The Kids Aren’t Alright

I first noticed the change in their questions.

Medical students have long stayed after class with anxious questions about how to sort out sheep from goats. A decade ago, most students asked academic psychiatrists like me how to distinguish between an adjustment and a post-traumatic stress disorder, when to prescribe fluoxetine instead of venlafaxine, and the comparative benefits of measuring cortisol in the hair instead of the blood to assess a stress response. Their nerdy questions were asked with a worried tone, but the kind of anxiety that yokes a student to the profession. Med school examinations seem life-threatening to med students because the actual work of doctoring consists in critically sorting the pathological from the benign. The work students do in distinguishing between the wrong and right answers on their examinations is a low-stakes prelude to the high-stakes work of doctoring.

My colleagues who teach the basic sciences underlying heart disease still get the old style of med student questions, whose subtext is: Did I get it right? The questions that students ask me are increasingly about their own anxiety, ADHD, depression, eating disorders, and thoughts of suicide. They want to know: Why am I not all right?

This broad change in mental well-being is not limited to med students. Two recent books propose reasons why. In Bad Therapy, the journalist Abigail Shrier makes the case that mental health treatments wrapped a whole generation of high achievers in therapeutic bubble wrap. We kept them safe, Shrier writes, when we needed to set them free.

From my recent interactions with students, I often found myself nodding along to Shrier, even when she told just-so stories. Shrier writes that today’s parents were spanked as children, so when we became parents, we swaddled our children and sent them off to therapy. We were well-intentioned, wanting to make our children happy; we settled for keeping them safe. Our kids dutifully delayed substance use and sexual activity, sought therapy and meds, but the therapeutic work undid our kids – “the most anxious, depressed, pessimistic, helpless, and fearful generation on record.”

Our kids. In a preliminary author’s note, Shrier, identifies two kinds of mental health crises. The first is the children and adolescents experiencing “profound mental illness” who are neglected and untreated. The second is the worried but well; the young people who seek a mental health diagnosis and treatment to explain life’s problems.

Schrier unapologetically focuses on the latter, children at elite high schools and colleges who have learned to describe their troubles using therapeutic language. Some of this is pithy fun, as when a subheading reads, “Shouldn’t flowers bloom in powdered sugar?” A cheerfully absurd image comes to mind to explain why some med students think diagnoses designed for combat veterans apply to their experience of preclinical medical training. Some of it is shrill, as when she accuses clinicians of medicating away feelings. Some of it feels unfair, as when she unfavorably compares the adverse experience of today’s children to Holocaust survivors. Some of it feels like bad intent, as when Shrier cultivates the distrust of “experts” while endorsing the experts she trusts.

Photograph by Halfpoint / Adobe Stock.

Underneath the bluster, Shrier does marshal evidence to illustrate some of the ways normal developmental challenges are pathologized by the mental health industry. Instead of moral language that marks out some behavior as aberrant, therapists teach a therapeutic language where each behavior is a symptom. Patients focus on their emotional state instead of the actions they are undertaking. A diagnosis can become an identity. Patients lose their agency to change, instead being affirmed and accommodated for their behaviors.

Some version of this critique has been published from all sides, left and right, religious and secular, since the formation of modern psychiatry. Like many psychiatrists, I teach a lot of those criticisms to students myself, emphasizing, say, that a psychiatric diagnosis is not a neutral act, that a psychiatrist is prohibited against personal relationships with patients outside of treatment, that self-administered questionnaires of psychiatric symptoms should be not used to diagnose, that resilience is the most common response to an adverse experience, that anxiety is often worry instead of generalized anxiety disorder, that psychiatric drugs generally work best for the people with the most severe mental illnesses, that many people suffer by having lost their sense of the past, that our lives are governed by isolating individualism, that we suffer from too many choices, and that the questions we ask each other form us. Unlike Shrier, I also teach the classic formulation that the purpose of therapy is precisely to build the agency of the person I meet as a patient.

The agency of patients, of high achievers like med students, and of faculty physicians has been thinned by the digital devices we carry. Unlike the tools of an earlier era, the smartphone in our pocket and the laptop in our hands are ways of interacting with ourselves, each other, and the world. We live, the late social critic Ivan Illich commented in one of his last interviews, in an era of systems instead of tools.

Few social critics have been more influential in characterizing how the next generation is being harmed by these systems than the social psychologist Jonathan Haidt. In his newest book, The Anxious Generation, Haidt attributes the altered worries of young people to “overprotection in the real world and underprotection in the virtual world.” Unlike Shrier, who feels most at home in her prose, Haidt can be read through a series of charts correlating the incidence of a host of adverse mental health outcomes with the introduction of the smartphone.

