‘Your now is not your forever’: Destigmatizing Mental Health through Young Adult Literature Ariane Manutscheri

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Abstract

This article explores the importance of destigmatizing the topic of mental illness among young people, and the potential that lies in working with young adult literature to meaningfully contribute towards such destigmatization efforts in our language classrooms. According to the WHO, on average, every fifth adolescent in the world was already battling a serious mental health condition before 2020. With COVID-19 presenting an unforeseen challenge to most people’s mental well-being, it is not surprising that several studies around the globe now indicate an even further decline of mental health among our youth, a decline that frequently goes unnoticed and untreated for years, in part because mental illness still has a great deal of stigma attached to it, and many feel afraid to come forward. Although written from an immediate Austrian context (bearing in mind the specifics of an Austrian school setting), this article aims to carry wider implications for English language classrooms in other countries as well. It examines John Green’s Turtles All the Way Down (2017) for viable classroom discussion ideas and features a range of suggestions for practical classroom application that aim to help teachers interested in broaching the topic of mental health with their students.

Keywords: mental health representation; destigmatization; young adult literature; language classroom; John Green; Turtles All the Way Down

Ariane Manutscheri is a pre-doctoral university assistant at the Department of English and American Studies, University of Vienna, and member of the research platform #YouthMediaLife. She holds a teaching degree for English and Philosophy/Psychology. Her research interests include mental health representation, fan studies, pop culture, and pedagogy in the literature and culture classroom.

 

Introduction

Why Mental Health? Why Literature? Why the Classroom? Why Now?

In March 2021, Pieh, Plener, Probst, Dale & Humer published a study seeking to assess mental health in Austrian adolescents during the COVID-19 pandemic. When compared to statistics from 2018, their findings suggest a significant decrease in mental well-being and an increase in the prevalence of mental disorders among our youth. Different indicators of mental health problems were taken into consideration (such as depressive symptoms, anxiety, stress, eating attitudes, life satisfaction, and sleep quality) for this self-report study and, across the board, scores for mental well-being had dropped. Of all 3,052 participants (aged 14 to 20), 55 per cent, for example, showed ‘clinically relevant’ depressive symptoms, 47 per cent scored above the cut-off for anxiety, as did 64 per cent for eating disorders.

Pieh et al. (2021) then also looked at similar studies from around the world (Brazil, China, Germany, India, Italy, Spain and the US), which all present evidence for the same basic conclusion, namely that the COVID-19 pandemic and its consequent regulations, such as confinement rules, had a major negative impact on young people’s mental health. This is particularly troublesome because ‘adolescence is well-known as a period of enhanced vulnerability to mental health disorders’ to begin with (Pieh et al., 2021). The ‘average age-of-onset’, which is the age at which the majority of people first experience symptoms of a mental illness, lies between our teens and early twenties, as Kessler et al. (2007, p. 359) explain: ‘Roughly half of all lifetime mental disorders in most studies start by the mid-teens and three-fourths by the mid-20s’. The fact that this period in our lives is one of fundamental shifts, ‘a point of cognitive, social and emotional transitions’ (Power, Hughes, Cotter & Cannon 2020, p. 2), with youth forming more important peer relationships and spending less time at home (Pieh et al., 2021), as well as  preparing for their entrance into the world of work (Power et al. 2020, p. 1), helps to explain why young people are so frequently and so strongly affected by mental illness and why they are now (under the given circumstances) even more vulnerable to the risk of impaired mental health.

A comparison of these results to studies of the mental health situation before the pandemic should not leave the impression that the increasing rate of mental illness among young people has only very recently become an issue of concern. The numbers were already alarming back in 2016, when a study conducted by Wagner et al. (2017) uncovered that between a fifth and a quarter of adolescents in Austria were suffering from serious psychological problems. These numbers roughly concur with the global data provided by the WHO, revealing that ‘[a]n estimated 10-20% of adolescents globally experience mental health conditions’ (Adolescent mental health, 2018), a large percentage of which are left undiagnosed and untreated, because (among other important reasons) those affected feel too ashamed about their condition and too fearful of social exclusion to talk about this openly and get help (Wagner et al., 2017, p. 1496).

This shame and the ensuing avoidance of treatment are the result of a painful history encompassing centuries of stigma. Stigma, which can be defined as ‘visible or invisible social distinctions that disqualify individuals or social groups from full social acceptance’ (Calhoun, 2002), manifests itself through prejudice and discrimination towards those we deem ‘other’. In the case of mental illness, some common stereotypes are that people with a mental disorder are violent, dangerous, unpredictable, unable to live independently or have successful and fulfilled lives (see Corrigan, Roe & Tsang, 2011, p. 27).

