Mental Health Literacy in Schools: Let's talk about how we talk about mental health

Teens are particularly at risk of developing a mental health problem, and among the least likely to seek help if they do. Why might this be? One reason could be that adolescents tend to have low mental health literacy (MHL). Knowing how to recognise poor mental health, and how to get help is especially important for adolescents to support their mental health now and on into adulthood. It is crucially important to support young people in achieving good MHL, and to empower them to seek appropriate help for their mental health by the giving them the information they need.

Globally, around 1 in 7 adolescents experiences a mental health problem, and half of all mental health problems are estimated to begin before the age of 14. In Australia, 1 in 3 young people experienced high levels of psychological distress during the pandemic, and more than two thirds of young Australians who experienced poor mental health said that they didn’t seek help because they were too scared or anxious to do so. With this in mind, it comes as no surprise that school-based initiatives to promote mental health literacy are increasingly used around the world.

What is Mental Health Literacy?
Mental health literacy was first defined in Australia in 1997, and Australia remains a leader in promoting MHL in school (e.g. Beyond Blue’s ‘Be You’). MHL was originally defined as ‘knowledge and beliefs about mental health problems that aid their recognition, management or prevention’. This definition included six important dimensions of knowledge:

• Ability to recognise specific disorders
• Knowledge about causes and risk factors
• Knowledge about self help
• Knowledge about professional help
• Attitudes that aid help-seeking and recognition
• Knowledge of how to seek mental health information.

More recent definitions focus on promoting understanding of how to obtain and maintain good mental health; reducing the stigma towards mental health problems; understanding of disorders and their treatments; and enhancing young people’s belief in their ability to seek effective help. 

This shift towards a focus on maintaining good mental health, and reducing stigma reflects that it is important to arm our teens with knowledge about mental health problems, but that it is also important to shift the narrative to discussing positive mental wellbeing, treatment and recovery, and to provide guidance on how to take action to support their mental health.  Increasing MHL can support young people in identifying when their emotions are a typical response to their environment (like extra stress during exam times), and when they may need some additional support with their thoughts, feelings or behaviours.

Why is it Important?
In a recent UK survey, over half of teens said that they did not seek help for poor mental health, because they didn’t understand what it was that they were going through. This is why it’s important to increase young people’s MHL. Doing so is likely to help young people identify when they need help, minimise stigma or shame around doing so, and help them feel empowered to support themselves or ask for help.

Stigma remains one of the biggest barriers to seeking help among young people. While this is also a factor when adults may want to seek help for their mental health, stigma is especially detrimental to adolescent help-seeking. Adolescence is a time when fitting in is crucial. This stage of life is often marked by an elevated need for peer acceptance, and so teens tend to stick rigidly to their group norms to fit in.  Deviating from norms or being seen as ‘other’ is likely to be a particularly scary concept for teens. To minimise stigma (one of the key dimensions of MHL), it is important to normalise the spectrum of mental health, good and bad, and to normalise having conversations around seeking help and supporting each other.

This is something that MHL sessions in schools can work towards. By discussing positive mental health and related aspects, such as emotional intelligence, and having open conversations about how to identify when and how to seek help when maintaining their mental health becomes difficult, we can normalise the spectrum of mental health, and normalise speaking to each other about when managing mental health gets tough.

Teens almost face a developmental double whammy in relation to asking for help for mental health problems. On one hand it feels important to maintain peer acceptance, and not be different, on the other, adolescence is a time when young people are aiming to go from being interdependent, towards asserting their independence as emerging adults. This means there might also be a preference to handle things on their own, rather than to talk to their parents, teachers, or friends when they begin to struggle with their mental health. This is where it is important to help adolescents be aware of what help is available and how to access it, and to enable them to identify when it is important to speak to trusted adults (e.g. parents) who can help them get the support that they need.

Mental Health Literacy in schools
Schools are often seen as the ideal place to deliver MHL to adolescents. So much of their time is spent in the safe and familiar school setting, and sessions for MHL can be adapted to existing pedagogical approaches that are known to be effective in improving educational outcomes. Schools are already set up to deliver interventions using a literacy approach, and integrating MHL interventions into existing school curricula and settings may be especially effective in key goals of reducing stigma towards mental health problems, and successfully promoting help-seeking behaviours among students.

