TIFT #51: The Adolescent Mental Health Crisis, A Fresh View

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The New YorkTimes recently published an article on the adolescent mental health crisis. They cited many factors but missed the center of the problem. Yes, puberty comes earlier than ever, while brain maturation has not speeded up to match. So there is indeed a mismatch between the mind’s “brake pedal” and the adolescent “accelerator.” But for parents and clinicians those are the areas over which we have little control. When young people are in trouble, how can we make sense of what is happening in a way that points more towards what we can do?

Here is a place, where the lens we look through makes a great deal of difference. I begin by arguing that the prevalent “medical model” leads us further astray, while a developmental model is more likely to yield helpful answers.

The Medical Model

Traditional medicine looks at symptoms in a relative vacuum, having sprung up by chance and asking to be brought under control by some medical intervention. When people say “I have depression,” they are adopting a medical model point of view. They have “caught a case of depression” and need only to wait for some intervention to make it go away. Easy!

This model may work for pneumonia, and even cancer, but focusing on relief of suffering without seriously considering the complex factors that lead adolescents to become lost is an oversimple answer to a complex problem and likely to fail. At best, available remedies for the symptoms are of limited value, while failure to address the real causes predictably leads to even more serious problems.

A Developmental Model

The opposite of the medical model might be called a developmental model because it focuses on the notion that problems are the result of arrested development and less healthy coping. The goal of family help and professional treatment is to support further development of healthy life skills. This remains true regardless of the individual’s current level of developmental and regardless of biological factors. Anyone can do better, and that becomes a source of hope and relief, whatever the baseline might have been.

From this point of view, the adolescent mental health crisis is one of young people facing monumental challenges with inadequately developed coping abilities and supports, often leading to ineffective adaptation and getting more “lost” at every turn. As the adolescent spirals out of control, things keep getting worse until and unless there is a bad outcome or someone realizes what is happening and intervenes in a personal and effective way.

The Mental Health Crisis

Looking at the situation from a developmental point of view, young people are more challenged than ever, both biologically by early puberty and by an ever expanding availability of choices that lead away from healthy development instead of towards it. This is made more serious by today’s tendency to adhere to the medical model, which seems so attractive but leads to dangerous oversimplification of what is going on and what to do about it.

Beyond monitoring screen time or bed time, we need to pay much closer attention to how young people are developing, the choices they make, and why they make them. In today’s world of extreme respect for individuality and freedom, influencing young people to make the often harder choices that lead to more positive development is what counts the most. Not surprisingly, that turns out to be highly challenging, perhaps one reason why young people, parents, and professionals so often resort to oversimplified solutions.

Adolescent Development in a Nutshell

Surprisingly, development is basically very simple. Whenever we try something new and unfamiliar, we acquire new experience and skills. As these skills become a regular part of our personal repertoire, we can apply them in ways that lead to more experiences and yet more positive development. Humans are capable of developing in many directions depending on what they try out and whether the results are painful or satisfying. Here are some of the healthy acquisitions of adolescence, roughly in the order they are (hopefully) developed. Some, like impulse control, may be affected by brain development, but, regardless of where we start, it can be improved.

1. Learning impulse control and self-management allows the young person to do things that are valuable but not immediately pleasurable. This gives high returns socially as well as in making it possible to stick with learning enough to acquire specialized skills such as playing a musical instrument.
2. Learning one’s strengths, weaknesses, and place in society by daring to interact with others and explore the limits of one’s capacities in multiple areas.
3. Learning by experience how to enjoy deep relationships.
4. Discovering one’s personal likes, dislikes, and characteristics through making hard choices.
5. Taking ownership of one’s own values, as opposed to “borrowing” parents’ and peers’ values.
6. Arriving at a sense of full ownership of one’s own life. (my definition of adulthood).

