Upstream-Midstream-Downstream
Prof Peter Fonagy has spoken with the BBC about his soon‑to‑be‑released independent review into rising demand for mental health, ADHD and autism services in England.
Much of the review will likely focus on services, assessments and support pathways – the midstream of youth mental health.
A Human Field lens looks earlier.
It asks what is happening upstream, where the ground is prepared, and downstream, where human beings move with what has arrived.
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The pressures that meet
Young people carry several pressures at the same time – school expectations, peer dynamics, family boundaries and the density of digital life.
Society carries its own pressures – productivity, fairness, stability, identity and limited resources.
These pressures meet.
Sometimes the meeting becomes difficult to hold.
Pressure builds.
Sometimes it reaches crisis.
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Upstream: preparing the ground
Upstream work prepares the ground for pressure to move when it arrives.
Institutional
Schools need young people to meet expectations.
Young people need room to show what those expectations are costing them.
Relational
Families see the child at home.
Schools see the child in a different world.
Both carry part of the picture.
Generational
Some learned toughness because toughness was required.
Some carried pressure quietly because there was nowhere else for it to go.
Others grew up with different expectations about expressing difficulty.
Community
Young people move between worlds that rarely fully meet – home, school, friendship, online life and community.
Adults often see different pieces.
These things rarely sit neatly apart.
They overlap. They pull against each other. Sometimes they help each other. Sometimes they don’t.
Keeping enough room between them for people to breathe may matter more than finding the perfect answer too early.
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Midstream: organising the response
Midstream work is where systems and services begin to act.
It includes early‑intervention pathways, multi‑agency coordination, shared approaches and the structures that organise support.
Midstream gains strength when upstream breathability is already present.
Midstream organises the response to what has arrived.
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Downstream: moving with what has arrived
Downstream work is where people move with what has arrived.
It looks like:
• teachers adjusting responses
• families creating steadiness
• youth workers building contact
• communities sharing responsibility
Downstream movements carry the response into real situations.
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The whole picture
When conversations stay open, pressure has somewhere to move.
When conversations close, pressure has fewer places to go.
Upstream prepares the ground.
Midstream organises the response.
Downstream moves with what arrives.
Mental‑health systems gain strength when there is enough breathability for human beings to meet what arrives.