Stigma works (and hurts!) on different levels: ‘public stigma’ or ‘social stigma’ occurs when a community endorses stereotypes and harmful myths about mental illness and mistreats affected individuals accordingly; ‘structural stigma’ refers to ‘particular policies of large entities (e.g., governments, companies, schools) that place restrictions on the rights or opportunities of persons living with mental illness’ (Barnes, 2017, p. 28) and finally, ‘self-stigma’ means the internalization of the aforementioned negative stereotypes by those with mental illnesses themselves (Corrigan et al., 2011, p. xiii), often resulting in shame, guilt, or self-hatred.

Stigmatization is deeply interwoven with the language choices we make when talking about mental health and the way mental illness is portrayed in the media – the narrative about mental illness that is ‘spun’, so to speak, has great influence on how those with a mental health condition view themselves and their chances in life, as well as how others perceive them and the opportunities they give them (jobs, housing, education….). There are a great number of texts that portray mental illness in deeply harmful ways, thus contributing to the fostering of more stigma: a plethora of horror movies and thrillers, for instance, use mental illness as a trope for inducing fear in their audiences (see, for example, Friedman, Forcen & Shand, 2014; Kambam, 2013). On perhaps the flipside, there are also tendencies to romanticize or glamourize mental illness. Whether a mental health issue, such as compulsive behaviour, is presented as a quirky personality trait that serves to make somebody ‘interesting’, or depression, self-harm and suicidal ideation are depicted as ‘beautiful tragedy’, these troublesome depictions are prevalent in our (social) media landscape and they are deemed to be highly dangerous by many mental health professionals. For example, note the US National Institute of Mental Health’s (2019) warning in response to the recently televised novel by Jay Asher, 13 Reasons Why, and Bine’s (2013) investigation of social media content for harmful depictions of depression, self-harm and suicidal ideation.

Many myths about mental illness have become ‘naturalized’ over time, accepted as natural or common-sense givens, and have therefore gone unquestioned for years (Baglieri & Shapiro, 2017, p. 28). There are, however, an increasing number of ‘counternarratives’ – stories that provide alternatives to widely accepted beliefs, give voice to marginalized groups and raise questions about why and how these groups came to be marginalized in the first place (Mutua, 2008). Books that feature the subject of mental health have experienced a recent boom (Tonkinson, 2018), and among them a great number are targeted towards young adults (e.g., Jensen, 2018).

For teachers who use literature as part of their students’ second or foreign language education, the incorporation of such mental health themed young adult novels could serve multiple purposes. On the one hand, these stories let young people affected by mental health problems know they are not alone. On the other, engagement with such literature could help foster empathy in those who have not previously had any frame of reference of what it is like to have a mental illness by being invited to take on the perspective of a character dealing with this condition. There is scientific evidence that suggests this exercise in ‘perspective-taking imagination’ (Keen, 2018, p. 126), which reading fiction provides us with, can (at least temporarily) enhance our Theory of Mind, that is ‘the ability to detect and understand others’ emotions’ (Kidd & Castano, 2013, p. 377). Optimistically speaking: our capacity to empathize with other human beings could be improved by reading literature. Furthermore, introducing mental health related young adult literature (from here on abbreviated as YAL, or YA for young adult) opens up a general dialogue about mental health and serves as a great starting point to give our students fact-based input. Scholars researching and promoting the destigmatization of mental illness agree that education is one of the most powerful weapons we have against stigma (Corrigan et al., 2011, p. 55). This is where teachers can make an impact. Corrigan et al. (2011, p. 101) refer to teachers as ‘opinion leaders’, because they have the opportunity to ‘influence the attitudes of large numbers of people’. Teachers are also often consulted for guidance, especially in situations where students feel uncomfortable confiding in their peers or family members. In this position, teachers can act as the connecting link to mental health professionals or other counselling services, facilitating contact for their pupils wherever necessary.

To add to these substantial responsibilities, language teachers in particular can address issues related to their subject, such as the relationship between language and power, language and our emotions, or, more broadly, language and our general perception of reality, in their classrooms.  They can help foster a consciousness for different word choices we can make in the same situation and thus promote and model a reflective use of language that avoids the perpetuation of stigma.

To aid them in their efforts, this article aims to provide practical classroom advice: In the next section, an analysis of a mental health-related YA novel, John Green’s Turtles All the Way Down, will serve as a sample of the possible themes and motives that could be carved out with students in the literature/language classroom.

