For anyone dipping in at this point, this is the fourth essay written for my Masters in Mental Health Recovery and Social Inclusion. I have drawn on my experience of travelling to Australia and Finland for my Churchill Fellowship to provide a comparison for how youth mental health services can be delivered in a different way.
Module 3: Legislation and Policy for Mental Health Recovery and Social Inclusion
Introduction
Despite an increasing body of research demonstrating the association between social and income inequalities and the risk factors for many mental disorders (Allen et al., 2014; Burns, 2009; Marmot et al., 2010), global mental health policies continue to focus primarily on biomedical approaches that largely ignore the sociocultural context in which such illnesses emerge (Carbonell et al., 2020). The current institutionalised, medical, and largely negative, discourse surrounding mental illness views it purely as a pathological and biological state, situated firmly within an “individual disease framework” (Burns, 2009, p. 21), and fails to take into account the conditions into which people “are born, grow, live, work and age and inequities in power, money and resources – the social determinants of health” (Marmot, 2020, p. 1).
In the UK, there has been growing concern about the rising mental health difficulties experienced by children and young people (CYP) in recent years. UNICEF’s 2020 report on child wellbeing (Innocenti, 2020) ranked the UK lower than most of the world’s wealthiest countries for child mental wellbeing – 29 among 41 EU and OECD countries, and the United Nations (UN) Special Rapporteur on extreme poverty and human rights noted in his 2019 report (Alston, 2019) that austerity policies pursued since 2010 have amounted to “retrogressive measures in clear violation of [the UK’s] human rights obligations” (p. 8), having disproportionately impacted children and families, exacerbated child poverty and pushed people into crisis.
In 2017, the Children’s Commissioner for England highlighted the ongoing under-funding, under-prioritising and increasing unmet need for mental health support, as well as the underlying sociogenic factors (Rosa, 2018). Despite the prevalence of mental illness, and its impact on young lives, existing services are failing to meet their needs (Department of Health, 2014). Long waiting lists, regional funding variances (Davidson, 2008), poorly managed transitions (Kennedy, 2010), inconsistencies in available interventions, and stigma and discrimination (Collins et al., 2017) all impact on CYPs’ ability to access appropriate and timely support. Notwithstanding successive governments’ commitments to addressing the deficits (Parkin & Long, 2021), these issues largely remain. In 2018, common themes – service accessibility, prevention and early intervention, and cross-sectoral working – were once again identified as lacking in the Care Quality Commission’s review of child and adolescent mental health services (CAMHS) (Care Quality Commission, 2018).
Jenkins (2003) proposes that “[e]ffective interagency working at national, local and individual level is fundamental to the delivery of good mental health care, and needs to be firmly addressed at policy level” (p. 17). For this assignment I have therefore chosen to examine two international population-based, youth-focussed models which integrate mental wellbeing with other youth health and welfare support to address the social and structural contributory factors to mental illness. Rather than concentrating on narrow models of care targeting individuals and their behaviours, a population health approach is one that focuses on “the health and overall wellness of the broader population it serves” (Shahzad et al., 2019, p. 2) – headspace (Australia) and Ohjaamo One-Stop Guidance Centres (Finland) offer examples of such initiatives. My personal interest in these two models developed during my 2019/20 Churchill Fellowship (www.churchillfellowship.org) research into initiatives preventing the escalation and recurrence of mental illness in young people. As such, alongside the academic and grey literature cited, I include personal observations from my visits to these services.
I will critically discuss the policies and frameworks that underpin these innovative models of support and consider their fit within the context of recovery-focused, socially inclusive, and human rights-based approaches, with particular focus on the UN Convention on the Rights of the Child (CRC) (Unicef, 1989), a legally-binding international agreement which sets out the social, civil, political, economic and cultural rights of every child. I will also critically reflect on the current legislative and policy frameworks operating here in the UK.
Rationale
As a parent who has supported a child through severe mental illness, I have a particular interest in youth mental health and the challenges faced by young people in their transition to adulthood. Beyond my own experience, however, research shows this to be a widespread problem, with half of all lifetime mental disorders starting by the age of 14, and three-quarters by age 24 (McGorry & Mei, 2018; Plaistow et al., 2014). Worldwide it is estimated that 10-20% of young people experience disabling mental illness (Kelly & Coughlan, 2019; Settipani et al., 2019). Long-term low socio-economic status is strongly correlated with higher rates of mental illness in this cohort (Reiss, 2013); in particular poverty, neglect and abuse have been shown to have a significant impact (Basu & Banerjee, 2020; Felitti et al., 1998). Latest estimates suggest that, in the UK, 4.3 million children live in poverty and 2.5 million in food insecure households (Rashford, 2021).
One area of particular concern relates to emerging adults (16-25s), who are increasingly falling between gaps in policy and services for both children and adults (Youth Access, 2017) at the point when they are most vulnerable to mental disorders – the transition from childhood to adulthood (Goldman‐Mellor et al., 2016; McGorry, 2013), with its associated challenges of high youth unemployment, increasing debt, rising accommodation costs (Public Health England, 2015) and climate anxiety (Hickman et al., 2021; Wu et al., 2020). Notwithstanding the clear societal benefits (Hancock & Hinds, 2017), neither CAMHS nor adult mental health commissioners have a duty to prioritise this demographic, revealing a fundamental shortcoming in the current paediatric-adult mental healthcare paradigm (McGorry & Mei, 2018).
There is no universally agreed definition of the youth age group. While the UN defines ‘youth’ as a developmental period between ages 15 and 24, the CRC refers to children as being up to age 18. The World Health Organization (WHO) defines ‘adolescents’ as aged 10 to 19, and uses the term ‘young people’ to combine both youth and adolescents (10-24s) (WHO, 2014a). While these terms are used interchangeably in this assignment, its primary focus is on ‘youth’.
