Are rising levels of anxiety a sign of a youth mental health crisis—or evidence that we need to better distinguish between "expected" anxiety and discomfort severe enough to interfere with functioning?
A recent episodefrom the keyInside Senior Edwith a news and analysis podcast, examines an issue that has been at or near the top of the list of concerns of those working in and around higher education as students report record levels of depression, anxiety and other ailments; strain campus counseling and health centers overcrowded with students seeking treatment; and struggles academically, sometimes to the point of dropping out entirely.
Lisa Damour, psychologist and author of the book, took part in the discussionEmotional life of teenagers, Nance Roy, Chief Clinical Officer of the Jed Foundation (JED), which works with high schools and colleges to strengthen their mental health, substance abuse and suicide prevention programs; and R. Ryan Patel, a senior psychiatrist at The Ohio State University and chair of the American College Health Association's division of mental health.
The following is an edited version of the conversation.
Inside Senior Ed:Lisa, your recent book,Emotional life of teenagers, advocated, among other things, resetting the definition of mental health. Can you explain what the definition was, what it has become and what it should be?
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From love:I've been working as a psychologist for almost 30 years, and in that time I've watched the cultural definition of how we talk and think about mental health slip away from how we think about it as psychologists. The definition that seems to exist around us in the culture, in the media, is one that equates being healthy with feeling good or calm, relaxed or happy.
Psychologists want that for people, but that's not the way we think about mental health. In my book, I try to present a definition that is much more consistent with the way we think about it clinically and academically, which is a two-part definition of mental health. One is to have feelings that fit the moment, feelings that fit the context. The transition to college is a stressful transition in itself. So young people who feel stressed during that transition respond in many ways.
The second part is to manage those feelings effectively. There are many ways people deal with distressing emotions. Some are adaptive - they will bring relief, not harm - and some are less adaptive; they will bring relief, but they come with a price. What we are interested in as psychologists is not really the presence or absence of suffering - that in itself does not tell us much. What we're interested in with students is, can they handle the stress of college and the transition to college by reaching out to supportive peers and taking good care of themselves in terms of sleep, diet, and exercise? Or do they manage that stress through substance abuse or behavior? Both will bring relief, but apparently come with a price?
Inside Senior Ed:What are the reasons for the deviation from the academic and formal definition as it is culturally interpreted?
From love:I don't know, but I have a few ideas. One is that over the last ten years we have seen the emergence of an industry focused on wellness. I am for wellness, but there is a lot of commercialization of wellness. Money can be invested in promoting the idea that there is a Zen place somewhere that we can all try to get to with enough right practices, products, etc. Wellness has a place in this - it's a great way to deal with it. But it certainly cannot and must never be presented as something that can prevent suffering, because it cannot.
On the other hand, so much reporting on the psychological impact of the pandemic, especially on young people, has conflated anxiety and mental health issues. They are two very different things. Adversity is an essential part of life, and fear was a very appropriate response [to the pandemic]. There is not really a clear line drawn between young people who experience great distress as a function of the pandemic and young people who either develop significant mental health problems or who have had mental health problems that have been exacerbated by the pandemic. The more precisely we can distinguish between predictable and actually natural distress, versus when it's actually time to worry and step in with significant support, the better we can take care of everyone involved.
Inside Senior Ed:Nance and Ryan, what do you think of Lisa's description of the development of a cultural definition of youth mental health and how it is proposed to reframe that definition in line with your work?
Roy:It resonates. The pandemic has finally shed some light on mental health and well-being, but we know this has been a trend for the last 10 years or more, especially among students and young people, with anxiety and depression on the rise. Let's go back to what Lisa said about appropriate responses: look at the world. These young people are growing up with school shootings, political divisions, hate crimes, climate change. I mean, if they weren't anxious and a little depressed, I'd be more concerned.
Student experiences can be divided into three categories. They will be pleasant, hopefully uncomfortable, and sometimes impossible. Situations that are uncomfortable and unmanageable are not the same thing. A lot of undergraduate courses will be uncomfortable because it means you're growing, right? —Lisa Damour
But for the discussion, it's not that they shouldn't be upset, anxious or depressed - it's about how do you deal with those feelings? Do they get to the point where they become overwhelming and interfere with functioning rather than a normal response to the current situation we find ourselves in? In a university setting, you think about the demand for services and how all the [counseling] centers feel overwhelmed. When does something rise to the level of need for clinical intervention versus the need for support in life skills development? How do we deal with conflicts, disappointments?
