8 ms·

Do no harm: can school mental health interventions cause iatrogenic harm? [pdf]

81 points by bumbledraven 4y ago

PaulHoule 4y ago
In my mind both CBT and ‘mindfulness’ can be pernicious. (Like that time I was suffering from asthma and anxiety at the same time and the last thing I wanted to do was pay attention to my breath.)
- renewedrebecca 4y ago
  Just about any time I've tried to pay attention to my breathing, my heart rate goes up, so I totally get where you're coming from here.
  - arrosenberg 4y ago
    Are you rapidly mouth-breathing? The point of focusing on it is to make sure you are doing slow, steady nose-breathing. Slow nose-breathing causes your body to produce calming biochemical signals (for most people).
    - PaulHoule 4y ago
      I would point to this as a practice that works, it is about controlling the breath instead of observing it https://help.welltory.com/en/articles/3973614-long-exhale-for-parasympathetic-nervous-system-activation https://help.welltory.com/en/articles/3973614-long-exhale-fo... I was taught this method first at a Kempo Karate dojo in the late 1980s, it was also in Yoga books. It is associated with https://en.wikipedia.org/wiki/Vagal_tone#Respiratory_sinus_arrhythmia https://en.wikipedia.org/wiki/Vagal_tone#Respiratory_sinus_a... and well established scientifically today.
    - renewedrebecca 4y ago
      Nope, slow nose-breathing. There's a few things that my body does that are kind of the exact opposite of what is supposed to happen, so I don't worry too much about it.
- KennyBlanken 4y ago
  Focused breathing (which is not "mindfulness") is a technique for centering oneself and drawing focus to the sensations of breathing, instead of whatever is stressing you out, such as pain or emotions that have become overwhelming. If you're having an asthma attack, then of course focusing on breathing won't help, because the breathing issues are what's stressing you out. Whenever I've seen focused breathing, literally never have I seen "and it's great for people having an asthma attack!" Filling up your car with gas is normal and necessary. Would you still try to fill up your car with gas if it were on fire? And then complain that filling up one's car with gas is dangerous and didn't help that one time your car was on fire?
htag 4y ago
There's a body of evidence that some adults that practice mediation will have anxiety or depression worsen instead of improve (~10-25% depending on the study). Even this simple activity with thousands of years of history is not well understood and can do harm. Other interventions have even less history. One thing about being an adult is that if mindfulness increases your anxiety you can choose not to practice it. Children are often forced into mental health interventions by schools. Imagine being compelled into doing something that worsens your mental health by someone trying to improve your mental health. The authors are correct that we should be selective about which students get which treatments. Often these are applied more broadly than is appropriate. The authors make no claim about the size of the impact of this practice, or the number of students negatively impacted. Note: I'm from the US, the paper specifically comments on the UK education system.
- savingsPossible 4y ago
  I'll look into google scholar, but do you happen to have a good source?
concinds 4y ago
Paper says that for some kids, CBT and mindfulness can increase negative symptoms, or have no effect. Not surprising, because they don't address the fundamental issues. Why would mindfulness help with depression, better than teaching these kids how to grieve in an effective, healthy way? CBT can be helpful, but it 'intellectualizes' problems too much. How about teaching these kids how to increase their self-confidence? How to identify their emotional needs? How to build their social skills, resolve conflicts in relationships, and assert their personal boundaries? Most sure aren't learning that from their parents. These interventions are far too superficial to obtain the intended results. I'll be pointlessly provocative now: they almost seem intended so that teachers/interveners can avoid having to deal head-on, one-on-one, with their students' "messy" emotions. No need for school adults to have empathic, difficult conversations with kids whose parents are undergoing a divorce. Instead, just teach the kids (as a group) how to intellectualize their emotions, or distance themselves from them. It minimizes the role of teachers and other trusted adults as a social support system, it places the onus on kids to "fix themselves", and it downplays the importance of emotions in causing these problems in the first place. It makes things very impersonal. Imagine if sex-ed classes were founded on Victorian notions of decency, would they be of any help? It concerns me that so many intelligent, thoughtful scientists are barking up the wrong trees. If they refocused their efforts, they could be far more effective.
- deleted 4y ago
  [deleted]
- narwally 4y ago
  > CBT can be helpful, but it 'intellectualizes' problems too much. How about teaching these kids how to increase their self-confidence? How to identify their emotional needs? How to build their social skills, resolve conflicts in relationships, and assert their personal boundaries? Most sure aren't learning that from their parents. All the things you listed are already directly addressed within CBT.
  - concinds 4y ago
