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

Episode Date: March 3, 2023

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 Learn more about your ad choices. Visit podcastchoices.com/adchoices

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in Shopify. coms bar records. 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 miss 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 in, gulfed 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 3,000, 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 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. 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-tale 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 Beale, 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. Matthew Beale 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 Haidt, 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'd outline. 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. The 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, 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 cause of this crisis in our conversation about social media, or two times with friends, and some of the other things that you've written about. Secondly, I want to point out is I see the distress in adolescence 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 child care and elder care, as well as by less support from the communities around them. It makes sense that teenagers, we know the teenagers in any era, 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, emotional states, particularly intense negative emotional states like sadness or anxiety or loneliness, as central to our experience. And so the stories, you know, 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's 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 know, you, I'm sure, read about how this is affecting just about every single category of teenagers. This is not just something that affects, you know, 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 D.C., 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? rise 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 I think 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 know, you've talked about on your show with John Haidt 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 of mental health. That evidence gap is closing. I think there's stronger and stronger evidence, even in the last two or three years,

as Professor Heights 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 who 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 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 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 had 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 may 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 reference 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. I mean, that's my, scientific answer. I think my clinical intuition tells me that girls are much more oriented towards social comparison in general than boys. And social media is this very available an insidious tool for social comparison,

particularly for upward social comparison and for sort of 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, 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 a 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 is, 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 adolescence 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 like 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, you know, to borrow 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 at your future. 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 pick up sports or going out to the mall or going on and 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. I want to 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 can't say that without feeling nauseated. It's the ubiquity of terrible trauma in kids' lives is so profound and as such to do, so much to do with this crisis. And at the same time, the word trauma. 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. Like, 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, repeated 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 Dan Eden study from New Zealand and the Great Smoky Mountain study that ran out of Duke that show by the time you're 40 years old, 60 or 70 or 80% of us are going to have an 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 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 if 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 word. 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 softened 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. Just flourishing is not the absence of mental health challenges. It's the persistence in the return to health in the setting of these things happening that happen to a lot of people a lot of the time. Well said. I feel bad for listeners that we're expecting a bit more of a debate, considering that my head is nodding 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. It 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 of 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 accommodated 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 want to 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 connotate 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 and allow their kids to have the kind of future that they imagine for them. And so I think that's sort of a conversion point in a very complicated terrain. The fourth bucket that I want to 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 heterogene 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 this sense of, gee, from this graduating class, only five kids are going to get into the Ivy League. How do I make sure my kid is one of those kids? And I think there's a there's a congruent but very different anxiety in different communities in schools that my team and I work with that are in communities that are historically divested 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 competitiveness in schools is quite interesting because I think kids do experience that very directly. They experience it as zero sum and either I'm going to succeed or you're going to 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, you know, 1,500 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.

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 going to 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.

Because all of us made some of those attribution errors about what's going to really matter. matter. And it causes us 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 will really help them. Let's talk about what to do about this. And as we talk about solutions, I want to 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 want to start with your solutions? Let's, let's, I'll follow your rubric exactly. Exactly. So, you know, 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' well-being. Secondly, parents stay involved in your teen'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 health care, I just want to come back to this thing about school connectiveness. 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 a school that we worked with in D.C.

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 got a relationship with. That you know, you know what they like to play at 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-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 partner with psychiatrists and psychologists. and therapists to identify and work on mental health concerns while kids are in the pediatrician's 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 who's 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 child care and the child tax credit, these are policy

decisions and choices that affect the mental health of families and kids. And by ignoring those those screaming needs from families to make their lives more manageable, there are downshame 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 payment as other health conditions, if this finally happens and is enforced that will draw more practitioners into mental health care and will incentivize the health care systems at large to invest in mental health infrastructure. If that doesn't happen, we're not going to 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, you know, 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 real world, the physical world alternative, is worse? Yeah, it's a good question.

So 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 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 from 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 want to 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 U.S. 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 tradeoffs, 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 let's 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 and kids and adults when they're emergent or when they're mild and 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, are undercompensated. And this is critically important work that gets treated as sort of the stepchild of the health care system and doesn't get adequately compensated. And so we're not drawing enough people into 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, or 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 going to happen here. 100%. This stuff is very accessible and teachable to kids as young as five and six years old.

And should 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. lives. And school is the way places to do it. Let me just jump in there. We're not going to 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 in 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 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 how they're feeling.

It helps 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, some sort of. 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 to, Derek. I mean, 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 Beale, thank you so very much.

This was really valuable to me. I appreciate it. Really enjoyed it. Thank you, Derek. Thank you for listening. Plain English is produced by Devin Manzi. If you like the show, please go to Apple Podcast or Spotify. Give us a five-star rating.

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