These are things that the younger generation we have now does not have much experience with. Caregivers and others protected young people from disappointment and conflict. Navigating through it and pushing through it gives you a sense of competence and resilience. If we shield children from that all the time, we are really doing them a disservice.
Patel:Looking at trends over the past 10 years, the Centers for Disease Control and Prevention's Youth Health Survey shows persistent feelings of sadness and hopelessness among young people, rising from 36 percent to 57 percent. Young women [are witnessing] an increase in suicide attempts from 19 percent to 30 percent... Over the last 10 years, we've seen a steady increase in mental health help-seeking, which is a good thing. But the way we deal with youth mental health also needs to be [multifaceted]. Some people need more attention on life skills, some people need more attention on coping, some people need clinical treatment. Not everyone needs professional clinical intervention, whether medication or counseling, to address mental health issues.
Inside Senior Ed:From my perspective, we've hit rock bottom. We can all see an increase in...depression, anxiety, and demand for services far beyond what most colleges can meet. The question for me is how do we differentiate between -- I don't even know exactly the right terms to use -- but between serious, significant mental illness that requires traditional treatment, versus what isit is notin that category? When we think about our audience of institutional leaders, mental health directors, etc., how do we think about the different needs of students and the different ways to meet those needs?
From love:I really liked what Ryan said that [there is] a whole range of support that can be offered to students where different students need different things on the menu. We can diagnose depression - it doesn't look like sadness; Those are two different things. We can diagnose anxiety disorders, which is not the same as healthy anxiety, like the kind I'd like to see in a teenager if they walk into a party that's out of control, or if they haven't studied for an exam and are about to go.
We want to continue to make that distinction between predictable distress and distress that interferes with functioning, as Nance said, because it requires different kinds of interventions and different kinds of support. Some of this will go to the young people themselves in the messages, to convince them that not all experiences of fear have to scare them. Part of what we're dealing with is these CDC reports; they are disturbing. They are terrifying for parents and for youngsters who see the headlines.
We have to be very careful in how they are reported. The CDC data released in early February was collected in the fall of 2021, and asked questions about the previous year's mood, about depression over a two-week period. I had a daughter who at that time was entering the last year of high school, the third year of a disturbed school. She was miserable, like everyone she knew.
We have to watch out for the opposite of a vicious circle: we have worrying data, it's being reported in a very worrying way, it's scaring young people, it's scaring their parents. Understandably, this makes parents much more protective, much more concerned about any discomfort in their children. Much can be done to change the message, distinguishing between when anxiety is actually evidence of mental health, as it often is, and when anxiety is cause for concern.
Inside Senior Ed:Ryan, what is the institutional role in driving that difference home? How successful do you see your colleagues in this?
Patel:A useful role for universities is to teach students in which situations professional help might be more appropriate, situations in which self-care work might be more appropriate, life skills work might be more appropriate. And offer that menu and where different menu choices are more appropriate. Also informing university staff and community members and parents that there are different options for mental health care for different problems. We at [Ohio State] and about 40 percent of the institutions use a multi-tiered approach to care where a student can come in for an initial screening, [and] a specialist can work with the student to determine what's going on with the arm and maybe who might be the most appropriate resource for that student.
Roy:I think sometimes we pathologize the feelings that fit the situation [students] are in. Yes, the data shows an increase in feelings of sadness. If you've watched television for more than five minutes, you'll see, "Oh, are you sad?" Take this medicine.” There is a need for instant gratification to feel good all the time. Similarly, at the Jed Foundation we cooperate with more than 400 universities. Often when we talk to them, their gut reaction, especially college presidents, is, "Oh, we need to add 20 more counselors or psychiatrists." This will never solve the problem, and it confirms that everyone needs psychotherapy. Not every student on campus needs direct clinical care, but all can benefit from a culture of caring and compassion, where a student can make no mistake in seeking support.