    I received CBT, and that's not my experience. Learning the thought patterns involved in these behaviors is different from learning the underlying skills needed to improve those behaviors. Just like reflecting on the thought patterns behind piano-playing won't help me play the piano. It might help me improve the way I practice, but it doesn't teach me what to do with the keys. And CBT frames emotions as being caused by thought-patterns, when the causality is not quite that "clean". I'm not rejecting CBT's usefulness. It's a good tool. But I found it better at improving symptom management than at addressing underlying problems.
MollyRealized 4y ago
For those who want to know what 'iatrogenic' means prior to dipping further into this thread: "Induced unintentionally in a patient by a physician. Used especially of an infection or other complication of treatment." Basically: is it causing the very thing the intervention is intended to help.
- woodruffw 4y ago
  At the risk of nitpicking: iatrogensis isn't confined to the very thing the intervention intends to address; it can be any condition induced at the cost of treatment. Blinding a patient during eye surgery to remove a tumor is an iatrogenic outcome, for example.
  - narwally 4y ago
    Would that also include side affects from medications?
    - woodruffw 4y ago
      Yes. Iatrogenesis doesn't imply an overall negative outcome: livesaving medications and treatments can have iatrogenic consequences that are outweighed by their intended, positive ones (or vice versa).
mkl95 4y ago
The elephant in the room is that schoolchildren are not empowered to solve their issues. If I'm having a rough day I can let my employer know and take some time off, or quit my job if I have had enough. There's no such flexibility when you are a kid, you are expected to show up and do your time unless you have some strong, tangible proof you are unable to. Iatrogenic harm could be as simple as exposing this fact to the patient, who is trying their best to ignore it. Nobody wants to be reminded they are a virtual slave.
- version_five 4y ago
  > If I'm having a rough day I can let my employer know and take some time off, or quit my job if I have had enough I'm lucky enough to be in the same position but I don't think that's how it works for > 90% of the adult world.
  - em-bee 4y ago
    i think it could work like that for many but most don't have the courage to ask. frankly a company where it doesn't work like that is not a healthy work environment to begin with. (like some examples discussed here: https://news.ycombinator.com/item?id=35032286 https://news.ycombinator.com/item?id=35032286 )
    - krageon 4y ago
      Most physical labour (construction, but also work in harbours etc) just doesn't work this way. Perhaps that's not a healthy work environment, but if it is the only way you can earn the money that feeds you and perhaps your family why does that matter?
      - em-bee 4y ago
        well, it does seem to matter because since covid more and more people refuse to work in such conditions.
psychphysic 4y ago
Maybe it's too much to ask that every intervention is pure perfection with nothing but good results. Afterall, people have choked to death on salads.
- chmod600 4y ago
  Is there rigorous evidence that these treatments do more good than harm?
  - psychphysic 4y ago
    I doubt it.
jjtheblunt 4y ago
This headline is a counterexample to Betteridge's Law of Headlines. https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headlines https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...
AlbertCory 4y ago
I can totally believe that middle schools' and high schools' intervention for mental health causes harm, and often. Do not ask for citations on this because I don't have them. Whether the harm outweighs the good is up for debate. In very affluent neighborhoods, lots of the kids are in therapy already. In lower-middle class or poor neighborhoods, the kids are probably resistant to it and it is, indeed, stigmatizing. So how much good can it possibly do?
- faeriechangling 4y ago
  I complain about the fact we don't have data on this one way or another but we fund it.
ggm 4y ago
How can you tell in advance? Whats the iatrogenic rate for use of SSRI and other interventions? "first do no harm" carries huge burdens. Sometimes, harm is unavoidable because doing nothing itself represents the potential for harm to emerge and if its a conscious choice, you did something: you decided not to do something else.
Animats 4y ago
That paper is somewhat vague. I get the impression that they're talking around something, but I'm not familiar enough with the field to know what they're talking around.
PragmaticPulp 4y ago
