Mental health and “expectable” vs. “unmanageable” discomfort: Key podcast

Are rising levels of anxiety a sign of a mental health “crisis” among young people—or evidence that we need to better differentiate between “expectable” distress and discomfort that is severe enough to impair functioning?

A recent episode of The Key, Inside Higher Ed’s news and analysis podcast, explores an issue that has been at or near the top of the worry list for those who work in and around higher education, as learners report record levels of depression, anxiety and other conditions; strain campus counseling and health centers overwhelmed by students seeking treatment; and struggle academically, sometimes to the point of stopping out altogether.

Participating in the discussion were Lisa Damour, a psychologist and author of The Emotional Lives of Teenagers, Nance Roy, chief clinical officer at the Jed Foundation (JED), which works with high schools and colleges to strengthen their mental health, substance misuse and suicide prevention programs; and R. Ryan Patel, senior staff psychiatrist at Ohio State University and chair of the mental health section of the American College Health Association.

An edited conversation of the conversation follows.

Inside Higher Ed: Lisa, your recent book, The Emotional Lives of Teenagers, argued, among other things, for resetting the definition of mental health. Can you please explain what the definition used to be, what it has become and what it should be?

Damour: I’ve been a practicing psychologist for nearly 30 years, and in that time, I’ve watched the cultural definition of how we talk and think about mental health slid away from how we think about it as psychologists. The definition that seems to be around us in the culture, in the media, is one that equates being mentally healthy with feeling good or calm or relaxed or happy.

Psychologists want that for people, but that’s not how we think about mental health. In my book, I’m trying to advance a definition that squares much more with how we think about this on the clinical and academic side, which is a two-part definition of mental health. One is having feelings that fit the moment, feelings that are appropriate to the context. The transition to college is an inherently stressful transition. So young people who are feeling stressed in that transition are having, in many ways, a very appropriate reaction.

The second part is that those feelings are managed effectively. There are a wide range of ways that people cope with distressing emotions. Some are adaptive—they’re going to bring relief and do no harm—and some are less adaptive; they’re going to bring relief but come with a price tag. What we’re interested in as psychologists is actually not the presence or absence of distress—that on its own doesn’t tell us very much. What we’re curious about in college students is, do they manage the stress of college and the transition into college by reaching out to supportive peers, taking good care of themselves on all things sleeping, eating and exercise? Or are they managing that stress by abusing substances or acting out? Both of which will bring some relief but obviously come with a price tag?

Inside Higher Ed: What are the reasons for the divergence of the academic and formal definition from how it’s interpreted culturally?

Damour: I don’t know, but I have a couple of ideas. One is that we have seen over the last decade the rise of an industry around wellness. I’m all for wellness, but there’s a lot of commercialization of wellness. There may be money caught up in advancing the idea that there is some Zen place out there that we can all try to get to with enough of the right practices, products, etc. Wellness has a place in this—it’s one wonderful way to cope. But it certainly cannot and should not ever be advanced as something that can prevent distress, because it can’t.

The other side is that so much of the reporting around the psychological impact of the pandemic, especially on young people, has conflated distress and mental health concerns. Those are two very different things. Distress is very much a part of life, and distress was an entirely appropriate response [to the pandemic]. There hasn’t been much of a clean line drawn between young people feeling a whole lot of distress as a function of the pandemic versus young people who go on to either develop significant mental health concerns or who had mental health concerns that were exacerbated by the pandemic. The more specific we can get in making that distinction between expectable and in fact natural distress, versus when it’s really time to worry and step in with significant supports, the better we will care for everybody involved.

Inside Higher Ed: Nance and Ryan, what do you make of Lisa’s description of how the cultural definition of mental health of young people has evolved, and how does the proposed resetting of that definition square with your work?

Roy: It does resonate. The pandemic shed light, finally, on mental health and well-being, but we know this has been a trend over the past 10 or more years, especially with college students and young people, with increases in anxiety and depression. Back to what Lisa was saying about appropriate reactions: look at the world. These young people are growing up with school shootings, political divisiveness, hate crimes, climate change. I mean, if they weren’t anxious and somewhat depressed, I’d be more concerned.

But to the point of the discussion, it’s not that they shouldn’t be distressed or anxious or depressed—it’s how do you manage those feelings? Do they reach a point where they become overwhelming and impair functioning, versus a normal reaction to the current situation we find ourselves in? In a college setting, you think about the demand for services and how all [counseling] centers are feeling overwhelmed. When does something rise to the level of needing a clinical intervention, versus needing support in developing life skills? How do we manage conflict, disappointment?