This does not mean that faculty members are therapists. But if you notice something is wrong with Nance today, call in, "Hey, Nance, are you okay?" You were silent in class for several days." Knowing where to seek professional help if I bring up a big problem. When we work with schools, we're really talking about developing a culture of care, developing life skills that promote connectedness. Loneliness here is reaching epidemic proportions. How do you develop relationships? How to recognize when students are just starting to struggle? Let's not wait for them to come to your office and burst into tears. At that first sign of struggle, we can compensate for many situations, from spiraling to the point where the student needs emergency care. Not looking at crisis management, direct services, but a public health approach where everyone in the community has a role to play in supporting the growth and development of young people.
From love:Student experiences can be divided into three categories. They will be pleasant, hopefully uncomfortable, and sometimes impossible. Situations that are uncomfortable and unmanageable are not the same thing. A lot of undergraduate courses will be uncomfortable because it means you're growing, right? It's part of student life. If we introduce those categories, we can help lower the temperature and endure more discomfort.
Then there's what Nance said: if we see that the student is uncomfortable, that's a good time to look. Because the disobedient usually do not come overnight; the kids will get there eventually. If we follow a child who is uncomfortable and normalize him, but also follow closely, we can do two good things at once. One is to reassure that young person that we are not afraid that they will feel uncomfortable - discomfort is part of life, and certainly part of learning. However, we also monitor them carefully so that they do not slip into the category where it becomes unfeasible. But I worry that one of the consequences of this discourse, where there is a lot of concern about students who present themselves as vulnerable, will turn it into "they're OK". It's too extreme, isn't it? They're fine, or they're uncomfortable, or they're unmanageable, and we want to work in those three categories.
Inside Senior Ed:Nance and Ryan, have you seen any successful attempts to help students distinguish between the unpleasant and the unruly?
Roy:Regardless of whether we consider something extreme, it doesn't really matter. That is their experience. The first order is to confirm: “I hear you; I understand that you feel A, B or C.” Then start teasing out the underpinnings of it - how do they succeed or fail? Then it's up to the psychologist in the room to help us figure out if this is something that actually requires direct clinical intervention or if we can talk to the student about some coping strategies for what it is. sad or sad about?
Inside Senior Ed:You just set the scenario according to which the person comes to the professional. There is usually more demand for clinical services than most facilities can provide. None of us would want a situation where a student who is in the "unsustainable" zone has to wait two and a half weeks to see a specialist, perhaps because they are being pushed out by people whose situation is best handled by a non-clinical doctor. intervention. Are there any approaches we can use to extract even more or approach this problem in a different way?
Patel:There are a number of approaches. One is the intervention of observers. We provide educational programs for students to help them identify a peer who may be in trouble - they may be suicidal, they may have thoughts of harming others, or they may be at risk of harming themselves or others. There are programs like Mental Health First Aid that help train teachers and staff to recognize warning signs [that] require further assessment and intervention. A number of counseling centers use this approach where the student has an appointment before the first appointment - a brief meeting with the clinician within three days of the client making contact and providing emergency care if necessary... due to the psychological distress of the health symptoms they are experiencing.
Roy:If we can create a culture of care and compassion on campus, we will indeed see fewer students running to the counseling center when they feel the first signs of fear. They will experience a sense of belonging, closeness to adults in the community or peers they can turn to, and this atmosphere will go a long way toward saving the counseling center for students who really need direct clinical care.
We need to be careful when we talk about educating faculty and staff about identifying students who may be struggling. We've done ourselves a disservice in the field by making it a huge eight-hour training session where you feel like you have to be the clinician who can diagnose whether someone has clinical depression or not. It's terrifying. This makes people feel like they are going to say the wrong thing or make things worse. This isn't rocket science: most of the information you need to convey about how to recognize when someone is struggling, what to look for, can be done effectively in about 20 minutes.
From love:Let's put this in a public health context, using dental health. Consider primary, secondary and tertiary intervention. A primary intervention is what the whole population gets, like fluoride in the water. What is fluoride in water [for mental health], the thing that goes to every student? Maybe that's what Ryan was talking about, where all the students get a warning of what to look out for, when they need to worry about someone and sound the alarm if there's any concern. Fluor could be an additional education on what can reasonably be expected in terms of expected stresses associated with the transition to college and how we recommend dealing with them. It's fluoride. Everyone understands that.