Discussion
Human rights
The CRC is the most widely ratified human rights treaty in history, and was signed by the UK government in 1991. Although the rights set out in the CRC are not part of UK domestic law, in 2010 the government committed to do everything possible to uphold those rights when making new legislation or policy, including those relating to health services, local government and education (Rosa, 2018).
A bidirectional and complex relationship exists between mental health and human rights; rights violations can deleteriously impact mental wellbeing, while respecting those rights improves mental health (Mann et al., 2016). Indeed, Article 24 of the CRC sets out a child’s right to the highest attainable standard of health. Not only, therefore, is there a moral imperative for human rights-based approaches (HRBA) to be implemented, but with improved therapeutic outcomes, there is also a strong empirical, financial and economic argument for doing so (Mann et al., 2016).
Whilst the devolution of public health responsibilities to local authorities has provided an opportunity for local improvements in youth health and wellbeing outcomes (Public Health England, 2015), a purely public health response perpetuates the paternalistic perspective that mental disability is a health issue only, requiring a medical solution. By way of contrast, a rights-based response fully acknowledges “the social, economic, and political forces that result in the disability” (Burns, 2009, p. 21). It also requires the embedding of participatory practices to redress the inequalities and discrimination that exist in society (Burns, 2009).
The Department of Health’s ‘Achieving Equity and Excellence for Children’ (2010) stated, “At all times our focus will be on what works best from the perspective of young people [and] their own experiences” (p. 26) . Yet, a 2018 report (Rosa, 2018) into children’s rights in mental health policy, citing the Joseph Rowntree Foundation, reported that “human rights, including children’s rights, are rarely integrated into UK public policy and in public debates on social policy, poverty and exclusion” (p. 1). A children’s rights approach centres around the child’s voice and best interests, and ensures their views are taken into account and given “due weight” (Parker, 2007, p. 175). Despite the 2007 amendment to England’s mental health legislation strengthening safeguards for children (NSPCC, 2021), with no mechanisms in place to embed it, there has been no systematic application of the CRC to CYP with mental illness (Parker, 2007; Rosa, 2018).
The key CRC Articles – of non-discrimination, best interests of the child, right to life survival and development, and right to be heard, largely align with the principle values of recovery-oriented and HRBA to mental health: participation, social inclusion, dignity, and autonomy (Hunt & Mesquita, 2006; Slade et al., 2014; Stastny et al., 2020). Whilst the concept of personal recovery is now well-defined and documented within adult mental health research (Anthony, 1993; Bird et al., 2014; Leamy et al., 2011), limited literature exists relating to young people (Ballesteros-Urpi et al., 2019). Despite some overlapping themes (personal agency, connection, identity, hope and optimism), Law et al.’s (2020) qualitative study found that, to be of relevance to CYP, the recovery process needs to be individualised, and take account of developmental considerations, contextual factors and “the ecological system of the young person” (p. 465) – family and friends, educational setting and societal influences.
Current UK policy position
Mental health legislation is critical to protecting the rights of people experiencing mental disabilities who, globally, continue to face stigma and discrimination (WHO, 2014b). However, its purpose should not simply relate to treatment legislation within the narrow context of institution-based care, but also extend to civil rights, mental health promotion, and prevention (WHO, 2014b).
Mental health policy can be defined as a formally adopted document that sets out a vision for the future, and determines a broad action plan for its realisation (WHO, 2005b). A mental health plan “details the strategies and activities required to realize that vision and achieve the objectives of the policy” (Funk & Freeman, 2011, p. 135).
In England, current mental health legislation – the Mental Health Act 1983 (amended 2007) – is chiefly focused on involuntary detention and treatment, and the protection of rights to liberty (Zigmond, 2017). Whilst this legislation, which also covers the assessment, treatment and rights of CYP under 18 years (NSPCC, 2021), is now largely compliant with WHO standards (Freeman & Pathare, 2005), it does not protect the broader social and economic rights that lead to social exclusion and marginalisation (Zigmond, 2017).
As part of the 2010-2015 Coalition Government’s commitment to achieving ‘parity of esteem’ between physical and mental health, the 2011 mental health strategy, ‘No Health Without Mental Health’ (Department of Health, 2011) pledged to provide early intervention support for mental health problems and to transform the way people with mental ill health are supported within society. Yet despite this, and an unprecedented national policy focus on youth mental health in the intervening years (Department of Health, 2010, 2014, 2015; Mental Health Taskforce, 2016; Public Health England, 2015), the ‘treatment gap’ (the difference between prevalence and percentage treated) has continued to grow (Hunt et al., 2021).
The UK government’s 2017 Green Paper on CYP mental health (Hancock & Hinds, 2017), as with previous youth mental health policy, has primarily focused on increasing funding to existing frontline mental health services (Gunnell et al., 2018), despite acknowledging the importance of not focussing “too narrowly on targeted clinical care, ignoring the wider influences and causes of rising demand” (Department of Health, 2015). Indeed, the Health and Social Care Committee’s response (Halfon & Wollaston, 2018) widely criticised the Green Paper for failing to take account of sociogenic factors, the need for preventative action, and cross-departmental strategies and policies. The Committee also expressed concern that there were no recommended policy interventions to support the most socially disadvantaged and vulnerable groups of young people, including NEETs (an acronym for 16-24 year olds not in employment, education, or training).
Social and developmental factors
In respect of young people, UNICEF defines mental health as “the ability to achieve and maintain optimal psychological and social functioning and wellbeing” (Unicef, 2021, p. 6). This includes a sense of self-worth and identity, the ability to learn, be productive, be able to use resources for personal growth, and have the capacity to deal with developmental challenges (Unicef, 2021). Poor mental health is therefore linked to other health and developmental concerns in CYP, including lower educational attainment and substance misuse (Patel et al., 2007). In turn, substance use can result in increased susceptibility to mental health problems (Yung et al., 2020), reduced academic achievement (Oldham et al., 2021) and NEET status (Public Health England, 2021).