Those are things that the younger generation we have at hand have not had a lot of experience with. Caregivers and others have protected young people from disappointment and conflict. It’s navigating that and working your way through it that gives you a sense of competence and resilience. If we’re protecting kids from that all the time, we’re really not doing them any favors.

Patel: When we look at the trend over the last 10 years, the youth behavioral health survey from the Center for Disease Control and Prevention shows persistent feelings of sadness and hopelessness among young people going from 36 percent to 57 percent. Young females [see an] increase in suicide attempts from 19 percent to 30 percent … Over the last 10 years, we see a continued rise in seeking help for mental health, which is a good thing. But the way that we address mental health in young people also has to be [multifaceted.] Some people need more attention on life skills, some people need more attention on adversity management, some people need clinical treatment. Not everybody needs professional clinical intervention, whether that’s medication or counseling, to address their mental health concerns,

Inside Higher Ed: We’ve gotten right to the nub of it from my perspective. We can all stipulate an increase in … depression, anxiety and in demand for services, greatly outstripping what most colleges can meet. The question for me is how do we differentiate between—I’m not even sure exactly the right terms to use—but between a serious, significant mental health condition that warrants traditional treatment, versus what’s not in that category? Thinking about our audience of institutional leaders, mental health counseling directors, etc., how do we think about the different needs students have and different ways of meeting those needs?

Damour: I really liked what Ryan said about there [being] a whole menu of supports that can be offered to students, with different students needing different things on the menu. We can diagnose depression—it doesn’t look like sadness; those are two different things. We can diagnose anxiety disorders, which is not the same as having healthy anxiety, such as the kind I would want to see in a teenager if they walk into a party that’s out of control or they haven’t studied for a test and should get going.

We want to continue to make that distinction between expectable distress and distress that’s impairing functioning, as Nance mentioned, because those are going to require different kinds of intervention and different kinds of support. Some of that is going to be in messaging to the young people themselves, offering them reassurance that not all experiences of distress need to scare them. Part of what we’re up against is these reports coming from the CDC; they’re harrowing. They’re scary to parents and to the young people who see the headlines.

We have to be really careful about how these are reported. The CDC data released in early February were collected in the fall of 2021, asking about mood over the previous year, about low mood over a two-week period. I had a daughter who was entering her high school senior year at that point, her third year of disrupted school. She was miserable, like everybody she knew.

We have to watch out for the opposite of the virtuous cycle: we have concerning data, they get reported in a particularly concerning way, this scares young people, scares their parents. It causes parents to become understandably much more protective, much more anxious about any discomfort in their kids. There’s a lot that can be done around shifting the messaging, making distinctions between when distress actually is evidence of mental health, as it often is and when distress is grounds for concern.

Inside Higher Ed: Ryan, what’s the institutional role in driving that distinction home? How successfully do you see your peers doing that?

Patel: A useful role for universities is to educate students on what are situations where professional help may be more appropriate, situations where perhaps working on self-care is more appropriate, working on life skills is more appropriate. And providing that menu and where different choices of the menu are more suitable. Also educating university staff and community members and parents that there are a variety of mental health support options for a variety of concerns. We at [Ohio State] and something along the lines of 40 percent of institutions are using a stepped-care approach where a student can reach out for an initial screening appointment, [and] the professional can work with the student to identify what is going on and perhaps what might be the most suitable resource for that student.

Roy: I think sometimes we pathologize feelings that are appropriate to the situation [students] find themselves in. Yes, the data is showing an increase in feelings of sadness. If you watched television for any more than five minutes, you’re going to see, “Oh, you’re feeling down? Take this medication.” There’s a need for instant gratification to feel good all the time. Similarly, we work at the Jed Foundation with over 400 universities. Often when we talk with them, their gut reaction, college presidents especially, is “Oh, we have to add 20 more counselors or psychiatrists.” That is never going to solve the problem, and it reinforces that everyone needs psychotherapy. Not every student on campus needs direct clinical care, but they all can benefit from a culture of caring and compassion, where there’s no wrong door for a student to walk through for support.