 

Turtles All the Way Down –
Destigmatizing Potential and Themes for Classroom Discussion

This short analysis only serves as a teaser for the abundance of topics that can be tapped into through the use of YAL to promote mental health literacy. Turtles All the Way Down (abbr. Turtles) fulfils the role of a model here, from which I assert that the questions and themes discussed around this text could be transferred for an analysis of other mental health-themed YA novels. And while every mental health-related YA novel hopefully also brings new ideas and fresh approaches to the table (depending, for example, on the particular mental disorders they address), this list of recurring motifs, techniques and patterns could prove useful in identifying some key discussion points to review in class.

Turtles All the Way Down by John Green (2017) tells the story of 16-year-old Aza Holmes and her struggle with OCD (obsessive compulsive disorder), all the while navigating high school, first love, friendship, and investigating a mystery disappearance. Throughout the novel, readers become aware of how much Aza is battling with her intrusive thoughts about infection with a type of bacteria called C.diff, which she is terribly afraid of contracting. These thoughts and the compulsive rituals she must perform to mitigate her anxiety (such as researching facts about C.diff for hours, continuously re-opening a wound on her finger to drain it from bacteria, or drinking hand-sanitizer in an attempt to cleanse herself from the inside) are shown to affect every aspect of her life. Her relationship to her mother is strained because the latter is extremely worried about her daughter’s condition, which frequently leaves Aza with guilt; her best friend Daisy Ramirez is often puzzled and annoyed by the social consequences of Aza’s condition, and her budding romance with Davis Pickett is complicated by the fact that Aza struggles with being physically intimate, due to her fear of bacteria.

Despite its at times very gritty representation of mental illness that never runs the risk of glamourizing or sugar-coating what it is to live with such a condition, this story is far from pessimistic. In fact, the book serves to give hope that there is help out there, that mental illness is treatable and manageable, and that, as Aza’s mother tells her daughter: ‘Your now is not your forever’ (Green, 2017, p. 93). I found Turtles to be a deeply moving read and suitable for closer analysis to work out a range of themes that all connect to the idea of presenting our students with a compelling ‘counternarrative’ that helps combat existing prejudice or misinformation and inspires empathy by allowing us to walk a mile in the character’s shoes. In unveiling some of the narrative techniques, stylistic choices and themes that occur in the story, I present ways in which the audience’s ability to feel for and understand the protagonist is engaged, while simultaneously offering a range of potential topics that can be explored with students in class.

Deconstructing the idea of ‘normal’

Comparing one’s behaviour, personality or mental state to what is normal can be very damaging to one’s self-image, if ‘normal’ is not understood to be an artificial construct and rather falsely perceived as a natural given. In Turtles, Aza frequently feels shame and self-hatred because she views herself as ‘other’, and not normal. She is worried that she will never be able to have a normal life, normal career or maintain normal relationships. Her inner voice incessantly criticizes and taunts her with all the ways in which she falls short of being a ‘normal’ person:

He’s trying to treat you like you’re normal and you’re trying to respond like you’re normal but everyone involved knows you are definitely not normal. Normal people can kiss if they want to kiss. Normal people don’t sweat like you. Normal people choose their thoughts like they choose what to watch on TV. Everyone in this conversation knows you’re a freak. (Green, 2017, p. 157, italics in original)

To the protagonist these deviances from the perceived norm are a mortifying personal failure; an attitude she only very gradually (and with much help and support, especially by her therapist Dr Singh) begins to move away from in favour of adopting a more positive self-image, as well as more realistic aims and standards, focusing her recovery efforts on feeling better instead of feeling normal. Looking into this theme during a lesson could bring about many fruitful exchanges on the sociological, or indeed, philosophical fundamentals of what is considered normal and who gets to define it. How do we as a society determine norms, out of which interests, and how do we treat those that deviate from them? The political nature of those questions and their treatment in class will have deeper implications on how students understand society and its embedded hegemonic structures – reflections that go far beyond the topic of mental illness alone.

Understanding that stigma is harmful because it causes us to hide our pain

Feeling anxious and trapped in thought spirals, zoning out from one’s surroundings, constantly performing cleansing and checking rituals, receiving medication for a mental illness, having to go to a therapist: all of those things are parts of Aza’s life that she desperately tries to hide from others, because she has been made to feel that these circumstances and practices are not normal, that they are embarrassing. As a result, she does not always communicate honestly and effectively with those wishing to help her. Aza lies to her friends in order to fit in, to her mother to ease her worry, telling her she is fine when she is really not, and even stops taking her medication without consulting her therapist. These habits of ‘lying, denying and covering-up’ (Manutscheri, 2020, p. 38) lead the main character straight into a major crisis. Working with students, it is a good idea to compare the effects of Aza’s attempts to conceal or ignore her mental illness to the real-life harm that the perceived need to keep a mental health condition hidden can cause. According to Corrigan et al. (2011, p. 35), many ‘[p]eople distance themselves from mental health clinics, psychiatrists, and college counselling centres so they are not associated with the kinds of places that mean they are somehow mentally insufficient’. Making students aware of the direct link between stigma and treatment avoidance is one of many powerful lessons to be learned from reading a book like Turtles, and one that has the potential to positively impact the actual help-seeking behaviour of our own pupils.

