care are sometimes ill-prepared to offer the kind of specialist support that
young people need. In addition, there is a growing body of research that points clearly to evi-
dence that counselling in schools does make a difference. I believe that there is a great unmet
need for counselling in educational settings, and I want to advance the case that all schools
should ensure that pupils have access to this kind of in-depth support.

The British Association for Counselling and Psychotherapy (BACP) has for years put the case for
school counselling, and Counselling Children and Young People (CCYP) – the specialist divi-
sion of BACP – continues to push for a counsellor in every school.

A number of pioneer LEAs have, in the past, offered counselling through a centrally funded,
school counselling service. Dudley LEA has been particularly innovative over the years. Today,
counselling is finding its way into schools in a variety of creative ways, including consortiums,
the youth service, the voluntary sector, and services that are coordinated by the LEA but which
use devolved monies to buy such services into schools. Many schools have opted to simply buy
in an independent counsellor from their own funds. This remains a popular way to offer the
benefits of an on-site service.

BACP (2005) defines counselling as follows: Counselling and psychotherapy is a contractual

arrangement by which a practitioner meets a client, in privacy and confidence, to explore distress the
client may be experiencing. This may be a difficulty; their dissatisfaction with life; or loss of a sense of
direction and purpose.

BACP (2001) also suggests that, with regard to young people: Counselling is a process which assists
that individual client to focus on their particular concerns and developmental issues, whilst simultane-
ously addressing and exploring specific problems, making choices, coping with crises, working through
feelings of inner conflict and improving relationships with others.

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These definitions serve to distinguish counselling from other forms of support in schools, such
as guidance and advice, and from roles such as those of the learning mentor and the teacher
employing the kinds of counselling skills set out earlier in this chapter.

Counselling in schools takes many forms, and cognitive-behavioural approaches that focus on
the relationship between thoughts, feelings and behaviour, and solution-focused models have
taken over from humanistic and psychodynamic approaches, which are seen to be longer-term
interventions. However, many schools do, of course, employ counsellors working from a
person-centred perspective, and often counsellors work in more integrated ways, drawing from
a range of ideas. Counsellors working with younger clients are also increasingly looking to
other creative therapies to complement their ways of working, and it is not unusual to see coun-
sellors in school drawing upon the ideas and practice of art, play, music and drama therapists.
Each different approach with its own philosophy and practice has its merits and value, but I
believe that with children and young people it is the quality of the relationship, rather than any
particular model, that effects change and facilitates growth and emotional well-being.

The remainder of this chapter sets out in summary form some of the key points that should be
considered when employing a counsellor in school as part of its approach to supporting pupils
with mental health problems. BACP is very willing to offer guidance and support to schools
exploring the possibility of employing a school counsellor, and published materials to support
such a decision are available from the main offices in Rugby (full details can be found in
Chapter 9). The ideas set out here represent my own views, based on experience and awareness
of practice, but they are neither prescriptive nor definitive; it is offered as a starting point.

Ethics in counselling and psychotherapy

All counsellors are expected to work ethically in the best interests of their clients. BACP has set
out such principles in its Ethical Framework for Good Practice in Counselling and Psychotherapy.
This document sets out key values, such as commitment to human rights and dignity, integrity,
professional knowledge, the alleviation of distress and suffering, fostering a meaningful sense
of self and increasing personal effectiveness. Ethical principles include honouring the trust
placed in the practitioner, respecting the client’s autonomy, promotion of the client’s well-
being, avoiding harm to the client, justice, and the self-respect of the practitioner. Personal
moral qualities in the counsellor are highlighted and include empathy, sincerity, integrity,
resilience, respect, humility, competence, fairness, wisdom and courage. The document also sets
out clearly and in detail the kinds of standards expected of counsellors. Any school employing a
counsellor should expect the practitioner to adhere to these standards.

Counsellor qualifications
It is expected that counsellors working in schools will not only possess excellent interpersonal
skills and counselling experience but also will be qualified to a minimum of diploma level in
counselling theory and practice. Applicants for posts may also be educated to first-degree level
or have a Master’s degree in counselling or a related field, such as art or play therapy. A coun-
selling qualification in itself is not necessarily an indication of a person’s ability to work with
young people in a school setting. Working with adults and working with young people
can be very different experiences; certainly, some theoretical understanding of adolescence

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would be necessary. It would be unusual to employ a counsellor who had little or no experience
of working with vulnerable young people.

Recruitment
Any specialised counselling journal, such as the BACP publication Therapy Today, would be a
good place to advertise. Other publications such as the Young Minds Magazine may attract some
interest. Sometimes advertisements for school counsellors appear in the Times Educational
Supplement and may attract teachers with counselling qualifications. The Guardian society and
education supplements may also catch the eye of potential candidates. It may also be appropri-
ate to advertise through colleges and universities offering more advanced level counselling
qualifications. Sometimes, voluntary counselling agencies have counsellors with appropriate
qualifications, keen to pursue a more defined career line.

The use of students and trainees

Clearly, student and trainee counsellors require placements as part of their course requirements,
but, as a general rule, they should work only in schools where there is a mature service already
in operation and where an experienced counsellor can support and monitor trainees in their
work. Trainees should not be used in place of experienced, qualified counsellors.

