Q&A about students’ mental health support

Photo caption, from left to right: Ms Victoria Fee, Assistant Director for Mental Health and Resilience, Senior Specialist and Clinical Psychologist; Mr Sean Ng Chye Shin, Lead School Counsellor at the Student Development Curriculum Division; and Ms Malar Palaiyan, Counselling Psychologist and Lead Specialist.

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1. Is stress good for my students?

Some stress is good for students. Adaptive stress can help them rise to life’s challenges as it generates a buzz of energy and helps students feel alert, focused and creative. Too little stress can lead to boredom, while too much stress can cause anxiety and poor health; the right level of stress tunes up the brain and improves the students’ task performance as well as physical and mental health.

Everyone’s threshold for managing stress is quite different; it is important for students to monitor their levels of stress so that they are aware when it becomes unhealthy (what we refer to as distress). In Mental Health Education components in the Character and Citizenship Education curriculum, we teach the students to distinguish between stress and distress and equip them with skills to manage and cope with their day-to-day stresses (see BASIC Ph article). Students are also taught to identify common mental illnesses such as depression and anxiety.

We should not assume that students who are doing well academically are coping well physically, emotionally or mentally. Young children may not have the language to express their feelings of stress and/or anxiety, and adolescents may tend to keep their issues/problems to themselves. Feeling down and tired occasionally is normal. However, feeling down and tired constantly may indicate that something is not right. If left unchecked, there is a possibility that this may lead to serious physical or mental health issues in the future.

It is possible that some students may not recognise their distress signs. This is where teachers play a critical role by looking out for students’ out-of-character behaviours. Some students may require additional help/support to manage and cope with their distress. Teachers can share some useful stress management strategies and coping resources with the students and encourage peers to look out for each other. They could also destigmatise mental health issues by letting students know that it is normal to feel unpleasant emotions during difficult times, helping students understand that reaching out for help is a sign of strength and resilience and assuring students they will not be ‘blacklisted’ for seeing the School Counsellor.

2. How do stressors change when a student progresses through the levels?

The stressors of children and adolescents usually revolve around relationships at home and in school, and with school performance and expectations (from self and others). Lower primary school students tend to be more anxious about friendships, homework issues and test/exams. For adolescents (including upper primary students), it could be about managing the myriad of emotions they are experiencing, or perhaps self-worth or self-perception issues, if they do not get into a CCA of their choice, perform to their expectations, or get accepted into their desired social groups. Family and life events such as negative financial events, changes in family composition/dynamics, or transition issues also impact a student’s emotions and behaviours.

Adolescence is also a time of accelerated physical changes (e.g. puberty, brain development). These students may be driven by their brain’s limbic system and act emotionally, impulsively or even irrationally. This is a time when they try to exert their independence while seeking to figure out who they are and what they want to do with their lives. Social belonging is very important at this stage as friendships become a big part of forming their sense of identity outside the family. Our youths need to be equipped to navigate the complexities of their growing up years, made more challenging by the online space that many of them engage in. 

The Character and Citizenship Education curriculum (which includes cyber wellness and social-emotional learning) provides students with the knowledge and skills to navigate the developmental challenges. 

3. Can a student with depression just ‘snap out of it’?

Depression is a clinical condition usually diagnosed by a mental health professional, like a psychiatrist. When a student is clinically depressed, they are constantly dealing with an avalanche of negative thoughts and emotions. They also lose interest in activities which are normally enjoyed; and there can be trickle-on effects on their relationships with others. We know there are elements of both biological (e.g. genetic vulnerability) and environmental factors (e.g. conflictual relationships) which can contribute to our students developing depression.

Mental illness is often difficult to detect externally. It is not uncommon to hear family and friends say, “Why can’t you just get out of bed and go about your daily chores like me?” or “I have my difficulties too and can put them aside; why can’t you?”. Outward behaviours may be misinterpreted by family and friends as indulging in self-pity and even laziness.

A student with depression struggles with thoughts such as “I’m not good enough”, “what’s the point of even trying”, or “they will reject me anyway”. It’s as if they are wearing perpetual sunglasses and see themselves, people around them and their future as bleak and dreary. Even when an opportunity presents itself, like being invited to try out for a CCA they are keen on, they just can’t shake off those sunglasses and may dwell on past failures or challenges. This reinforces their belief that they’re not good enough, making them feel lower, which then reduces their energy levels even more. Eventually, when the try outs come along, the student may not have the strength to get out of bed to attend the try outs. It’s about being trapped in a vicious cycle.

One is unlikely to just snap out of depression, and treatment will usually be required. Cognitive Behavioural Therapy is one of the evidence-based treatments effective for depression, which usually includes:

• Encouraging them to start out with scheduling some meaningful and pleasurable activities. Being active can also release some neurochemicals to help lift the mood.
• Helping them learn how to manage negative thoughts by being able to ‘catch’ those thoughts and bring them to their awareness. By being aware of the ‘thought traps’ (e.g. catastrophising thoughts), the student could then critically examine and challenge these thoughts and underlying beliefs. The student can then replace them with more rational, helpful thoughts.

