Dr Sam Ponnuthurai is a Consultant Child and Adolescent Psychiatrist working in Essex in the UK. He trained in medicine both at the University of Nottingham and St George's University of London (a long story, as Sam says himself!). He also has a BA in Philosophy and English Literature from Trinity College Dublin and a postgraduate diploma in Systemic and Family Therapy from the Tavistock and Portman NHS Foundation Trust.
Áine Mahon: Sam, can you say a little about what first drew you to working in the area of Child and Adolescent Mental Health?
Sam Ponnuthurai: Well I was training as a psychiatrist and had to do a placement with children and adolescents. At the time, ‘had to’ was very much how it felt! In psychiatry you have to have worked in various settings and with various age groups in order to be confirmed as having enough of a grounding. I was worried about having to work with the anxieties and concerns that parents would have about their children and if I would be able to answer them. I had come out of about a year of working with adults who had often been in the care of a mental health team for many years and had either so-called chronic or hard to treat conditions. So I was also looking for a fresh perspective.
What drew me to this area was the fact that to achieve results I had to work with all of the aspects of the psychiatric model of care – the 'biopsychosocial model' – but unlike with adults all of the layers seemed available to interrogate and work with. The biopsychosocial model challenges the psychiatrist and their team to assess somebody's needs in all of these layers, simultaneously thinking about the interaction between them. I found that it was more possible to do this with children because the social grounding for their psychology was present, allowing not only better assessment but treatment too. Here you get to understand a young person's development both from their own perspective and that of their carers. You are able to obtain knowledge of family difficulties with mental health as well as other developmental disorders. This provides an awareness that may be lost when it comes to treating an adult without their family and parents being around to talk to. That is where the challenge begins at least!
Áine Mahon: As you know, much has been written about ‘a crisis’ or ‘tsunami’ of mental health difficulties for young people in the wake of the Covid-19 pandemic. What is your own sense of this Sam? Do you agree that there has been an escalation in the numbers of young people presenting with mental health difficulty? Or, perhaps, a discernible change in the nature of these difficulties?
Sam Ponnuthurai: I work at the acute end of things and so probably have quite a warped view of what's happening in the community as a whole. However, my community clinic colleagues are describing a continued increase in referrals.
I think the children and adolescent mental health system was already feeling that it could not meet the demands from the population or the felt suffering as the numbers rose pre-pandemic. Services were already struggling to name an endpoint for their interventions. No one was sure if this was a problem with expectations or inadequate interventions or both. An increase in referrals and an increasingly burnt-out workforce has only made these struggles worse.
Then there are those who had already been diagnosed with a difficulty or had just recovered. Unfortunately, the pandemic undoubtedly exacerbated the problems or led to relapse for many. Getting help from services that were already struggling to respond swiftly became even harder.
The sense I have is that Covid, through the locking and unlocking, catalyzed and reinforced the awareness of difficulties that were already there. I think that as a society we have become more aware and conscious of these difficulties. On the one hand, this has benefits for self-awareness and good mental health but on the other it runs the risk of pathologising normal experience. Adolescence seems heightened not only in adolescents. The natural instinct for comparison with others has grown now having many others with which to compare oneself. This might mean that our own difficulties are even more in stark relief.
Áine Mahon: ‘The risk of pathologising normal experience’: that’s so interesting. Are there ways of avoiding this pathologizing?
Sam Ponnuthurai: Perhaps 'pathologizing experience' would have been better because the term 'normal' is a relative one, and both the old normal and the new normal have their problems. I think threading this particular needle is one of the main challenges. We don't want to return to the previous avoidance and stigmatisation of mental illness and the facts of trauma. But we also want to be able to use all of the resources available to us as humans, especially as social humans, and have confidence that these can work now as they did in the past.
Áine Mahon: Sam, you and I studied philosophy together as undergraduates at Trinity College Dublin in the more innocent days of the early 2000’s. Can you say a little about how your background in philosophy influences your psychiatric practice today? Do you see much connection or conversation between the two disciplines? More generally, do you see psychiatry as an area that is open to or welcoming of interdisciplinary engagement?
Sam Ponnuthurai: Thank you for asking me this – it's certainly a relationship that was there for me at the beginning of my journey in psychiatry but I struggle to articulate it! It could be because my knowledge of philosophy began and ended as an undergraduate!
I thought about bringing phenomenology into psychiatry when I was finishing up as an undergraduate. I thought that knowledge of phenomenology’s emphasis on the inescapability of the subjective and of how we model our own reality was surely something that would benefit people whose reality had been overwhelmed with the symptoms of mental illness.
How can you define health when it comes to someone else's model of reality? How could you, having only partially understood someone else's situation through discussion, then go on to label it as sick or healthy?