Accreditation
At the time of writing, BACP is working with other professional bodies and the Department of
Health to explore the most effective ways in which the professions of counselling and psy-
chotherapy can be regulated to best effect in the interests of better protection of the public. If
statutory regulation is the best route, the titles of counsellor and psychotherapist will be pro-
tected, and unless practitioners are registered with the statutory regulator, they will not be able
to call themselves, or practise as, counsellors or psychotherapists. BACP has been working
closely with partner organisations to establish the standards for entry on such a register, and
this work continues. The current position is that a counsellor or psychotherapist can become
accredited with BACP, or indeed any other professional body. With regard to becoming accred-
ited with BACP, practitioners are required to provide evidence of substantial approved training
with associated, supervised practice, and evidence of purposeful work with real clients and
adherence to a recognised model of counselling. Counsellors currently have to renew their
accreditation status by providing evidence of continuing practice and professional develop-
ment. Accreditation through BACP can be verified by contacting the Rugby office.

Personal and knowledge qualities

Potential school counsellors should possess some of the qualities of congruence, unconditional
positive regard and empathy in ways described earlier in this chapter. Clearly, counsellors must
demonstrate superb listening skills and attention. They should be able to communicate effec-
tively with young people, have the ability to build trust and mutual respect, and be able to create
a caring and safe environment where young people feel able to share their concerns and worries.

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Interviews need to test more than theoretical understanding. Essentially, the school should be
looking for training, experience and the personal qualities. It would be useful to get a local
counselling organisation, familiar with the selection of counsellors, to assist with the process,
which should include interview activities designed to demonstrate the applicant’s skills and
personal qualities.

There exists some debate as to the importance of specific experience of working with young
people. I consider this to be a real asset in any selection process. Certainly, any potential coun-
sellor employed by the school should have some knowledge of this client group and the
developmental issues common to this age group. School-based experience is useful to enable
the school counsellor successfully to negotiate many of the potential difficulties of working in
this complex setting.

Job specification
A school counsellor should have a contract that sets out the role of the counsellor in relation to
pupils, parents and the school. It should cover matters such as:

liaison with staff and outside agencies

the setting up of the service, including referral and appointment systems

counselling hours

supervision

record keeping and reporting on the service

confidentiality and child protection

training.

Dual roles
It is not recommended that the school counsellor be in another role at the same time, such as
teacher or mentor, as this will inevitably lead to complex boundary issues and conflicting role
expectations. It is also felt that, whilst professionals such as Connexions workers and nurses
may use counselling skills very effectively as part of their work, they should not be operating as
counsellors with some of the pupils referred to them by the school.

Supervision
All counsellors are required to have regular clinical supervision. This normally amounts to a
minimum of 11/2 hours per month. Supervision may be on a one-to-one basis or in small
groups. It may be paid for by the school, the contributing agency or the self-employed counsel-
lor. Supervision is the formal overseeing of the counsellor’s work with the young person, and
seeks to ensure that the counsellor is working ethically and that professional standards are
maintained, thereby serving to protect the client. Supervision offers counsellors an opportunity
to explore their work with an experienced professional, often with additional training.

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Supervision also has a supportive, developmental and educative role and acts as the bridge
between theoretical knowledge and practice. Working without supervision would be deemed to
be unethical, and supervision is therefore an essential requirement.

Insurance
Whilst school personnel may be covered by professional organisations and the school authori-
ties, it is strongly recommended that counsellors have additional professional indemnity
insurance from insurers specialising in this kind of protection. This is especially important due
to the nature of work with young people and an increasingly litigious culture that places coun-
sellors at risk of claims of negligence and malpractice. The counsellor, if an employee of the
LEA, may be covered for insurance purposes in the normal way, but it may be best to check first.
With regard to addition liability insurance, BACP would be pleased to offer information on
companies offering such cover.

Information about the service

Information about the counselling service specific to the school should be included in all
appropriate policies and handbooks. Counsellors should design, possibly with pupil involve-
ment, user-friendly leaflets explaining the service and make them readily available, and pupils
and parents should be aware of the availability of the school counsellor through assemblies,
parent consultation evenings and governors’ reports. Pupils can be made aware of the service by
posters around the school, talks in assembly time or counsellors introducing themselves to the
young people in groups over a period of time.

Rooms and facilities

The school will need to provide a safe, comfortable and soundproof room where sessions are
unlikely to be interrupted. The room should not be a teaching area or office that has other associ-
ations for the pupil. The room should be available at the same times each week and have a
secured cabinet for the storage of confidential papers. A confidential telephone line should ideally
be available for counsellors to make calls to referrers and supervisors. A notice outside the room
should indicate when a session – normally not identified as a counselling session – is in process.

Referral procedures
Counselling should be a voluntary activity, and pupils should not be required to attend sessions
against their will. At the very least, such coercion may prove to be counterproductive. Similarly,
participation in counselling should not be used as a threat or used against pupils, should they
find themselves facing permanent exclusion from school. Problem behaviour would not nor-
mally constitute an appropriate referral, although, as this book has argued, many young people
displaying difficult behaviour may well be facing significant problems in their lives that may be
affecting their mental health and well-being. If a pupil is not happy to see a counsellor, an alter-
native intervention should be tried.

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Referrals can be made by teachers, pastoral staff or parents, although if a school feels confident,
self-referral should be encouraged. It may be useful for the school to identify a member of staff
to liaise directly with the counsellor over referrals.

Appointment systems
The school counsellor should ensure that the appointment system is as discreet as possible, but
also needs to recognise the complex nature of schools; thus, ‘appointment slips’ and ways of
recording attendance will need to be introduced to ensure support from teaching staff. The
most confidential appointment system is that which takes place in the counselling room when
meeting times are agreed. As most schools operate computerised roll-call and registration sys-
tems, an appropriate code could be recorded to explain absence from particular lessons.

