Keynote speech ‘Making Connections”
by Dr Caroline Jessel, Dandelion Time Founder & Chair
Open Forum Event 12.2.2019 #CAMHSOFE
I do hope that this talk will help you to think differently about childrens mental health and perhaps make some small changes in the way you either deliver services or commission them … which will have huge impacts for our children’s future and mental health.
I am speaking today partly with a sustainable development hat on. I worked in the Sustainable Development Unit for NHS England for a number of years before recently retiring. The Unit is a joint funded by Public Health England and NHS England – set up to make the health and care system more sustainable. It has networks around the country to look at things like social prescribing, air pollution and focus on thinking sustainably. That means to ensure there is a proper balance between social and economic and environmental issues in the way we work and design our services. It is about thinking long term and making the right decisions today that won’t do more harm than good in the future. Hearing that children’s mental health is the ‘Cinderella of Cinderella services’… it struck me that children are our future … children and young people in this country … and yet we are still not prioritising them as we should be for their health and well-being and things are in fact getting worse if the data is correct.
So how did I get into all this? As a GP I worked at a prison, you might not recognise this as a prison from the picture but it’s a women’s open Prison in Kent called East Sutton Park. I did a session there twice a week, talking to the prisoners there and they had access to working on the farms, the gardens and in the kitchens as part of their sentence supporting their rehabilitation. Many of the prisoners had a background of horrendous trauma and abuse as children, often going into prostitution, abusing drugs and offending through that route. I was struck by how many of them said that if I had had this opportunity when I was young, I wouldn’t have ended up with the life I’ve had and I really want to change … and that was due contact with the natural environment, with animals and with the farm and gardens. I thought well why did they not have this opportunity when they were younger? Wouldn’t it be fantastic if children with difficulties could have a real chance to change when they are young and then that might make all the difference?
Now we have a situation which is really incredibly shocking – hunger, self-harm, domestic violence and rising levels of mental disorder in children. We have to sometimes stand back to realise what’s happening. We have many young children in this country facing huge challenges just to stay moderately well, mentally and physically, and the media talk about the root causes of our mental health difficulties and how we can no longer trust the world around us, for many reasons.
As we heard in Jenny’s talk, recent studies have shown a rise in prevalence of mental health disorders in children. So this is going in the opposite direction to physical heath. As a GP, I worked for 30 years and the physical health in children has improved dramatically over that period but their mental health has declined – heading in opposite directions. So we’re not getting it right. This is particularly striking in girls in the older age groups. The boys are much more stable over the time.
The question is why is this happening? Are girls not presenting their symptoms at an early stage so they can be addressed? We know that girls are very good at covering up their difficulties and keeping them quiet and boys are more overt at presenting them. Or is it all down to Instagram? We don’t know and we need more studies to find out. But we do want to think about the future of our children and broaden out our thinking to include the future of our world, our planet that we live on.
The Rise of Solastalgia
We have an environmental crisis and what is the impact of this on our collective mental health? Issues like climate change, species loss, environmental degradation. How does this impinge on the well- being of our children? How do their parents see the future? Hopefulness? Plans and so on… What is the subconscious affect and is there a connection between the way we unfortunately trash our planet and our apparent lack of care for children and young people who are in difficulties? Psychiatrists have invented a term, a new term, for the sadness that people feel for what we have lost and for what we are destroying and it’s called Solastalgia – a kind of mixture between solace, nostalgia and pain. This feeling is being measured in our society and it is rapidly increasing unfortunately. Fortunately, we now have clear global goals, the internationally agreed goals for sustainable development. These actually followed the millennium goals which surprised everybody by being successful, and the majority of the objectives were achieved by 2015.
Solastalgia: noun. From the Latin solacium (comfort) and the Greek root –algia (pain). “the pain experienced when there is recognition that the place where one resides and that one loves is under immediate assault . . . a form of homesickness one gets when one is still at ‘home’.”
I put this slide up to encourage you to think very broadly but also to look at the connections. You cannot imagine addressing any one of these goals if you look at them carefully and think about how you’d set about changing things without looking at several others at the same time – they are all interconnected. There is a parallel here with children’s mental health, you can’t address poverty, domestic violence, addiction … you have to address all of them together and address them throughout a child’s life, their family, the education system – through multiple channels or we’re not going to make progress. So our services need to be very far reaching.
Conceptual models of health
We have always had the biomedical model that what I grew up on as a doctor. You go through history, examination, investigation, diagnosis and treatment – and we had to learn that process and follow it. Now that is a linear model, a simple model if you like, with a nice sense of progression in it. It’s all about the body having something wrong with it and then we fix that like a car or any other machine. Then as people realised this model wasn’t working for a lot of complex conditions, we got the biopsychosocial model, which is much more helpful – but that is still leaving out an enormous chunk of what makes us well and healthy, which is the natural environment.
So we now have moved on to think more in terms of the total environmental model for our well-being which includes everything that surrounds us and influences us, the system around the child. We also need more individual solutions for each child and a menu of options to pick from. If you take a parallel condition like obesity, for years as a GP, I would prescribe drugs and weigh people regularly and so would my nurses and we would all get frustrated because you couldn’t make people lose weight using just the medical model. Obesity is something that results from multiple factors and the factors and causes surround us and influence us and are not really about free choice, particularly in children. So we have created a world where obesity is often the easiest choice. Going back to the George walking 6 miles each way to go fishing he was not very likely to become obese, so we’ve created a world where it’s not felt to be safe for children to run around, go outside, people feel it’s unsafe and they’re frightened, their fear is transmitted to their children. The medical model doesn’t work for complex conditions, that’s really important.
