Plain English with Derek Thompson: Why Are American Teens So Unhappy? How Do We Solve This Crisis?

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This episode is the second installment of

Happiness Week on the plain English podcast.

On Tuesday, I spoke with the directors of

the Harvard Study on Adult Development

about what makes a good life based on

their 80-year longitudinal study.

And if you missed that episode,

I would very strongly encourage

you to go back and listen to it.

Today's episode is about the phenomenon of

rising and rising and rising teenage unhappiness.

American teens, especially girls and especially

kids who identify as lesbian,

gay, bisexual, or questioning are engulfed

in historic rates of anxiety and depression.

And everybody seems to think they know why.

Some people say it's the phones.

Others say it's school pressure.

Some people say it's the parents fault.

Some people say the world is just terrible

and young people are merely paying attention.

I'm going to get to theories in a second,

and we're going to talk about theories

a lot in this episode.

But first, let's just review the raw numbers.

The Youth Risk Behavior Survey,

which is published by the Centers for Disease Control

and Prevention, the CDC, is the gold standard

for measuring the state of teen behavior and mental health.

And between 2011 and 2021,

this survey found the share of teens

who say they experience persistent feelings

of sadness or hopelessness has done nothing but go up.

Every year, for a decade.

For girls in particular,

the number has increased from 36% to 57%,

with the highest jump coming during the pandemic.

Six out of 10 girls now say they are persistently

sad or hopeless.

I think it's important to say that life appears to be worse

for LGBTQ teenagers in just about every respect

measured by this survey.

They are less likely to feel close to people at school,

twice as likely to be bullied,

three times more likely to have considered suicide.

That alone is a really important phenomenon,

and I think I'm going to go deeper into it

in a future episode.

But on the nature of this general phenomenon

of teen sadness, what makes it so interesting,

so surprising to me,

is that this surge has coincided with other behavioral trends

that aren't obviously bad.

Reports of smoking are down.

Drug use and drinking have declined among teenagers.

Bullying has not increased among boys and for girls,

it's actually declined slightly, according to the CDC.

And while a handful of people seem very eager

to hang this phenomenon on the fact that,

well, the world just sucks and being doom and gloom

is just being rational.

Well, let's take this argument seriously.

Climate change is awful.

School shootings have become a bit more common.

Inflation sucks.

The world is a mess.

But let's take a deep breath here.

The world is always a mess.

Teen sadness has gotten worse every year for a decade.

Has the world really gotten worse every single year

in the last decade?

The truth is that in the period

when teen anxiety has increased,

joblessness, poverty, child hunger,

these things have actually all gone down.

Real disposable income has grown

for the vast, vast majority of families.

Meanwhile, in the last decade,

a lot of the worst long-tail scenarios for climate change

have actually become less likely.

I do not think the idea that ever increasing teen anxiety

is a rational response to the state of reality.

I don't think that's a tenable claim.

In fact, it leads to one

of the most untenable conclusions possible,

which is that over time, over a long enough period,

everybody should be permanently and hopelessly depressed.

That is, to be frank,

one of the worst, most maladaptive ideas

I can possibly imagine.

So what is going on?

Today's guest is Matt Beal,

a leading adolescent psychiatrist in Washington, D.C.

And look, he's fantastic.

I like episodes that are a little bit contentious,

a little bit of a debate.

I can't say that's what you're about to listen to.

This guy is just spot-on across the board,

not just his ideas, but also in the beautifully nuanced

and balanced ways in which he expresses them.

I think this is a pretty special pod.

I'm Derek Thompson.

This is Plain English.

["Metallic Music"]

Matthew Beal is the Chief of Child and Adolescent Psychiatry

at Georgetown University Medical Center

and Chief Medical Officer at Fort Health.

Matt, welcome to the podcast.

Thanks so much, Derek. Great to be here.

So this is a topic that I've written a lot about,

that I've talked about on this show

with a few different people.

I've talked to John Height, the social psychologist.

I've talked to writers and economists and sociologists.

On Tuesday of this week,

we talked to the directors of the Harvard Study

of Human Development.

You are the first psychiatrist I've spoken to on this show,

not to mention the first adolescent psychiatrist,

not even to mention the first Chief of Adolescent Psychiatry

at a major university medical center.

So it seems to me that the only reasonable place

to start here is to acknowledge our profound expertise gap

and give you the floor for a second.

I know you've read some of my pieces.

You generally know where I stand on this issue.

What are you singing on the ground in your work and practice?

What is the state of teenage mental health

from your point of view?

Thanks, Derek.

I really got to be here.

I'm equally humbled by being in the presence of a writer

whose synthesis around these issues I've really admired.

So I think the work you've been doing

has been really important.

I've learned a lot from it.

So I'm glad to be here in dialogue with you today.

I mean, I think there's a couple of things

that I had outlined.

Many of us have been really shocked

and dismayed at the data that came out from the CDC

last week around adolescent mental health.

And I think I'd start by saying, as someone

who sees young people and their families in my office

every week, that this crisis is very real.

There are a huge number of kids that

are in terrible distress.