This is done with the guidance of a psychologist or a counsellor as it’s hard for anyone to get out of the vicious cycle on their own. The support of family, significant adults (e.g. teachers) and friends is also a critical success factor.

Prevention is better than cure. We want to bring some of these thought-challenging skills early to students so that they are equipped to manage challenges faced. Through Mental Health Education within the enhanced CCE curriculum, students will learn about ANTs (short for automatic negative thoughts) and how to challenge them through the 3Rs strategy of ‘record, rationalise, replace’.

4. Is mental illness hereditary?

It is not uncommon to think that if a parent has a mental health condition, the child may have it as well. We have come across anxious parents having anxious children. Mental illness is really a complex interplay between a person’s biological make up and their environmental situation. While some mental illnesses can appear to run in the family, there may not be a clear genetic link to this. Instead, these observations could be due to their shared family environment. For example, a child living with a depressed mother in an abusive family environment is more likely to face mental health problems.

Common life events, such as loss of loved ones, play a significant role in the development of mental health problems. Once triggered by a stressful event, the student’s usual coping abilities are overwhelmed. The student may experience strong negative emotions (sadness, anger, fear) and/or physical difficulties (e.g. difficulty sleeping, stomach aches, loss of appetite). Coupled with a negative thinking pattern (e.g. “things will never get better”), the student may start modifying their behaviour (e.g. avoiding similar situations, lashing out at others). The behaviour reinforces the student’s thoughts and emotions and keeps them stuck in a vicious cycle. If these challenges persist over a prolonged period of time, anyone can develop mental health problems, regardless of family history. Therefore, it is possible for a student to develop mental health issues even though their parents may not have mental illness.

It is important to help students realise there is nothing shameful about having a mental health problem. When they seek help early through peers, significant adults and school counsellors, it enables and empowers them to gain some perspective, manage the stressors better and find ways to navigate that challenge in their life.

5. Once my student develops mental illness, is their life ‘doomed’?

Mental illness is most often not ‘permanent’ in the sense that its effects are not consistent over time, though one’s daily functioning can be impaired for a long time. Like physical illnesses where a part of the body does not function well, for mental illness, the organ that is not functioning well is the brain. Through evidence-based treatments by psychologists and counsellors, and supplemented by medications (if needed) prescribed by the psychiatrists, recovery is possible. As with all illnesses, early intervention ensures better recovery. 

For some mental illnesses (e.g. schizophrenia), however, long-term treatment is required. But that does not mean the student’s future is over. It’s like diabetes or hypertension; both require long-term medication. If one takes the prescribed medication, manages food intake and keeps healthy through regular exercise, one can also lead a normal life.

If a student with mental illness undergoes the required treatment (e.g. psychotherapy, counselling, medication) regularly, they can study and function with support from family, teachers and peers.

6. Why do my students have suicidal thoughts?

Suicide is a complex social issue, contributed by multiple underlying needs. It usually results from prolonged exposure to multiple stressors. Factors such as being in great emotional pain, hopelessness, helplessness, feeling like a burden, not feeling socially connected and having poor social problem-solving skills and rumination increase one’s risk of suicide ideation. Having some mental illness, such as depression, may indicate a higher risk but not everyone with depression will go on to develop plans and act out their suicidal thoughts.

One key factor that teachers can pay attention to is impulsivity. We know the emotional centres of adolescent brains develop faster than their cognitive control brain areas, which makes adolescents more prone to impulsivity and risk taking. There are instances when an adolescent may attempt suicide because they were looking for a way to escape the situation or even to avenge a loved one. That moment of impulse is usually fuelled by very strong negative emotions, e.g. a highly anxious student who is about to face some disciplinary action, a student nursing the emotional pain of a break-up finding out that her boyfriend has a new girlfriend or a student who thinks he had enough of his parent’s constant scolding. But if the student is stopped in time and asked later if they had the intent to die, there may be some degree of ambiguity in the student’s intention. Some mental illness, such as bipolar disorder, have a higher association with suicide attempts. This is because of its underlying characteristic of impulsivity. Thus, emotional regulation, included in Mental Health Education, is such an important skill to learn.

Every person’s struggle is unique, and an effective suicide intervention approach should take a holistic approach, addressing not only the mental health factors but also the multiple situational stressors that contribute to the suicide risk. Students still find it difficult to talk about problems because of the stigma and shame attached to it. As teachers, we should exercise sensitivity and continue to establish a caring and enabling school environment, so that they feel comfortable and safe to reach out to the teachers, school counsellor and their peer groups (e.g. in class or CCA) for support if they are struggling, especially with suicidal thoughts.

*If you know a student in need of help, refer them immediately to the School Counsellor for a risk assessment and/or follow-up support. You can also provide helplines (Samaritans of Singapore – 24 hrs – tel: 1800 222 4444; Tinkle Friend – tel: 1800 2744 788 or online chat via www.tinklefriend.sg)