The authors hypothesize that for some children, framing their struggles as mental health disorders that require treatment can actually worsen their situation by causing them to ruminate on it. Anecdotally, this isn’t limited to adolescents. There is a weird trend toward over-diagnosing common life struggles as major clinical health issues requiring intervention. I think this comes from a place of good intentions, where people don’t want to miss anyone who might have a major mental health issue that will benefit from treatment. However, over-diagnosing mental health conditions and convincing kids they even common struggles are actually mental health issues that require advanced treatment techniques has the opposite effect of amplifying common struggles into something much bigger. There’s a secondary phenomenon in some demographics wherein having a mental health diagnosis is perceived as providing some social advantage, as weird as that sounds. This isn’t just conjecture, it’s actual policy in some schools. It’s well-known among kids that having an ADHD diagnosis will grant people extra time to take tests in some schools, which becomes a cheat code for getting a leg up. I’ve also witnessed young adults swapping tips on how to say the right things to get certain mental health diagnoses and get specific drugs: Xanax for anxiety, etc. They were even swapping names of doctors and notes about who was more lenient about prescribing certain drugs in a Slack community. Coming up with rules to stop that behavior without triggering complaints about stigmatizing mental illness was a challenge.
- naasking 4y ago
  > The authors hypothesize that for some children, framing their struggles as mental health disorders that require treatment can actually worsen their situation by causing them to ruminate on it. Not just to children, just in general, the narratives we use to interpret the things that happen to us can actually cause more harm than the event itself. Simplistic example, but take a culture where scars are a mark of pride, say from surviving battle, compared to one where they are seen as ugly and so shameful. The physical harm in each case is the same, but the mental impact is very different. We even see this in trauma, like with sexual assault. Being pitied and told something that happened to you was the worst thing that can possibly happen to someone, it makes a far worse mental impact than it otherwise might have made without that framing. There are a number of reasons for this, but I think in general, disempowering people by removing their sense of control and the notion that they're resilient becomes something of a self-fulfilling prophecy. Sometimes, some people really are less resilient or lose their sense of control in some circumstances, and then they do need that help, but that should probably not be the default approach. We've had a bit too much of an over correction to the old, "suck it up and walk it off" mentality.
Euphorbium 4y ago
The same is true for psychedellic therapy.
chmod600 4y ago
As the headline is phrased, the answer is almost certainly "yes". Even if you have an objective diagnosis and a rigorously developed treatment, you'd expect far less than 100% success; and you'd also expect side effects and other harm that happens with almost any treatment. Given that mental health is much less rigorous than some other areas of medicine (because it's hard to make it rigorous), then its compounded by misdiagnosis and treatments where we don't understand the effects.
faeriechangling 4y ago
Oh boy this is just scratching the surface. I would go a LOT further and say the ENTIRE scholastic mental health system is a sham and a massive source of iatrogenic harm that students and teachers are pressured into in order to get more favourable treatment by the schools and government assistance, whereas the schools themselves get more government funding and lowered scrutiny in regards to standardised testing. How can mental health treatment in schools NOT cause harm with such perverse incentives? I had a particularly fraudulent school psychiatrist. When my IQ tested low enough, my IQ score was reported. When my IQ tested too high, it was censored on the grounds of being "misleading". Parental and teacher evidence was submitted to justify further mental health interventions which was grossly fraudulent (I was portrayed as unable to dress or feed myself) and a cursory 5 minute examination of me would have revealed this. One of the most disgusting things they did was pull me out of gym classes to spend more time sitting in a room with special needs teachers who occasionally nagged me to use a planner and do my homework. Exercise you know, being an extremely evidence based intervention for mental health, unlike whatever that shit was. Being treated as mentally ill and being perceived that way by myself and my peers did nothing to help me, especially since it only helped to reinforce the idea that the lifelong physical health problems which got worse during my school years were nothing but "anxiety" and that consequent declines in my mental health could be attributed to my earlier mental health issues and all the medical fraud helped to confuse the shit out of doctors. I think the mental health system is a sham and that it doesn't have proof it treats the problems it claims to treat, and if anything the rise of suicidality over the last few decades as scholastic mental health has become more common as well as increases in self-reported, parent-reported, teacher-reported, and physician-reported mental health problems among students proves its somewhere between totally impotent and actively harmful. The final goal of increased mental health interventions is not getting to a point where nobody is sick anymore, it's to create more patients. The biggest thing that pisses me off is that it's rarely measured if scholastic mental health interventions work, they are just ASSUMED to be positive without evidence. Nobody gives a crap about iatrogenic effects. The episode of King of the Hill "No Bobby Left Behind" speaks to me: https://kingofthehill.fandom.com/wiki/No_Bobby_Left_Behind https://kingofthehill.fandom.com/wiki/No_Bobby_Left_Behind