Our health care system is not able to respond as effectively

and as quickly as needed.

System doesn't have the bandwidth or the infrastructure

to deliver effective treatments to young people who need them.

And as a result, emerging problems

become entrenched problems and manageable clinical issues

become very difficult clinical issues

because we're not getting care to kids fast enough.

The rates of depression and suicidal thinking and behavior

in teen girls reported by the CDC are extremely alarming,

as are the rate of exposure to bullying and community

violence and sexual violence.

And these data reflect exactly what my colleagues

and I are seeing in our clinical practices.

I think we'll have a chance to talk later today

about some of the potential causes of this crisis

in our conversation about social media,

we're doing time with friends, and some of the other things

that you've written about.

Secondly, I want to point out, I see the distress

in adolescents as revealing a broader level of distress

in our society.

And in particular, based on my clinical experience,

I interpret this data about teens

in the context of a larger state of crisis in families.

Parents and families are struggling terribly.

Americans of all ages are struggling

to feel connected, to feel hopeful, to feel purposeful.

Parents are feeling overwhelmed, overwhelmed

by fears about the future for themselves

and for their kids in particular,

by economic uncertainty, by the cumulative burdens of work

and childcare and elder care, as well as by less support

from the communities around them.

It makes sense that teenagers, we know that teenagers

in any era are vulnerable to mental health challenges

due to the developmental obstacles they face.

And they're struggling, particularly in our current era.

Teenagers don't exist in a vacuum.

They live in families and families right now

are not flourishing.

So I think it's important to address

this crisis from the standpoint of asking

how we can support entire families

to feel less overwhelmed, better connected,

better able to cope effectively.

And then finally, Derek, you've written

about how in the last 10 years we have learned,

or maybe we've been conditioned, to take in information

and to respond to information on the internet

in a very specific way.

Social media and all digital media really

emphasize anger and despair and hopelessness and disconnection.

This is the material that gets the most attention,

the most clicks.

And I think that this has really cheapened the way

that we talk about our emotions.

And this cheapening, this kind of coarsening

is affecting the way that all of us, including teenagers who

spend so much time online, experience our lives.

It makes it much more likely that we

identify intense emotional states, particularly

intense negative emotional states like sadness or anxiety

or loneliness, as central to our experience.

And so the stories that we tell ourselves about our lives

and about our world shape our internal emotional landscape.

And when the stories that we hear and that we're engaged

with online are all about rage and misunderstanding

and trauma, there's a considerable and cumulative

emotional toll.

Wow, there is a lot there.

And we're going to get a little bit deeper

into just about every single part of that menu

that you wrote up for us.

I have one more question about these CDC numbers.

You, I'm sure, read about how this is affecting just

about every single category of teenagers.

This is not just something that affects one ethnicity group

or another.

This is something that is happening for every race,

for straight teens and gay teens,

for students in every year of high school,

for teens in all 50 states and the NDC,

even though there are several groups like American Girls

and LGBTQ teenagers for whom it's happening the most.

That's the general picture here.

And I just wonder, before we get into the possible causes,

whether there's anything in this report that

rang false or really surprising to you,

anything that diverged from your experience

or the testimony of psychiatrists,

where you and your friends looked at the CDC result

and said, huh, I didn't even realize that was the case.

Any surprise like that?

It's a great question.

I wish there were more surprises.

I wish that we had gotten some unexpected good news,

particularly about mental health and risk of suicide.

I think there were some silver linings

that maybe we can talk about more.

One of those was with regard to substance use

and alcohol use, which continues on a trend going down

among young people, which actually is a complicated finding,

I think, that maybe we'll talk about more.

I think that the degree to which kids feeling connected

to their schools was a protective factor.

It's something that got lost in the headlines,

but something that this data found very strongly.

Feeling connected to your school means

that you feel like your school is safe.

You feel like there are people there that both peers

and adults that you have relationships with

and that care about you.

And then it's a place that you feel good being.

When that was present, that was clearly

a protective factor for young people.

I think that's a really important finding.

And then getting back to the family piece,

I think that I hope that in future iterations of this survey

that they start to ask more interesting questions

about families.

The question they asked in this survey was,

basically, do your parents know where you are

and who you're hanging out with?

And most kids said yes.

Of course, most kids feel like their parents

are hanging over their shoulder all the time

and probably overestimate how much their parents are actually

aware of what they're doing and who they're hanging out with.

And I don't think that was probably the best measure

of understanding the protective factors that families can play.

So that's something that needs more attention

and more thinking going forward.

So I think the best way to structure the rest of the conversation

is to talk about causes and then talk about solutions.

And the first cause, obviously, everybody listening

knows that this is coming.

Let's talk about social media and the smartphone.

What is your take on the connection

between social media and smartphone use

and rising teen anxiety?

So you talked about on your show with John Hyde

and another folks about what the data shows.

And many of your listeners probably

know that there is a difficulty that

has been described in making a causal connection between social

media use and effect on mental health, particularly

negative effect on mental health.

That evidence gap is closing.

I think there's some stronger and stronger evidence.

