Into the Snake Pit and Out Again

By the time I was thirteen, everything that I read had taught me that you didn't reveal your own weaknesses or you would be carted off to hospital and marked for life as an outsider. And if you had a mad person in your family, it was a secret, never, ever to be told. I learned all this from the books I was reading. So have things changed?

Over the past ten years there has been the development of the Child and Adolescent Mental Health Services (CAMHS) and The National Service Framework for Children, Young People and Maternity Services (2004), which includes 'The Mental Health and Psychological Well-being of Children and Young People'.

There is now much more social and political awareness of the needs of children and adolescents with mental health problems. But many young people who may be experiencing mental health problems still do not know or understand what is happening to them, nor are they aware of how or where they can get help when they feel they need support.

The biggest obstacle to getting help is the fear of being seen as different by their peers, and the fear of what will happen to them if they ask for help. Sometimes the only source where they can get information, or have an awareness of difference, is through reading. But there are pitfalls in this.

For the author there is the dilemma of driving a plot, creating tension between characters, and good writing, versus factually correct information that readers can rely upon to try to understand their own inner turmoil or others' problems and to find ways to resolve them.

Some authors introduce an element of fantasy as a plot device, making it more difficult to know what is for real. The balance can be very difficult to strike between creating a good piece of literature and creating a safe place for young people to explore some of their fears about mental health.

Robert Westall's Gulf mixes the fantasy of the psychic link between two boys in different part of the world with the reality of the child's experience in the mental health hospitals.

Several children's books address issues of mental health, and it is not always clear where the line between fact and fantasy is crossed. Robert Westall's Gulf mixes the fantasy of the psychic link between two boys in different part of the world with the reality of the child's experience in the mental health hospitals.

As a depiction of the contrasts between the two societies and the futility of war, it is a powerful and effective story. But to drive the story, the stigma of mental illness is reinforced, and the process of engagement with mental health services is blurred, leading the reader to believe that essential mental health services have to be paid for and are difficult to access.

Meg Rosoff's novel Just In Case similarly gives a very good description of a disaffected youth, full of black humour as he struggles to cope with adolescence, growing sexual feelings, and the lack of support from parents who are unable to understand what he is experiencing.

There is a mixed picture of schizophrenia-type symptoms of delusional beliefs, hallucinations and depression, during which time the boy becomes increasingly isolated from his family, but paradoxically closer to his friends and lover.

The novel is an effective look at what happens to young people with mental health problems. Justin has an invisible dog (plausible as a hallucination), but the dog is visible to and commented on by characters in the story that are particularly close to the main character - a fantasy element.

The climax of the story, where Justin collapses and is diagnosed with a physical illness, may lead the reader to suppose that the symptoms, which have been present for over a year, are related to the physical illness and not to a mental illness.

Both the shared hallucination and the physical illness are good devices to move the storyline, but they detract from the mental health symptoms and could cause confusion if trying to relate to the reader's personal experience.Whilst a good read, the reader was left with the impression that treatment for the physical illness implied a treatment for the schizophrenia-type symptoms.

Paradoxically, JK Rowling's Harry Potter and the Prisoner of Azkaban gives a very good description of the feelings of depression by the actions of the dementors as they suck out all the hope and leave Harry full of despair and coldness.This writing is influenced by Rowling's personal experience.

The treatment is the teaching of the spell 'Patronus', which is a 'very difficult' spell which Harry has to work hard at and takes a long tome to perfect. It shares some elements with cognitive behavioural therapy and I frequently use the concept of the 'Patronus' in my work with children who are depressed.

More realistic presentation is found in Jacqueline Wilson's The Illustrated Mum. It is told in the first person from the point of view of Dol (short for Dolphin). She is nine and lives with her mother, Marigold, and her elder sister, Star.

Marigold has a manic depressive illness. The story relates how the two children care for and manage their mother whilst trying to care for themselves. As the two fathers of the children enter their lives, Marigold's illness cycles out of control and she is eventually admitted to hospital.

