Agency in Youth Mental Health (5): Lisa Bortolotti

This post is the fifth in a series of posts on a project on agency and youth mental health funded by a MRC/AHRC/ESRC Adolescence, Mental Health and the Developing Mind: Engagement Award and led by Rose McCabe at City University. Today it is my turn (Lisa Bortolotti) to answer four questions about the project. 

I am Professor of Philosophy at the University of Birmingham, affiliated with the Department of Philosophy and the Institute for Mental Health. I am a philosopher of psychology, interested in belief, rationality, self-knowledge, and mental health. 

What interests you about clinical encounters with young people in the mental health context?

The encounter between a mental healthcare practitioner and a young person experiencing a mental health crisis is the paradigmatic case of an interaction characterised by power imbalances: the practitioner is an expert who can assess risks and prescribe treatment, whereas the young person is thought of as a vulnerable and inexperienced person who depends on the practitioner for further support. We would expect epistemic injustice to flourish in this context. Epistemic injustice occurs when a person is discredited as a knower due to negative associations triggered by the person's identity. 

Indeed, in our study we have witnessed practitioners' behaviours that undermine young people's capacity to contribute valuable information to the exchange. A young person seeking support for mental health problems may trigger negative stereotypes (being fickle, attention seeking, unreliable) that may lead to the practitioner dismissing the young person's experiences. Unfortunately, there is a risk that such negative conceptions are internalised because the young person's identity is still developing and the most important relationships in the young person's life which could provide some anchoring are also evolving in the transition from childhood to adulthood.

Why is the focus of agency important in this context?

For the typical human being, the concept of the self involves a concept of agency. We see ourselves as capable of intervening in the surrounding physical and social environment so as to pursue our goals and interests and securing our wellbeing. Ultimately, agency means that we can give some shape to our own lives. 

We tend to think of agency as a power that we can exercise as individuals, but any realistic assessment shows that agency survives in the wriggle room we manage to carve from the constraints of our environment and the pressures of our social world. We are never agents in a void and we are never agents alone. As agents we support and obstruct, cooperate and manipulate one another.

When the young person's shifting sense of self is impacted by interactions with teachers, parents, friends, and mental healthcare practitioners, the young person may feel empowered or helpless, supported or abandoned, understood or dismissed, as a result of those interactions. Interactions of this sort are not the whole story, of course, but may make a difference to whether the young person will seek the help they need to bounce back.

What do your experience and disciplinary background bring to the project?

In this project, I am learning, not leading. I am new to youth mental health, and new to some of the methods used in the study, such as the conversation analysis of clinical encounters. But I have a deep interest in the strengths and limitations of the concept of agency and the role of agency in our identity.

Indirectly, I have worked on agency for the whole of my academic career, first thinking about how we attempt to understand the behaviour of other agents by ascribing beliefs to them; then questioning whether agency depends on the person conforming to standards of rationality; next arguing that poor mental health does not need to translate into compromised or reduced agency; and more recently reflecting on the role of optimistic conceptions of the self in supporting motivation and boosting resilience.

What do you hope to see as an outcome of this project?

I would like for everybody who deals with young people, not just healthcare practitioners, but also parents and educators, to appreciate the damage that unchallenged negative stereotypes can cause in interactions, and how easy it is, often without malice or ill-intent, to communicate in a way that makes young people feel bad about themselves and leaves them unsupported.

We are developing something we have called the agential stance: a set of practices that help us recognise and nurture a sense of agency in young people, without burdening them with the overall responsibility for the situation they find themselves in. I would like that stance to be discussed as part of parental education and the professional development of teachers and healthcare practitioners, together with examples of good and bad practice.