The US’s Youth Mental Health Crisis: A Plea for a Better Answer

Ernesto Valdez

Summary: An educator’s response to the youth mental health crisis in the US and insight into the shortcomings of the national response – Editors

The Limits of the Surgeon General’s Address

Late last year, the Surgeon General put out a statement declaring a mental health crisis amongst youth in the United States. For most, this statement is so obvious it hardly needs saying– the COVID-19 pandemic has wrought disorder and difficulty that has permeated even the most personal realms of our social fabric.

It may also be lingering in the backs of the minds of American parents that, not too many years ago, alarms were being raised throughout the media about the twin epidemics of depression and anxiety amongst the youth in the US. The Surgeon General’s recent Youth Mental Health Advisory clearly states these two facts: 1) The US has seen an undeniable and significant increase in mental illness and associated quality-of-life outcomes for youth between the years of 2009 and 2019. 2) COVID-19 has exacerbated this rolling boil of a crisis into something more akin to a grease fire. In other words, whatever social impacts we see from the pandemic are actually pre-existing issues simply exacerbated in the face of our current crisis (a phenomenon not just true for the issue of mental health but across the board).

I suspect that the pandemic and the tumultuous social movements of the last few years have paved the road for the wider scope that the Surgeon General has used in framing the current state of youth mental health– While the discourse around mental health has too frequently been shrouded in shame and discussed as a personal burden to conquer, COVID-19 has had such an overarching impact that it is impossible for one of the most prominent public health figures in America to ignore the systemic and structural violences that impress themselves upon the American psyche. Along with that admission being granted and backed up by empirical research, there is little choice but to also admit that these violences are doled out in a way that clearly reflects inequities that pervade all other aspects of American life.

Nevertheless, this address, as much as it must acknowledge the most heavily impacted groups and the shortcomings in all sectors in managing mental health, continues to fall short of recognizing capitalism as a key burden on mental health. (Indeed, economic instability is mentioned only superficially, as just one of many factors that impact mental health in any given group rather than an issue deeply intertwined with other forms of oppression like misogyny and racism.)

This fatal (though unsurprising) myopia has insidious consequences in the second half of the Surgeon General’s address, which is dedicated to advising different sectors on ways they can alleviate the current youth mental health crisis. From issues of self-harm to houselessness, proposed tactics to combat the crisis are trapped by painfully myopic neoliberal strictures.

A brief summary of this second half here:

  • The address gives the youth experiencing poor mental health and their families advice on how to better regulate and moderate their mental health.[1]
  • It also asks professionals in the realms of education, then in health and community organizations to shift their framework to be more community-minded and to be more “trauma informed” when providing care.[2]
  • Employers are advised to take measures to minimize the mental health strain they place on their employees and their families[3] while private media/social media entities are advised to modify their products to create “safer” consumables.[4]
  • Government entities are advised to shift policy to get more resources to people who need it[5] while founders and foundations are advised to pour more resources into research gaps and increasing available mental health interventions.[6]

What is notable here is the way that these different groups are encouraged to act within their prescribed circles, in their prescribed roles. There is no acknowledgement of grassroots advocacy and its ability to shift policy, among other things. Moreover, in asking companies to do things like making their services less addictive[7], the Surgeon General asks corporations to act against their best interests without giving any incentive for them to do so.

There is also a failure to connect the issues of mental health with holistic health in a meaningful way, making it much more difficult to conceptualize the benefits of structural change. There is an ease with which behavioral/individualistic interventions are recommended over political ones despite so much of the Surgeon General’s preface stating that structural changes truly are necessary.

I can’t help but be frustrated at how much this address curbs its own assertions– Why stop at promoting the connection of people to a system with as many issues as Medicaid (the act of connecting itself so bound up with issues of accessibility) when the American healthcare system needs broader reform to connect everyone with better access to healthcare?

The truth is that the extent of the advice the Surgeon General gives to various industries and sectors in society to address this mental health crisis are little more than triage instructions to a deep, long-brewing ill. The Office of the Surgeon General places so much importance on the easily calculable details of an inequality that is so obvious to Americans yet is entirely unwilling to treat the crisis as what it is: an indictment of capitalism’s brutality on the human spirit.

 

Back-to-School and the Codification of the Triage Approach

 In Biden’s December 2021 Remarks on the Jobs Report, he states that he considers the American Rescue Plan a success, since it “got the economy off its back and moving again, back on its feet, getting over 200 million Americans fully vaccinated; got people out of their homes and back to work, even in the face of wave after wave of COVID”.