And even in the last two or three years,

as Professor Hyde pointed out in some of his writing,

that shows that we're making stronger and stronger cases

about that causal connection, in particular for girls,

in particular for early adolescent girls,

for girls who are 12, 13, 14, 15 years old,

in particular for kids who use social media in a passive way.

So social media that's used for lots of hours

in a way that's scrolling and looking and scrolling

and looking and basically engaging

in negative social comparison.

As opposed to kids use social media in a briefer way

that's more active, that's connecting

with posting, writing to friends, making plans.

Those are very different ways of using social media.

So there, as the research has progressed,

I think we're getting a finer and finer and clearer

and clearer picture of the fact that there's no doubt

that social media is having a really deleterious effect

on mental health for young people, particularly

some of these vulnerable groups.

I'll say in my clinical practice, Derek,

I see that there are really specific vulnerable groups that

seem most disposed toward experiencing

the harmful effects of social media.

I definitely see the effect with girls.

I see the effect for girls who have preexisting mental health

conditions, girls who struggle, perhaps already,

with anxiety or with depression or with OCD,

who tend to use social media much more obsessively

and much more passively and in a much more self-destructive way.

I see it with kids who have ADHD, who

tend to struggle with reward processing in their brain

and the ways that they respond to immediately

enjoyable activities and their ability

to postpone immediate gratification

for larger goals than they'd be pursuing.

For all of those reasons, kids with ADHD oftentimes

are quite vulnerable to the negative impacts

of social media.

I think there are other groups as well.

I think you referenced the impacts on LGBTQ youth.

I think that's a nuanced picture.

On the one hand, sometimes it allows kids to connect

when they don't have kids in their local community with whom

they're connecting around identity.

On the other hand, I think that they can really

be drawn into deep, passive, destructive engagement

with social media.

I see that in my clinical practice all the time as well.

So I think it's a nuanced picture,

but I think we have to move past saying, well, gee,

we don't really know.

I think we say we know that it's bad,

and we're finding out just how bad it is and for whom.

Why girls?

Why does the effect seem to be so much stronger for young teenage

girls?

It's a good question.

I think that's a question that needs more research.

That's my scientific answer.

I think my clinical intuition tells me

that girls are much more oriented

toward social comparison in general than boys.

And social media is this very available and insidious tool

for social comparison, particularly

for upward social comparison and for a fear of not being

where you want to be.

And so I suspect that that's a big part of it.

I can absolutely identify with that particular statement.

I mean, it's almost beyond obvious.

The internet, in many ways, is a machine

for displaying to you where you fit

in any social hierarchy in which you want to be situated.

Like, if I want to know how popular this podcast is,

well, there's a Spotify ranking.

There's an Apple podcast ranking.

And guess what?

I'm not number one.

There's a lot of podcasts ahead of me.

If I want to know how my tweets are doing,

I log on to Twitter and right there at the top

are a bunch of tweets that are doing better than mine.

It's the same for Instagram or TikTok.

There will always be people that are funnier and taller,

stronger, more successful, richer, more beautiful, always.

The internet is, as you said, a beautiful tool

for finding groups that you belong to.

But almost by that very same token,

it's an unusually and berserkly successful tool

for situating you inside of hierarchies

that can be devastating to people

that are sensitive to social comparison.

I think that's exactly right.

And for all the reasons we talked about earlier as well,

our minds gravitate toward extremes.

And so the input that we're most attentive to on social media

is the input that is terrifying, that is ostracizing,

that draws our threat systems because we're

acutely attuned to threat on a very basic biological level

for the sake of survival.

And so we're looking, we're part of survival

for being a human being, for being a primate,

is finding your place in the social fabric

and surviving there.

And so we're so attuned to these social signals.

And the social signals that we get on social media

and on digital media in general are fundamentally distorted.

It's really important to say, and this

is sort of my grand theory about what social media

and smartphones are doing to us.

It's not just about the five hours of daily smartphone use.

It's about what those five hours are displacing.

So Lauren Steinberg, who's an adolescent researcher,

I talked to a lot about these topics, told me once,

if Instagram is displacing TV, I'm

not that worried about it, for the most part.

If it's displacing sleep, I'm worried.

And the truth is, it is.

The share of teens who got eight or more hours of sleep

declined 30% between 2007 and 2019.

As you mentioned, today's teens are less likely to drink,

less likely to go to parties, less likely to do drugs,

less likely to smoke, less likely to do illicit drugs.

But they're also less likely to just be out with their friends,

to get a driver's license, to play youth sports.

They spend much, much more time alone,

and they suffer for it.

One in five millennials say they have no friends.

These are people in their 20s and 30s,

but I can only imagine what the effect is for Generation Z.

So to borrow a watchword from our episode earlier this week,

I'm worried about the social fitness of America's teenagers,

that social media provides an inferior good for sociality,

and as a result, true social fitness atrophies

as people enter their 20s and 30s,

and life really starts to come at them,

and they need this bank of social support.

They need this roster of friends

that they haven't been able to build in the physical world

because they have been submerging their face

in this virtual world of inferior friendships.

I think you're so on it, Derek,

and that concept of social fitness

that your previous guest spoke about is so important.