So how can we as a whole society redesign the whole thing? Public health, and architects and town planners have thought about this and come out with design ideas that would make you healthy and of course it involves the natural environment. However, very often our beautiful plans and schemes get cut at the last minute because it saves a bit of money. Which I’d say is a very short sighted because it’s creating a huge amount of disability here in our society which we then pay for through more expensive health services. So the public health world, and the NHS are waking up now to the role of the environmental health:
Duncan Selbie, CEO of Public Health England: The role of the environment we live in is hugely important in shaping our lives and, consequently, our health…having access to high quality, local natural environments is critically important to promoting physical health and wellbeing in children and adults.”
The difficulty lies in translating this thinking into policy, planning and commissioning. It tends to get diluted as it goes through the system and the joining up of the dots gets lost as we stick with our separate budgets and we all have our silos. And this is really a challenge, we understand the importance but we have not yet incorporated it into the way we design and deliver our services.
Consider the evidence about green space and health inequalities. You can see that children growing up with very little green space have a high level of health inequality as adults, but where there is plentiful green space and the same degree of income inequality the result is much less health inequality. This shows we can address health inequality by improving income but if that’s not possible we can also address it by improving the amount of green space people live off. There is wealth in nature which children are often denied, that opportunity for mindful connectedness.
Knowing this about the natural environment and health, and seeing that children in my surgery were getting more and more problems with their mental health, getting anxiety, depression, OCD, eating disorders at a young level of age, I realised that this was not good. I didn’t want to give drugs and I didn’t want to send a lot of children to see psychiatrists because that was perceived by many parents to be stigmatising and they didn’t like that, they didn’t want to see a psychiatrist. So with some like-minded colleagues, I started an organisation called Dandelion Time to try a different approach. It uses the natural environment as a place to support our therapeutic programme. The opportunity that it gives is amazing: on a small farm with animals, with lots of activities, growing vegetables, craft activities … to find something that inspires each child. This creative environment has given rise to a new therapeutic approach and allows our children to work on their difficulties with their families, which is fantastic.
We now teach this new approach through our academic programme developed with the Association of Family Therapy. There is a lot of good evidence now to support this methodology, but when we started there was very little evidence behind it but I just had a hunch from my work at the prison that it might work. So we found that creating this wonderful resource was very liberating and empowering, it was very engaging for children and their families, they really liked to come to Dandelion Time, which made the therapeutic work easier.
Now we have more recent research in the field of neuroscience which supports our method of the using the natural environment as a therapeutic setting. That’s come from people like Professor Jules Pretty of Essex University. Jules, using functional MRI scanning, has shown the mechanism in the brain for the impact of green space on mental health and stress. Being out in green space increases the activity in the parasympathetic nervous system, reducing sympathetic nervous system activity, and that creates the relaxation state known as immersion or flow. It creates the opportunity for unfocused attention rather than focused attention. It’s a huge benefit which has been shown for example in children with ADHD, and we all know that ourselves when we go for a walk in the woods or by the sea how it relaxes you and helps you think differently. Children with ADHD have a limited supply of focused attention and it exhausts very quickly, and this allows them to relax and regain their ability to pay attention. Activity in the natural environment has been shown to reduce stress, improve blood pressure and improve concentration and academic performance. This works for all ages and all conditions, particularly for mental health, but the physical benefits are amazing too, as I said earlier the two areas are not separate. So we found it very effective using a non-drug approach and developing our own therapeutic model. There are other examples of what we now call ecotherapy around the country.
In my role of lead for sustainability in the south I visited several doing great work and providing a service via social prescribing or other commissioning models. One example would be Jamie’s Farm, a farm-based project in the South West of the country. There are four or five farms set up now and there is one coming to East Sussex. Jamie’s Farm takes teenage children from schools that are having difficulty with behaviour, mental health and coping with school. It takes them on a week’s course and has shown enormous benefits for their mental health and their ability to stay in school. There is another one call Natural Therapy CIC on the Isle of Wight, set up specifically for bullying and antisocial behaviour. They found that by using children’s understanding of their own sensory engagement with the natural environment, how its excites them, it helps them identify that we are all individuals and we are all different and therefore bullying someone because they are different is not very helpful.
So my main messages are:
1) Change from within if you can. Be the change you wish to see. Think about the world broadly, think about children’s health more broadly and the opportunities that you can get from looking at their diet, their family relationships, their creativity, their future plans and hopes, thinking of all of that and bringing that into your work.
2) Remember that we are interconnected with the natural environment, and our health and well-being cannot thrive without it. So through addressing that interconnectedness and starting to take on the challenges that we face as a world it actually benefits our mental health because tackling a problem makes it less, even if it’s just small changes.
3) Engage in the wider debate, don’t feel shy about societal change because it’s the only way we’re going to address all this and reverse the path we are on. Make sure we commission holistically and in a joined up fashion as we move forward. There have been examples here today of how that has been done and we ought to do it on a much bigger scale with the voluntary sector as well as the statutory side.
To read more about Dandelion Time please see Why I started Dandelion Time.