81 points by bumbledraven 4y ago

In my mind both CBT and ‘mindfulness’ can be pernicious. (Like that time I was suffering from asthma and anxiety at the same time and the last thing I wanted to do was pay attention to my breath.)

renewedrebecca 4y ago
Just about any time I've tried to pay attention to my breathing, my heart rate goes up, so I totally get where you're coming from here.
- arrosenberg 4y ago
  Are you rapidly mouth-breathing? The point of focusing on it is to make sure you are doing slow, steady nose-breathing. Slow nose-breathing causes your body to produce calming biochemical signals (for most people).
  - PaulHoule 4y ago
    I would point to this as a practice that works, it is about controlling the breath instead of observing it https://help.welltory.com/en/articles/3973614-long-exhale-for-parasympathetic-nervous-system-activation https://help.welltory.com/en/articles/3973614-long-exhale-fo... I was taught this method first at a Kempo Karate dojo in the late 1980s, it was also in Yoga books. It is associated with https://en.wikipedia.org/wiki/Vagal_tone#Respiratory_sinus_arrhythmia https://en.wikipedia.org/wiki/Vagal_tone#Respiratory_sinus_a... and well established scientifically today.
  - renewedrebecca 4y ago
    Nope, slow nose-breathing. There's a few things that my body does that are kind of the exact opposite of what is supposed to happen, so I don't worry too much about it.
KennyBlanken 4y ago
Focused breathing (which is not "mindfulness") is a technique for centering oneself and drawing focus to the sensations of breathing, instead of whatever is stressing you out, such as pain or emotions that have become overwhelming. If you're having an asthma attack, then of course focusing on breathing won't help, because the breathing issues are what's stressing you out. Whenever I've seen focused breathing, literally never have I seen "and it's great for people having an asthma attack!" Filling up your car with gas is normal and necessary. Would you still try to fill up your car with gas if it were on fire? And then complain that filling up one's car with gas is dangerous and didn't help that one time your car was on fire?

htag 4y ago

There's a body of evidence that some adults that practice mediation will have anxiety or depression worsen instead of improve (~10-25% depending on the study). Even this simple activity with thousands of years of history is not well understood and can do harm. Other interventions have even less history. One thing about being an adult is that if mindfulness increases your anxiety you can choose not to practice it. Children are often forced into mental health interventions by schools. Imagine being compelled into doing something that worsens your mental health by someone trying to improve your mental health. The authors are correct that we should be selective about which students get which treatments. Often these are applied more broadly than is appropriate. The authors make no claim about the size of the impact of this practice, or the number of students negatively impacted. Note: I'm from the US, the paper specifically comments on the UK education system.

savingsPossible 4y ago
I'll look into google scholar, but do you happen to have a good source?

concinds 4y ago

Paper says that for some kids, CBT and mindfulness can increase negative symptoms, or have no effect. Not surprising, because they don't address the fundamental issues. Why would mindfulness help with depression, better than teaching these kids how to grieve in an effective, healthy way? CBT can be helpful, but it 'intellectualizes' problems too much. How about teaching these kids how to increase their self-confidence? How to identify their emotional needs? How to build their social skills, resolve conflicts in relationships, and assert their personal boundaries? Most sure aren't learning that from their parents. These interventions are far too superficial to obtain the intended results. I'll be pointlessly provocative now: they almost seem intended so that teachers/interveners can avoid having to deal head-on, one-on-one, with their students' "messy" emotions. No need for school adults to have empathic, difficult conversations with kids whose parents are undergoing a divorce. Instead, just teach the kids (as a group) how to intellectualize their emotions, or distance themselves from them. It minimizes the role of teachers and other trusted adults as a social support system, it places the onus on kids to "fix themselves", and it downplays the importance of emotions in causing these problems in the first place. It makes things very impersonal. Imagine if sex-ed classes were founded on Victorian notions of decency, would they be of any help? It concerns me that so many intelligent, thoughtful scientists are barking up the wrong trees. If they refocused their efforts, they could be far more effective.

deleted 4y ago
[deleted]
narwally 4y ago
> CBT can be helpful, but it 'intellectualizes' problems too much. How about teaching these kids how to increase their self-confidence? How to identify their emotional needs? How to build their social skills, resolve conflicts in relationships, and assert their personal boundaries? Most sure aren't learning that from their parents. All the things you listed are already directly addressed within CBT.
- concinds 4y ago
  I received CBT, and that's not my experience. Learning the thought patterns involved in these behaviors is different from learning the underlying skills needed to improve those behaviors. Just like reflecting on the thought patterns behind piano-playing won't help me play the piano. It might help me improve the way I practice, but it doesn't teach me what to do with the keys. And CBT frames emotions as being caused by thought-patterns, when the causality is not quite that "clean". I'm not rejecting CBT's usefulness. It's a good tool. But I found it better at improving symptom management than at addressing underlying problems.