Recognizing that there is nothing romantic about mental illness

In contrast to the glamourizing, trivializing or romanticizing accounts of mental illness which can be found all over our media landscape, this YA novel dismantles such potentially harmful narratives by having Aza critically reflect on them. She, for example, has this to say about the popular trope that mental illness somehow correlates to artistic and/or intellectual brilliance:

You hear a lot about the benefits of insanity or whatever – like, Dr. Karen Singh had once told me this Edgar Allan Poe quote: ‘The question is not yet settled, whether madness is or is not the loftiest intelligence.’ I guess she was trying to make me feel better, but I find mental disorders to be vastly overrated. Madness, in my admittedly limited experience, is accompanied by no superpowers; being mentally unwell doesn’t make you loftily intelligent any more than having the flu does. (Green, 2017, pp. 132-133)

Because media play such an integral role in our lives, it is vital that students understand the genuine harm a romanticization of mental illness can cause: glamourized or trivialized accounts of mental disorders and their symptoms can cause young adults to perceive them as relatable or even desirable and those actually diagnosed with a mental illness might be misled to believe that their serious condition is so common or banal that they need not bother with treatment (Jadayel, Medlej, & Jadayel,  2017, p. 474).

Learning how to get help and help others

I see a very distinct didactic potential in YAL’s capacity to give readers hope that there is help out there for those who are battling mental problems. We need books and discussions which will fit that purpose. In Turtles, treatment (in Aza’s case, a combination of therapy and medication) is not presented as a miracle cure, and is instead depicted as a long, hard, but ultimately effective process. Furthermore, school is shown to be a helpful and supportive environment: peers and teachers are reaching out to Aza in time of crisis and sending messages of encouragement, which means a lot to her, as she had previously been very afraid of being treated differently and becoming the subject of gossip, once others found out about her mental illness. Readers are also introduced to the positive effect of establishing communication strategies on how best to talk about mental illness with a loved one. Aza’s relationship to her mother is shown to improve as both characters have an open and honest conversation about Aza’s needs and wishes when it comes to discussing her own mental state. Her mother (who, out of worry, has developed a habit of repeatedly asking Aza if she was feeling anxious at the moment) ultimately accepts that her persistent questions make her daughter feel even more anxious and guilty, so she promises to try and change this communication pattern. The overriding motif of open communication – a willingness to listen and simply ask a person what they need in time of distress, serves as a lesson on how to best support others (and by extension also how to get support for oneself) during a psychological crisis.

Appreciating the significance of narrative techniques and their effect on the reader

One of the major strengths of Turtles, in my opinion, is how it explicitly addresses the difficulty of verbalizing one’s own mental pain to someone else. Because we cannot see into other people’s heads, we cannot truly know another person’s anxiety, depression, etc. Aza’s friends and family are often at a loss as to what is going on inside her brain, why she does the irrational things she does and why she cannot simply stop doing or thinking about them. Aza’s therapist Dr Singh phrases the basic problematic as follows:

One of the challenges with pain […] is that we can really only approach it through metaphor. It can’t be represented the way a table or a body can. In some ways, pain is the opposite of language. […] And we’re such language-based creatures that to some extent we cannot know what we cannot name. And so we assume it isn’t real. (Green, 2017, p. 89)

Here another common harmful assumption is addressed: namely, that mental illness is somehow not real or less real than a physical ailment; that it might just be an imagined problem, perhaps to get attention, which one could simply overcome with enough willpower (see, for example, Corrigan et al., 2011, p. 57). In the story, this prejudice is then linked to the lack of immediacy of another person’s inner life and the perceived impossibility to sufficiently express pain through language. Nevertheless, John Green manages to employ a variety of narrative and stylistic devices in order to render the character’s inner world visible and emotionally accessible through language. Designing discussion questions and activities that draw learners’ attention to those techniques will help them become aware of the significance of figures of speech, narrative situation, as well as other key elements of literary analysis, and understand their role in shaping readers’ affective response, specifically empathy. The two examples below serve to illustrate what a closer inspection of narrative devices could look like:

