It's time to get creative
BACP Children, Young People and Families, September 2022

In this article, I explore the prevalence of mental health problems in children and young people and how psychological wellbeing in this age group can be improved. First, I examine whether the rise in mental health conditions is real or artefact. Next, I look at reasons behind the increase in such conditions, including the role of the COVID-19 pandemic. Finally, I propose that we need to be more imaginative about interventions to improve psychological wellbeing and resilience in young people. 

This includes consideration of how the mind works, as well as more creative use of resources, such as fiction, to promote wellbeing.

Rise in mental health problems in children and young people: real or artefact?

The mental health challenges for children and young adults are immense. This was the case pre 2019, but since the pandemic, there has been a significant rise in the demand for services for depression, anxiety, phobias, eating disorders, obsessive compulsive disorder (OCD), addictions and the like. In April 2021, the Royal College of Psychiatrists (RCPsych) said, ‘…the country is in the grip of a mental health crisis, with children worst affected’.¹ On 21 March 2022, the British Medical Journal reported that the RCPsych had urged the Government to fund a recovery plan for specialist mental healthcare due to ‘unprecedented demand’.²

So, what is the cause of the apparent mental health crisis in young people and the ‘unprecedented demand’ for services and support? Having spent the last two decades working in national and international director roles in public health – alongside an academic position – I have learned much about interpretation of such trends. One ever-present explanation is that the data are artefact rather than representing reality; such as, when subjective answers to survey questions don’t equate to objective assessments. For example, as a GP, I used to observe that people often understate the number of cigarettes per day they smoke, or parents might label breathing problems in children as wheeze rather than asthma.

Mislabelling can reflect under-representation or over-representation of a condition, but a line of argument for this article would be that there is no true increase in incidence (the number of new cases per year) of mental health conditions, rather they are being mislabelled as such. I suspect, however, that this is not the case. While inevitably there will be some level of data inaccuracy, it still seems most likely that the current situation is under-representation of the true picture rather than the reverse.

The reason for this is two-fold. First, the prevalence of mental health conditions in children and young adults has probably been higher than realised for some time. In other words, there have been more depression, anxiety and eating disorders than have been appreciated. The requirement for services has always existed, but the ‘need’ has not been recognised. In public health terms, we call this ‘unmet need’, and the pandemic has probably played a part in bringing existing unmet need out of the woodwork. Second, on top of a higher-than-realised prevalence, the incidence of mental health conditions in young people has likely increased during the COVID-19 pandemic, meaning more new cases. This is discussed further in the next section.

The pandemic, insecurity and anxiety

Intuitively and observationally, it is apparent that the pandemic has been tough on the mental health of children and young adults. Direct mental health consequences of surviving a severe, hospitalised COVID-19 episode include the post-traumatic stress of witnessing nearby ward deaths, survivor guilt and the mental exhaustion of long COVID. The indirect mental health consequences of COVID-19 are equally insidious and wide-ranging. Social isolation, loneliness and loss can lead to depression, fear and phobias. Addictive behaviours – such as alcohol or substance misuse and gambling – have worsened during the pandemic. Damaged school and university experiences can create loss of direction and purpose. While some of these consequences may have attenuated more recently as the nature of the pandemic has changed, the long-standing impacts continue to be felt.

One indirect mental health impact of the pandemic, which has largely slipped under the epidemiological radar, is the anxiety associated with uncertainty. For young people (as well as adults), fear and worry have resulted from the uncertainty that the pandemic appears to have generated: uncertainty about one’s health and whether you will get the virus, uncertainty about the severity of any illness, uncertainty about the wellbeing of loved ones, uncertainty about the nature of social interactions, uncertainty about education, uncertainty about family finances and opportunities, uncertainty about hopes and dreams held in the balance, and uncertainty about what the future holds.

The rampant uncertainty of the pandemic appears to be responsible for the stress and anxiety that young people find unbearable, with those stresses, in turn, contributing to anxiety disorders, depression, eating problems and addictions. Yet, there is much more to uncertainty than meets the eye. The difficulty that many people experience in coping with uncertainty is premised on a widely held mis-appreciation of the relationship between thought and feeling. While it appears that we live in a direct experience of the outside world, instead we live in a thought-generated experience of the world. In other words, it’s not the exam, the rainy weather, or the pandemic that’s making us feel bad: it’s how we think about the exam, the rain or the pandemic that leads to our feelings about them. It is physically impossible for any external happening to put a feeling inside somebody, even though it often appears that our experiences of life are generated that way. As articulated eloquently in Michael Neill’s best-selling book, The Inside-Out Revolution, our feelings are generated from the inside, all of the time. We, quite literally, live in the experience of our own thinking.³ 

Without this understanding of the thought-feeling connection, people seek to counter the discomfort of uncertainty through striving for assurance, most evident in our efforts to control external circumstances. After all, if our external circumstances are responsible for our feelings (which they are not), optimising and maintaining those external circumstances should make us feel good. But the endeavour to control our external circumstances is not only misplaced – as our feelings arise from inside not outside – it is also thankless and deemed to fail. Life is, by its very nature, insecure: we are all flesh and bone, with a limited span, and nobody can command and govern what happens around us. Rather than using strenuous efforts to do so, a true understanding of the insecurity of the human condition would be far more helpful.

New and creative approaches to supporting psychological wellbeing

We can feel encouraged by an approach to psychological wellbeing which is based on an understanding of how the mind works and thereby an understanding of how we experience life, moment by moment and day by day. This understanding (sometimes referred to as the ‘three principles’) describes three connecting fundamental elements or principles – thought, consciousness and mind – and how these principles combine to create our picture of the world.⁴ By understanding how the principles govern our experience of life, this approach can help individuals reduce psychological distresses (for example, stress, anxiety, fear, discouragement, pressure) and uncover their inner wellbeing. The approach is therefore not just about managing life’s challenges, but also about facilitating the capacity for individuals to thrive and flourish.⁵ Informed by this approach, programmes are now being taught across schools in the UK and worldwide to improve psychological wellbeing and resilience in children and young adults. Results so far are promising, and further evaluation is underway.⁷

This understanding of how the mind works is also threaded through my own new detective series for children aged 11 to 15. The Five Clues, the first in a four-book series, is a young adult (YA) adventure book centred on 13-year-old Edie Marble, who discovers that her mother’s death a year earlier may not have been an accident. There is a public health plot (conceived before the pandemic!), corporate crime, school and family drama and a hitman. Alongside the excitement, Edie learns about the ‘three principles’ approach, first through her mother’s books, then through a psychological wellbeing programme taught at Edie’s school. The new understanding helps Edie to solve clues, bring criminals to justice and navigate life’s challenges. My intention is to create enjoyable books, while using fiction as a vehicle to share the ‘three principles’ understanding and support readers’ psychological wellbeing and resilience.

The current mental health crisis in children and young adults appears to be real. As a society, we need to be creative in the ways in which we nurture and develop the psychological wellbeing of children and young adults, drawing on innovative educational approaches and programmes, as well as underused opportunities such as storytelling.