That doesn’t mean having faculty members be therapists. But when you notice that something just seems off with Nance today, reach out—“Hey, Nance, is everything OK? You’ve been quiet for a couple of days in class.” Know where to get professional help if I reveal a huge issue. When we work with schools, we really talk about developing a culture of caring, developing life skills promoting connectedness. Loneliness is at epidemic proportions in our country. How do you develop connections? How do you identify when students are just beginning to struggle? Let’s not wait until they’re in your office, melting down in tears. At that first sign of struggle, we can offset many situations from spiraling to a point where a student may need direct care. Not looking at crisis management, direct services, but taking a public health approach, where everyone in the community has a role to play in supporting young people in their growth and development.

Damour: Experiences for college students are going to arrive in three categories. They’re going to be enjoyable, we hope, uncomfortable and sometimes unmanageable. Situations that are uncomfortable and unmanageable are not the same thing. A lot of undergraduate education will be uncomfortable, because that means you’re growing, right? That’s part of being a student. If we introduce those categories, we may help bring the temperature down around tolerating more discomfort.

Then it tracks what Nance was saying: if we see a student is uncomfortable, that’s a great time to have eyes on. Because unmanageable doesn’t usually arrive overnight; the kids get there over time. If we have eyes on a kid who has become uncomfortable and are normalizing it, but also watching it carefully, we can do two good things at once. One is reassure that young person that we’re not scared that they’re uncomfortable—discomfort is part of life and certainly part of being in college. But we’re also keeping a close eye so they don’t skate over into the category where things become unmanageable. But I worry that one of the upshots of this discourse, where there’s a lot of concern about students presenting as too fragile, is that that it then flips to “they’re fine.” It’s too extreme, right? They’re fine, or they’re uncomfortable, or it’s unmanageable and we want to work across those three categories.

Inside Higher Ed: Nance and Ryan, have you seen successful efforts at helping students differentiate between the uncomfortable and the unmanageable?

Roy: Regardless of whether we think something is extreme, it doesn’t really matter. That’s their experience. The first order of business is to validate: “I hear you; I get that you’re feeling A, B or C.” Then start to tease out what’s the underpinning of that—how are they managing it or not managing it? Then it falls to the psychologist in the room to be able to help tease out whether this is something that actually is in need of direct clinical intervention, or can we talk with the student about some strategies for managing whatever the thing is that they’re feeling upset or distressed about?

Inside Higher Ed: You just laid out a scenario where the person gets to the professional. There tends to be more demand than most institutions can accommodate for clinical services. None of us would want a situation where a student who is in the “unmanageable” zone has to wait two and a half weeks to get to the professional, perhaps because they’re crowded out by people whose situations might be best addressed by a nonclinical intervention. Are there approaches we can use to do greater sifting or otherwise address this problem?

Patel: There are a number of approaches. One is bystander intervention. We provide education programs to students to help identify a peer that might be in distress —maybe they’re suicidal, maybe they’re having thoughts of harming others, at risk of harming themselves or others. There are programs such as mental health first aid that help train faculty and staff to identify warning signs [that] require further evaluation and intervention. A number of counseling centers are taking this approach where before a first appointment, the student has a screening appointment—a brief meeting with the clinician within three days of the client reaching out and offering immediate assistance if needed … because of the distress of the mental health symptoms they’re experiencing.

Roy: If we do a good job of creating the culture of caring and compassion on campus, we will in fact see fewer students running to the counseling center when they feel the first sign of distress. They will have experienced a sense of belonging, connection, knowing trusted adults in the community or peers they can turn to, and that atmosphere will go a long way to saving the counseling center for students who really need direct clinical care.

We need to be careful when we talk about educating faculty and staff around identifying students who may be struggling. We’ve done ourselves a disservice in the field by making that into a huge eight-hour training where you feel like you need to be a clinician who can diagnose whether someone has clinical depression or not. It’s intimidating. It makes folks feel like they’re going to say the wrong thing or make matters worse. This is not rocket science: most of the information you need to convey about how to recognize when someone’s struggling, what they need to look for, you can do that effectively in about 20 minutes.

Damour: Let’s put this in a public health frame, using dental health. Think about primary, secondary and tertiary intervention. Primary intervention is what the whole population gets, like the fluoride in the water. What’s the fluoride in the water [for mental health], the things that are going to every student? Maybe it’s what Ryan was talking about, where all students are given a heads-up about what to look for, when to be worried about somebody and raise the alert if there’s concern. The fluoride could be more education around what to reasonably expect in terms of the expectable stresses that come with the transition to college and how we recommend managing those. That’s the fluoride. Everybody gets that.

