In the face of the COVID pandemic, social and academic pressures, and an uncertain future, young people are struggling. Each week we see another news reports about a “mental health crisis” among youth in North America, including rising suicide rates. Last fall, a consortium of physicians declared poor youth mental health a “national emergency.” More recently, on December 7, 2021, the U.S. Surgeon General issued an advisory on Protecting Youth Mental Health, which prescribes actions by families, schools, governments, media and other stakeholders.
Typically, these announcements call for getting kids greater access to mental health diagnosis and treatment. As MIA readers know, that frequently leads to more screening, more labels, and more prescriptions for psychiatric drugs. In his practice with children and adolescents, his research, and his teaching, Dr. Elia Abi-Jaoude is pushing back on that approach in favor of alternatives that more closely involve families and take environmental elements into account. Here, he tell us why and shares how he works in his practice with youth in crisis.
Elia Abi-Jaoude, MD, FRCP(C) is a psychiatrist working mainly with children, adolescents, and their families at The Hospital for Sick Children in Toronto, Canada, primarily in an inpatient setting. He is also an assistant professor, researcher, and clinical educator at the University of Toronto.
Dr. Abi-Jaoude is interested in how social factors influence how we view the experiences of youth and in asking critical questions about some of psychiatry’s assumptions about diagnosis and treatment, particularly the influence of the pharmaceutical industry. He is coauthor of a journal article taking a second look at the research behind the famous Study 329, which found that certain psychiatric drugs did not improve teenagers’ depression symptoms better than no drugs, as had been claimed.
The following transcript has been edited for length and clarity. Listen to the audio of the interview here:
Miranda Spencer: You work at a mainstream university and its hospital, but your approach to care comes from a more critical perspective. You’ve said that the “narrow biomedical response to kids’ mental health struggles has been inadequate and even counterproductive.” How so?
Elia Abi-Jaoude: When we talk about quote-unquote mental illness, people use it very loosely to refer to an adolescent who is struggling with anxiety or feeling down because of some difficulties at school or with their peers. And they also use it with someone who’s hearing voices and very disorganized and struggling as a result of that. So, I want to say that I don’t think it can be right to paint both of these situations by the same brush. So when we are referring to the rise in mental health difficulties among youth, we’re talking about health struggles in the form of emotional distress due to stressors in the context of psychosocial factors. And, yes, I think with these youth, applying the Diagnostic and Statistic Manual—this narrow biomedical approach—is very limited in terms of how it helps us, and I think often, it’s counterproductive.
So first of all, just using labels from the DSM, these add little information in terms of what’s happened [to a young person]. You basically are naming the emotions or difficulties the adolescent is experiencing and then you stick “disorder” at the end of it. [A diagnosis is] nothing but a descriptive label. The problem is then we use it as explanatory, as if it’s causative of what the [person] is experiencing, and then it becomes tautological. It becomes circular reasoning. Why are you feeling sad? It’s because I’ve got depression. Okay, on what basis do we decide that you have depression? Because I’m feeling sad!
The other thing is using this simplistic biological explanation. I see this regularly. I’ll see a young person who’s feeling suicidal. So I ask them, “So why do you want to kill yourself?” They’ll say, “because I’ve got depression.” I’ll say “Okay. Why are you feeling sad?” Deliberately changing the term from depression to sad. And they’ll look at me like, “I don’t know, it’s a chemical imbalance in my brain. What kind of stupid question is that?” So it’s disempowering. It’s external to your ability to do anything about it.
And the other thing is, they start identifying with being mentally ill. “I have a chemical imbalance. I am mentally ill.” They take on this role and, to borrow from Sami Timimi, a highly respected child psychiatrist in the UK, “the problem becomes the problem.” So no longer whatever it was that resulted in their struggles, it becomes almost secondary or no longer relevant. What’s relevant? Now it is that I’ve got depression.
The other thing is, [the diagnosis] triggers an algorithmic response. So if you see a young person who’s struggling, was feeling sad or anxious or worried, you want to talk to them. You want to understand what’s happening with them in [their] day-to-day life. But unfortunately, in this DSM world it triggers an algorithmic response, whether we’re talking about SSRI medication or some manualized therapy, and often that response can be quite removed from what the adolescent is experiencing.
Spencer: By an algorithmic response, you mean “if this, then that?”
Abi-Jaoude: Exactly. So it’s formulaic as opposed to really understanding. As opposed to, Let’s get real here. Let’s figure out what this person is going through. No, it triggers something, that we’re following an algorithm, a flowchart, a guideline. And that takes precedence over what the person is going through. We end up conflating suffering, distress, sadness with mental illness. There’s some recognition that oh, it’s normal to have emotions, it depends to what extent and how long and all of that. But the end result is really, in practice, emotions become suspect. People start worrying. “Oh, I am sad now, maybe I’ve got depression.” And it’s very easy for any of us to wonder!