In each case, advances are arrived at by doing something hard or emotionally risky. In an earlier era, when coming of age meant learning to be like one’s parent, it was relatively clear what hard things had to be done and learned. In today’s world no one has the answers, and following in parents’ footsteps is often the last thing a young person might wish. Furthermore, as a society, we are  experimenting with extreme individualism, where young people are unrealistically expected to chart their own course and to know what is best for themselves.

One major cause of trouble is the economic discovery that fortunes can be made by offering easy satisfaction of evolutionary biological and social needs such as calories, sex, self-esteem, connectedness, power, and the need to know the outcome. Businesses have found ever more concentrated ways to deliver gratification of these natural needs at progressively lower costs, while amassing astronomical wealth. To make matters worse, scientific marketing feeds fantasies that anyone can be (or appear to be) utterly “awesome and amazing” with no real expenditure of effort.

In most cases, easier access to these pleasures means bypassing historical requirements to do something hard in order to experience positive satisfaction. The end result is that adolescents are far too often faced with an easy way and a hard way to access similar pleasures. Unfortunately, the easy fork in the road usually means failing to gain the developmental benefits that result from practicing hard things.

The Complexity of Motivation

What makes one young person do something challenging and grow from it, while another seeks to avoid the effort? Let’s think about how motivation works. The human mind is strongly influenced by rewards. Evolution has programmed us to choose whatever will bring the greatest reward at the least cost. We also avoid pain, which can have an even stronger influence than pleasure. However, a simple summing of negative pain and positive pleasure is still inadequate to describe how young people make choices. Past experience, personal preferences, and internalized values strongly influence attraction to and avoidance of possible choices. Outside pressure and expectations from peers, media, society, and family have an inordinate influence. Criminologists talk about “means, motive, and opportunity.” For young people lacking in direction, feelings of boredom, opportunity, and availability of means can combine with minimal motivation to allow otherwise inexplicable choices.

Anticipation of pain and pleasure may be distorted from troubled early life and continue to influence adolescent choices. Motivation prior to adolescence is mostly a matter of what is successful within the family. For many children successes are not easy to come by. Young people with ADHD or other neurodiversity tend to miss out on rewards. Some families and individuals don’t give predictable rewards or give contradictory or negative ones. There can be a mismatch between parents and children such that the child doesn’t feel seen or understood. All these factors can obscure the young person’s ability to predict what will be rewarded in adult life. Confusion breeds bad choices.

Dreams and Passion

The most powerful sources of motivation come from dreams and ideals formed quite early in life. These are the source of “passion” that we are told to follow. If we are to have a positive influence, we will have to learn about deeper wellsprings of motivation that may not even be apparent to the young person. But following one’s passion can be a source of shame for those whose dreams have been killed or never allowed to form. What about those young people whose lives have been focused on physical or emotional survival? What about those who have put all their energy into coping with seemingly insurmountable obstacles? For them, passion hardly exists, leaving only a sense of inadequacy for not having one.

What if there once was a passion, but it has been suppressed, either by outward discouragement or because it conflicts with inner prohibitions? Then the dream gets put on ice, and waits for a chance to be expressed. When dreams are blocked, depression results and all motivation is dulled. It may take a lot of work to invite those dreams back to the surface.

For the therapist, exploring inner sources of motivation is critical, but so is the recognition of circumstances where the ability to experience passion has not yet formed and will require new development by living and experimenting as well as learning to listen inside for what resonates. Rarely will we be able to help our young client do hard things without helping them find ways to harness deep personal motivation.

Avoiding Hard Choices

In actual practice, motivation drives choice. Choices between homework and screens, choices between socializing and practicing an instrument, choices between friends who are higher functioning and more challenging versus those who are unambitious and avoid challenges, these are the daily arenas where development is won or lost. Avoiding the hard choices is all too easy. 

Today’s world offers young people an infinite and potent range of avoidances. Drugs remove pain and anxiety. Food fulfills emotional needs. Pets can substitute for human intimacy. Games develop skills with little worldly relevance. Pornography removes the need for the risks of intimacy. Fantasy fulfills dreams without requiring hard experience to achieve them.