The breadth and depth and frequency of friendships

is so profound, and of course, as kids and teenagers,

a primary developmental goal is practice.

You need reps to build social fitness,

just like physical fitness.

It has to come with reps,

and I've got a preteen and a teenager at home,

and when I watch my kids interact with a group of friends,

what it does to their vitality

when they're interacting with a group of friends in person,

playing pickup sports, or going out to the mall,

or going on to walk around town,

or just interacting outside of school,

and they get into the car

after interacting with a group of friends,

their vitality, what their biological signals are

about how they feel,

as opposed to the signals you get from kids,

and I know there are probably many parents listening,

the signal, what you see when your kid is on their phone

for 30 or 60 or 90 minutes,

and the signals that they send out,

what their body language tells you,

what their eye contact tells you,

it's a totally different physiological experience,

and it's building a very different kind of rep.

Yeah, to dumb it down a bit,

I think people just need to hang out more.

I think we need a renaissance of hangs in America,

to be quite honest.

That's the first bucket,

and I wanna make sure that we get to all of these

and give us some time for solutions.

The first bucket was social media and smartphones.

Second bucket is a little bit harder to describe.

It's the way we talk about mental distress.

I've become utterly fascinated by the way young people,

and really many people online, have absorbed the language

and the vocabulary of therapy.

You see so many more references to trauma and harm

and emotional capacity at triggers self-care,

but I'm so interested in the fact

that you see this ubiquity of therapy speak

coinciding with the emergence of a culture

that is not therapeutic at all.

You've mentioned this just minutes ago,

lots of research from including a Wharton University of Penn

that finds that these intense and negative emotions

are the most likely to go viral online.

Anger and outrage, an instinct to catastrophize everything,

to be doom and gloom about everything,

that's what gets shares, that's what gets retweets,

but modern, like cognitive behavioral therapy

will tell you that the emotions you want to avoid

in structuring your emotional response to the world

are anger, outrage, an instinct to catastrophize everything,

a doom and gloom approach to everything.

I wonder what you make of this.

Like in the Atlantic, I said,

it's kind of like the internet has become

the therapy version of a hospital

where the fake doctors know the words for every disease,

but half of the surgeries result in sepsis

and the patients are dying,

like we're all talking like therapists,

but online not practicing anything

like what CBT would encourage.

What do you make of that juxtaposition?

I love that analysis because I find it to be so accurate

and I think that there's several convergent trends here.

One trend is a very good one,

which is that stigma around talking about mental health

and talk about our emotional experiences

is on the rapid decline.

And I genuinely think that that is a path

towards less human suffering.

I think when people are not suffering in silence,

when people have language to describe

their emotional experiences

and have the bravery to talk about it

with their peers or with other adults

and to get support, that is a good thing.

At the same time, what you're talking about,

which I think is equally true and important,

is that we have sort of hollowed out

some of the meaning of terms like trauma.

I mean, trauma is a really important and profound concept

in human thriving and human health.

When people experience trauma,

especially during childhood,

it has really meaningful effects

on your long-term physical and mental health,

particularly if it goes unaddressed.

And trauma is real and all too common.

I mean, in this CDC data,

14% of teenage girls say that

they've been sexually assaulted in their lives.

I mean, I just, I can't say that without feeling nauseated.

It's the ubiquity of terrible trauma in kids' lives

is so profound and has so much to do with this crisis.

And at the same time, the word trauma is so overused

that it is being leached of meaning.

It is being diluted as a useful construct

because we're talking about trauma

in so many everyday occurrences

that I think it's very confusing to young people.

Have I been traumatized?

Was this a traumatic experience that I had?

And we're missing the opportunities

because of the way language is taking place

to engage in, again, what I think you talked about

in a previous show about post-traumatic growth

and all that we know about resilience

and about the ways that things

that people don't deserve to have happened to them,

they can survive.

And with support and with personal growth,

they can move past things.

And we're leaving that on the sidelines

and we're focusing sort of inexorably on harm.

What is the right way to talk to a teenager

or really anybody about how to balance

these two really important facts?

Number one, that the destigmatization of mental distress

and anxiety and depression is good for us.

But number two, that at the same time,

we've been destigmatizing the terminology around anxiety,

we've taken to overuse terms like trauma

that risk bankrupting the very thing we're trying to save.

How do you walk that fine, fine line?

Yeah, I love the question.

And it's not something that can happen

in one conversation with a young person, I think.

And so these are the kind of topics

that require lots of conversations or repeaty conversations

as well as a lot of listening

to teenagers' own perspectives about this

because that's where I do most of my learning

is hearing how young people are putting this together as well.

I think a couple of things.

One is I think that we used to think about mental illness

as like a lightning strike,

this terrible thing that happens to a few people

and God forbid it happens to me or anybody that I love.

And let's not talk about it.

And if it happens, goodness, what a terrible thing.

And I think everything that we know

from epidemiological data over the last 30 years

in both kids and adults is that mental health challenges

are a ubiquitous part of the human condition.