Evidence shows that prolonged economic inactivity has a pronounced impact on mental health – risks of depression, substance misuse and attempted suicide are significantly increased in NEET youth compared to their economically active peers (Scott et al., 2013). The government has declared itself to be committed “to preventing an increase in the numbers of young people, including those with mental health conditions, leaving education without further training or employment and flowing onto welfare” (Hancock & Hinds, 2017, p. 34). However, Maguire (2021) identified that austerity measures adopted post-2010 in the UK have resulted in the withdrawal of policies targeting youth NEET, and that no nationwide, government-led initiatives currently address this policy area. Ten percent of UK youth are NEET, among the highest in the rich world (Innocenti, 2020), and the Department of Education’s 2020 NEET brief revealed that one in five NEETs have a mental health condition (Parker, 2021).
Whilst it is beyond the scope of this essay to explore the causal direction of the link between mental illness and NEET status, which appears to be reciprocal (Baggio et al., 2015), childhood mental ill health is often a precursor to becoming NEET (Goldman‐Mellor et al., 2016). Such children are therefore at risk of future and potentially lifelong economic disadvantage and social exclusion. The strong correlate between substance abuse and youth mental illness highlights the need for integrated drug and alcohol and mental health interventions (Skogen et al., 2014); the heterogeneity of the NEET population, and the complex reasons and vulnerabilities leading to this status (Mascherini et al., 2017), further emphasise the need for single point-of-access services (Frederiksen, 2020).
Ohjaamo – One-Stop Guidance Centres (OSGC)
Whilst its mental health legislation (Mental Health Act 1990/1116) is considered outdated (Lantta et al., 2021) and prioritises “the need for treatment over personal autonomy” (Seppänen & Eronen, 2012, p. 93), Finland is reported to be the second most socially progressive country in the world (Henley, 2018). Globally, it is also ranked third (out of 128) in protecting human rights (Lantta et al., 2021). Youth policy development is informed by the Government Programme, and the National Youth Work and Policy Programme (VANUPO), supported by other Government strategies (Ministry of Education and Culture, 2021). The Youth Act (1285/2016) adopted in 2017, forms the legislative basis for this programme (Ministry of Education and Culture, 2020).
Finland’s Youth Act (Ministry of Education and Culture, 2017), which defines youth as those under 29 years of age, enshrines in law the rights of young people to participate and exercise influence in decision-making processes and implementation of all matters relating to their lives. Its further objects are to support youth independence, growth, social inclusion, improve living conditions, and to facilitate the development of individuals’ skills and capabilities to enhance their role in society (European Commission, 2021b; Ministry of Education and Culture, 2017).
Protecting and improving youth health is a national priority in Finland, involving cross-sector multi-agency collaboration (Välimaa et al., 2008); promoting their mental health is an important part of youth policy (European Commission, 2021a). The VANUPO programme states that “the most effective means for preventing social exclusion is ensuring the preconditions for a meaningful life for all young people” (Ministry of Education and Culture, 2020, p. 14).
In October 2020, amidst concerns about the long-term impact of the COVID-19 pandemic on employment opportunities for CYP, all EU countries reaffirmed their commitment to implementing the enhanced Youth Guarantee, a programme which supports young people under age 30 to gain a place in quality employment, training, apprenticeship or further education to prevent long-term youth unemployment (OECD, 2021; Sorsa, 2019). A further requirement of the Youth Guarantee is to provide targeted and individualised support to vulnerable young people, and in Finland, OSGCs are critical to the delivery of this programme.
The OSGC operating model is an innovative “public-private-people partnership with young people actively shaping their own future” (Sorsa, 2019, p. 1). It offers low-threshold early intervention support tailored to a young person’s individual needs and circumstances (Kettunen & Felt, 2020). Now numbering more than 80 across metropolitan and rural Finland, OSGCs provide a range of co-located services that CYP can access on a drop-in basis, with a particular emphasis on NEETs (Frederiksen, 2020; Savolainen, 2017). A multidisciplinary team offer information, advice and guidance relating to mental health, substance use, welfare support, employment and education, and the development of social and other life skills (Kettunen & Felt, 2020), as well as more recently adding low-threshold psychological support services (OECD, 2021). Whilst the professional staff at the centres remain employees of their diverse organisations, barriers between the various public and private sector entities have been removed through the development of transdisciplinary working practices. The Ohjaamo model therefore provides a good example of horizonal policy integration that has resulted in a higher quality, more streamlined service (Kettunen & Felt, 2020).
Unlike many NEET interventions which often fail to invest in long-term solutions or to tackle the underlying causes for youth disengagement (Maguire, 2021), OSGCs have embedded lifelong learning and guidance practices which support young people to identify and develop their competencies, interests and personal agency (Kettunen & Felt, 2020). Shifting from the management of individual problems to a model that allows for the growth of capabilities is critical to the development of personal agency and sustained change (Cottam, 2018). Indeed, Ohjaamo’s methodology fits with the ‘capabilities approach’ (Nussbaum, 2001; Sen, 1993), which focuses on what people are able to do and be (their capabilities) rather than merely their right to do so (Robeyns, 2005). By helping young adults to build the skills and tools to improve their social situation, OSGCs “invest in young people’s social capital” (Sorsa, 2019, p. 1).