Point of view. Turtles features the protagonist Aza as the story’s narrator. Consequently, most of the book is written in the first person, which gives readers access to the intrinsic perspective of her thoughts and feelings. However, Green also shifts the narrative situation in certain chapters to a second-person point of view, so that the pronoun switches from ‘I’ to ‘you’. Some of Aza’s most painful experiences are told in the second person:

The next morning, you wake up in a hospital bed […]. […] For a moment, you think you’re better. […] And then you feel a wave of nausea, a fist clenching from within your rib cage, cold sweat hot forehead […].  (Green, 2017, pp. 230-31)

Is the pronoun ‘you’ being used as a form of addressing the reader, thereby drawing them into the fictional realm? Is it, as Fludernik (2011, p. 106) has suggested, a stand-in for ‘anyone, therefore: possibly me’?  What does the switch from ‘I’ to ‘you’ change in terms of immediacy? Students can be guided towards an investigation of differences in narrative perspective and draw their own conclusions about the possible impact on an audience.

Metaphor. Aza regularly uses metaphors to describe and make sense of her inner turmoil. She refers to the image of a ‘spiral’ to express what it feels like to be pulled in, or controlled by her intrusive thoughts. She further tells readers that her OCD makes her feel as though she was trapped in a prison cell, or that she, in fact, herself was the prison cell. She likens living with her condition to ‘cohabitating with a demon’, or being possessed by it, and frames her struggle to somehow beat or overcome her OCD as attempting to ‘slay the dragon’. There are countless more examples of these vivid images Green manages to draw up in readers’ minds. Letting students explore and search for these devices in the text themselves, as well as decipher their various possible meanings, could be a very productive way of engaging learners to come up with their own, autonomous interpretations of literature.

Leaving the specificities of Turtles All the Way Down and moving towards more general suggestions for teaching with mental health-related YA literature, the following is a list of advice, guidelines and recommendations (by no means exhaustive!) that I have garnered from a range of materials on teaching literature as well as mental health awareness and education programmes (see also Manutscheri, 2020, pp. 74-88).

 

How to Approach Mental Health through Literature in the Language Classroom

First things first: Establishing a solid factual baseline

This recommendation is presented across all the literature I have encountered in my search for viable guidance on a classroom’s introduction to mental health-related YAL. As a primary step, teachers need to familiarize themselves with the topic of mental health before they can pass on reliable information to their students. The Mental Health & High School Curriculum Guide (Kutcher & Wei, 2017, pp. 10-45), for example, suggests an extensive self-study unit which features a pre- and post-quiz section to help teachers identify areas in which they need more information and a teacher knowledge update which will supplement the necessary facts, before teachers can successfully promote mental health literacy to their pupils.

What is mental illness? What are some standard definitions professionals operate with? What makes these definitions problematic? Is mental illness just a social construct? How do we distinguish behavioural deviance from actual mental illness? What are the borderlines (if, indeed, there are borderlines) between a mental health issue and neurodiversity (Silberman, 2013)?  Which common different mental disorders are prevalent among the youth we teach? What are some effective treatments? Which roles do medication and therapy play in someone’s recovery? What is the treatment situation like in the country in which I am teaching? Those are only some of the questions worth investigating for ourselves before designing our lesson plans.

Because teachers are not trained to be mental health professionals, they should not feel the pressure of having to answer all of these questions alone and instead can make the best use of resources around them, such as experts they could invite into their classrooms.

Acknowledging the sensitivity of the subject matter and planning accordingly

When presenting students with YAL that discusses mental illness in its different forms and explicitly depicts various signs or symptoms (for example, detailed accounts of anxiety, depressive thoughts, suicidality, starvation or self-harm practices), perhaps even quite graphically, there is no denying that we are dealing with delicate and, quite possibly, distressing subject matter. I firmly believe that teachers have an ethical responsibility to consider the fact that the literature they assign could leave students feeling upset, shocked, offended or in other ways emotionally burdened ­– especially if they happen to be going through a crisis or critical period in their lives, which teachers may not always know about. It may not be feasible to prevent every student’s negative emotional response to a text, but there are some helpful principles to bear in mind to make sure the introduction of such a serious topic is done in the most cautious and sensitive way possible.