There are longitudinal studies,

very high quality longitudinal studies,

the Dunedin study from New Zealand

and the Great Smoky Mountain study that ran out at Duke

that show by the time you're 40 years old,

60 or 70 or 80% of us are gonna have

and had an episode of mental illness.

A period of time we were depressed,

a period of time we were overwhelmed by anxiety,

a period of time we were already drinking too much

or misusing drugs.

It's a part of the human condition.

And so I think the way that we talk to kids about it is,

this is something that could happen to you.

It has happened in our family

because it's like show me a family where it hasn't.

And the key is to understand it,

to recognize it, to talk about it,

to get help when you need it.

And also the story doesn't stop there.

This is something that people can live with,

can recover from, can make a part of how you become stronger,

can make you a better friend and a better parent

and a better student and a better work.

There's all these things that these very common

human experiences of getting depressed

or getting terribly anxious and then getting help

can be part of a long-term story

and narrative towards strength.

So that's sort of an amalgam

of the different kind of conversations

that I have with kids.

No, I think it's definitely deserving

of a longer conversation,

but that's really a fantastic answer.

And such an important thing, I think,

for people to remember,

to keep us humble

about the preciousness of happiness,

to keep us from judging those

that are dealing with mental health crises,

and to encourage us to be soft on ourselves

when we're having problems,

to remember that this is a very common part

of the human experience

and there's not something wrong with us.

This is proof of our humanity,

not an exception to our humanity.

Correct, correct, correct.

Flourishing is not the absence of mental health challenges.

It's the persistence and the return to health

in the setting of these things happening

that happen to a lot of people all the time.

Well said.

I feel bad for listeners

that we're expecting a bit more of a debate,

considering that my head is knotting off of my spine

every single time you talk,

but we'll move right along to the third bucket

and see if maybe we disagree a bit here.

The third bucket is the parenting piece.

And I know that this is a little bit more controversial.

There is a theory that was the subject

of a 2020 Atlantic feature

called What Happened to American Childhood

by Kate Julian.

The talks about this phenomenon of accommodative parenting

that especially among college-educated,

higher-income parents that are spending

a lot more time with their kids,

especially a lot more time with their teens

getting them ready to go to college,

that anxious parents in attempting to insulate their kids

from ever-experiencing risk and danger and disappointment

are unintentionally transferring their anxiety

to their kids and making them ill-equipped

to deal with the inevitable distresses of life

that you've just described.

How do you feel about this third bucket,

the role of accommodative parenting?

Well, I think this is one of those situations

in which we have to give proper respect

to the weakness of this problem,

of this mental health problem.

And it's really complex.

So I think that piece was interesting.

And I think it was fairly specific

around socioeconomic status and cultural groups

that it was referring to.

What's interesting when you go back to the CDC data,

as you pointed out in the introduction,

this is across all groups, all cultural groups,

ethnic groups, linguistic groups, socioeconomic status.

And so I don't think we can,

we can't defer to an explanation

that is specific just to one slice of SES.

So I think there's no question

that there is a lot of accommodative parenting.

And I think of it in terms of there's a mentality,

I think that a lot of parents have,

particularly parents who have achieved

or were born into middle class

or upper middle class status.

And there's a degree to which

they want to future proof their children.

They wanna make sure that their children have lives

that are as good as or better than their lives.

They experience the world as a world of scarcity.

There are shrinking opportunities.

It's harder to get into the good colleges

and there are fewer great jobs.

And so I need to do everything I can

to make sure that my kid has every opportunity that I had.

And that means SAT tutors and fancy summer experiences

and a resume for college applications

that look like somebody who's been in the workforce

for 20 years.

I'll do anything that I have to do

to help my kid be successful.

And I think that that does connote a lot of anxiety

in the part of parents.

And I think, again, that's specific to certain groups.

There are other groups of cultural groups

and ethnic groups that are dealing

with a whole other kind of anxiety.

Anxiety about economic precarity.

Anxiety about a racist and violent world

in which they live and they wish they worry

about the safety of their kids

when they go out into the community each day,

when they walk to school,

when they get behind the wheel of a car, God forbid.

And so that's a different kind of anxiety

that parents are coping with

and that probably drives a whole other kind

of parenting behavior that may impact kids as well.

I think the common denominator is we have parents

who are in a state of hypervigilance,

of overwhelm, of not knowing exactly what to do

or how to take care of their kids in a way

that's allowed in a lot of their kids

to have the kind of future that they imagine for them.

And so I think that's sort of a convergent point

in a very complicated terrain.

The fourth bucket that I wanna ask you about,

and I am writing an article about this right now.

So my understanding of this particular zone

is a little bit underdeveloped,

but I just read this study looking at international data

comparing school intensity across countries

to reports of adolescent distress.

And to make a very long story short,

richer countries seem to have sadder teenagers.

In part because richer countries

have higher education standards,

which means they have more competitive

and intense schools, which means

they have more scholastic competition,

which means that they have more stressed out teenagers.

So I'm wondering, and as I'm reciting

the finding of this study, I'm definitely hearing

in my recitation that there's an SES element to it,

that not every school is going to have

the exact same level of intensity

and that a heterogeneity of intensity

might yield a heterogeneity of adolescent distress.