So even more so, when it comes to things related to emotions and psychological experiences, when you read the DSM, things become suspect, medicalized, and it undermines the value of emotions—not just positive emotions but even difficult, negative emotions. They have a role. What’s the value of these emotions? To take stock, consider bigger questions about what’s happening in your life, thinking more broadly, even beyond you as an individual. So it becomes a lost opportunity to address whatever issues are going on.
And then last but not least, in terms of the narrow biomedical lens, it de-politicizes the social and the economic circumstances that are contributing towards one’s difficulties. So there’s a larger context as well in terms of what’s going on, but then rather than starting to pursue that question, the focus becomes the individual. It situates whatever the problem is in society in the individual, right?
Spencer: How is your approach to child and adolescent psychiatry different from the standard diagnosis-and-medication model? What would it be like if a twelve-year-old walked into your office?
Abi-Jaoude: So, first of all, I want to understand their story. I would hope that regardless of who’s seeing the patient, including someone who’s well immersed in the biomedical model, also wants to understand their story. But for me, it’s central. This is what it’s all about, and the symptoms become secondary. I do ask about symptoms, but how much weight I give them depends on the context. In general, they’re not primary. I think often in the very biomedically based [psychiatry], it’s the opposite. The symptoms are given the central role and the psychosocial context ends up being secondary or an afterthought.
Then I want to explore what’s happening. There are some common themes with adolescents in terms of emotional distress: the relationships with their peers, their relationships with their families, academic pressures. There are other things of course, and each person has their own story. But these are kind of common things and you want to get into them. I want to know the names of their friends and all the drama. I want to understand the background. Maybe what is it from their past experiences that’s led them to experiencing what they are experiencing now. I’m getting to know them and then I want to validate what they’re going through, I want to truly get it and I want to show them that I get it. But at the same time, I want to normalize what they’re going through. ”You know what? Your reactions are understandable given the circumstances.” There’s a reassurance to this.
I do check on safety because as we know, this is a major problem today with many adolescents, but I don’t dwell on it. I don’t externalize it as if they’re completely helpless and powerless when it comes to their safety. But ultimately, the focus is not the safety itself. The focus is on understanding their story and helping them with that and also recognizing for myself and for them that there’s no quick fix. We’re talking about gradual, small steps and being modest and humble about my role in their lives.
And then, when it comes to medications, I do prescribe, [but sparingly]. But I would say the way I see [the drugs] and the way I use them [isn’t typical]. I don’t see them as fixing anything or treating anything. I’ll be very explicit about it. These are very crude tools, and really, depending on what medication we’re talking about and the context, basically we’re hoping to take the edge off whatever it is so that we can try to pursue whatever can help you.
Spencer: What have you learned from your patients and their families that other practitioners and parents can apply to helping young people cope better?
Abi-Jaoude: It’s really coming back to basics. It’s compassion, listening, showing genuine interest in what people are going through and experiencing. It makes a world of a difference. You know, I’m sometimes taken aback by how readily appreciative [patients and families] are. When I’m working with residents, I tell them to be genuinely interested, ask questions that are even not necessarily relevant to clinical care just because you’re curious, to get real that way.
I think another big one is communication within families. Adolescents don’t exist in a vacuum. They’re part of a family unit. They’re part of a larger community and we always want to be thinking about that. So, what’s it like in the family, in the relationship? Often the young person is the person coming to see [me]. But really, I think of it as the families coming to see me. Assuming the families are caring, which the vast majority of the time they are. You want to check: Are these parents still connected to their young person, or has life taken over? The stresses of day-to-day life, everyone running around, and the adolescent as a normal thing wants more independence and so they’re just doing their own thing and the parents are busy with their own thing. And then the relationship becomes more around managing things or dealing with stressful situations rather than [what should be] an open, supportive kind of communication.
You know, it’s surprising, often the young person is not aware to what extent their parents care [about] and love them, and really want to be there for them. And the other way around, too, to where the parents are not aware to what extent the adolescent is struggling, You’ll see a young person [who] had a serious [suicide] attempt and the parents say, “I had no idea.” So you want to check the communication between them.
The other big thing is acceptance. I don’t mean resignation: Okay, nothing’s going to get better, suck it up kind of thing. I mean accepting [that] the difficulties are not something that’s necessarily bad, but something to be worked through and something to grow from. And then accepting your parents, your parents accepting [you] and growing together that way.
Spencer: Let’s look at the bigger picture. What’s eating kids? In recent years, there has been a dramatic increase in the numbers of youth experiencing and expressing emotional distress, including suicidality. What do you make of this?
Abi-Jaoude: Being witness to this dramatic rise in adolescents experiencing emotional distress to the point that there’s self-harming or to the point that they’re suicidal has shaken me, and has kept me thinking about what’s going on –very concerned but also curious. As a result, I’ve been kind of trying to think more broadly.
Adolescence today is more challenging. There are many things that are different. I mean, it’s always had its own challenges. Part of the role of adolescence is pushing back against what is being imposed on you, and that maybe has an evolutionary role. So, there’s often these kinds of tensions and challenges, but I think there’s some things today that are specific and unique to what adolescents are experiencing.