Nilsen et al. (2013, p. 360) advise us to leave room for students’ choice and voluntariness when it comes to the readings and activities we wish to work on with them: no one should be forced to read a book or participate in its subsequent discussion if it is causing them high levels of emotional anguish. This, of course, requires a certain adaptability on the side of the teacher: is there a backup activity if a student expresses discomfort with a certain task? Is a setup conceivable in which not everybody in the class has to read the same book? Maybe students should be allowed to pick from a selection in the library? Maybe a class gets to vote on a reading? As a general rule, Berman (2002, pp. B7-B9) also recommends that teachers ideally make themselves available for individual talks, should their students wish to come to them if they feel a book is too upsetting or putting them at risk; an offer several students accepted and benefited from during his teaching experience with risky subjects in higher education.

Furthermore, Nilsen et al. (2013, p. 360) warn us not to try to match a book to a particular student’s personal problem (for example, give a student we know to have an eating disorder a book about said eating disorder, or assign it to the class they are in). It is probably best to become familiar with a class before introducing the discussion of a certain mental disorder or mental illness in general: What is the current class climate like? Are there any major ongoing conflicts / bullying problems? Do we know of students who are battling a mental illness? Can colleagues, head teachers, or guidance counsellors tell us more about the class in which we wish to start working on this topic?

In my personal view, when it comes to addressing sensitive issues, the most important precept is honesty. Showalter advises ‘clear labelling’ of content, letting students know what they can expect from a certain piece of literature and telling them that it may contain themes they find distressing (2002, p. 126). Such trigger warnings (a concept originating from trauma theory) have become a popular, albeit controversial, way on TV, YouTube, or social media platforms, to warn an audience that they might find the content that follows upsetting, especially if they can connect it to personally traumatic experiences (Böhl, 2020). It is crucial to point out here that none of these measures are intended to shield students from emotionally engaging with difficult subject matter, they just provide crutches to do so in a way that does good rather than harm.

Selecting books that represent mental illness realistically and from diverse perspectives

A very important criterion in the choice of which texts to introduce to the class is, whether the disorder discussed in the story is accurately depicted, as opposed to a sensationalist, glamourizing or romanticizing account that does not appropriately convey the facts, such as the symptoms and treatment of a particular mental illness. To this end, Richmond has looked at a plethora of YA novels published since 2000 and explored how mental illness is portrayed in them and how the representation of a particular mental disorder in a story matches up with the disorder’s description in the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, which is the leading tool for the classification and diagnosis of mental illness in the US). I highly recommend her book Mental Illness in Young Adult Literature: Exploring Real Struggles through Fictional Characters (2019), which is structured around the discussion of a particular mental illness in each chapter, providing facts on those different mental disorders and in-depth analyses of current YAL portraying those disorders, as well as featuring extra resources, such as sample lesson plans. I have found it to be an invaluable introductory work for teachers interested in the topic, as it immensely facilitates the selection of appropriate mental health-themed YAL for the classroom.

Part of an authentic depiction of mental illness is also a realistic narrative of what it means to get better, to receive treatment and make progress. Everyone loves a ‘happy ending’, but it is very important to make clear (to ourselves and our students!) that mental illness as such cannot be cured. Scrofano (2015, p. 18) discusses a faulty, idealized pattern or formula she has encountered in many mental health-related YA novels:

First, there is the hiding of the mental illness, the denial that help is needed, the fear of what will happen if others find out. Then, there is a climax or crisis point where the illness can no longer be hidden or ignored. Finally, the story is resolved with a diagnosis or care prescribed; this might be seen as a sort of happily ever after.

Scrofano recommends looking for books that understand mental illness as a chronic condition, not a one-time obstacle that can be quickly overcome; and thus focus on recovery and management of an illness, that is ‘life after diagnosis and treatment’ (2015, pp. 18-19) rather than a cure:

We need stories of mental illness that focus on the illness as a biological brain disorder, a chemical imbalance in the brain. […] [W]e […] need books that mirror teens’ experiences of clinical illness, including visiting the psychologist’s or psychiatrist’s office, trying out different medications, dealing with side effects, having conflicts with family members, and all the rest that a modern-day diagnosis of mental illness entails. (Scrofano, 2015, p. 15)

Moreover, Scrofano (2015, p. 16) advocates for the introduction of books told from different points of view, since ‘[t]eens reading about mental illness have different relationships to it’ and different ways in which it affects their personal lives. To address those varied experiences, stories ‘might be narrated from the point of view of the ill person, a sibling, or a child’, for example (Scrofano 2015, p. 16). In addition to this, what needs to be considered when it comes to bringing in a diversity of perspectives is the inclusion of diverse characters: race, gender, class, sexual identity and orientation, as well as socioeconomic and political circumstances, are all dimensions that will affect a character’s mental health narrative, just as these variables significantly influence people’s mental health in our real world (Pieh et al., 2021).