In line with the Finnish government’s commitment to youth participation through its Youth Act, service user involvement is integral to the OSGC model (Sorsa, 2019). A case study into Turku OSGC demonstrated that, through active participation and cooperation from the project’s inception, it achieved its goal to empower young people to create a service that works for them (Sorsa, 2019). More widely, through an ongoing process of co-development and co-production, OSGCs have developed an accessible, cost-effective model of support (Kettunen & Felt, 2020). Utilising the 4P framework (private-public-people partnership) (Ng et al., 2013) shifts decision-making powers from policy-makers to citizens through bottom-up participatory practices, so ensuring that services effectively meet the needs of those who use them (Kettunen & Felt, 2020).
headspace (National Youth Mental Health Foundation)
headspace, Australia’s innovative youth mental health network, offers a model of care which brings together traditionally separate CYP services into one integrated community-based youth service hub (McGorry et al., 2007; Settipani et al., 2019). Funded by the Australian Federal Government, it was established in 2006 in response to the growing prevalence of mental disorders among adolescents and emerging adults (Rickwood et al., 2019). Targeting 12-25 year olds, headspace aims to break down the barriers to service access experienced by this demographic by providing cohesive early-intervention, low-threshold support (Rickwood et al., 2019) through a network of over 150 centres nationwide.
headspace, an NGO consortium which blends its youth mental health services with research and advocacy (McGorry et al., 2007), came into being after a powerful, high-profile lobbying and advocacy campaign highlighted the importance of youth mental health, and offered this one-stop-shop model as an evidence-based solution (Whiteford et al., 2016). Recognising the need for change, Government policymakers funded the initial ten youth-friendly headspace centres, and substantial block funding from the Federal government continues to be one of the primary sources of funding. This has resulted in headspace transforming the landscape of youth mental healthcare delivery in Australia (Jorm & Kitchener, 2021).
headspace centres provide four key service streams that align with the primary needs and concerns of this age group – mental health, substance use, vocational, and physical health (McGorry et al., 2013; Whiteford et al., 2016). Mental health, being the main health concern, comprises the primary service focus (Rickwood et al., 2019). In recognition of the complexity of adolescent mental health needs which often cannot be met by one service or programme, service integration has formed a large part of the Australian Government’s mental health strategy in recent years (Gallagher, 2009; Hennessy, 2017); the headspace model provides a holistic model of care offering person-centred, timely and targeted support to young people through co-located, multidisciplinary teams (Holloway et al., 2018) in line with current best-practice evidence (Orygen, 2018).
With CYP showing a marked reluctance to seek help for mental health problems, particularly professional help (Plaistow et al., 2014), designing services that are genuinely youth-centric is vital to ensuring they are both responsive and appropriate; youth involvement and participation is therefore a core component of the headspace model (Rickwood et al., 2019). The needs of young people are a key driver of this model, and to ensure its continuing relevance, youth participation occurs at three levels. Firstly, policies and procedures ensure the CYP are enabled to participate in decisions about their own care, which includes a collaborative treatment plan. Secondly, CYP are involved in ongoing service development through centre-specific and national Youth Reference Groups, who input into the design, delivery and evaluation of services. The third level includes young people in the highest level of governance procedures, through attendance at Board meetings and providing input into operational and strategic planning (Rickwood et al., 2019).
Participatory practices
Policy guidance increasingly specifies that participatory practices are required across mental health services, and the views of CYP are a vital component in the development of effective youth programmes and policy (Collins et al., 2017), increasing the likelihood of positive outcomes for systems, organisations, and young people themselves (Halsall et al., 2020). Indeed, Article 12 of the CRC sets out a child’s right to be heard, to have their views taken seriously and integrated into all decisions and services that affect their health and development (Checkoway, 2011; Hunt & Mesquita, 2006; Lansdown, 2001).
As stated by Sigfùsson (2017), “children have the right to have a say about what they want, what they do and how they feel. We have the obligation to make good use of what they tell us, react and constantly try to make their lives better” (p. 25). Larkin et al. (2015), however, argue that the NHS lacks effective mechanisms for translating patient experience into effective change in mental health services. Kelly (2006) goes further to state that the failure to prioritise mental health policy is the result of people with mental illness being systematically excluded from full community participation and political decision-making, due to the negative way mental illness continues to be viewed and treated in our societies.
Despite an increase in youth participatory practices across the UK (Collins et al., 2017), and recognition that CYP have “a body of experience and knowledge that is unique to their situation … and views and ideas as a result of that experience” (Lansdown, 2001, p. 4), mental health reforms seem not to be progressing in line with either government policy or research findings. Young people want an integrated and holistic ‘one-stop-shop’ model that addresses all factors affecting their life and health by bringing together a variety of youth-focussed NHS, public health and charitable sector services in a friendly, accessible, and non-stigmatising venue (Aynsley-Green, 2008; Collins et al., 2017; Department of Health, 2015; Kennedy, 2010; Lavis & Hewson, 2010; Public Health England, 2015). Despite UK policy recommending meaningful and active participation and consultation in commissioning, developing and transforming services, in line with the CRC, Robinson (2010) has concluded that CYP are “consulted but not heard” (p. 323).
Challenges
WHO outlines mental health policy as being vital to the coordination of services, stating that “without adequate policies and plans, mental disorders are likely to be treated in an inefficient and fragmented manner” (WHO, 2005a, p. viii). However, mental health policy and legislation need to look beyond treating illness to reducing morbidity and promoting good mental health, and establishing links with other government departments, including welfare, education and housing (Jenkins, 2003). Further, simply having a policy is not sufficient. No matter how well researched and conceived, without political support and adequate funding to meet its objectives, it will have little chance of success (WHO, 2005a).
High and middle income countries have created expensive and inefficient mental health systems that are neither universal nor allow for meaningful service user involvement (Carbonell et al., 2020). The Global Mental Health Movement has come under increasing criticism for its focus on a narrow biomedical model and the medicalisation of human distress, which has deflected attention from the development of alternative approaches and the need to address the social determinants of health (Dhar, 2020; Pūras, 2019). Embedding service user involvement and co-production is an effective way to create meaningful system improvements that better help people, rather than just treat disease (Damji et al., 2019); it is therefore vital that young people are provided with opportunities and the power to effect change (Collins et al., 2017). Whilst genuine participation can be challenging to implement, this should never be used as justification for failing to involve young people (Collins et al., 2017), and a paradigm shift is required to make participatory practices “easy, intuitive and natural” (Cottam, 2018, p. 46).