But let me just pose the question to you this way.

In your practice, how true does this ring

that school and college anxiety

are a major driving factor of teenage anxiety?

I think it's a profound factor.

And again, it tends to track around

what the perceived opportunities are for young people.

I think in communities and settings

in which kids are in very high achieving competitive schools,

whether those are public schools or private schools,

and there's the sense of, gee, from this graduating class,

only five kids are gonna get into the Ivy League.

How do I make sure my kid is one of those kids?

And I think there's a congruent,

but very different anxiety in different communities

and schools that my team and I work with

that are in communities that are historically divested

and in which there is a sense of far fewer opportunities

in post-secondary education and in the workforce

and parents feel an anxiety

about the basic safety of their kids,

as well as what levers can they possibly pull,

what can they do to open up opportunities for their kids

in a world where it feels like opportunities are scarce?

So I think there is a common thread there.

I think the data that you cite around

competencies in schools is quite interesting

because I think kids do experience that very directly.

They experience it as zero sum

and either I'm gonna succeed or you're gonna succeed,

we can't both succeed,

which is a really tough way for kids to operate.

There was an amazing study by the late economist Alan Kruger

about how where people applied to college

was more predictive of their adult income

than where they actually went.

That is a student with a 1500 SAT

who goes to Penn State but got rejected from Penn

earned just as much on average as a student

with the same SAT score who got into the Ivy League.

So for most students, the set of schools

where you apply is more predictive

than the school that actually accepts you.

And I find that so profound and so compelling.

And when I go back to high schools

and I talk to seniors, 17, 18 years old,

I say, this is maybe the single most important factoid

I could possibly impress upon you.

I did not get into my first choice of college.

I did not get into my second choice.

I didn't get into my third choice.

I didn't get in my fourth choice.

I got in my fifth choice and it was a great school

and I had a great time and I'm very happy

with where I am in my life.

And if I could go back to 17, 18 year old Derek

and make like one edit to my psychology,

I would reduce my anxiety about college

by a factor of literally 100.

And I so wish that I could have that impression,

that I could have that effect on college students today

because one implication of this academic research

that is more important where you apply than where you go

is that the habits that you develop

when you're 18 years old are a better indicator

of the person you'll be at 38

than where you go to school for four years.

Habits are more important than the outcome

of what school randomly accepts you.

And I just, I wish I could have some way

of making every 17 and 18 year old that I confront

recognize this fact.

I have a few quick reactions to that story.

One, I love it, I'm gonna use it.

Two, as much as teenagers need to hear it,

parents need to hear it more.

So I hope you go around and share that story

with the parents of those 17 year olds.

And three, I think all of us who have young people

in our lives should take your example

and think of the things that we worried about

that we wish we hadn't spent so much time worrying about

and share that with young people in our lives.

Cause all of us made some of those attribution errors

about what's gonna really matter.

And it causes a lot of suffering.

So if we're able to reflect on that with our kids

and young people in our lives,

I think it would really help them.

Let's talk about what to do about this.

And as we talk about solutions,

I wanna be attentive to the fact

that I'm sort of imagining our audience

breaking down into roughly three groups.

We might have younger listeners dealing with exactly

the kind of adolescent distress that we're discussing.

I have to imagine that we have parents of adolescents

or maybe older children, younger children

who want guidance in this area.

And then finally, number three,

I think there are people who are interested

in the biggest solutions here

at the public or public policy level.

So being attentive to those groups who are listening,

where do you wanna start with your solutions?

Let's, I'll follow your rubric exactly.

Exactly, so for those young people

and families that are listening,

these are some things that I think

are useful to think about.

And I'll just try to be simple and direct.

First is please limit the time

that you spend on social media.

Please limit the time that your kids

spend on social media.

Parents, you can do that.

You have that ability and please use it.

It will have a meaningful effect on your kids' wellbeing.

Secondly, parents stay involved in your team's lives.

Ask questions, be curious, get to know their friends.

They're going to push back on that

because they're trying to develop independence.

I mean, that dynamic is normal,

but your active and persistent role

is valuable and crucial and appreciated

even if you don't feel the appreciation.

Parents talk to trusted peers

when you're concerned about your kids,

talk to your relatives, talk to clergy,

talk to your pediatrician, talk to your kids' teachers.

Seek clinical support if your concerns persist.

Many parents operate under the assumption

that getting help somehow might intensify the problems.

Talking about suicide might plant

the idea of suicide in kids' heads.

That's just not true.

Getting clinical help is the first step

towards relieving their suffering.

And then the last part for parents in particular

is please take care of your own mental health.

Get your own clinical support.

If you're feeling depressed, if you're overly anxious,

if you're drinking too much,

if you're feeling constantly overwhelmed,

that will impact your kids.

So please take care of that.

Please limit your own social media.

Think about your own digital media hygiene

and invest time and effort

in enhancing your own social network.

Build your social fitness.

Spend time with friends and family in particular.

At the level of schools and healthcare,

I just wanna come back to this thing about school connectedness.

It's a crucial protective factor.