Parental consent
At present, pupils have a right to access counselling without their parents’ prior knowledge or
consent. This principle has been accepted for a number of years because of what has been
referred to as the Gillick principle: As a general principle it is legal and acceptable for a young person
to ask for confidential counselling without parental consent, provided they are of sufficient understand-
ing and intelligence (Gillick v. West Norfolk AHA, House of Lords, 1985). However, it is felt that as
a matter of good practice, parental consent should be established wherever possible. In most
cases, parents are only too willing to agree to support for their child, especially where they, too,
have been concerned about their son or daughter. It is rare for a pupil to insist on parents not
knowing, and there would need to be clear reasons why the work might proceed without the
parents knowing. In such circumstances, the head teacher would normally take responsibility
for this decision. Some schools have added the precaution of including a statement in the
annual prospectus highlighting the existence of a counsellor in the school and pupils’ right to
confidential access.

Timing of sessions
Adult sessions normally last for the ‘therapeutic hour’ of 50 minutes. In schools, it will be less,
normally 35–40 minutes, depending upon the age of the pupil. Whilst the regularity of ses-
sions each week is crucial to the therapeutic relationship and work, some schools vary the
times when a young person is withdrawn from lessons so that the pupil does not miss the
same lesson each week, and to avoid the disapproval of staff teaching that young person. Some
schools may offer drop-in sessions at out-of-lesson times, but holding full counselling sessions
during the lunch break may be resented by young persons because it prevents them from
socialising with friends and deprives them of time to eat, and sessions at this time are more
likely to be disturbed by other pupils. In my experience, teaching staff are highly supportive of
the help offered by counsellors and are keen to collaborate in the best interests of the young
person in difficulty. Some counsellors work open-endedly, but the most recent trend is to work
to a fixed number of sessions.

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Record keeping
Counsellors keep case notes and may also keep personal ‘process’ notes that record their
thoughts and feelings in relation to their work. Both counsellors and schools need to be aware
that legislation has given pupils over the age of 16 and parents access to educational records,
and this needs to be borne in mind when establishing the school counselling service. I believe it
is best to keep notes to an absolute minimum, and the counsellor should be cognisant of the
fact that notes may be read by interested parties. Notes should record only a summary of the
session or key words and ideas. These notes are retained and stored safely by the counsellor,
who is responsible for them. They should not be included as part of the child’s normal school
file. Computer files may record session times and dates and when counselling ends. It should
be recorded in policy that other staff in the school do not have access to these notes except in
extreme circumstances and with the authority of the head teacher and the agreement of the
counsellor. BACP would be happy to offer more detailed guidance in this area.

Boundaries
The maintenance of tight boundaries is an important component of all good counselling and is
essential in the establishment and maintenance of a strong therapeutic alliance. Boundaries are
in effect the ground rules of counselling and define clearly, among other things, the structure
and timing of sessions, confidentiality and its limitations, forms of contact and – especially
important in the context of schools – the nature of the relationship between the counsellor and
client. This must have limits, and contact outside sessions is likely to prove unhelpful and
adversely affect the quality of work in sessions. Counsellors, therefore, need to be clear with
pupils from the outset that they are not normally accessible until the next scheduled session.

Confidentiality
The establishment of high levels of confidentiality is fundamental to building sufficient trust
for young persons to explore their innermost thoughts and feelings with an adult. The school
counsellor needs to establish clear working principles in relation to such matters as child pro-
tection, sexual activity, suspected pregnancy, crime and drug misuse. Again, BACP would be
pleased to field enquiries relating to this complex legal area.

The courts
Courts are often sensitive to the role of the counsellor, but it should be understood that the
courts can access counselling notes and records. Whilst counsellors are not necessarily required
to appear in court with these papers, they can be required to do so by court order. Notes may
also be requested in family court proceedings, as in custody disputes and adoption hearings.

Child protection
Counsellors working in schools are expected to work within child-protection guidelines estab-
lished by the local authority. If a disclosure has been made or if they believe that a pupil is ‘at
risk’, they will normally explain to the young person why a referral needs to be made and gain

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their agreement. Where a referral is made against the pupil’s wishes, it is good practice to
inform the client that information is going to be shared with other agencies, and details of
those agencies should ideally be given to the pupil.

Feedback to the senior leadership team

Whilst specific counselling outcomes with particular pupils may remain confidential, the
school counsellor should be expected to provide information about the service, including
details of appointments, use of the service by different year groups, and use by gender and eth-
nicity. It is also useful for the counsellor to record statistically the kinds of client issues
presented, especially where these may turn attention to the need for school-based action, as in
the incidence of bullying or exam stress.

Reflection box ?

 To what extent is your school a ‘listening school’?

 What kind of listener are you? How can you improve?
 What peer projects already exist in your school?
 Does your school offer pupils counselling?
 What personal and professional issues might emerge for you if a school counsellor were
appointed to support pupils with mental health problems in your school? How would
such an appointment be received by your colleagues?

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U S E F U L O R GA N I SAT I O N S A N D R E S O U RC E S

The following organisations, websites and contacts offer a wide variety of useful informa-
tion, resources and services that can be of great use to the school concerned for the
mental health and emotional well-being of its pupils. Please feel free to email me directly:
[email protected].

General
Advisory Centre for Education (ACE)

A charity offering information about state education, dealing with bullying, SEN and exclu-
sions. Offers advice, publications, training and membership.

1c Aberdeen Studios, 22 Highbury Grove, London N5 2DQ

[email protected]

www.ace-ed.org

Antidote
Emotional literacy organisation. Antidote works collaboratively with schools, offers training
and publishes in the area of emotional literacy.

45 Beech Street, London EC2Y 8AZ

Tel: 020 7588 5151; Fax: 020 7588 4900
[email protected]

www.antidote.org.uk

@ease
A website-based mental health resource for young people. @ease provides advice, support and
information, and works to break down stigma attached to mental illness.