There have been criticisms levelled at the headspace model for failing to reduce the reported prevalence of mental disorders in young people despite significant funding (Higgins & Collard, 2019; Jorm & Kitchener, 2021). However, such observations focus largely on clinical recovery, and do not take into account other significant outcomes such as “youth voice in co-design, engagement and patient satisfaction, and accessibility for youth that have been historically marginalised” (Looi et al., 2021, p. 121). Hawke et al.’s (2019) recent literature review also identified that ‘youth-friendly’ services (bright, comfortable and welcoming environments, with individualised and integrated support) increase service uptake and satisfaction. Having visited several headspace centres while in Australia, these elements immediately struck me, with young people sharing their experience of using the service as being non-stigmatising, safe and empowering. Perhaps then headspace has become a victim of its own success with more young people now willing and able to seek help?
Ohjaamo too has been highly successful in reaching young people in need, especially NEETs, but some evidence suggests that the service has been less successful in achieving employment outcomes (OECD, 2019). However, again this quantitative outcome fails to take account of what matters to young people. Young people have consistently rated their experiences as extremely positive, and when visiting Turku OSGC – a cheerful, welcoming and lively place situated on the main high street – young people freely shared their thoughts with me about how the service had helped them in overcoming mental health challenges and social isolation, and in building vocational and life skills. With universal access to services and support that young people can choose according to their preferences and circumstances, Ohjaamo have also significantly reduced stigma and provided a service which young people feel safe and comfortable to use (Kettunen & Felt, 2020).
In both cases, the underlying framework and principles of these models are being applied internationally (Frederiksen, 2020; Rickwood et al., 2019). Whilst large-scale replication can be dangerous (Jenkins, 2003), locally tailored solutions based on existing models can be achieved through taking into account different health systems, funding streams, cultural contexts and youth needs (Rickwood et al., 2019). All countries are “a mixture of developed and developing” (Jenkins, 2003, p. 18) that can learn from each other to address the burden of mental disorder in young people. International cooperation can therefore make an important contribution to the development of effective youth mental health policy (WHO, 2005a).
Conclusion
There is increasing pressure on governments to prioritise the prevention of mental ill health (Funk, 2016), but mental disability cannot be addressed through a purely biomedical, or public health model. Mental health and social inequalities are strongly correlated, and the UK government needs to adopt youth mental health policies which take account of the epidemiology of disorders, and address the causal psychosocial factors through explicit cross-sector collaboration and integration. On a broader level, further policy development and innovative solutions are required to support young people through the transition to adulthood and independence, including those who are economically inactive.
CYP mental health policy is most impactful when underpinned by a framework that relates youth development to an understanding of their human rights. By uniting traditionally fragmented and disparate services into single, youth-friendly entities, and embedding participatory practices, mental health services can align with recovery-focused and rights-based approaches, as advocated by the CRC.
Whilst treatment of youth mental illness is complex and requires significant resources, leaving it untreated is more damaging and expensive. The degree to which this challenge is met is not dependent on legislation and policy alone, but also on creativity and innovation, and a willingness to prioritise young peoples’ futures. One-stop-shop models such as headspace and Ohjaamo are consistently favoured by young people, and considerable research evidence exists to support their implementation and effectiveness. Young people are telling us what they want, but it seems they are not being listening to.
References
Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International review of psychiatry, 26(4), 392-407. https://doi.org/10.3109/09540261.2014.928270
Alston, P. (2019). Visit to the United Kingdom of Great Britain and Northern Ireland. Report of the Special Rapporteur on extreme poverty and human rights. Report No. A/HRC/41/39/Add, 1, 22.
Anthony, W. A. (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial rehabilitation journal, 16(4), 11.
Aynsley-Green, A. (2008). Out of the shadows? A review of the responses to recommendations made in ‘Pushed into the Shadows’: Young people’s experience of adult mental health facilities. In.
Baggio, S., Iglesias, K., Deline, S., Studer, J., Henchoz, Y., Mohler-Kuo, M., & Gmel, G. (2015). Not in education, employment, or training status among young Swiss men. Longitudinal associations with mental health and substance use. Journal of Adolescent health, 56(2), 238-243.
Ballesteros-Urpi, A., Slade, M., Manley, D., & Pardo-Hernandez, H. (2019). Conceptual framework for personal recovery in mental health among children and adolescents: a systematic review and narrative synthesis protocol. BMJ open, 9(8), e029300. https://doi.org/10.1136/bmjopen-2019-029300
Basu, S., & Banerjee, B. (2020). Impact of environmental factors on mental health of children and adolescents: A systematic review. Children and Youth Services Review, 105515. https://doi.org/10.1016/j.childyouth.2020.105515
Bird, V., Leamy, M., Tew, J., Le Boutillier, C., Williams, J., & Slade, M. (2014). Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers. Australian & New Zealand Journal of Psychiatry, 48(7), 644-653.
Burns, J. K. (2009). Mental health and inequity: a human rights approach to inequality, discrimination, and mental disability. Health & Hum. Rts., 11, 19.
Carbonell, A., Navarro‐Pérez, J. J., & Mestre, M. V. (2020). Challenges and barriers in mental healthcare systems and their impact on the family: A systematic integrative review. Health & social care in the community, 28(5), 1366-1379. https://doi.org/10.1111/hsc.12968
Care Quality Commission. (2018). Are we listening? Review of children and young people’s mental health services.
Checkoway, B. (2011). What is youth participation? Children and youth services review, 33(2), 340-345.
Collins, R., Notley, C., Clarke, T., Wilson, J., & Fowler, D. (2017). Participation in developing youth mental health services:“Cinderella service” to service re-design. Journal of Public Mental Health. https://doi.org/10.1108/JPMH-04-2017-0016
Cottam, H. (2018). Radical help: How we can remake the relationships between us and revolutionise the welfare state. Hachette UK.
Damji, A. N., Henriks, G., & Rejler, M. (2019). What is best for Esther? What Canada can learn from the Swedish health care service. MD, MSc, Göran Henriks and Martin Rejler, MD.
Davidson, J. (2008). Children and young people in mind: the final report of the National CAMHS Review. London: Department of Health.
