In a recent article published in the BJPsych Bulletin, researchers argue that school mental health interventions may inadvertently harm some adolescents. As the United Kingdom aims to implement mental health programmes more broadly in schools, the authors caution that a national rollout could exacerbate these adverse effects. They also provide possible explanations for why these programmes, intended to alleviate distress, might sometimes worsen it.
The authors, Lucy Foulkes and Argyris Stringaris, from the University of Oxford, UK, write:
“A growing body of quantitative research indicates that some aspects of school-based mental health interventions increase distress or clinical symptoms, relative to control activities, and qualitative work indicates that this may be partly due to the interventions themselves.”
The article’s primary objective is to present evidence that school-wide mental health interventions can harm some adolescents. To achieve this, the authors review previous research on the negative effects of these interventions and propose potential mechanisms for the harm they may cause.
The authors identify one major issue with school-based mental health interventions: their universal application to all students. Such generalized interventions can impart irrelevant, unhelpful, or even harmful information while consuming valuable time and resources that could be better spent on more effective strategies for reducing distress.
A meta-analysis of school-based anti-bullying interventions revealed that some students who participated in cognitive behavioural therapy (CBT) experienced increased distress compared to those who did not receive the intervention. In addition, a randomized control trial also found that some students who had undergone CBT reported increased symptoms of distress.
The article also cites research on a school-based mindfulness programme. While the intervention did not change depressive symptoms on average, students with higher rates of mental health symptoms experienced a slight increase. The authors argue that, as with this particular mindfulness-based programme, the harm of other school-based mental health interventions may be concealed by average results.
The authors note that these findings align with research on mental health interventions (and public health interventions) in general, where a minority of people experience harm.
Though limited research has been conducted on how these school-based mental health interventions cause harm, the authors suggest possible mechanisms. For instance, the interventions might cause some adolescents to ruminate on their distress, thereby exacerbating it. In addition, encouraging adolescents to label their negative emotions with psychological terms (such as “anxiety”) could alter their self-image (thinking “I am someone with anxiety”) and behaviour (avoiding situations that induce “anxiety”).
Peer influence is another potential factor in the harm caused by school-based mental health interventions. Since adolescents are highly susceptible to peer influence, discussing distress in group settings could lead to increased distress in others.
The authors express concern that implementing these school-based interventions nationwide could amplify their negative effects. Even if these programmes are merely ineffective rather than harmful, they still monopolize resources that could be allocated to more beneficial practices, such as additional sleep, physical exercise, and socializing time. The authors conclude:
“There is currently a pervasive assumption that school-based mental health interventions are beneficial for all adolescents. The possibility that some individuals may deteriorate or experience harm as a result of such efforts has been almost entirely neglected. As a matter of urgency, research should begin that explores and documents what intervention harms might look like in school settings and which adolescents are most at risk. In time, all studies assessing school-based mental health interventions should measure and report cases of symptom deterioration and other adverse effects as standard, as happens with clinical trials. More importantly, it should become standard to have a plan of what to do with adolescents who deteriorate during these interventions.”
There is research that demonstrates that certain types of school-based mental health initiatives can yield positive results. For instance, one study revealed that bystander training aimed at preventing bullying enhanced student mental health. Similarly, another study indicated that school-based programmes targeting anxiety and depression contributed to a decrease in symptoms. Likewise, a study on a school-based mindfulness programme reported reduced stress levels. However, consistent with the current work, research has also discovered that universal interventions in schools frequently fall short and may result in detrimental outcomes.
The field of psychiatry has long been familiar with allegations of iatrogenic illness, a phenomenon in which treatment provided by practitioners leads to illness instead of relief. The now-debunked chemical imbalance theory, still endorsed by some mental health professionals, has the potential to cause iatrogenic harm by persuading individuals that they require medication to rectify non-existent chemical imbalances. Psychotropic drugs can bring numerous adverse effects, including the onset of psychiatric symptoms. Several practitioners contend that mental health disciplines should emphasize addressing and preventing iatrogenic harm.
Foulkes, L., & Stringaris, A. (2023). Do no harm: Can school mental health interventions cause iatrogenic harm? BJPsych Bulletin, 1–3. https://doi.org/10.1192/bjb.2023.9 (Link)
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