Two approaches to mental health in schools

Student wellbeing has been as big theme for us over the last couple of years, as it has for so many educators and parents around the world - and especially under the Covid situation, .  It’s woven into every aspect of school life (many connected thoughts on the topic here) – just as our childrens’ wellbeing is woven into our family lives.  It is a lens through which we view every action, every decision – and we are well aware of the need to be well-informed as to best practices and ideas.  I was therefore fascinated to read about a particular therapeutic approach – new to me – which flatly contradicts what is perhaps the dominant, very successful approach; but which nevertheless has excellent results and a coherent philosophical framework.

The dominant therapeutic approach I am talking about is Cognitive Behavioural Therapy (CBT) which has been described as the “gold-standard psychological treatment” (David et al 2018).  It is very simple in structure – it seeks to help people to get better by helping them to learn how to identify and then change the destructive thought patterns that can lead to negative emotions.  The idea is that CBT allows us to identify, challenge, and replace negative thoughts with more objective, realistic thoughts.  A key feature is that it looks at evidence to challenge mental health issues (here’s a quick video overview from mental health charity MIND).

It seems so straightforward in outline (if not in application); find a negative thought, challenge it, make it better. Of course it’s not without its critics (e.g. see Mace, 2018) but it does have a strong empirical base as well as appeal to common sense, so I was amazed at how compelling I found a diametrically-opposed alternative – Acceptance and Commitment Therapy (ACT).

The difference in approach is simply put: CBT challenges the facts.  ACT accepts them and this comes from a fundamental difference in philosophical underpinning. Amazingly, ACT does not actually try to reduce symptoms because it refuses to accept that there is a ‘healthy normality’ and that ‘symptoms’ are some deviance from this normality, that we need to challenge.  ACT instead aims to change the way we think about difficult thoughts and feelings, so that we no longer see them as ‘symptoms’ but instead as “harmless, even if uncomfortable, transient psychological events” (Harris 2006).

There are alternative therapeutic techniques. (source)

This struck me as strange – aren’t the very negative thoughts that can lead to self harm, for example, a problem?  It turns out that ACT agrees they are problems, but does not accept the base assumption that happiness and fulfillment are the natural conditions for us all, if only these problems can just be solved.  Harris (2006) cites studies suggesting that in any year “almost 30 percent of the adult population will suffer from a recognised psychiatric disorder; that one in five people will suffer from depression at some point in their lifetime”  and so argues that “…the psychological processes of a normal human mind are often destructive, and create psychological suffering for us all, sooner or later."

On this basis, he argues that the happy is normal belief is untrue; furthermore that to believe it is highly destructive, because it can lead to us always worrying why we are not happy (I call it the Facebook effect).  It’s worth quoting him at length:

“Anxiety disorders provide a good example. It is not the presence of anxiety that comprises the essence of an anxiety disorder. After all, anxiety is a normal human emotion that we all experience. At the core of any anxiety disorder lies a major preoccupation with trying to avoid or get rid of anxiety. OCD provides a florid example; I never cease to be amazed by the elaborate rituals that OCD sufferers devise, in vain attempts to get rid of anxiety-provoking thoughts and images.”                                           

So ACT sees problems to deal with, that arise in the course of life, not symptoms to overcome to get back to the mythical normal, as with CBT.  The ideas is that this frees us up from the sense that we are always failing, and is, Harris argues, why ACT is so successful. “Ironically, it is through this process that ACT actually achieves symptom reduction—but as a by-product and not the goal”.

I’m not qualified to write about the details of ACT   – I have just come across it – but it does resonate with the mindfulness movement about acceptance of difficulties.  Instead of challenging the destructive feelings, confronting them with evidence and trying dismiss them, the idea is to learn to reduce their impact by standing outside them, and by noticing them as unpleasant but ephemeral (more on that here). It seems, ironically, that by not treating these feelings as symptoms, ACT achieves symptom reduction as a by-product, not as a goal.

The idea of acceptance in this context may not appeal –  surely anyone seeking therapy does not accept their situation; rather they are hoping to improve it?   I think, though, that there is a difference between accepting that something is true, and accepting it is desirable.  As far as mental health goes, accepting that we all have difficulties does not in any sense mean giving up on working for a happier life –it just means accepting what we need to in order to free us up to place our energies elsewhere.

I've written about ACT with some enthusiasm as it seems to provide such a refreshingly different approach to CBT.  I am sure there are many others - and what counts here, in our context, is to have a range of tools to use, as we have a range of students.  Perhaps it's a matter of personal choice; or perhaps some issues respond better to one approach than another.   As so often happens in human matters, there are no hard and fast rules, only open possibilities to be explored.  As our High School counselor is taking a course in ACT, I'll be fascinated to see if any patterns emerge as to what works for who.

Thanks to Marie-Anne Glavan for telling me about ACT.

References

• David, D, et al (2018) Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Front Psychiatry; 9: 4.
• Mace, W. L. (2018) What's the Solution for a Coddled American Mind?
• Harris, R (2006) Embracing Your Demons: an Overview of Acceptance and Commitment Therapy. Psychotherapy in Australia 12:4