Most people I know have mixed feelings, at best, about going back to work in the face of a pathetically controlled pandemic. None, however, feel particularly saved or supported. The stress of the pandemic has put Americans between a rock and a couple of hard places, juggling the threat of illness, inflation, ballooning debt, unemployment, and reliance on a healthcare system carrying a Sisyphean weight. Biden’s so-called success crassly ignores the human cost of getting people “back to work” and, in the case of children, back to school.

 I began working on a middle school campus in Fall 2021, around the time that many school districts (including mine) had decided to return to in person teaching despite any strong plan in place to accommodate students who were immunocompromised. The school I work at looks a lot like the ones that I attended growing up: underfunded, overly standardized, and terribly underequipped to promote mental wellbeing in a way that wouldn’t contradict the overwork and zealous deference to authority that students in the public education system are being trained for. This is only made worse when taking into account that, when surveyed, students and their families at my campus have consistently reported mental health support as the biggest need they face this school year.

In my time on campus, I have met a terribly dedicated yet terribly underpaid staff of workers, many of whom go out of their way to facilitate programs that they aren’t being paid for. This not only includes teachers and administrators, but a dedicated mental support staff as well. Nevertheless, all their efforts colliding with the very real mental health needs of students gave me clarity on one particular point: the current support systems in place can’t fix this issue.

Mental health support efforts at my workplace generally parallel the Surgeon General’s suggestions. Staff prioritizes campaigns to help students feel more connected to alleviate alienation (backing student clubs and a full return to after-school activities) while on-campus social workers have linked students and their families to a short list of community resources that have been approved by the school district. These resources are meant to address mental health as well as key contributing socioeconomic factors like food and housing. Nevertheless, using the triage approach to dole out this aid treats things like food, housing, and medical interventions like last-ditch efforts though they are often the root of mental health problems. Before deciding whether or not the student or their family are in sufficient need of these resources, school administration prefers behavioral intervention in the form of “self-help” practices that put the onus on the student to self-police and self-moderate without linking them to more in-depth care. The shallowness of these interventions is also worsened by the -isms (authoritarianism prominent along racism, sexism, and ableism, to begin with) that inform some administrators’ judgements on whether to bridge or deny students’ access to care. None of these issues are especially unique to the school I work at, but since it is a larger public school with a relatively more generous support network compared to neighboring schools, it’s easier to see the shortcomings of the neoliberal social work scaffolding integrated into the school to address the needs of its students.

Aside from these directly reported needs, the move back to in-person instruction has also meant consistently lower attendance than in previous years. Due to the nature of the pandemic, this low attendance looks like the long-term absence of a few convalescing students mixed with the more typical, short-term absences of many. In other words, there is a not insignificant group of children who have a large gap in their education histories because they are expected to, yet cannot, learn on campus. On the other hand, students who do attend class in person face the risk of catching (or spreading) the virus. Moreover, the task of bringing children to school in the mornings is more strenuous for many caretakers who have had to work longer hours just to make ends meet throughout the pandemic. The elaborate, coordinated stress that it takes just to keep butts in seats makes a return to school impossible even for some who would like to.

Unfortunately, the absence problem also means that whole families are losing their singular link to social work interventions. In a family in which all adults are working or are unable to work and in which children are largely self-sufficient as a result, there is little to no time to proactively seek help with necessities in the form of things like free food/household items, rent assistance, or childcare. Often, the only way a family’s need is addressed by formal mechanisms is if the need is visible via their children at public school.

And yet, as long as students are absent, these professionals are very limited in their ability to help them. Schools should not be the first intervention, but because public schools are often the only constant interaction that a family has with a professional “helping” institution, they often are burdened with identifying and beginning to address need.  At the same time, there is no singular government agency that should be responsible for bridging families with help. Educators acknowledge that mental health and socioeconomic needs are complex, intergenerational, and require a holistic and cooperative understanding to approach. So why does the public school system fall so short of approaching this need accordingly?

 

Behavioral Intervention, Therapy, and Alienation

In the last year alone, mental health supports have been rolled out across different populations and by many healthcare providers/government services in attempts to help people cope with the new and unique stresses of the pandemic. Unfortunately, in a lot of cases, this looks like short-term access to short counseling sessions, often heavily relying on CBT (Cognitive Behavioral Therapy) as the basis for the framework for counseling/therapeutic intervention. CBT is often the primary framework used for therapy non-profits who work with marginalized communities and has been considered the gold standard, the “best practices”, of research-supported therapeutic approaches. In fact, for many counselors and therapists, since CBT is regarded as “best practices”, reporting that they have used CBT-informed interventions with their clients is the only way to report their therapy sessions in a way that will encourage healthcare providers to cover their fees.