Psychiatry is surprisingly empty of a philosophy and is Frankenstein-formed of all of the many approaches in attitudes to mental well-being. As well as biological perspectives I've been lucky enough to train and work in various psychotherapies too. What surprised me is that all of these approaches seem to be united by that same awareness of the limits and implicit biases of subjective experience both in the observer and the observed that phenomenology had first shown me. So actually I went into psychiatry hoping to bring it some philosophy and found out that it was there already. What is strange to me about it is that all of the disciplines in mental health feel that they must be at odds with each other in some way when actually they may share a similar philosophy fundamentally.
I think it is through sharing this philosophy that we all end up facing the same dilemma. How can you define health when it comes to someone else's model of reality? How could you, having only partially understood someone else's situation through discussion, then go on to label it as sick or healthy? For a start, doing so presumes that one knows what health looks like for this person with their specific history. It assumes an understanding of the function of what you might call the symptoms.
This is where systemic therapy comes in for me as it allows you to widen the model to family and generational stories. It looks at how someone’s perception works in a system of related others whose realities interact with their own to create a wider systemic whole. It also acknowledges how you become part of the system, albeit hopefully a part that is carefully aware of its own bias.
I think because of its multifaceted approach, psychiatry readily absorbs approaches from any discipline. Unfortunately much of its dialogue with others seems to be argument over biological reductionism and the illness or medical model. I think both sides that participate in this end up being defined by it which only ends up impoverishing either side. But I have hope!
Áine Mahon: You mentioned training and work in various psychotherapies, Sam. I’d be interested to hear more about your experience here. What psychotherapies have you worked with? What has surprised you or interested you in broadening your practice in this way?
Sam Ponnuthurai: It's a surprisingly well-kept secret that psychiatrists in the UK and Ireland (as well as many other countries) train in psychotherapy as part of their training. I started off training in cognitive behavioural therapy and then worked in dialectical and systemic therapies.
I think the problem facing psychiatrists is that we're challenged to borrow from biological, social, and psychological ways of looking after patients in order to provide holistic assessment and treatment. This is a challenging task. In order to do this effectively we channel the multiple perspectives of our colleagues into the formulations and care we provide. Unfortunately, within the public health service, the time to do this fully is always limited.
Áine Mahon: Sam, with this idea of a holistic approach in mind, I’m interested to know: how do you reflect on the relationship between psychiatry and psychotherapy?
Sam Ponnuthurai: I actually think that the relationship between psychiatry and psychotherapy is intrinsically entwined. When you look at the history of some of the protagonists in the psychotherapies some of these were themselves psychiatrists. I don't think psychiatrists are only taking a biological perspective inasmuch as I don't think psychotherapists are only taking a psychological and social perspective. I think the division over reductionism is because we are trying to resolve a problem that we share. We are both affected by the ambition and pitfalls of intervening in the maladaptations that we label in the subjective experiences of others.
When you actually drill down into the research and look at the data from interventions across the range of psychology and psychotherapy, treatment effectiveness actually ends up being very similar. That is – effective for some, but not all, and not as effective as we would wish.
I think this tension means that we battle over the politics of experthood, and being the discipline that is self-aware enough to be justified enough to have the answers. We then fight over what gets labelled as real knowledge or evidence-based treatment. When you actually drill down into the research and look at the data from interventions across the range of psychology and psychotherapy, treatment effectiveness actually ends up being very similar. That is – effective for some, but not all, and not as effective as we would wish.
Áine Mahon: Sam - if we can return to a focus on young people in particular - some philosophers argue that there has been “a coalescence” around a particular set of concepts and discourses in the area of mental health. The idea here is that certain terms become privileged over others and hold such strong cultural meaning that it can be difficult to think or talk outside them. These words might include, for example, “anxiety” or “depression” or even “mental health” or “wellbeing”. The worry is that such words may not capture what a young person might actually be feeling (which may, perhaps, be captured by a different lexicon – “sadness” or “loneliness” or “uncertainty”, or even more old-fashioned terms like "melancholia" or "despair").
On this same point, Adrian Skilbeck in a recent article for the Journal of Philosophy of Education (2022) has suggested that for many young people “the words available to them are failing them, running out, leaving them with scars on their arms and their hearts”. Moreover, for Skilbeck, “the challenge for educators is to help the young find the right words”.
What is your sense of the language that is available to young people, Sam - a language that they draw on when communicating their experience of suffering or vulnerability?
Sam Ponnuthurai: What an interesting area to explore! For me this is the cutting edge of practice in acute mental health where we work with emotional distress in response only to classic problems like OCD or psychosis but to adverse childhood experiences of all kinds.
Currently I think that it is very concerning how the expression of difficult emotions has increasingly found expression through self-harm in adolescents. Perhaps this is more scarring than previous expressions of emotional difference that found more externalized expression through the visible membership of groups within the peer environment. Unfortunately much of our lives now are lived online and in the thoughts of others rather than in the physical presence of them that returns home to an ever more self-reflexive and reflective self.
I think the challenge now is how we might use the approaches we have and share them more widely. How can we simultaneously move away from the pathologisation of experiences? I think the well-being approach was an attempt at this but it has struggled in opposition with things like the tsunami of the last question.