The evidence is compelling and punctuated by pull quotes that I found myself writing out: “Social media is a conformity engine.” “Experience, not information, is the key to development.” “Risky outdoor play is better than adult-supervised sports.” “Parent like a gardener, not a carpenter.” Haidt synthesizes and frames like a master professor, while ending each chapter with takeaway messages for his readers. Like a conscientious student, he also shows his work, repeatedly inviting readers to visit websites where he makes more evidence available. A score of commentators are engaging Haidt’s evidence to discern if his findings are more correlation or causation. While it is critical to eventually resolve this distinction, I also teach medical students that sometimes you must pursue immediate clinical action without an answer to questions of causation.

The children we raise are not our own; we are simply gifted them for a time.

So it is with Haidt, because he proposes four common-sense clinical actions: delay smartphone use until high school; raise social media age limits to sixteen; remove phones from child and adolescent classrooms for the entire school day; and encourage the agency of children through unsupervised play.

Each of these seems so reasonable that I left the book wondering who might best advance each action. Parents can delay buying smartphones. Legislators can raise the age limits for social media. Educators can lock up digital devices. City planners can build natural playgrounds.

Throughout his writings, Haidt puts the social before the psychological, Durkheim before Freud. While Freud believed religious faith a delusion, Durkheim recognized its social utility in organizing a community. Haidt describes himself as an atheist who admires how powerful collective faith experiences create community and benefit believers by reducing self-focus and selfishness.

The limit of Team Durkheim though is found in Haidt’s assumption that we live in a secular society. When he imagines a better world, it is without a horizon. Haidt is trying to reform this world, the world where high-achieving children are formed and malformed. The more I read him, the more it sounds like he is trying to reform the university.

When I work with med students, some tell me they prefer to watch lectures from home so they can avoid being called on by the professor. Others say they feel invalidated when told that TikTok diagnoses of anxious attachment disorder do not meet the criteria for psychiatry’s diagnostic manual. A few brave souls ask if the reward circuit pathways activated by methamphetamine explain their online pornography habits. Many of the students seem to be visibly suffering from Haidt’s four harms of smartphones for adolescents – social deprivation, sleep deprivation, attention fragmentation, and addiction.

So do the faculty. Zoom meetings have replaced in-person happy hours, after-hour student emails have replaced office hour visits, course management software alerts have replaced raised student hands, and addictions proliferate that are simply more upscale than the students’ own. Why do children want smartphones? In part, because adults want smartphones. The digital systems in which children and adolescents are now ensnared are incentivized to extract the attention of adults as well. The kids aren’t all right, but neither are the parents.

Haidt’s book may prove to be the Silent Spring of the smartphone era, the book that ignites a movement by distilling evidence into actionable messages, but I found myself lingering over a few lines from Shrier. Toward the end, Shrier observes that the children we raise are not our own; we are simply gifted them for a time.

Reading those lines, I thought of my own children. Of the ways they were different from each other from the beginning. Of the work we did to develop attachments to each child. Of the ways they surprised us. Of the ways they changed us from students into parents.

My wife and I met on the first day of med school. When I make observations about the misbehavior of today’s students, she mentions my own faults from that era. She sometimes suggests that my teaching assignments are penance for the days when I badgered faculty about exam questions because of my own misplaced worries about sheep and goat work.

With her encouragement, I return to the classroom each morning with a little prayer for myself, for my students, and for the people we will meet as patients. I stand before the students and teach them that not everyone needs therapy. Therapy, like any other medical treatment, is most beneficial when you are most ill. I teach them the work of the psychotherapy researcher Jerome Frank, who found effective therapy remoralizes, renews people’s hope in their ability to effect change. I tell them therapy is a form of relationship with another person that advances agency. We form an emotional bond, we work together on tasks, toward a shared goal.

The shared goal I am pursuing with students is not that they will get the questions right, not even that they will be all right themselves, but that they will be transformed into people who care for others.

I thought again of Shrier’s author’s note, her qualification that her arguments were not about the care of people with serious mental illness. As a psychiatrist who has long been sympathetic to concerns about pathologizing normal developmental challenges, I want to steer med students to caring for the persons with the greatest need. I want them to become physicians in safety-net settings who care for the most ill.

The real mental health scandal of the day is that we shift mental health resources away from the people with the most severe mental health illnesses and toward the wellness industry, including the professionals who profit from promoting techniques for self-care.

In the end, Shrier and Haidt are critical of two therapies used to modulate the self – psychotherapy and smartphones, respectively – because they believe that neither is the best way to improve the self. Both struggle to find the end of their arguments because they are engaged with immanent conversations about improving the self. Shrier can say that our children are not our own, but not that our children belong to God. Haidt can say that collective experiences are better for our well-being, but not that we ought to bend our knees together because creation is divine.

The kids, and the parents, don’t need to be all right. They need to be transformed.