Then what Nance is talking about in terms of kids starting to eat a lot of candy where there's a concern that there could be a gap in the queue. Nance, when you talk about 20 minutes, I see you saying to professors, "Tell us if someone has stopped showing up for class" or "Tell us very clear basic signs that a child is starting to be overwhelmed." I will call it secondary prevention: knowing who these students are. And then tertiary, right, while there's a gap, that's where the counseling center usually belongs and steps in. Using those models, I've found, takes on a problem that seems so overwhelming and sometimes overwhelming.
Inside Senior Ed:We see significantly more students entering colleges and universities with previously diagnosed mental illnesses. How do institutions deal with them, recover them, if that is expected of them?
Roy:First, we must recognize that not all students are the same. We will have some students coming to campus who are quite resilient, who have been through a lot of adversity and who have developed many strategies and skills to deal with suffering. We may still have a whole group of students whose janitors, thinking they are doing the right thing, have protected them from any disappointment - it's that T-ball, everyone gets a trophy. Get a 4 and feel like their life is over. Then you have specific populations: You are one of the few LGBTQ or racially diverse students on campus. The people who come to our campuses are in many cases very different and we have to take that into account.
We also need to meet students where they are. So as an institution, apart from health and counseling centers, how can we integrate this into our campus? For example, how do our faculty members integrate life skills development in the classroom into curricula? How do coaches and trainers deal with these problems on the playing fields? We return to a public health approach: the whole community takes responsibility for the students it interacts with and helps them develop from where they are, because they will be at different stages of readiness.
Inside Senior Ed:Lisa, you made some good points in this conversation about how my colleagues and I in the media can contribute to this problem with the language we use to discuss the current situation. It is said a lot that we have a mental crisis among young people. Whether this is a crisis or not, do you think institutions will face this indefinitely? After all, we are a pendulum swinging society - is that part of the pendulum swinging? Can this be resolved by achieving some kind of stagnation, instead of just feeling like we're spiraling out of control?
From love:I hope it doesn't get out of hand. However, this is what we're dealing with in terms of a mental health crisis: it's real. The pandemic has been terrible for teenagers and has set off a wave of adolescent suffering and pushed many more children into the needy category than before. This was related to the fact that there are not many people who care for teenagers and young adults. It's actually a very specialized job, so we've had a huge increase in demand and we haven't been able to develop the workforce to meet it. Those two things combined to create a very real crisis.
It seems to be improving somewhat. But we really need to be careful how we talk about suffering in young people. If we minimize that - which we shouldn't, but I understand why people sometimes tend to go that way - the reaction of young people will be, "No, you don't understand, you don't hear." "The goal here is to try to find a way to talk about it that's deeply compassionate. As Nance said at the beginning, it's not an easy time to be young in this world. Deeply compassionate about that, while again making a clear distinction between expected and typical suffering and mental health problems.
Another thing we come across is the fatigue of the adults who surround the youth. The pandemic has disrupted [students'] education, slowed maturation, slowed ownership of learning. It may be impossible; they were not in school in a conventional way. One thing I hear when I spend time with teachers is that they both understandUthey are tired of meeting it. A lot of work needs to be done to support the adults within the institution, to have constant patience and empathy for the fact that the students who still come to campus have had very disrupted periods of their education that still have consequences or if the adult is ready to move on.
Roy:The term 'crisis' bothers me. I don't mean to diminish the level of distress many people are in, but the word "crisis" creates a kind of panic, a kind of aggravation that I'm not sure always helps. For me, it gives more of a sense of helplessness and hopelessness. I would rather focus on, yes, this is a very difficult and difficult time, but we have numerous ways in which we can help each other and the youth. Lisa, you mentioned college. Somehow sometimes we forget that they also went through the pandemic - they also have losses; they also fought. So, not only are we asking them to make a real effort to help our youth who are struggling because of the pandemic, but they are still struggling themselves. We often hear from the institutions we work with that it's not just about how do we support our students, but how do we support our faculty and staff? Because they are very necessary, often just as much as the students.