National advice line: 020 8974 6814

www.rethink.org/at-ease

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USEFUL ORGANISATIONS AND RESOURCES

BACP (British Association for Counselling and Psychotherapy)

Leading professional body for counselling and psychotherapy and an automatic reference point
for anyone seeking information on these fields.

BACP House, 35–37 Albert Street, Rugby, Warwickshire CV21 2SG

Tel: 0870 443 5252; Fax: 0870 443 5160

www.bacp.co.uk

British Association of Psychotherapists

Specialist psychotherapy organisation offering training and setting professional standards for
clinical practice.

37 Mapesbury Road, London NW2 4HJ

Tel: 020 8452 9823

www.bap-psychotherapy.org

British Psychological Society

A body which represents psychologists and psychology in the UK. BPS encourages the develop-
ment of psychology as a science and profession, seeks to raise standards of training and
practice, and hopes to raise public awareness.

St Andrews House, 48 Princess Road East, Leicester LE1 7DR

Tel: 0116 254 9568

www.bps.org.uk

CareLine
Provides confidential counselling and support to young people and adults, including those in
crisis.

Cardinal Heenan Centre, 326 High Road, Ilford IG1 1QP

Tel: 020 8514 1177

www.webhealth

CCYP (Counselling Children and Young People)

BACP division with a particular focus on children and young people. Holds regular conferences,
offers advice and publishes a journal.

Contact Gemma Green, Divisional Administrator:

[email protected]

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ChildLine
Free 24-hour helpline for children in distress or danger. Also publishes an outreach service to
schools. Young people can phone ChildLine on 0800 111 or write to: ChildLine, Freepost 111,
London N1 OBR.

www.childline.org.uk

Contact a Family
A charity providing advice, information and support to the parents of all disabled children.

209–211 City Road, London EC1V 1JN

Tel: 020 7608 8700; helpline: 0808 808 3555

www.cafamily.org.uk

Department for Education and Skills

Sanctuary Buildings, Great Smith Street,London SW1 3BT

Tel: 0870 000 2288
[email protected]

Department of Health
Richmond House, 79 Whitehall, London SW1A 2NS

Tel: 020 7210 4850
[email protected]

www.doh.gov.uk

Institute of Psychiatry
A postgraduate research and teaching institution concerned with the treatment of mental disorders.

King’s College London, De Crespigny Park, London SE5 8AF

Tel: 020 7836 5454

www.mentalhealthcare.org.uk/

Mental Health Foundation

Important mental health organisation involved in media work, publication and information.

9th Floor, Sea Containers House, 20 Upper Ground, London, SE1 9QB

Tel: 020 7803 1100; Fax: 020 7803 1111
[email protected]

www.mentalhealth.org.uk/peer

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Mental Health Media

Seeks to reduce discrimination on mental health grounds by promoting the diversity, visibility
and credibility of people who experience mental distress. Offers a range of media resources.

356 Holloway Road, London N7 6PA

Tel: 020 7700 8171
[email protected]

Mentality
134–138 Borough High Street, London SE1 1LB

Tel: 020 7716 6777

www.mentality.org.uk

Mind
A leading mental health charity addressing the needs of people with mental health problems.
Offers information and publications, and seeks to influence policy through campaigning and
education.

15 Broadway, London E15 4BQ

Tel: 020 8519 2122; information line: 0845 766 0163

www.mind.org.uk

Mind Out
An awareness and action campaign seeking to bring about changes in attitudes and behaviour
surrounding mental health.

Freepost LON15335, London SE1 1BR

www.mindout.clarity.uk.net/

National Association for Pastoral Care in Education

An interest organisation concerned with school-based pastoral care and personal and social
education. It produces a journal.

c/o Institute of Education, University of Warwick, Coventry CV4 7AL

Tel: 024 7652 3810; Fax: 024 7657 3031
[email protected]

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National Children’s Bureau

Promotes the voices, interests and well-being of children and young people. The organisation
works with children and young people, promotes cross-agency partnerships and influences
policy development and research.

8 Wakley Street, London EC1V 7QE

Tel: 020 7843 6000; Fax: 020 7278 9512

www.ncb.org

NHS Direct

0845 46 47.

www.nhsdirect.nhs.uk/

NSPCC
The leading charity specialising in child protection and the prevention of cruelty to children.
Work includes face-to-face child protection work, a 24-hour helpline, public education cam-
paigns, parliamentary campaigning, training and advice, research and information.

Weston House, 42 Curtain Road, London EC21 3NH

Tel: 0808 800 5000 (24-hour helpline)

www.nspcc.org.uk

ParentLinePlus
Offers a range of services providing help and support for parents of all kinds.

3rd Floor, Chapel House, 18 Hatton Place, London EC1N 8RU

Tel: 0808 800 2222

www.parentline.co.uk

Relate
The UK’s largest provider of relationship counselling and sex therapy.

Herbert Gray College, Little Church Street, Rugby, Warwickshire CV21 3AP

Tel: 01788 573 241; Fax: 01788 535 007

www.relate.org.uk

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Rethink
Information, support and advice for people suffering from mental illness, their carers and
professionals.

28 Castle Street, Kingston-Upon-Thames, Surrey KT1 1SS

General enquiries Tel: 0845 456 0455

www.rethink.com
[email protected]

Royal College of Psychiatrists

The main professional and educational body for psychiatrists in the UK.