Discussing appropriate language and making language choices explicit

By the time the topic of mental illness is introduced in the classroom, students, most likely, will already have been exposed to derogatory language to describe mental illness in the media or out and about during everyday conversations with their peers. Mental health-related YAL like Turtles also uses this type of language, which should not be left undiscussed. Language teachers are in a prime position to render the links between language and power visible and intelligible to their students. Language shapes the way we think about and treat people with a mental illness (Baglieri & Shapiro, 2017, p. 45). If derogatory language such as ‘crazy’, ‘nutso’, ‘mad’, ‘freak’, ‘psycho’, ‘spaz’, ‘loony bin’ etc. is used, it is important to have students engage with the question of why. Is a character being insulted by a bully? An insensitive or potentially ignorant friend? Are protagonists calling themselves names – self-deprecatingly as Aza so frequently does in Turtles or, perhaps, re-appropriating a term for pride and identity purposes? How does it make a character feel to use these words or be called them? How does it make readers feel to read such words? Additionally, where do these terms come from in the first place? Here one could, just as an example, trace ‘loony’ back to the word ‘lunatic’, which in turn goes back to the Latin term lunaticus – an indication of the fact that mental illness was once thought to be determined by the phases of the moon (Hoad, 1996).

How do students feel about using euphemisms, such as ‘special’ (Baglieri & Shapiro, pp. 40-41), to talk about mental illness, or disability in general – are those terms ‘nicer’ or just as bad as pejorative language and, if so, why? Can grammar make a difference in the way we describe, and indeed perceive, mental illness? What can, for instance, be said about the distinction between the syntactical construction ‘depressed person’ as opposed to ‘person with depression’? This example of a contrastive analysis between the approaches of ‘identity-first’ vs. ‘person-first’ language could be used to illustrate the importance of grammar for meaning making to language learners. Teachers could provide and model (or collaborate with students to create) a set of principles on how to talk about mental illness respectfully. Here I can recommend the American Psychological Association’s ‘Style and Grammar Guidelines on Bias-Free Language: Disability’ (2019) as a helpful guiding resource.

Cooperating

Through interdisciplinary cooperation between colleagues, different teachers could bring in their expertise to a larger project, for ‘[t]ackling a subject like mental illness is no easy feat for one teacher alone’ (Manutscheri, 2020, p. 73). A psychology teacher, and those teaching history, biology, or social studies could all provide valuable support on explaining either the definition, the neurological basis and treatment of mental illnesses, or their societal perception throughout history. This dual focus on both a content subject and language teaching at the same time also presents a great opportunity for Content Language Integrated Learning (CLIL) and the ‘holistic educational experience’ this approach aims for according to Coyle, Hood & Marsh (2010, p. 1) through the use of authentic texts, addressing ‘subject matter[s] […] highly relevant to the lives of the learners’, letting them experience an immediacy of purpose, and facilitating the learning of languages through its ‘integr[ation] into other types of learning […] carried out in a “naturalistic” environment’ (pp. 10-11). A unit, as envisioned in the proposed collaboration between a psychology teacher and an English teacher, for example, has good preconditions to fulfil all of these criteria.

What further needs to be highlighted about such a cooperation between a foreign language teacher and the teacher of another subject, is a specific advantage the language teacher could bring to the table, in addition to the ones related to language awareness already outlined, namely one that has to do with maximizing students’ emotional safety. There is ample scientific evidence (see, for example, Morawetz et al., 2017; Dylman & Bjärta, 2018; Iacozza, Costa & Duñabeitia, 2017) that suggests speaking and/or reading about emotionally difficult subjects in a foreign language creates more affective distance than doing the same in one’s native language(s) would. According to these studies, a significant decrease in participants’ stress levels could be measured in both their self-assessments and the actual responses of their sympathetic nervous system when they were using their L2. This distance established through the use of another language could be an effective way to diminish psychological distress in students and prevent them from approaching stories with too much personal involvement when reading potentially upsetting narratives about mental illness.

However, it is also worth considering going beyond cooperation between teachers and inviting the participation of mental health professionals from outside the school structure, such as psychiatrists, doctors, chairs of local mental health non-profit organizations, or social workers.  Practitioners of bibliotherapy, a form of therapy which seeks to ‘promote good mental health’ by providing ‘information, guidance and solace through reading’ (McNicol & Brewster, 2018, p. xiii) would certainly also be most fascinating invitees for the language and literature classroom. Hayn and Kaplan (2012, p. 212) recommend organizing a panel discussion with some of the experts mentioned above after reading mental health-themed YAL in class: students should prepare questions in advance and then, through the exchange with the panel members, gain insight into whether their readings portray experiences of mental illness realistically. Bringing in experts from outside also helps establish that crucial first contact between students and a variety of helpful professionals in the mental health sector.