MollyRealized 4y ago

For those who want to know what 'iatrogenic' means prior to dipping further into this thread: "Induced unintentionally in a patient by a physician. Used especially of an infection or other complication of treatment." Basically: is it causing the very thing the intervention is intended to help.

woodruffw 4y ago
At the risk of nitpicking: iatrogensis isn't confined to the very thing the intervention intends to address; it can be any condition induced at the cost of treatment. Blinding a patient during eye surgery to remove a tumor is an iatrogenic outcome, for example.
- narwally 4y ago
  Would that also include side affects from medications?
  - woodruffw 4y ago
    Yes. Iatrogenesis doesn't imply an overall negative outcome: livesaving medications and treatments can have iatrogenic consequences that are outweighed by their intended, positive ones (or vice versa).

mkl95 4y ago

The elephant in the room is that schoolchildren are not empowered to solve their issues. If I'm having a rough day I can let my employer know and take some time off, or quit my job if I have had enough. There's no such flexibility when you are a kid, you are expected to show up and do your time unless you have some strong, tangible proof you are unable to. Iatrogenic harm could be as simple as exposing this fact to the patient, who is trying their best to ignore it. Nobody wants to be reminded they are a virtual slave.

version_five 4y ago
> If I'm having a rough day I can let my employer know and take some time off, or quit my job if I have had enough I'm lucky enough to be in the same position but I don't think that's how it works for > 90% of the adult world.
- em-bee 4y ago
  i think it could work like that for many but most don't have the courage to ask. frankly a company where it doesn't work like that is not a healthy work environment to begin with. (like some examples discussed here: https://news.ycombinator.com/item?id=35032286 https://news.ycombinator.com/item?id=35032286 )
  - krageon 4y ago
    Most physical labour (construction, but also work in harbours etc) just doesn't work this way. Perhaps that's not a healthy work environment, but if it is the only way you can earn the money that feeds you and perhaps your family why does that matter?
    - em-bee 4y ago
      well, it does seem to matter because since covid more and more people refuse to work in such conditions.

psychphysic 4y ago

Maybe it's too much to ask that every intervention is pure perfection with nothing but good results. Afterall, people have choked to death on salads.

chmod600 4y ago
Is there rigorous evidence that these treatments do more good than harm?
- psychphysic 4y ago
  I doubt it.

jjtheblunt 4y ago

This headline is a counterexample to Betteridge's Law of Headlines. https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headlines https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...

AlbertCory 4y ago

I can totally believe that middle schools' and high schools' intervention for mental health causes harm, and often. Do not ask for citations on this because I don't have them. Whether the harm outweighs the good is up for debate. In very affluent neighborhoods, lots of the kids are in therapy already. In lower-middle class or poor neighborhoods, the kids are probably resistant to it and it is, indeed, stigmatizing. So how much good can it possibly do?

faeriechangling 4y ago
I complain about the fact we don't have data on this one way or another but we fund it.

ggm 4y ago

How can you tell in advance? Whats the iatrogenic rate for use of SSRI and other interventions? "first do no harm" carries huge burdens. Sometimes, harm is unavoidable because doing nothing itself represents the potential for harm to emerge and if its a conscious choice, you did something: you decided not to do something else.

Animats 4y ago

That paper is somewhat vague. I get the impression that they're talking around something, but I'm not familiar enough with the field to know what they're talking around.

