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Why the Teen-Mental-Health Crisis Is So Hard to Solve

You have to admit, it seemed like a great way to help anxious and depressed teens.

Researchers in Australia assigned more than 1,000 young teenagers to one of two classes: either a typical middle-school health class or one that taught a version of a mental-health treatment called dialectical behavior therapy, or DBT. After eight weeks, the researchers planned to measure whether the DBT teens’ mental health had improved.

The therapy was based on strong science: DBT incorporates some classic techniques from therapy, such as cognitive reappraisal, or reframing negative events in a more positive way, and it also includes more avant-garde techniques such as mindfulness, the practice of being in the present moment. Both techniques have been proven to alleviate psychological struggles.

This special DBT-for-teens program also covered a range of both mental-health coping strategies and life skills—which are, again, correlated with health and happiness. One week, students were instructed to pay attention to things they wouldn’t typically notice, such as a sunset. Another, they were told to sleep more, eat right, and exercise. They were taught to accept unpleasant things they couldn’t change, and also how to distract themselves from negative emotions and ask for things they need. “We really tried to put the focus on, how can you apply some of this stuff to things that are happening in your everyday lives already?” Lauren Harvey, a psychologist at the University of Sydney and the lead author of the study, told me.

But what happened was not what Harvey and her co-authors predicted. The therapy seemed to make the kids worse. Immediately after the intervention, the therapy group had worse relationships with their parents and increases in depression and anxiety. They were also less emotionally regulated and had less awareness of their emotions, and they reported a lower quality of life, compared with the control group.

Most of these negative effects dissipated after a few months, but six months later, the therapy group was still reporting poorer relationships with their parents.

These results are, well, depressing. Therapy is supposed to relieve depression, not exacerbate it. (And, in case it’s not clear, although it’s disappointing that the therapy program didn’t work, it’s commendable that Harvey and her colleagues analyzed it objectively and published the negative results.)

But for people who study teen-mental-health treatments, these findings are part of a familiar pattern. All sorts of so-called universal interventions, in which a big group of teens are subjected to “healthy” messaging from adults, have failed. Last year, a study of thousands of British kids who were put through a mindfulness program found that, in the end, they had the same depression and well-being outcomes as the control group. A cognitive-behavioral-therapy program for teens had similarly disappointing results—it proved no better than regular classwork.

D.A.R.E., which from the ’90s to early 2000s taught legions of elementary-school students 10 different street names for heroin, similarly had little to show for its efforts. (The curriculum has since been revamped.) The self-esteem-boosting craze of the ’80s also didn’t amount to much—and later research questioned whether having high self-esteem is even beneficial. Anti-bullying programs for high schoolers seem to increase bullying.

Reading these findings, haters of high-school assemblies might tingle with schadenfreude. But the consistent failure of these kinds of programs is troubling, because teen mental health is now considered a crisis—one that has so far resisted even well-considered solutions. From 2007 to 2016, pediatric emergency-room visits for mental-health disorders rose 60 percent. Most teen girls—57 percent—felt “persistently sad or hopeless” in 2021, up from 36 percent in 2011. That figure is a still-not-great 29 percent among teen boys. Nearly a third of teen girls have considered suicide, according to the CDC. (Although school closures probably didn’t help things, these numbers were rising even before the coronavirus pandemic began.) The kids are not all right, and frustratingly, we don’t really know how to help them. It feels like we should be able to just sit the teens down and tell them how to be happier. But that doesn’t seem to work, and sometimes it even backfires.

These types of programs tend to flop for a lot of different reasons. In the case of the Australian study, the teens didn’t opt in to the intervention; they were signed up for it, class by class. But teens don’t like being told by adults how to think or what to do, even if it’s something that could benefit them, experts told me. The Australian kids were instructed to practice the DBT exercises at home, and those who did so had better outcomes, but only about a third practiced at least weekly. This could be considered low, but does anyone really enjoy doing their “therapy homework”? Especially when they have, you know, regular homework? “It’s just another thing they are required and asked to do without any input from them,” as Jessica Schleider, a psychologist at Northwestern University, puts it.

What’s more, these complex, therapy-adjacent concepts might confound young teens—the average age of the kids in the DBT study was just 13.5. And in order to make the program palatable to so many kids, the instructors might have had to dilute DBT beyond the point where it was actually helpful. “It’s kind of like giving somebody a couple of doses of an antibiotic for a serious illness in an attempt to prevent that illness from emerging at a population level, which intuitively makes no sense,” Schleider told me.

That brings us to another problem with universal interventions. Many therapists use DBT to help people struggling with suicidal ideation and self-injury, through months of intensive individual treatment. But the teens in this study weren’t, on average, clinically depressed or anxious to begin with. Many of them were just normal, happy kids. It’s possible that by teaching kids to notice their negative thoughts, the program inadvertently reinforced those thoughts.

“Maybe everybody thinking about how anxious or hurt they are might not be the best idea,” says Jean M. Twenge, a professor of psychology at San Diego State University and the author of Generations. “We might be taking people who are doing just fine and trying to teach them these techniques, which may actually call attention to their distress.”

That leaves the question of why the relationships between the DBT kids and their parents soured, even months later. Harvey, the study author, thinks the fact that the intervention didn’t include the parents might have created a gap of sorts between the parents and their kids. The kids might have learned to advocate for themselves more assertively, but if parents didn’t understand where that was coming from, family tensions might have arisen.

Of course, there’s not a huge risk that American public schools will apply mental-health treatments to ninth graders without their parents’ consent. School boards can barely agree on which books to allow, so I don’t anticipate mandatory therapy coming to our shores anytime soon. (Many U.S. schools incorporate “social-emotional learning” into their curriculum, but this differs from the programs mentioned in any of these studies.)

Still, we’ve had our share of impotent programs aimed at making teens “better.” And it would be nice if something like a Big Mindfulness Assembly worked. Schleider said that rather than subject entire classrooms of kids to therapeutic information, mental-health treatment should be available to kids when they feel that they need it, not just when it happens to be fifth period. (She has designed some interventions along these lines.) In many states, adolescents can’t access any mental-health care without parental consent. “For teens who don’t feel comfortable going to their parents, that basically just means too bad for them,” Schleider said. “Which, unfortunately, in our research, is about a third of teens.” Most teens don’t have their own money or insurance; many couldn’t drive to a therapist’s office if they wanted to. So they turn to social media, which might actually reinforce poor mental health.

The upshot of all of these failed experiments, from the cheesy D.A.R.E. to the trendy mindfulness, is the old chestnut that you can’t change people who aren’t ready to change. Teens can make poor choices, but they are smart and, on some level, know themselves. Alleviating the teen-mental-health crisis may require something that is not altogether comfortable for adults: trusting that teenagers will know when they need help. We may need to make treatment available but not obligatory. Teens have plenty of obligations as it is.

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