Giving students concrete advice on how to get help

Highlighting the importance of bridging the gap between fictitious accounts of mental illness and our pupils’ lived reality further, I advocate that part of the lessons be used to provide students with practical advice for coping with mental health issues in their own lives (see Manutscheri 2020, p. 87). Teachers could compile and distribute a handout among students which features the most important information on how to get help in case of psychological crises or problems for those affected, or knowing somebody who is. This handout should include a list of mental health counselling services available in and around the school’s district and the contact information of those services. The Mental Health & High School Curriculum Guide (Kutcher & Wei, 2017) lists the following categories to be included in a handout: school resources, local community resources, mental health information (websites), as well as help-phone lines, and also provides a template for the creation of such a handout (p. 119); but of course, this can be adapted to any school’s particular needs. In order to make sure that students do not lose this vital source of information, it might also be prudent to make a digital version of the handout permanently available on the school’s website or e-learning platform.

Contextualizing international resources

When I first set out to answer the questions of how and why books discussing mental illness should be brought into the classroom, I had to ensure that the recommendations I compiled through the analysis of an abundance of international sources fit the particular context of my country’s (Austria) education system. What was needed was a thorough examination of the general framework conditions within which my endeavour would be put into practice. This meant thinking about supplementing the existing resources according to different learners’ needs: the language level, prior knowledge and subject familiarity (not every Austrian school type offers psychology as a subject, for example) have to be assessed so that appropriate additional materials can be designed. Thought must especially be given to the fact that resources or activities designed to be worked on by students in their L1 might need to be modified for students working on them in their L2.

Such considerations, for example, could be connected to the previously mentioned idea of inviting mental health experts to do a roundtable discussion. Hayn and Kaplan (2012) originally recommended this activity for an L1 context, but in an Austrian EFL classroom, the experts invited might not be comfortable or fluent enough to speak English all the way through their presentations or discussions. As a consequence, teachers might need to make allowances for some L1 being used during these lessons. The practice of ‘tabooing’ or completely banning the L1 from a foreign language classroom has been criticised in general, for its infeasibility (Kelleher, 2013; Kerr, 2019). but in this instance in particular, it might be beneficial to incorporate some pre-planned and scant use of L1 (Kelleher, 2013, p. 2041), to help students become comfortable with expressing complex ideas during the beginning stages of the topic or facilitate the learning of sophisticated, medical definitions and clinical terms.

Adapting international resources and recommendations to the Austrian educational system also meant going through the legal education regulations, subject curricula, education decrees and the ‘overriding teaching principles and educational goals’, especially those regarding health education, as declared by the Austrian Ministry of Education (Gesamte Rechtsvorschrift für Lehrpläne [Comprehensive legislation for curricula]). Reading these documents carefully was necessary in order to find sufficient grounds for justifying the allocation of time and other resources to the engagement with the topic of mental health in English language teaching.

And finally: Being cautiously optimistic and preparing for realistic outcomes

With a health and social justice issue as important as the destigmatization of mental problems, it can be all too easy to develop impossibly high expectations for oneself and one’s students. A crucial piece of wisdom I discovered after an initial period of boundless idealism had led me away from planning for realistic outcomes, was understanding the limits to what both YAL and the teachers who bring it into the classroom can realistically accomplish. I needed to acknowledge that ‘[t]eachers are not psychiatrists, therapists or social workers’ (Manutscheri, 2020, p. 87). They will not be able to cure a pupil’s mental illness by introducing them to a book (see also Nilsen et al., 2013, p. 360). Furthermore, students are not, and will not over the course of a few lessons, become mental health experts. They will not acquire what it takes professionals in the field decades to learn (see also Corrigan et al., 2011, p. 91). Hence, some advice that I suggest bearing in mind when defining the aims and objectives of a ‘mental-health-lit’ focused learning unit is that we cannot ‘guarantee that readers will behave in socially approved ways’ (Nilsen et al. 2013, p. 360) that is expect, for example, that students never use stigmatizing language again after engaging with a particular YA novel.

Hesse’s observation that ‘[t]he effect of reading is not always immediately visible’ (2009, p. 79) reminds us that in providing information and a counternarrative that has the potential to inspire empathy, we can only help set a process in motion which will hopefully guide our students towards becoming more comfortable with talking about mental health and finding the resources they need to help themselves and others – which is a goal that, due to recent events, has increased even more in significance and urgency since the original inception of my project.

 

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