There are more subtle ways to avoid, too. Doing just what one is supposed to can be an avoidance of learning one’s personal, inner dreams and values. It can block the difficult process of learning to make personal choices and to value one’s own likes and dislikes. The easy path can simply ben doing what is expected, leading to lack of hope or motivation.

 Young people today are taught that stress is bad. They learn that anyone can achieve great success without effort. They feel shame that their own trajectory does not match what they see on screens. They may be motivated to set things right by self-punishment and self-harm. Or they may simply follow the easy path of avoidance of all challenges.

Avoidance means failure to do the hard things that lead to further growth and maturation. Greater avoidance means falling further behind peers. Like a wheel going backwards, each avoidance widens the gap between vision and achievement. As hope fades, the temptation to avoid takes on yet more alure. A young person can become hopelessly lost, not knowing where to turn or what to choose. Choices can become random and senseless, as positive options seem impossible.

Diagnosis

As young people become more lost, they experience symptoms. They feel depressed, they experience anxiety. They become addicted to substances and harmful behaviors. They find themselves trying to exert control over food and circumstances in ways that further endanger their wellbeing. The medical model is quick to focus on a diagnosis that relieves the young person of shame and responsibility for their plight. Medications may relieve some symptoms but they do nothing to set the young person on the right track. Diagnosis may stop a runaway train, but it is blind to the slow process of habilitation that is the path to health.

Influence

The reason we have an adolescent mental health crisis is that for so many young people, finding and following a track of hard choices, ones that lead to personal growth, are faithful to inner dreams, and are adaptive in society, is just too hard. The more consistently they avoid the hard choices, the further they fall behind and the more anxious and depressed they become.

Lending our adult influence to young people is as difficult as their own struggle to find their way. We may know what works in society, at least for our own generation, but how can we know their inner dreams? How can we guess that hours spent learning the guitar may be more formative and valuable than learning to write a social studies essay? Practice in writing is of broad value. It can open many doors. Guitar playing may feed an ephemeral rockstar fantasy, but might just be the only way this particular young person is going to persist at anything.

For us who want to help, the job is dauntingly complex. It means listening for inner dreams and encouraging them. It means supporting any movement that leads towards better functioning. It means valuing the young person’s own decisions and wishes, while being concerned about avoidance.

Parents may have more than influence. They may have real “leverage,” the ability to shape rewards and consequences strongly enough for the young person to make positive choices. But there is always the danger of suffocating natural motivation as well. This is a job of leadership, but leadership means listening as much as imposing. I have a few rules to suggest:

1. A young person’s own decision, unless obviously disastrous, is worth 1.5 times as much as the adult’s possibly better informed choice. The reason is that young people need to learn from experience and a decision imposed by others takes away the chance to own the lessons learned.
2. Parents tend to shape their parenting in order to solve the problems they encountered as children. That means their solutions are two generations behind and have little to do with the problems of their children. We all need to open ourselves to the real world of rewards and challenges faced by the young person.
3. Becoming one’s own person is painful and hard, and young people often deal with this by setting up conflict with parents. The real conflict is the young person’s inner ambivalence about the need to stay close to parents vs. the wish to be independent. This can’t be solved by parents. They need to support independence and still be available, while showing some degree of tolerance for the contradictions and erratic behavior.
4. For young people, having someone who really understands the impossible job they are facing and appreciates their individuality can be a great help.

Conclusion

I wish there were an easy answer. The challenges are so real, the reasons to become lost so abundant, and the paths that lead to growth and maturation are often so difficult that the whole process may seem impossible. Yet, young people do grow. Eventually most of them find some kind of life and make some kind of adjustment. Is it any wonder that arrival at adulthood seems to happen later and later? What we most hope is that young people do enough of the hard things to acquire enough skills to make a place for themselves from which to keep growing.

Jeffery Smith MD