CBT aims to guide the client to change unhelpful or outright harmful behaviors, feelings, self-talk, and perspectives about the world around them. At its best, CBT is led by the client’s values, responsive to their needs, and allows clients to build their ability to self-regulate, therefore becoming more independent as opposed to reliant upon validation from their therapist. At its worst, CBT is “apolitical”, invalidating, dehumanizing, and isolating. A brief explanation of how:

  1. “Apolitical”: CBT is supposedly value-neutral and solution-focused in that therapists follow the problems that clients wish to focus on. Therapists are not ethically compelled to acknowledge the unjust systems that inform their clients’ problems, and those that do are trained to minimize external factors in favor of isolated emotions and pragmatic, individual solutions. A handful of my friends with a history of disordered eating have left therapy because their therapists worsened their disorders by encouraging them to take actionable steps to lessen their negative feelings without first relating their struggles to the well-studied impacts of diet culture.
  2. Invalidating: CBT asks you to evaluate whether your response is proportional to reality or “useful”. While this is a useful tool in abstract, this all-too-often puts the onus on the patient to defend the validity of their emotions, which can be especially traumatizing in cases of systemic oppression and in cases (such as domestic abuse) where victims are already forced to tirelessly self-advocate against resistant state systems and social circles. CBT is also dangerous when used as an intervention by undereducated therapists that work with people that have invisible disabilities, since invisible disabilities are already undertreated and thoroughly dismissed as mild or as behavioral issues. In all cases, it is easy for poorly trained CBT-oriented therapists to call for “attitude adjustments” while giving far too little credence to their clients’ personal accounts.
  3. Isolating: CBT asks you what concrete steps you can take to soothe and manage your main. While this can be empowering, these steps rarely encourage clients to think about interrogating their lives in a broader way and about broader changes. (For example, clients should first put their effort into regulating their nervous response to racist aggression instead of channeling their anger toward changing it.) This parallels the myopic and individualistic solutions proposed by the Surgeon General.

Despite the glowing reception it commonly enjoys, there are concerns not just about the research gap when it comes to CBT outcomes for marginalized clients, but philosophical questions about how well and how ethically CBT can truly treat marginalized patients.[8] (I, along with other non-White friends, have shared anecdotes about feeling worse after callously conducted CBT interventions.)  Add, on top of this short-sighted way of doing therapy, the way that the most affordable and available therapy via insurance companies and tech start-ups has shifted to small, 30-minute blocks of CBT “check-ins”[9], and the result is therapists who have an absurdly large caseload with too little time to administer responsible, respectful, and responsive therapy. There is a rush for therapists to find the “knots” in their clients’ metaphorical backs and iron them out without taking the proper time to tailor their approach to each person.

I mention CBT because it epitomizes the poverty of philosophy so dangerous in common therapeutic practice today. (Scholars have traced CBT’s philosophical origin back to classical Stoicism[10], and many of Stoicism’s shortcomings when dealing with issues of social inequality are shared by CBT.) I also mention the growing availability of overburdened and rushed therapists because it epitomizes both the broadening availability and shallowing scope of therapeutic practice. These patterns pervade the public-school setting, too. When it comes to preventative measures for mental health, the school (following the district’s framework) takes a small-scale approach. They work bottom-up, placing a heavy emphasis on individual behavioral change before one’s poor mental health has the chance to inconvenience anyone else.

CBT has a close relative in the CASEL wheel, the framework used in many schools to teach children to be more socially and emotionally competent. CASEL (Collaborative for Academic, Social, and Emotional Learning) is an organization that introduced the concept of SEL (Social Emotional Learning) into the field of education twenty-eight years ago.[11] The CASEL wheel is a more holistic framework than CBT. (Then again, it was intended to be a framework, whereas CBT is a style of treatment with an implicit philosophy that goes relatively un.) CASEL acknowledges that, aside from individual change, students’ ability to thrive is dependent on classrooms, schools, and communities that nurture while encouraging things like communication and trust.

Ideally, SEL gives students the tools to take ownership of their emotions by first acknowledging and interrogating them, then evaluating how these feelings motivate their actions and the way they relate to the world around them. By feeling centered and self-assured in themselves, they say, students have a solid foundation for building more purposeful goals and connections with others.