Department of Health. (2010). Achieving Equity and Excellence for Children. Department of Health London
Department of Health. (2011). No health without mental health.
Department of Health. (2014). Closing the gap: Priorities for essential change in mental health. Department of Health London
Department of Health. (2015). Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing.
Dhar, A. (2020). The slippery and the sane: Decolonizing psychology through a study of the Indian girl-child. Feminism & Psychology, 30(3), 391-413. https://doi.org/10.1177/0959353520922419
European Commission. (2021a). Finland: Health and Well-being – Mental Health. Retrieved 22 December from https://national-policies.eacea.ec.europa.eu/youthwiki/chapters/finland/75-mental-health
European Commission. (2021b). Youth Policy in Finland. Retrieved 22 December from https://national-policies.eacea.ec.europa.eu/youthwiki/chapters/finland/overview
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
Frederiksen, N. (2020). Guide – How to Set Up a One Stop Shop: Experiences for the Baltic Sea Region. N. Association. https://www.s2wflagship.eu/wp-content/uploads/2020/03/one-stop-shop_20-kompri-integrate-neets-knowledgeplatform.pdf
Freeman, M., & Pathare, S. (2005). WHO resource book on mental health, human rights and legislation. World Health Organization.
Funk, M. (2016). Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Retrieved on, 30.
Funk, M., & Freeman, M. (2011). Framework and methodology for evaluating mental health policy and plans. The International journal of health planning and management, 26(2), 134-157. https://doi.org/10.1002/hpm.1049
Gallagher, K. (2009). National Mental Health Policy 2008. Australia Retrieved from https://www.health.gov.au/sites/default/files/documents/2020/11/national-mental-health-policy-2008.pdf
Goldman‐Mellor, S., Caspi, A., Arseneault, L., Ajala, N., Ambler, A., Danese, A., . . . Williams, T. (2016). Committed to work but vulnerable: Self‐perceptions and mental health in NEET 18‐year olds from a contemporary British cohort. Journal of Child Psychology and Psychiatry, 57(2), 196-203. https://doi.org/10.1111/jcpp.12459
Gunnell, D., Kidger, J., & Elvidge, H. (2018). Adolescent mental health in crisis. In (Vol. 361): British Medical Journal Publishing Group.
Halfon, R., & Wollaston, S. (2018). The Government’s Green Paper on mental health: failing a generation. House of Commons
Halsall, T., Lachance, L., & Kristjansson, A. L. (2020). Examining the implementation of the Icelandic model for primary prevention of substance use in a rural Canadian community: a study protocol. BMC public health, 20(1), 1-10. https://doi.org/10.1186/s12889-020-09288-y
Hancock, M., & Hinds, D. (2017). Transforming children and young people’s mental health provision: A green paper. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf
Hawke, L. D., Mehra, K., Settipani, C., Relihan, J., Darnay, K., Chaim, G., & Henderson, J. (2019). What makes mental health and substance use services youth friendly? A scoping review of literature. BMC health services research, 19(1), 1-16. https://doi.org/10.1186/s12913-019-4066-5
Henley, J. (2018). Safe, happy and free: does Finland have all the answers? The Guardian. https://www.theguardian.com/world/2018/feb/12/safe-happy-and-free-does-finland-have-all-the-answers
Hennessy, J. (2017). The Fifth National Mental Health and Suicide Prevention Plan. Australia Retrieved from https://www.mentalhealthcommission.gov.au/getmedia/0209d27b-1873-4245-b6e5-49e770084b81/Fifth-National-Mental-Health-and-Suicide-Prevention-Plan
Hickman, C., Marks, E., Pihkala, P., Clayton, S., Lewandowski, R. E., Mayall, E. E., . . . van Susteren, L. (2021). Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. The Lancet Planetary Health, 5(12), e863-e873.
Higgins, I., & Collard, S. (2019). Headspace is ‘easy for politicians’, but failing Australia’s youth, experts say.
Holloway, E. M., Rickwood, D., Rehm, I. C., Meyer, D., Griffiths, S., & Telford, N. (2018). Non-participation in education, employment, and training among young people accessing youth mental health services: demographic and clinical correlates. Advances in Mental Health, 16(1), 19-32.
Hunt, J., Allan, L., Bristow, P., Cooper, R., & Evans, P. (2021). Children and young people’s mental health. House of Commons Retrieved from https://committees.parliament.uk/publications/8153/documents/83622/default/
Hunt, P., & Mesquita, J. (2006). Mental disabilities and the human right to the highest attainable standard of health. Hum. Rts. Q., 28, 332.
Innocenti, U. (2020). Worlds of Influence: Understanding what shapes child well-being in rich countries. Innocenti Report Card, 16.
Jenkins, R. (2003). Supporting governments to adopt mental health policies. World Psychiatry, 2(1), 14.
Jorm, A. F., & Kitchener, B. A. (2021). Increases in youth mental health services in Australia: Have they had an impact on youth population mental health? Australian & New Zealand Journal of Psychiatry, 55(5), 476-484. https://doi.org/10.1177/0004867420976861
Kelly, B. D. (2006). The power gap: Freedom, power and mental illness. Social Science & Medicine, 63(8), 2118-2128. https://doi.org/10.1016/j.socscimed.2006.05.015
Kelly, M., & Coughlan, B. (2019). A theory of youth mental health recovery from a parental perspective. Child & Adolescent Mental Health, 24(2), 161-169. https://doi.org/10.1111/camh.12300
Kennedy, I. (2010). Getting it right for children and young people: overcoming cultural barriers in the NHS so as to meet their needs.
Kettunen, J., & Felt, T. (2020). One-stop guidance service centres in Finland. In Career and career guidance in the Nordic countries (pp. 293-306). Brill Sense. https://doi.org/10.1163/9789004428096_020
Lansdown, G. (2001). Promoting children’s participation in democratic decision-making.