17 Belgrave Square, London SW1X 8PG

Tel: 020 7235 2351; Fax: 20 7245 1231

www.rcpsych.ac.uk

Rural Minds
A Mind initiative with a particular interest in mental health in rural settings.

c/o South Staffs CVS, 1 Stafford Street, Brewood, Staffs ST19 9DX

Tel: 01902 850060

www.mind.org.uk/About+Mind/Networks/ruralMinds/
[email protected]

Sainsbury Centre for Mental Health

Research and training aiming to influence policy and practice in health and social care.

134–138 Borough High Street, London SE1 1LB

Tel: 020 7827 8300
[email protected]

Samaritans
Crisis telephone counselling for people of all ages in distress or who may be considering suicide.

10 The Grove, Slough, Berks SL1 1QP

Tel: 08457 909090 (24-hour helpline)

www.samaritans.org.uk
[email protected]

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SaneLine
Offers emotional and crisis support for people suffering from mental illness. Provides informa-
tion for professionals and organisations working in the mental health field.

1st Floor, Cityside House, 40 Adler Street, London E1 1EE

National mental health helpline, open daily noon–2 am on 0845 767 8000

www.sane.org.uk

Self-Esteem Network
32 Carisbrooke Road, Walthamstow, London E17 7EF

Stonewall
A campaigning organisation working to address prejudice and issues of equality for gay, lesbian
and bisexual people.

46 Grosvenor Gardens, London SW1W 0EB

Tel: 020 7881 9440

www.stonewall.org.uk

Teacher Support Network/TeacherLine

A free information, support and counselling service for teachers.

Hamilton House, Mabledon Place, London WC1H 9BE

Tel: 08000 562 561 (24-hour helpline); 020 7554 5200 (information)

www.teacherline.org.uk

Trust for the Study of Adolescence (TSA)

A charity undertaking research, training and publications; seeks to influence policy makers.
Concerned with increasing understanding about adolescence and young adulthood.

23 New Road, Brighton BN1 1WZ

Tel: 01273 693 311
[email protected]

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UK Council for Psychotherapy

Seeks to promote the art and science of psychotherapy, and promote research and education in
the field.

2nd Floor, Edward House, 2 Wakley Street, London EC1 7LT

Tel: 020 7436 3002

www.psychotherapy.org.uk
[email protected]

WHO (World Health Organisation)

UN specialised agency for health.
Avenue Appia 20, Geneva 27, Switzerland

Tel: (+41 22)791 21 11

YoungMinds
Concerned directly with children and young people. Offers comprehensive website, informa-
tion service, a magazine, and leaflets and booklets for young people, parents and professionals.

48–50 St John Street, London EC1M 4DG

Tel: 020 7336 8445 (parents’ information service: 0800 081 2138); Fax: 020 7336 8446

www.youngminds.org.uk

Youth Access
National membership organisation for young people’s information, advice, counselling and
support services.

1–2 Taylors Yard, 67 Alderbrook Road, London SW12 8AD

Tel: 020 8772 9900
[email protected]

Specific
ADHD (attention-deficit and hyperactivity disorder)
ADD Information Services (ADDISS)
Information and resources for parents, sufferers, teachers or health professionals.

10 Station Road, Mill Hill, London, NW7 2JU

Tel: 020 8906 9068

www.addiss.co.uk

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Anxiety
Anxiety Care
East London charity helping people to recover from anxiety disorders and to maintain recovery.

Cardinal Heenan Centre, 326 High Road, Ilford, Essex 1G1 1QP

Tel: 020 8262 8891; 135: 020 8478 3400

www.anxietycare.org.uk

National Phobic Society

A user-led organisation working to relieve those living with anxiety disorders.

Zion Community Resource Centre, 339 Stretton Road, Hulme, Manchester M15 4ZY

Tel: 0870 122 2325

www.phobics-society.org.uk

No panic
Charity concerned with panic attacks, phobias, obsessive-compulsive disorder, generalised anxi-
ety disorder and tranquilliser withdrawal.

93 Brands Farm Way, Telford, Shropshire TF3 2JQ

Helpline: 0808 8080545

www.nopanic.org.uk

Social Anxiety Disorders Sufferers

www.social-anxiety.org

Autistic spectrum disorders

Autistic Society

www.autisticsociety.org/

National Autistic Society

Offers advice, information and support.
393 City Road, London EC1V 1NG

Tel: 020 7833 2299
[email protected]

Bereavement
Child Bereavement Network
Concerned with improving access to information, guidance and support services.

8 Wakely Street, London EC1V 7QE

Tel: 020 7843 6309

www.ncb.org.uk/cbn

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Cruse Bereavement Care

Provides counselling and support as well as information, advice, education and training.

Cruse House, 126 Sheen Road, Richmond, Surrey TW9 1UR

Tel: 020 8939 9530; helpline: 0870 167 1677

www.crusebereavementcare.org.uk/

National Association of Bereavement Services

Provides information about services, training and referral.
2 Plough Yard, London EC2A

Tel: 020 7247 1080

Winston’s Wish
Offers practical support and guidance to families and professionals concerned about a grieving
child.

Clara Burgess Centre, Bayshill Road, Cheltenham GL50 3AW

Tel: 0845 2030 405
[email protected]

www.winstonswish.org.uk/

Bullying

Anti-bullying Campaign
10 Borough High Street, London SE1 9QQ

Tel: 020 7378 1446 (advice line)

Bullying Online
[email protected]

www.bullying.co.uk/

Childwatch
19 Spring Bank, Hull, East Yorkshire HU3 1AF

Tel: 01482 325 552

www.childwatch.org.uk

Kidscape
Charity established to prevent bullying and child abuse. Offers a helpline and a range of
resources, and carries out research.