Wilson outlines the myths and dilemmas about mental illness along the path, and allows the action to take place under those constraints. When the crisis occurs Wilson takes the reader with her, but challenges the myths, leaving the reader with an alternative and authorative account of what really happens.

This is a very authentic account of what happens in a family where a parent has manic depression, and readers learn about mental illness, some of the signs and symptoms of the illness and the behaviour associated with it. Mental health workers have used it with families where a member has mental illness as a way of exploring the issues.

Sue Mayfield's Blue describes the issues of depression and how it is managed (or rather not managed) in families and schools. There is the bullying of one of the child characters (and how she copes with that, eventually leading to a suicide attempt), balanced against her mother's depression.

Mayfield shows how the assumption of parents and school about both the ability of a child to cope, and the belief that there would be no bullying in a 'nice' school, inhibit them both in recognising and dealing with the problems.

Readers would learn about mental illness and depression, and some of the signs and symptoms associated with it. They would learn about the unpleasantness of hospital procedures and the real threat of death as a consequence of side effects of a suicide attempt, but nothing about what services could have been used to prevent it.

The afterword acknowledgments show that Mayfield intended to bring the problem to the attention of a wider audience, but she does not indicate that there are alternatives that a child in a similar situation can seek out.

Anne Fine's Up on Cloud Nine is narrated by the teenage character, Ian, as he sits by the hospital bedside of his best friend Stolly. Stolly is unconscious after having been found injured in suspicious circumstances.

Ian tells the story in flashback as he tries to write Stolly's biography in order for Stolly to appreciate that he is valued, has made an impact on people's lives and that he has a reason for living.

Against this is the backdrop of Ian's determination that 'the authorities' will not find out that Stolly has tried to self - harm and has possibly tried to kill himself over the years, and that Ian fears that this latest incident is a bungled suicide attempt.

Fine describes the issues relating to mental health problems fairly accurately and addresses the dilemma that young carers experience. However the use of an unreliable narrator, with no alternative voice to explore the options, may cause the reader to follow the words of the narrative without seeing that there are other issues involved.

There is sufficient doubt as to what Fine intends the 'right thing' to be. There are powerful lessons to be drawn from Up on Cloud Nine about mental health problems, the reality, the myths and the role of young carers. However, there is no authoritative voice to give alternatives, and there is no roadmap to support young people in getting the help that they need to access.

Tabitha Suzuma's A Note of Madness, charts Flynn's journey as a promising musical student who becomes very depressed.

Tabitha Suzuma's A Note of Madness, charts Flynn's journey as a promising musical student who becomes very depressed. He then has manic phases during which he does some amazing creative work, but his erratic behaviour puts himself at risk.

His friends struggle to understand what is happening, and remain supportive and concerned. While under the care of a psychiatrist Flynn takes medication, starts to feel better and then stops taking the medication.

He experiences a dramatic relapse, putting everything he has worked for at risk. Again with the support of his friends and family (and medication) he becomes settled and achieves his goal of playing at a top concert.

This is a very authentic description of the feelings and experiences of someone developing a manic depressive illness, and the responses of people around them. It is done sympathetically and without stigmatizing.

The device of Flynn's brother as a doctor who gets him psychiatric care blurs the problems of how to get access to mental health services, and it is implied that the treatment he gets is as a favour to his brother rather than what can be expected.

However the overall plot is positive, demonstrating that people with a developing manic depressive disorder can be given help and not rejected by people around them.

The current presentation of mental illness in children's literature is far removed from the mad woman in the attic, but there is little in the literature that explores the availability and use of services that young people may access.

Most readers will have a view of mental illness that remains tinged with stigma and confusion about what can be done. There would be some value in having a final page in each book with some reference to, for example, a website such as Young Minds (www.YoungMinds.org.uk), where additional information could be found about mental health issues.

A child's quality of life may improve as a result of the information that a book imparts and the alternative point of view that it offers. A book might show a reader a pathway out of suicidal thoughts and feelings. It could save a life.

Just as Bettelheim describes fairy tales as taking children into the forest and out again, children's fiction that is going to address mental illness also needs to take them into the s