I've seen great work showing for example how informing peers to support other peers can be much more effective than practitioners supporting young people. I think that this is happening even without public health services trying to share this knowledge. The problem is that there is still a lot of confusion out there over the medical labels and the treatments and any sharing of knowledge can be muddied by this.
In the UK, whole school intervention from embedded mental health teams has been going for a few years now. It will be interesting to see if they can meet these challenges.
Áine Mahon: It’s so interesting that you mention a lack of ‘groups within the peer environment’ and the tendency to live lives online. Do you think that young people are lonely Sam? Lonelier than they used to be?
Sam Ponnuthurai: Again this isn't straightforward. I think there's good evidence to say that the variability of social media has allowed many more to find a social group than would previously have been possible. But then what comes with that is exposure to a feeling of or of actually being judged by others. There’s also a pool of lives with which to compare one’s own that is much bigger than any young person has ever had before. I suppose this does create a certain isolation (if not loneliness) that is new. It also has the capacity to make the journey of forming an identity much more of a struggle. But then perhaps another word for that struggle is ‘adventure’: adolescents are much more worldly than they have ever been.
Áine Mahon: That’s definitely true Sam. And I suppose another foundational element of any young person’s social world is their school, or college, or university. Would you see a role for schools or third level institutions in helping young people, as Skilbeck suggests, to find the right words?
Sam Ponnuthurai: I think educators have a very big role in helping young people find the right words because education is much more broadly focused on being in the world. Mental health interventions, unfortunately, often only focus on certain exploded elements of it or certainly tend to begin with these. Finding an approach and the language for any of the negative feedback we get while we converse with reality and develop our model is beneficial. And we know that the framework that gets built early on has a tendency to stick the longest.
The brain reflects this process beautifully. The number of connections proliferate during childhood and are 'pruned' as adolescence progresses to form the branches upon which adult experiences are elaborated.
Áine Mahon: That’s really thought-provoking, particularly with reference to the role of adolescence in preparing us for later adverse experience. I’ve read recently (in a paper from my Philosophy of Education colleague, Dr Alexis Gibbs) that the UK charity, Mentally Healthy Schools, divides stress intro three categories – positive, tolerable, and toxic – suggesting that exams can be sources of ‘positive’ stress in preparing young people for life. What do you think of such designations Sam? Are they helpful?
Doesn't labelling something as toxic make us immediately move towards a medicalised view of the difficulty? Is this always helpful? Mightn't this immediately reduce the scope of the kind of change a young person and their carers might think of? We have to be careful about the language and frameworks that we use.
Sam Ponnuthurai: I think these categories have some logic. They might help us to structure our approaches and become confident about them again. But are they in danger of becoming too absolute? Could a toxic experience eventually become tolerable or even positive and vice versa? Doesn't labelling something as toxic make us immediately move towards a medicalised view of the difficulty? Is this always helpful? Mightn't this immediately reduce the scope of the kind of change a young person and their carers might think of? We have to be careful about the language and frameworks that we use.
Áine Mahon: Do you think that university can be a difficult time for young people, Sam? I’m interested in the notion of ‘belonging’, for example, and how the university experience both allows for that (in the loveliest sense that it can develop friendships between like-minded people) but also disrupts it (certain identity factors such as social class, disability, race etc may encourage a sense of belonging in some but not others).
Sam Ponnuthurai: Certainly the figures seems to suggest it is a challenging place given the increasing rates of illness and suicide that we're finding in young university students.
It's not an age group that I have worked with for some time but my sense is that, as you say, university offers an opportunity to start afresh in a place that is much more accepting of difference than younger adolescent environments. It offers somewhere where others are equally as keen to start afresh as adulthood beckons. But then of course that is all fine as long as things are going well.
Perhaps the barriers you describe, as well as fate, can work against someone. They might start to feel stuck while others look like they are flourishing. They might feel like they have ruined their chances before their adult lives have begun. I definitely think that social class and economic factors might affect this group more now than when we were in university. Not only are students themselves faced with more debt but they are also faced with greater challenges in terms of living costs and employment after university.
Áine Mahon: I think you’re right. Certainly from my own teaching experience I see students struggling with so many life issues that I think our generation was insulated from.
For those interested in Philosophy and Mental Health, Sam, would you have any suggestions for further reading or listening?
Sam Ponnuthurai: I think a great starter text is Mind, Meaning, and Mental Disorder by Bolton and Hill. But really I think the best philosophy comes from points at which psychiatry meets other disciplines. For me, currently this is with neuroscience which seems to be able to communicate with biological, psychological, and social interpretations. I think two books recently - Know Thyself: The Science of Self-Awareness by Stephen Fleming and Being You by Anil Seth – are examples. But then books that are not even aimed at illuminating mental health like The Social Instinct by Nichola Raihani made me think about altruism and what the whole endeavour of trying to help another means by thinking about it within the animal kingdom of which we still are very much a part.
Áine Mahon: Sam Ponnuthurai – thank you very much.