2 Grosvenor Gardens, London SW1W 0DH

Tel: 08451 205 204

www.kidscape.org.uk/

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Depression

Depression Alliance
Seeks to raise awareness of depression and provide information and support services.

PO Box 1022, 35 Westminster Bridge Road, London SE1 7JB

Tel: 0845 123 2320

www.depressionalliance.org/

Depressives Anonymous (Fellowship of)

A nationwide self-help organisation made up of members and groups who meet locally for
mutual support.

Box FDA, Ormiston House, 32–36 Pelham Street, Nottingham NG1 2EG

Tel: 0870 774 4320

www.depressionanon.co.uk

Domestic violence

Victim Support
A charity helping people to cope with the effects of crime.

Local branch in the telephone directory

Women’s Aid Domestic Violence Helpline

Tel: 0345 023 468

Eating disorders

Eating Disorders Association

Works to improve the quality of life for people affected by eating disorders. Provides informa-
tion, help and support, and campaigns for improved standards and availability of treatment
and care for sufferers.

103 Prince of Wales Road, Norwich NR1 1DW

Tel: 0870 770 3256; youth helpline: 0845 634 7650
[email protected]

Eating Disorders Research Unit

Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF

www.eatingresearch.com

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Lucy Serpell’s Eating Disorders Resources Page

News, research, reports, conferences and opinions on eating disorders.

http://edr.org.uk

Mirror Mirror
Website concerned with body image.

www.miror-mirror.org/eatdis.htm

Overeaters Anonymous
A fellowship of individuals who are recovering from overeating.

www.oa.org

Emotional and Behavioural difficulties

SEBDA (Social, Emotional and Behavioural Difficulties Association)

Promotes excellence in services for children and young people with SEBD.

Church House, 1 St Andrew’s View, Penrith, Cumbria CA107YF

Tel: 01768 210 510
[email protected]

www.sebda.co.uk

Enuresis

ERIC (Enuresis Resource and Information Centre)

Provides information for children, parents and professionals concerned about wetting and soiling.

34 Old School House, Britannia Road, Kingswood, Bristol BS15 8DB

Tel: 0845 370 8008

www.eric.org.uk

Ethnic minority organisations

African-Caribbean Mental Health Association

Provides legal advice, housing support, counselling and psychotherapy to Afro-Caribbean
people experiencing mental health problems.

Suites 34 and 37, 49 Effra Road, Brixton, London SW2 1BZ

Tel: 020 7737 3603

www.directions-plus.org.uk

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African-Caribbean Mental Health Service

Zion Community Health and Resource Centre, Hulme Clinic, Royce Road, Hulme, Manchester
M15 5FQ

Tel: 0161 226 9562

Asian Men’s Group

Mandala Centre, Gregory Boulevard, Nottingham NG7 6LB

Tel: 0115 960 6082

Black Mental Health Resource Centre

Bushberry House, 4 Laurel Mount, St Mary’s Road, Leeds LS7 3JX

Tel: 0113 237 4229

Chinese Mental Health Association

Provides direct services and raises awareness in the Chinese community and society generally.

Zenith House, 155 Curtain Road, London EC2A 3QY

Tel: 020 7613 1008

www.cmha.org.uk

Jewish Association for the Mentally Ill

16a North End Road, London NW11 7PH

Tel: 020 8458 2223; Fax: 020 8458 1117

www.mentalhealth-jami.org.uk

Qalb Centre
Counselling and complementary therapies for Asian, African and African-Caribbean people
with emotional problems.

Low Hall Lane, Walthamstow, London E17 8BE

Tel: 020 8521 5223
[email protected]

Refugee Council
Largest organisation in the UK working with asylum seekers and refugees, to ensure that their
needs and concerns are addressed.

240–250 Ferndale Road, London SW9 8BB

Tel: 020 7346 6700

www.refugeecouncil.org.uk

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USEFUL ORGANISATIONS AND RESOURCES

Vishvas (Asian Women’s Mental Health)

A culturally sensitive and accessible mental health service offering information, support and
counselling for the South Asian community.

Tel: 020 7928 9889

www.cio.org.uk

HIV/Aids

National AIDS Helpline

85/89 Duke Street, Liverpool L15 AP

Tel: 0800 567 123

Terrence Higgins Trust

For people affected by HIV.

52–54 Grays Inn Road, London WC1 8JU

Tel: 0845 1221 200
[email protected]

www.tht.org.uk

Manic depression

The Manic Depression Fellowship

Organisation offering membership and working to help people with bipolar disorder/manic
depression take control of their lives.

Castle Works, 21 St George’s Road, London SE1 6ES

Tel: 08456 340540

www.mdf.org.uk
[email protected]

Obsessive-compulsive disorder (OCD)

OCD Action
A registered charity providing information, advice and support to people with OCD.

Aberdeen Centre, 22-24 Highbury Grove, London N5 2EA

Tel: 0870 360 6232; helpline: 0845 390 6232

www.ocdaction.org.uk/home.htm

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OCD UK
Information and support for sufferers from OCD.

OCD-UK, PO Box 8115, Nottingham NG7 1YT

Tel: 0870 126 9506

http://www.ocduk.org

Phobia

Triumph over Phobia (TOP UK)

Helps sufferers of phobia or obsessive-compulsive disorder.

PO Box 3760, Bath BA2 4WY

Tel: 0845 600 9601

www.triumphoverphobia.com

Schizophrenia

Rethink Severe Mental Illness (Formerly National Schizophrenia Fellowship)

28 Castle Street, Kingston-Upon Thames, Surrey KT1 1SS

www.rethink.org.uk

Schizophrenia.com
Provides in-depth information, support and education relating to schizophrenia.

www.schizophrenia.com

Seasonal affective disorder (SAD)

SAD Association
A voluntary organisation and charity which informs the public and health professions about
SAD and supports and advises sufferers from the illness.