When kids feel safe and valued

and connected to other students and adults at the school,

their mental health improves.

So schools need to invest time and resources

in building and sustaining relationships.

Work extra hard to reach the disconnected kids.

Just a brief anecdote with the school

that we worked at in DC, Derek.

There was a school that on the first

professional day of the year,

they put the name of every kid in the school

on a post-it note and put it up on the wall

in an auditorium.

And every adult that worked in the school

was in the room.

And they said to all the adults,

go over and pull off the name of every child

that you've got a relationship with.

That you know, you know what they like to play a recess,

you know what's their favorite subject.

And so all the adults did that

and some had two post-it notes and some had eight.

And then they looked at the 20 or 30 post-it notes

that were still on the wall.

And they said, those are the kids

that we need to be worried about.

Those are the kids that we need to make

an extra effort to reach out to.

They're not connected and we can do something about that.

That's just an example of the kind of thinking

that needs to be brought to bear.

And then we need to reduce barriers

to great mental health care for all the kids who need it.

We need resources to expand mental health services

in schools.

We need resources to allow pediatricians

to address mental health concerns in primary care.

So they need to be able to part with psychiatrists

and psychologists and therapists

to identify and work on mental health concerns

while kids are in the pediatricians office.

We need to intelligently deploy telehealth

and digital health tools to expand access to care.

Obviously the telehealth thing has been huge

since the pandemic, I think mental health

is one of the best use cases for telehealth.

And we deploy it in a way that intelligently intersects

with the systems where kids spend time in schools

and in their pediatrician offices

in order to be most effective and reach the most kids.

And then finally, for my colleagues in mental health,

we need to think about the mental health of the whole family.

Not just a young person is identified

with depression or anxiety, but what's going on

with that family?

What's keeping them from flourishing?

What can we do to help them?

And then finally at a policy level,

and I know you spend a lot of time thinking

and writing about this Derek,

we need to explore strategies to reduce access

to social media for young people

and particularly for early adolescents.

That's something that I know is being talked about a lot now.

We need to take steps to make families' lives more manageable.

So things like paid parental leave

and affordable childcare and the child tax credit,

these are policy decisions and choices

that affect the mental health of families and kids.

And by ignoring those screaming needs from families

to make their lives more manageable,

there are downstream effects on teens' mental health.

And then finally, we need to really enforce

mental health parity laws so that mental health

and addiction care truly gets the same coverage

and the same payments as other health conditions.

If this finally happens and is enforced,

that will draw more practitioners into mental health care

and will incentivize the healthcare systems at large

to invest in mental health infrastructure.

With that, if that doesn't happen,

we're not gonna move forward.

That's a fantastic answer.

I feel like it's practically a congressional testimony.

I hope we have some people from some Congress people's office

who are listening.

I have two follow-up questions.

One is, you mentioned, you said two things

that I wonder how they fit together.

One is that when we deal with people virtually,

we get less data from them, from their bodies.

It's not like being with them physically

and that in some ways, virtual hangouts

aren't the same as real-world hangouts.

I also know that telehealth therapy

is becoming very popular.

Do we have evidence that telehealth therapy,

which is obviously in many ways more convenient

than the physical world alternative, is worse?

Yeah, that's a good question.

My reference earlier to some of those signals

we get from kids is what I'm imagining

when you see kids who are on Instagram

or who are on Snapchat and are scrolling

and passively consuming digital information or input,

interaction by video on a FaceTime call

or in a telehealth appointment actually is quite rich.

And so I think that they're particularly for kids

in the right age group.

So kids older than eight or nine years old

who can really engage in a conversation by video.

I think there's a lot of anecdotal evidence

and emerging real strong clinical evidence

that telehealth interventions for mental health are effective.

And I think that we really should rely on them.

We should do more research

and we should get a finer and finer picture

of for which kids and adults

and for which conditions does telehealth work best.

But I think most of us in the field feel confident

based on our experiences over the last three years

that we can really reach kids effectively

with clinical interventions by telehealth.

It's the answer that I'm rooting for.

I just wanna make sure that the answer

that I'm rooting for is in fact the correct answer

because sometimes motivated reasoning can lead one astray.

The second question that I had,

the second follow-up question that occurred to me

is that you mentioned that the system

that currently exists does not have the bandwidth

to deal with the demand with the adolescent

maybe even adult demand for mental health services.

I know that the US is unique

in terms of how long and how expensive

our medical education system is.

We have the longest medical education system in the world

with eight years.

We have the most expensive medical education system

in the world in terms of average debt accumulated

by the time someone has finished.

Do you think we need to make it easier

to become a psychiatrist, a psychologist, a therapist?

There are trade-offs, of course, in making it easier.

If there's less training, there's less training.

That's just ipso facto.

But do you think that given this wave of demand

that we are clearly seeing from young people

that it's time for a national conversation

around making it easier to become a therapist or counselor?

I think the workforce issues are critical.

The way I would think about it is not so much

as make it easier, it's let's open more doors

and less incentivize people in a more effective way.