MHL delivery in schools is largely split into two methods. One, being external delivery (such as mental health first aid training for teachers). These can be added to existing school activities, and are usually delivered using resources external to the school environment. Arguably more sustainable are so-called “school friendly” MHL interventions which are designed to be easily integrated into the existing curriculum and can be delivered by trained teaching staff using familiar pedagogical approaches. These can build the professional development of teaching staff and also improve the MHL of both staff and students together.

While school-based approaches to promoting mental health literacy are increasing in popularity around the globe, the evidence for their effectiveness can be mixed. This may in part be due to differences in delivery (e.g. external vs internal). While improvements in stigma reduction and improved attitudes to help-seeking are seen after receiving MHL teaching, often these effects are not sustained in the long-term. Given that MHL may play such an important role in keeping teenagers mentally well, it is vital for researchers to determine what works, and why.

One way we can make sure that MHL teaching in schools is more effective is to ensure that it is delivered early, and then continued throughout schooling, rather than in short term or one-off sessions. This is something that’s done well in countries such as Finland, where mental health promotion is embedded in the national curriculum from early learning, though to the end of high school.

What’s next for Mental Health Literacy?
An important area for attention is related to the different dimensions of knowledge included within MHL. At the moment, only little is known about whether any of those key building blocks of MHL are more or less effective in reducing stigma and increasing willingness to ask for help. For example, would teaching more about treatment and recovery have better impacts, than teaching about causes of mental ill health, or knowledge about how to recognise specific disorders? Once we know more about which aspects of MHL are most likely to result in long-lasting stigma reduction and increased willingness to speak out and seek help, we can incorporate these ‘active ingredients’ of MHL into how we talk about mental health in schools.

It may also be beneficial to develop peer-led MHL programmes, or to include parents in the delivery of MHL in schools. This is because we know that stigma from peers plays an important role in holding young people back from talking about their experiences of poor mental health. However, we also know that while teens may perceive there to be a lot of stigma towards poor mental health from their friends and peers, when you ask them about their own stigma beliefs, these are actually quite low.  Having interventions that are delivered by peers could help in minimising the perceived levels of stigma between teens, whilst simultaneously improving their MHL.

Another option may be to involve parents in the delivery of MHL. While the beliefs of peers are important in a young person’s decision making when seeking help, we also know that beliefs modelled by parents in the home are particularly important. In relation to seeking help for a mental health problem, it is often parents who gate-keep formal support services, and yet young people may not want to seek support from parents if they believe their parents or carers hold negative attitudes towards mental health problems. By delivering MHL programmes to both parents and teens in tandem, this could help young people see their parents as a source of support free from judgement.

Finally, young people themselves are often overlooked when programmes to deliver MHL are being developed. This may harm how effective they can be. What is important going forward, is that the voices and experiences of young people are harnessed to develop programmes that are maximally engaging. It might be that teens would hate the idea of learning about MHL with their parents in the room, but we won’t know until we ask!

Adolescents themselves are key to conversations about how we talk about mental health in schools
Adolescents who don’t seek help for a mental health problem are more likely to have poorer mental health outcomes. This can have knock on effects into adulthood and affect educational, health and social outcomes in the long term. With increasing rates of poor mental health among adolescents, and the negative psycho-social effects of the pandemic, it has never been more important to improve the mental health literacy of young people and those who support them. The definition of mental health literacy has evolved since its conception and is in line with more holistic definitions of mental health, which state that mental health is more than an absence of mental illness, but also includes promotion of good mental health. Going forward, it’s important to determine exactly which dimensions of MHL are effective in promoting long-term behaviour change and stigma reduction, and to develop ways of delivering MHL in school that is in line with existing pedagogies, but mindful of teacher burden. We should also have young people involved in discussions around MHL, and how to successfully deliver this in school settings.

Claire Goodfellow is a public health researcher at the MRC/CSO Social and Public Health Sciences Unit at the University of Glasgow, Scotland. Claire has a PhD in Public Health and Health Policy. During her PhD Claire was seconded to New York University, as well as the Finnish Association of Mental Health in Helsinki.  Claire is interested in public health approaches to supporting adolescent mental health, and her recent research has investigated the impact of loneliness on youth mental health and wellbeing. Her doctoral research investigated mental health literacy and stigma in adolescence, and she continues to research this area.

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