PO Box 989, Steyning, West Sussex BN44 3HG

Tel: 01903 814942

www.sada.org.uk

Self-Harm

National Self-Harm Network

A survivor-led organisation that campaigns for the rights and understanding of people who self-
harm, but whose priority is to support victims and survivors.

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PO Box 7264, Nottingham NG1 6WJ

www.nshn.co.uk/index2.html
[email protected]

The Young People and Self-Harm Information Service

www.ncb.org.uk/selfharm

Sexual relationships

Brook Advisory Centres

Free and confidential sexual health advice and contraception for young people up to the age
of 25.

421 Highgate Studios, 53–79 Highgate Road, London NW5 1TL

Tel: 020 7284 6040

www.brook.org.uk

Family Planning Association

Seeks to improve sexual health. Provides information, training and publications.

2–12 Pentonville Road, London N1 9FP

Tel: 08455 310 1334

www.fpa.org.uk

Special educational needs

National Association for Special Educational Needs (NASEN)

Leading organisation to promote the education, training, and advancement and development
of all those with special and additional support needs. Membership available. NASEN produces
a number of journals and publications.

NASEN House, 4–5 Amber Business Village, Amber Close, Amington, Tamworth B77 4RP

www.nasen.org.uk

British Dyslexia Association

98 London Road, Reading, Berks R61 5AU

Tel: 01734 662 677; helpline: 01734 668 271

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Stress

International Stress Management Association

Promotes sound knowledge and best practice in the prevention and reduction of human stress.

PO Box 26, South Petherton TA13 5WY

Tel: 07000 780 430

www.isma.org.uk/index.htm

Substance abuse

Alcoholics Anonymous
Helps people who drink alcohol excessively to change their lives.

Tel: 0845 769 7555

www.alcoholics-anonymous.org.uk
[email protected]

Alcohol Concern
Acts as a national umbrella body tackling alcohol-related harm.

Waterbridge House, 32-36 Loman Street, London SE1 0EE

Tel: 020 7928 7377

www.alcoholconcern.org.uk/
[email protected]

National Drugs Helpline

Tel: 0800 77 66 00 (24-hour helpline)

www.ndh.org.uk

Talk to Frank
Information and advice on drug misuse.

Tel: 0800 776 600

www.talktofrank.com/
[email protected]

Turning Point
A leading social care organisation providing services for people with complex needs, including
those with mental health and drug and alcohol misuse.

New Loom House, 101 Backchurch Lane, London E1 1LU

Tel: 020 7702 2300

www.turning-point.co.uk/
[email protected]

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Young carers

Young carers
20–25 Glasshouse Yard, London EC1A 4JS

Tel: 020 7490 8898

Useful websites
BBC Mental Health

www.bbc.co.uk/health/mental

The Collaborative for Academic, Social, and Emotional Learning (CASEL)

Concerned with the relationship between social emotional skills and learning.

www.casel.org

E-mental-health.com

www.emental-com

Incentive Plus
Company that provides a catalogue of resources in the areas of emotional competence, emo-
tional health and positive behaviour in children and young people.

Tel: 01908 5261 120

Internet Mental Health

www.mentalhealth.com

LDA
Publishes useful resources catalogue.

Abbeygate House, East Road, Cambridge CB1 1DB

Tel: 0845 120 4776

Mental Health for Teens

Useful Australian website.

www.mydr.com.au

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National Mental Health Information Centre

Useful US website.

www.mentalhealth.samhsa.gov

Psychiatry24x7
Information on mental illness.

www.psywww.com/

www.readthesigns.org

Information on a range of mental illnesses.

Teenage Health Freak

Information for teenagers.

www.teenagehealthfreak.org

The Site

www.thesite.org/

UCLA School Mental Health Project

Useful website for anyone interested in school-based mental health.

http://psych.ucla.edu/temphome.

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Antonovsky, A (1987) Unravelling the mysteries of health: how people manage stress and stay well. San
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Atkinson, M and Hornby, G (2002) Mental health handbook for schools. New York: RoutledgeFalmer.
Audit Commission (1999) Children in mind: Child and Adolescent Mental Health Services (CAMHS).
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Ayalon, O and Flasher, A (1993) Chain reaction: children and divorce. London: Jessica Kingsley.
BACP (2001) Good practice guidance for counselling in schools. Rugby: British Association for
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I NDEX