Then what Nance is talking about in terms of kids who start to eat a lot of sweets, where there’s grounds for concern that there may be a cavity down the line. Nance, when you talk about the 20 minutes, what I picture is saying to faculty, “Tell us if somebody stopped showing up for class,” or “tell us very clear basic signs that a kid is starting to become overwhelmed.” I will call that secondary prevention—know who those students are. And then tertiary, right, by the time there’s a cavity, that’s usually where the counseling center belongs and steps in. Using those models, I have found, takes a problem that feels so enormous and at times overwhelming.

Inside Higher Ed: We’re seeing significantly greater proportions of students coming into colleges and universities with previously diagnosed mental health conditions. How do institutions go about addressing them, remediating them, to the extent that’s what’s expected of them?

Roy: We have to first recognize that not all students are the same. We’re going to have some students coming to campus who are quite resilient, who have faced a lot of adversity and have developed a lot of strategies and skills for managing distress. We may have another whole group of students whose caregivers, thinking they were doing the right thing, protected them from any disappointment—it’s that T-ball, everybody-gets-a-trophy approach. Getting a B and feeling like their life is over. Then you have specific populations: you’re one of very few LGBTQ or racially diverse students on campus. Who’s coming to our campuses is very diverse, in many cases, and we need to take that into account.

We also need to meet students where they are. So as an institution, separate from the health and counseling center, how do we integrate that into our campus? How are our faculty members, for example, integrating life-skill development in the classroom in curricula? How are coaches and trainers managing these issues on the playing fields? It’s back to the public health approach—the entire community taking responsibility for the students that they’re in touch with and helping them develop from where they are, because they will be at different stages of readiness.

Inside Higher Ed: Lisa, you’ve raised some good points in this conversation about how my colleagues and I in the media may contribute to this problem with the language we use to discuss the current situation. There’s a lot of talk about us having a mental health “crisis” among young people. Whether this is a crisis or not, do you think institutions are facing this open-endedly? We are a society of pendulum swings, after all—is this part of a pendulum swing? Can it be addressed, such that we reach a stasis of some kind, as opposed to just feeling like we’re spiraling out of control?

Damour: I’m hoping it’s not spiraling out of control. Here’s what we’re up against, though, in terms of the mental health crisis: that is real. The pandemic was horrible for teenagers and caused a surge in distress for adolescents and pushed a lot more kids into a category of needing help than had been in that category before. That was coupled with the fact that there are not a lot of people who take care of teenagers and young adults. It’s actually very specialized work, so we had a huge surge in need and were unable to develop the workforce to meet it. Those two things combined created a very real crisis.

That seems to be improving a bit. But we have to be really mindful of how we talk about distress in young people. If we minimize it—which we shouldn’t do, but I understand why sometimes people feel inclined to go down that road—the reaction from young people is going to be “No, you don’t get it, you’re not hearing us.” The goal here is to try to find a way of talking about it that is deeply empathic. As Nance was saying at the beginning, this is not an easy time to be a young person in this world. Deeply empathic to that, while again, making clean distinctions between expectable and typical distress and mental health concerns.

The other thing we are up against is fatigue on the part of adults who surround young people. The pandemic put a dent in [students’] education, it delayed maturation, it delayed ownership of learning. There’s no way it couldn’t have; they were not in school in any conventional way. One thing I hear as I spend time with educators is that they both get it and are tired of accommodating to it. There’s a lot of work to be done supporting the adults within the institution, to have ongoing patience and empathy for the fact that the students who continue to arrive on campus had wildly disrupted periods of their education that still have ramifications, whether or not the adult is ready to move on.

Roy: I do struggle with the term “crisis.” I don’t mean to diminish the level of distress many people are in, but the word “crisis” ensues some kind of panic, some kind of exacerbation that I’m not sure is always helpful. For me it gives more of a feeling of helplessness and hopelessness. I’d rather focus on, yes, this is a very difficult and trying time, but we have a number of ways that we can help each other and young people manage our way through. Lisa, you mentioned faculty. We somehow sometimes forget that they also went through the pandemic—they also have losses; they also were struggling. So not only are we asking them to really step up, to help our young people who are struggling as a result of the pandemic, but they themselves are still struggling. We hear often from the institutions that we work with that it’s not just how are we going to support our students, but how are we supporting our faculty and staff? Because they are very much in need, oftentimes as much as the students are.