PragmaticPulp 4y ago

The authors hypothesize that for some children, framing their struggles as mental health disorders that require treatment can actually worsen their situation by causing them to ruminate on it. Anecdotally, this isn’t limited to adolescents. There is a weird trend toward over-diagnosing common life struggles as major clinical health issues requiring intervention. I think this comes from a place of good intentions, where people don’t want to miss anyone who might have a major mental health issue that will benefit from treatment. However, over-diagnosing mental health conditions and convincing kids they even common struggles are actually mental health issues that require advanced treatment techniques has the opposite effect of amplifying common struggles into something much bigger. There’s a secondary phenomenon in some demographics wherein having a mental health diagnosis is perceived as providing some social advantage, as weird as that sounds. This isn’t just conjecture, it’s actual policy in some schools. It’s well-known among kids that having an ADHD diagnosis will grant people extra time to take tests in some schools, which becomes a cheat code for getting a leg up. I’ve also witnessed young adults swapping tips on how to say the right things to get certain mental health diagnoses and get specific drugs: Xanax for anxiety, etc. They were even swapping names of doctors and notes about who was more lenient about prescribing certain drugs in a Slack community. Coming up with rules to stop that behavior without triggering complaints about stigmatizing mental illness was a challenge.

naasking 4y ago
> The authors hypothesize that for some children, framing their struggles as mental health disorders that require treatment can actually worsen their situation by causing them to ruminate on it. Not just to children, just in general, the narratives we use to interpret the things that happen to us can actually cause more harm than the event itself. Simplistic example, but take a culture where scars are a mark of pride, say from surviving battle, compared to one where they are seen as ugly and so shameful. The physical harm in each case is the same, but the mental impact is very different. We even see this in trauma, like with sexual assault. Being pitied and told something that happened to you was the worst thing that can possibly happen to someone, it makes a far worse mental impact than it otherwise might have made without that framing. There are a number of reasons for this, but I think in general, disempowering people by removing their sense of control and the notion that they're resilient becomes something of a self-fulfilling prophecy. Sometimes, some people really are less resilient or lose their sense of control in some circumstances, and then they do need that help, but that should probably not be the default approach. We've had a bit too much of an over correction to the old, "suck it up and walk it off" mentality.

Euphorbium 4y ago

The same is true for psychedellic therapy.

chmod600 4y ago

As the headline is phrased, the answer is almost certainly "yes". Even if you have an objective diagnosis and a rigorously developed treatment, you'd expect far less than 100% success; and you'd also expect side effects and other harm that happens with almost any treatment. Given that mental health is much less rigorous than some other areas of medicine (because it's hard to make it rigorous), then its compounded by misdiagnosis and treatments where we don't understand the effects.

faeriechangling 4y ago

Oh boy this is just scratching the surface. I would go a LOT further and say the ENTIRE scholastic mental health system is a sham and a massive source of iatrogenic harm that students and teachers are pressured into in order to get more favourable treatment by the schools and government assistance, whereas the schools themselves get more government funding and lowered scrutiny in regards to standardised testing. How can mental health treatment in schools NOT cause harm with such perverse incentives? I had a particularly fraudulent school psychiatrist. When my IQ tested low enough, my IQ score was reported. When my IQ tested too high, it was censored on the grounds of being "misleading". Parental and teacher evidence was submitted to justify further mental health interventions which was grossly fraudulent (I was portrayed as unable to dress or feed myself) and a cursory 5 minute examination of me would have revealed this. One of the most disgusting things they did was pull me out of gym classes to spend more time sitting in a room with special needs teachers who occasionally nagged me to use a planner and do my homework. Exercise you know, being an extremely evidence based intervention for mental health, unlike whatever that shit was. Being treated as mentally ill and being perceived that way by myself and my peers did nothing to help me, especially since it only helped to reinforce the idea that the lifelong physical health problems which got worse during my school years were nothing but "anxiety" and that consequent declines in my mental health could be attributed to my earlier mental health issues and all the medical fraud helped to confuse the shit out of doctors. I think the mental health system is a sham and that it doesn't have proof it treats the problems it claims to treat, and if anything the rise of suicidality over the last few decades as scholastic mental health has become more common as well as increases in self-reported, parent-reported, teacher-reported, and physician-reported mental health problems among students proves its somewhere between totally impotent and actively harmful. The final goal of increased mental health interventions is not getting to a point where nobody is sick anymore, it's to create more patients. The biggest thing that pisses me off is that it's rarely measured if scholastic mental health interventions work, they are just ASSUMED to be positive without evidence. Nobody gives a crap about iatrogenic effects. The episode of King of the Hill "No Bobby Left Behind" speaks to me: https://kingofthehill.fandom.com/wiki/No_Bobby_Left_Behind https://kingofthehill.fandom.com/wiki/No_Bobby_Left_Behind