In practice, the amount of trust required to have young folks do that level of introspection and reflection hand-in-hand with school authorities is rarely met. SEL, despite efforts of those who understand SEL as the holistic framework it is, is taught in parts. And though it’s true that SEL has had its own successes, it can do more harm than good when taught in disjointed pieces. Research has shown that SEL is often used to extend carceral pedagogy and, moreover, that this policing of the mind is especially used to punish, criminalize, and control Black, Brown, and Indigenous students[12]. While SEL is meant to encourage young people to gain a better understanding of and control over their emotions, it is convenient to spend a disproportionate time teaching students how to “take ownership” of their emotions through self-regulating, self-policing, and self-soothing tactics. And while this responsibility, in theory, is only one part of a greater framework that acknowledges the importance of community, those administering SEL seem to favor harping on self-control as if nurturing, comfort, and integration into a greater society are not essential components to raising a child but luxuries to first be earned through mastering oneself. Simply put, the behavioral interventions that are labeled mental health support in schools are far too often a repackaging of the same wish that previous eras of administrators once had– to have students be perfectly parented (or to parent themselves) for the convenience of the school system.

The result of administrators asking students to process and defang their difficult emotions while not making themselves available for guidance or patience through that process (and, often, inflicting punitive measures when students fail at this task) is a broad sense of resentment and distrust. Giving students the task of owning and defanging gives room for educators and administrators to lay the task bare, all the while disguising emotional abandonment as support. Despite students reporting that they need help with their mental health throughout the entire school year, I have witnessed students’ strong intuitive distrust of the mental health interventions readily available to them, and rightfully so. The language of bootstrapping has permeated neoliberal models of mental health through concepts like resilience and grit, and I, for one, am not surprised when young folks are far from keen to accept it.

All this to say that the children are not all right, but they know that they aren’t and also that what we’re offering isn’t likely to help them. So, what can we do better when we try to heal the mental suffering that our youth are going through? What can we do to better prepare our children’s spirits to meet the great challenges that will undoubtedly arise within their lifetime? There are some clinicians and psychologists who are trying to find these answers. (Dr. Lynn Chancer’s Toward a Social Psychoanalysis focuses on the question of how a socially responsible clinical practice could look today.)

While I don’t have too many answers about how to change the way we “do mental health” in general, I do have some insights about the things that need to change:

  1. People don’t have to be perfect before trying to make change outside of their immediate circles. Of course, the ability to evaluate and regulate one’s emotions and to make concrete steps to change one’s life are important, but modern psychology seems to narrow imagination and change to a terribly lonely locus, waving the capacity for radical thinking off for everyone else except those able to first adequately “get their house in order”.
  2. For those working with today’s youth, the level of alienation they face shouldn’t be understated or ignored. They need to be reassured and comforted just as much as any other generation at their age– a culture of hyper-independence when it comes to regulating emotion is cruel, but it also stifles the important and collectively empowering ability to collectively make meaning out of pain. (See this student’s article for a glimpse into the anxieties, alienation, bleakness, and occasional fatalism of today’s young university students.[13])
  3. Finally, we must set an example by grappling with current paradigms that create mental burdens on society ourselves, letting ourselves truly feel through them and letting those feelings fuel our search for a better possible world instead of simply coping with the pain.

 

Conclusion

Although it is true, like the Surgeon General’s Address puts forward, that mental health desperately needs a more socially minded approach, it has been disheartening to see the discourse around mental illness change on such a surface level. Whether actors are called to make changes that are limited to their small circles or to simply work harder at policing their behavior or connecting people to incredibly overburdened resources, the Surgeon General’s advice does not go far enough. We must break the binds of such a neatly categorized approach, thinking more broadly about what it means to exercise agency and being more optimistic and imaginative about the things we can change.

There is also no escaping the truth of alienation that our youth carry with them– a level of alienation that goes far deeper than that brought about by the recent necessity of social distancing. In order to address the epidemic of mental health, it is absolutely necessary to rethink about what it means to have youth that are truly empowered. What will it take to build up a young generation that is not just “resilient” and competent at coping with a harmful system they have been taught to accept, but is critical of it and can envision a model of health that dares to think past the reality of the capitalist present? That is what we must provide to the next generation.

 

Footnotes

[1] https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf. pp 14-18. Pages cited in footnotes 2-7 are also from this file.

[2] pp. 19-22, 29-30.

[3] p. 33.

[4] pp. 23-28

[5] pp. 35-37.

[6] pp. 31-32.

[7] p. 28.

[8] https://www.theguardian.com/lifeandstyle/2020/feb/10/therapy-failing-bme-patients-mental-health-counselling (This article cites a thought-provoking but unfortunately deleted essay by Guilaine Kinouani that maps out CBT programs as a site of epistemic violence.)

[9] https://www.thecut.com/article/mental-health-therapy-apps.html

[10] https://dailystoic.com/donald-robertson-interview/

[11] https://casel.org/about-us/

[12] https://medium.com/@justschools/when-sel-is-used-as-another-form-of-policing-fa53cf85dce4

[13] https://imhojournal.org/articles/alienation-and-higher-education/

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