abnormality 11, 29 causes of difficult behaviour 3

academic outcomes 6, 71 conduct disorders 51
adolescence 11, 14, 74 in relation to schizophrenia 59–60
and bereavement 41 policy 73
and bipolar disorder 48 regressive 33
anger 4, 38, 74, 113 behaviourism 3
after a bereavement 40 belonging 6, 73
and divorce 34 and school climate 72
and looked after children 39 and sexuality 43
alcohol and drug abuse 30 bereavement 40–41, 75
and looked after children 39 Bipolar Disorder 48
anorexia nervosa British Association for Counselling and Psychotherapy
incidence of 13, 56 6, 86
anxiety 4,11, 12, 30 Counselling Children and Young People division
after a bereavement 41 (CCYP) 120
and abuse 31 bulimia nervosa 56
and bullying 36 incidence of 13
and domestic violence 33 bullying 35–36
and obsessive compulsive disorder 59 and looked after children 39
Generalised Anxiety Disorder (GAD) 56 anti-bullying policy 76
hypochondriasis 56 consequences of 36
incidence of 13 homophobic 43
linked to gay and lesbian pupils 43 of gifted and talented pupils 42
linked to school refusal 60 varieties of 35
of gifted and talented pupils 42
panic disorder 56 caring schools 28
physical symptoms 56 child abuse 31–32
phobia 56 and attachment 45
antidepressants 36 and conduct disorder 51
attachment disorder 45, 48 links to parent mental illness 38
separation anxiety 56 victims becoming perpetrators 33
Attention Deficit Hyperactivity Disorder 1, 48 Child and Adolescent Mental Health Services (CAMHS)
and looked after children 39 80–82
genetic inheritance 37 Childline 6
incidence of 12 conduct disorders 51
medication 49 and looked after children 39
Autistic Spectrum Disorders confidentiality 73, 113
Asperger’s Syndrome 45–47 counselling 120–127
Autism 13, 45 accreditation of counsellors 122
and child protection 126–127
barriers to learning 5, 71 and confidentiality 126
behaviour 14–15, 100–101 and parental consent 125
and medicalisation 13 and referral 124–125
and OCD as different from listening skills 111–112
and stigma 77 boundaries 126
being observant 75 Carl Rogers and the Person-centred Approach 112

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MENTAL HEALTH IN SCHOOLS

counselling (continued) after a bereavement 40–41

counsellor qualifications 121–122 and divorce 34
definitions of 120–121 and eating disorders 56
Dudley School Counselling Service 120 and sexuality 43
Ethical Framework for Good Practice in Counselling and
Psychotherapy 121 interagency working 7, 76, 77, 79–80
models of 121 benefits of 79
need for in schools 120 difficulties with 79
origins of in the UK 120
supervision of 124 junior secondary school transition 60, 76
culture and climate 72
labelling 11
denial listening 76, 106–107, 111–115
after a bereavement 40–41 looked after children 38–40
and divorce 34 definition of 38–39
depression 51, 54–55 statistics 39
after a bereavement 41
and gifted and talented pupils 42 Mental health
and school failure 51 and academic outcomes 5
genetic inheritance 37 and mental illness 8, 11
incidence of 13, 51 and poverty 30
linked to gay and lesbian pupils 43 and stress 36–37
relating to bipolar disorder 48 and teaching and learning 72
relationship to aggression 4 as a continuum 11
developmental disorders 12 definitions of 5, 6, 8–12
disruptive disorders 12 effects of academic pressure 36
divorce and separation 30, 33–35 incidence of problems 12–13
domestic violence 32–33 increasing awareness of 74
‘mental’ as a term of abuse 8, 77, 87
early intervention 7, 72, 79 not the role of the teacher 5
eating disorders 56, 57–58 pathogenic model of 6
binge eating 56 planning for 71
incidence of 13 prevention 6
link with stress 36 promotion 28
emotional literacy 75 salutogenic model of 6
emotions 70–71 schools role in exacerbating problems 6, 36
Every Child Matters 6, 73, 75, 79 through personal social health education 86
exam pressure 37 Mental Health Foundation 6
mental illness
failure biological factors 29–30
and depression 51 causes of 29
and gifted and talented pupils 42 early identification14
effects of bullying 36 environmental factors 30–31
fear of 37 effects of parent suffering from 37–38
links with ADHD 48 psychological factors 30
feelings 34, 38, 73, 101 warning signs 14–18
after a bereavement 40 mentoring 116
and bipolar disorder 48
and counselling 113 National Healthy Schools Standard 73, 117
of looked after children 39 nightmares
and bullying 32, 36
gifted and talented pupils 41–42
grief and loss Obsessive Compulsive Disorder 59
after a bereavement 40 and abuse 31
and divorce 34 incidence of 13
and looked after children 39 link with stress 36
guilt Ofsted 6

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INDEX

parents 28, 79 and bullying 36

pastoral care 3, 4, 114 incidence of 13, 60
origins of 120 kinds of 60
peer-support schemes 116–120 names given to 60
Post Traumatic Stress Disorder 59 shame
and abuse 32 and abuse 32
protective factors 23, 28 and divorce 34
punishment 6 and looked after children 39
and sexuality 43
racial and sexual harassment 30, 35, 73 and stigma 77
referral 75, 79, 82–84 in relation to a parent’s mental illness 38
relationships 72 sleep disturbance
after a bereavement 40 after a bereavement 41
and abuse 32 and bipolar disorder 48
and attachment 48 and bullying 36
and bullying 36 linked to exam stress 37
and post traumatic stress disorder 59 social phobia 56
when affected by anxiety 56 Social services 11, 82
being looked after 39 and child abuse 31
peer relationships of gifted and talented pupils 42 referral to where a parent suffers from a mental
resilience 9, 72, 93–95 illness 38
and gender 28 Special Educational Needs 76
being gifted and talented as a factor 42 stigma 73, 77, 91–92
definitions of 23 stress 30
factors 24–27 as a positive dynamic 3
risk factors 21–22, 93–95 effects on mental health of too much stress 36
statistics 20 of gifted and talented pupils 42
suicide 65–68
schizophrenia 59–60 and abuse 32
school councils 73, and bipolar disorder 48
school refusal 60–62 and bullying 36
effects of bullying 36 and academic pressure 36
in relation to school phobia 60 incidence of 13
self-esteem 74
and abuse 3, 31 teaching and learning 5, 71
and bipolar disorder 48
defences designed to protect self-esteem 71 underachievement 3
effects of bullying 36
low self-esteem of gifted and talented pupils 42 voluntary sector 79
sexual exploitation
and abuse 32 whole school approach 6, 71–72
sexuality 43 World Health Organisation (WHO) 8
self-harm 4, 60, 63–64, 75
and abuse 32 young minds 6

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