So open more doors, meaning I think that there is a lot

of really interesting work around expanding the workforce

to include paraclinical or preclinical folks

who can address mental health concerns in kids and adults

when they're emergent or when they're mild in severity.

So the use of trained mentors and therapeutic mentors,

community health workers, folks who have training,

but a more limited training to deal with milder problems

and to do it in community-based settings

that will reduce many barriers to care.

And then I think that we need to train more social workers,

counselors, psychologists, and psychiatrists.

We're already drawing more people into these fields.

I know at our medical school at Georgetown,

the rates of people going into psychiatry

and into child psychiatry are increasing

because people are more interested in it.

Neuroscience is fascinating,

the therapeutics work beautifully,

there's a lot of attention in the culture around it,

but we need to incentivize people further

by the pay that people can earn.

Not so much in psychiatry, but particularly in social work

and therapy and counseling and psychology,

people are undercompensated.

And this is critically important work

that gets treated as sort of the stepchild

of the healthcare system

and doesn't get adequately compensated.

And so we're not drawing enough people into these roles.

I think if we can adjust,

that's one of the reasons I mentioned parity,

if we can adjust compensation from third-party payers,

then we can increase compensation,

draw more talented people into the field

and broaden and deepen the workforce.

I wonder sometimes whether CBT, Cognitive Behavioral Therapy,

and some of the basics of CBT and DBT,

dialectical behavioral therapy,

should be taught in schools more broadly,

in high schools, and maybe even before.

I mean, how many tens of millions of Americans

had to read Animal Farm and the Great Gatsby,

even though they never became English professors

or English majors?

Look, I love reading, but how many?

I mean, tens of millions.

How many tens of millions of people

learned advanced algebra or pre-calc,

even though they never became computer scientists

or advanced mathematicians?

Tens of millions, but everyone has a brain.

60, 70% of adults, you said,

deal with mental health distress or mental health issues

by the time they're what, 40, 50 years old.

That's much higher than the share

that become English professors

or advanced mathematicians or computer scientists.

I'm not, by the way, denigrating pre-calc and Animal Farm.

I'm saying to the degree to which

our education system should be set up

to prepare future adults

for the challenges and opportunities of their adulthood.

It's not clear to me that the education system

is a perfect preparation

that reflects those inevitable opportunities and challenges.

Should we do it?

Should we teach CBT in high school?

I'm still waiting for us to have a chance to disagree.

So it's not gonna happen here.

100%, I mean, this stuff is very accessible

and teachable to kids as young as five and six years old.

And to be something that we teach,

that we introduce and teach again and teach again

and teach again and come back to this,

this is part of building healthy citizens.

It's like teaching civics.

We teach civics so that people can participate

in our democracy.

And that's more important than ever now.

We should be teaching emotional health skills

so that people can maintain emotional equilibrium

during the inevitable ups and downs of our lives.

And schools are the right places to do it.

Let me just jump in there.

We're not gonna do an entire 101 session

on cognitive behavioral therapy and there are time left,

but I'll pick up exactly where you left off,

five and six years old.

What is a lesson from CBT that we could teach

to someone in kindergarten or first grade?

Kindergarten and first grade can learn

how to identify emotions.

This is what it feels like to be angry.

This is what it feels like to be frustrated.

This is like what it feels like to be bored

or disappointed or excited or enthusiastic.

And being able to label emotional experiences

is very, very valuable for kids who are just finding language

to describe their experiences.

It helps them to resolve social conflict.

It helps them to identify their feeling,

get help from adults and it's super teachable.

I totally agree.

And I especially feel like the value of being able

to identify anger or jealousy or distress

isn't just that by shining a flashlight on it,

you can sometimes watch the feeling dissipate, go away.

But also you begin to see how all the feelings go away.

Happiness, joy, yes, jealousy, anger.

It all is just like this river going under a bridge.

Just swoosh, it's there and then it's gone.

And so in identifying these emotions,

you also get clarity on the bigger picture.

You don't just see the individual ripples on the water,

you see the entire river.

You see all of this is just moving through me

and I don't have to identify with any particular

passing feeling.

I can see that by the nature of their being feelings,

they're not going to last forever.

I love your use of metaphor there too, Derek.

I mean, that kids respond to metaphor

and thinking about emotions as moving water

or clouds across the sky or changing weather.

It really helps kids to identify

in a very deep, visceral way

with the fact that no feeling lasts forever.

Matt Biel, thank you so very much.

This was really valuable to me.

I appreciate it.

Really enjoyed it.

Thank you, Derek.

Thank you for listening.

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Machine-generated transcript that may contain inaccuracies.

This is our second installment of happiness week on the Plain English podcast. On Tuesday, I spoke with the directors of the Harvard Study of Adult Development about what makes a good life, based on their 80-year longitudinal study.
Today’s episode is about the phenomenon of rising teenage unhappiness. What's actually happening? Why is it happening? What theories make sense, and what theories don't? How can we fix this problem? Today's guest is Matthew Biel, the chief of child and adolescent psychiatry at Georgetown University Medical Center, and chief medical officer at Fort Health.
Host: Derek Thompson
Guest: Matthew Biel
Producer: Devon Manze
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