Lantta, T., Anttila, M., & Välimäki, M. (2021). Quality of mental health services and rights of people receiving treatment in inpatient services in Finland: a cross-sectional observational survey with the WHO QualityRights Tool Kit. International Journal of Mental Health Systems, 15(1), 1-15. https://doi.org/10.1186/s13033-021-00495-7
Larkin, M., Boden, Z. V. R., & Newton, E. (2015). On the brink of genuinely collaborative care: experience-based co-design in mental health. Qualitative health research, 25(11), 1463-1476.
Lavis, P., & Hewson, L. (2010). How many times do we have to tell you. Young Minds Magazine, 109, 30-31.
Law, H., Gee, B., Dehmahdi, N., Carney, R., Jackson, C., Wheeler, R., . . . Clarke, T. (2020). What does recovery mean to young people with mental health difficulties?–“It’s not this magical unspoken thing, it’s just recovery”. Journal of Mental Health, 29(4), 464-472. https://doi.org/10.1080/09638237.2020.1739248
Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445-452.
Looi, J. C. L., Allison, S., Bastiampillai, T., & Kisely, S. R. (2021). headspace, an Australian youth mental health network: Lessons for Canadian mental healthcare. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 30(2), 116.
Maguire, S. (2021). Early leaving and the NEET agenda across the UK. Journal of Education and Work, 1-13. https://doi.org/10.1080/13639080.2021.1983525
Mann, S. P., Bradley, V. J., & Sahakian, B. J. (2016). Human rights-based approaches to mental health: A review of programs. Health and human rights, 18(1), 263.
Marmot, M. (2020). Health equity in England: the Marmot review 10 years on. Bmj, 368.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., & Geddes, I. (2010). The Marmot review: Fair society, healthy lives. Strategic review of health inequalities in England post-2010. London: The Marmot Review.
Mascherini, M., Ledermaier, S., Vacas-Soriano, C., & Jacobs, L. (2017). Long-term unemployed youth: Characteristics and policy responses.
McGorry, P. (2013). Prevention, innovation and implementation science in mental health: the next wave of reform. The British Journal of Psychiatry, 202(s54), s3-s4. https://doi.org/10.1192/bjp.bp.112.119222
McGorry, P., Bates, T., & Birchwood, M. (2013). Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. The British Journal of Psychiatry, 202(s54), s30-s35. https://doi.org/10.1192/bjp.bp.112.119214
McGorry, P. D., & Mei, C. (2018). Tackling the youth mental health crisis across adolescence and young adulthood. BMJ: British Medical Journal (Online), 362. https://doi.org/10.1136/bmj.k3704
McGorry, P. D., Tanti, C., Stokes, R., Hickie, I. B., Carnell, K., Littlefield, L. K., & Moran, J. (2007). headspace: Australia’s National Youth Mental Health Foundation—where young minds come first. Medical Journal of Australia, 187(S7), S68-S70. https://doi.org/10.5694/j.1326-5377.2007.tb01342.x
Mental Health Taskforce. (2016). The five year forward view for mental health. London
Ministry of Education and Culture. (2017). Youth Act 2017. Helsinki, Finland Retrieved from https://okm.fi/documents/1410845/4276311/Youth+Act+2017/c9416321-15d7-4a32-b29a-314ce961bf06/Youth+Act+2017.pdf?t=1503558225000
Ministry of Education and Culture. (2020). The National youth work and youth policy programme 2020–2023. Helsinki, Finland Retrieved from https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/162381/OKM_2020_4.pdf?sequence=1&isAllowed=y
Ministry of Education and Culture. (2021). Policies and development related to youth affairs. Helsinki, Finland Retrieved from https://okm.fi/en/policies-and-development-youth
Ng, S. T., Wong, J. M. W., & Wong, K. K. W. (2013). A public private people partnerships (P4) process framework for infrastructure development in Hong Kong. Cities, 31, 370-381. https://doi.org/10.1016/j.cities.2012.12.002
NSPCC. (2021). Child mental health – Legislation and guidance. Retrieved 22 December from https://learning.nspcc.org.uk/child-health-development/child-mental-health#:~:text=Key%20legislation&text=It%20applies%20to%20all%20children,the%20Mental%20Health%20Act%202007
Nussbaum, M. C. (2001). Women and human development: The capabilities approach. Cambridge University Press.
OECD. (2019). Investing in Youth: Finland (Investing in Youth, Issue.
OECD. (2021). What have countries done to support young people in the COVID-19 crisis? (2708-0676).
Oldham, M., Livingston, M., Whitaker, V., Callinan, S., Fairbrother, H., Curtis, P., . . . Holmes, J. (2021). Trends in the psychosocial characteristics of 11–15‐year‐olds who still drink, smoke, take drugs and engage in poly‐substance use in England. Drug and Alcohol Review, 40(4), 597-606. https://doi.org/10.1111/dar.13201
Orygen. (2018). Youth mental health service models and approaches: Considerations for primary care. https://www.orygen.org.au/About/Service-Development/Youth-Enhanced-Services-National-Programs/Primary-Health-Network-resources/Youth-mental-health-service-models-and-approaches/Youth-mental-health-service-models-and-approaches?ext=
Parker, C. (2007). Children and Young People and the Mental Health Act 2007. November 2007 J. Mental Health L., 174.
Parker, K. (2021). Mental health conditions triple for Neet young people. tes magazine.
Parkin, E., & Long, R. (2021). Support for children and young people’s mental health.
Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: a global public-health challenge. The Lancet, 369(9569), 1302-1313. https://doi.org/10.1016/S0140-6736(07)60368-7
Plaistow, J., Masson, K., Koch, D., Wilson, J., Stark, R. M., Jones, P. B., & Lennox, B. R. (2014). Young people’s views of UK mental health services. Early intervention in psychiatry, 8(1), 12-23. https://doi.org/10.1111/eip.12060
Public Health England. (2015). Improving Young People’s Health and Well-Being: A Framework for Public Health. London: Public Health England
Public Health England. (2021). Young people’s substance misuse treatment statistics 2019 to 2020: report. P. H. England. https://www.gov.uk/government/statistics/substance-misuse-treatment-for-young-people-statistics-2019-to-2020/young-peoples-substance-misuse-treatment-statistics-2019-to-2020-report
Pūras, D. (2019). Open Statement by the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Removing obstacles to liveable lives: A rights-based approach to suicide prevention. https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=25117&LangID=E ]
Rashford, M. (2021). #endchildfoodpoverty. Retrieved 17 December from https://endchildfoodpoverty.org/
Reiss, F. (2013). Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Social science & medicine, 90, 24-31. https://doi.org/10.1016/j.socscimed.2013.04.026
Rickwood, D., Paraskakis, M., Quin, D., Hobbs, N., Ryall, V., Trethowan, J., & McGorry, P. (2019). Australia’s innovation in youth mental health care: the headspace centre model. Early Intervention in Psychiatry, 13(1), 159-166. https://doi.org/10.1111/eip.12740
Robeyns, I. (2005). The capability approach: a theoretical survey. Journal of human development, 6(1), 93-117.
Robinson, S. (2010). Children and young people’s views of health professionals in England. Journal of Child Health Care, 14(4), 310-326.
Rosa, G. (2018). Using children’s rights in mental health policy and practice. http://www.crae.org.uk/media/125976/mentalhealth-briefing-final-digital-version-.pdf
Savolainen, J. (2017). One-stop-shop guidance centres for young people (Ohjaamo).
Scott, J., Fowler, D., McGorry, P., Birchwood, M., Killackey, E., Christensen, H., . . . Nordentoft, M. (2013). Adolescents and young adults who are not in employment, education, or training. In (Vol. 347): British Medical Journal Publishing Group.
Sen, A. (1993). Capability and well-being73. The quality of life, 30, 270-293.
Seppänen, A., & Eronen, M. (2012). Mental health law in Finland. International Psychiatry, 9(4), 91-93. https://doi.org/10.1192/S1749367600003398
Settipani, C. A., Hawke, L. D., Cleverley, K., Chaim, G., Cheung, A., Mehra, K., . . . Henderson, J. (2019). Key attributes of integrated community-based youth service hubs for mental health: a scoping review. International Journal of Mental Health Systems, 13(1), 1-26.
Shahzad, M., Upshur, R., Donnelly, P., Bharmal, A., Wei, X., Feng, P., & Brown, A. D. (2019). A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration. BMC public health, 19(1), 1-15. https://doi.org/10.1186/s12889-019-7002-z
Sigfùsson, J. (2017). Evidence based primary prevention. 20 years of success Iceland, ICSRA. http://www.ecad.net/images/ECAD_documents/Activities_in_member_cities/Kaunas_2017/Evidence_-based_primary_prevention_-_ICSRA.pdf
Skogen, J. C., Sivertsen, B., Lundervold, A. J., Stormark, K. M., Jakobsen, R., & Hysing, M. (2014). Alcohol and drug use among adolescents: and the co-occurrence of mental health problems. Ung@ hordaland, a population-based study. BMJ open, 4(9), e005357. https://doi.org/10.1136/bmjopen-2014-005357
Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., . . . Whitley, R. (2014). Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems. World Psychiatry, 13(1), 12-20.
Sorsa, K. (2019). The youth guarantee and one-stop-guidance centers as a social innovation and a policy implementation tool in Finland. Implementing innovative social investment: Strategic lessons from Europe, 83-96. https://doi.org/10.1332/policypress/9781447347828.003.0005
Stastny, P., Lovell, A. M., Hannah, J., Goulart, D., Vasquez, A., O’callaghan, S., & Pūras, D. (2020). Crisis response as a human rights flashpoint: Critical elements of community support for individuals experiencing significant emotional distress. Health and Human Rights, 22(1), 105.
Unicef. (1989). United Nations Convention on the Rights of the Child.
Unicef. (2021). Discussion Paper. A Rights-Based Approach to Disability in the Context of Mental Health. https://www.unicef.org/media/95836/file/A%20Rights-Based%20Approach%20to%20Disability%20in%20the%20Context%20of%20Mental%20Health.pdf
Välimaa, R., Kannas, L., Lahtinen, E., Peltonen, H., Tynjälä, J., & Villberg, J. (2008). Finland: innovative health education curriculum and other investments for promoting mental health and social cohesion among children and young people. Social cohesion for mental well-being among adolescents. Copenhagen: WHO Regional Office for Europe, 91-103.
Whiteford, H. A., Meurk, C., Carstensen, G., Hall, W., Hill, P., & Head, B. W. (2016). How did youth mental health make it onto Australia’s 2011 federal policy agenda? Sage Open, 6(4), 2158244016680855. https://doi.org/10.1177/2158244016680855
WHO. (2005a). Mental Health Policy and Service Guidance Package: Child and Adolescent Mental Health Policies and Plans. https://www.who.int/mental_health/policy/Childado_mh_module.pdf
WHO. (2005b). Mental health policy, plans and programmes (9241546468).
WHO. (2014a). Adolescence: A period needing special attention (Health for the World’s Adolescents: A second chance in the second decade, Issue.
WHO. (2014b). Mental Health Legislation and Human Rights. 2003.
Wu, J., Snell, G., & Samji, H. (2020). Climate anxiety in young people: a call to action. The Lancet Planetary Health, 4(10), e435-e436.
Youth Access. (2017). Young, adult – and ignored (Getting a fair deal for 16-24 year olds from mental health services, Issue.
Yung, A. R., Cotter, J., & McGorry, P. D. (2020). Youth Mental Health: Approaches to Emerging Mental Ill-health in Young People. Routledge.
Zigmond, A. (2017). Mental Illness, Human Rights and the Law By Brendan D. Kelly. RCPsych Publications. 2016.£ 40.00 (hb). 272 pp. ISBN 9781909726512. The British Journal of Psychiatry, 211(1), 56-56.
Debbie Frances BLOG 