So one that has probably gotten the most attention is the issue of smartphones and social media. I think there’s a lot of compelling evidence and I continue to do research on this. I also often find myself hastening to say that I don’t think it’s the full story. I don’t think if cell phones somehow didn’t exist anymore, all would be good and resolved.
The issues with social media and smartphones involves a unique set of challenges in terms of interactions with fears. The issue of negative comparisons is an ongoing issue. That and the number of likes and whatnot, which is the currency of social media. Feeling left out is an ongoing issue. Misunderstandings. It’s easier to assume negative intentions. It’s easier to make negative comments when you don’t have the real life feedback of tone of voice, body language, facial expressions. And then cyberbullying, sextortion, all of these things.
A lot of these things are not new. Bullying didn’t come about from social media. But the difference is now you take it home with you. So often you’re taking it to bed with you. And then, good luck sleeping, right?
And we know a large number of people take their phones to bed with them. But there’s also the impact of the blue light or from the digital screen, suppressing your melatonin and interfering with your sleep that way. And if you’re chronically sleep-deprived, how is that going to help you with managing all these challenges that you’re experiencing?
The other thing that’s happening is I think there is a lot of emotional contagion happening on social media. Communities can be very positive, like if people are struggling and they can relate and empathize and support each other, and social media can facilitate that. There’s definitely positive that has come about from these technologies, especially in this day and age of physical isolation, physical distancing in the pandemic. It’s allowed a lot of people to stay connected, to commiserate about their experiences.
At the same time, there’s been a lot of negatives, because I think what’s happened is people are spending even more time on these technologies. So the sense of community and such can be certainly very positive, but oftentimes it’s not in a very productive way. It’s more a kind of wallowing in each other’s misery, bringing each other down. So, some romanticization of being unwell and normalizing of self-harm. And in extreme cases, there’s sharing pictures of cuts or talking about practical ways to commit suicide.
And then the issue with these [devices] also is they’re made to be addictive. They’re designed to hook you, capture your attention, and so it can be hard to stop and get off of these things. And it can happen at the expense of other, healthy things like having real-life relationship time with your family, exercising, doing your schoolwork.
I am very convinced that I do not think this is [not] the full story. Another one is family structures are very different today compared to before, if you’re in a large western city where many people in that city did not grow up and, as a result, do not have extended families and extended social networks there. At best, you’ve got the nuclear family and sometimes just one parent, so you don’t have the same kind of extensive social-support networks that can help contain what the person is going through.
I think the change in the family structures is an issue today and it is a more challenging role in terms of what the expectations are for everyone to achieve. It’s much more competitive. What is happening with the parents? And when we’re talking about a young person, we need to think about beyond the young person. We need to think about the environment they’re in. And if the adults in their lives are under stress, guess what? That’s going to affect the young person. And we know parents today are under stress. You’re expected to do more and more with less and less.
There’s also been a significant rise in social inequality across much of the world, especially in the last couple of decades. There is tons of evidence about the relationship between social inequality—meaning the gap between the top earners and the bottom earners in the society— and all sorts of measures of well-being in that society: complaints of depression, anxiety, suicidality, homicidality. The incarceration rates, drug use, teen pregnancy, obesity, you name it. The [wider] this gap is, the worse that society is on all these measures. So maybe it’s no surprise that we’re seeing these kinds of struggles.
Spencer: In terms of public messaging, our Surgeon General in the United States just came out with a report about a mental health crisis in youth and what we should do about it. You have said in the past that mental-health-awareness campaigns in schools may have actually contributed to the youth mental health crisis. How so?
Abi-Jaoude: These campaigns have been well-intentioned. The intended message is, if you’re struggling, if you have emotional distress, it’s not your fault, quote-unquote. You have a mental illness, quote unquote. It’s not a moral failing. It’s just a brain disease, like any other disease. So the idea of encouraging people to talk and seek care is not a bad thing in and of itself, but the problem is this narrow, biomedical messaging is problematic in this population that’s very impressionable. As I’ve said earlier, first of all, it’s pathologizing distress. The idea was to destigmatize, but it’s gone towards romanticizing.
The other thing is the focusing on symptoms, labeling things as a having a disorder, reifies the symptoms as a problem rather than having an understanding of the [person’s] broader experiences and context. As I said, the problem becomes the problem, the problem they identify as mental illness. And then, young people start getting the message, “Oh, everyone’s having a mental illness. Everyone’s got depression, self-harm, suicidality.” It becomes normalized, romanticized, in an inadvertent way.
I saw a great talk by someone from Save the Children and she was talking about some project at a Rohingya refugee camp in Bangladesh. She was sharing about some of their research work there, about how they wanted to check in with adolescents in terms of what their emotional experiences are, what they’re going through. They were being so thoughtful about how they worded their questions. They don’t want to just ask them, Are you feeling depressed? Are you feeling anxious? Are you feeling suicidal? They were concerned about giving the impression towards these adolescents that they should be feeling that way. I’m not saying we shouldn’t be looking into these things. But we need to be thoughtful about [it], whether it’s a survey project or intervention campaigns or screening.
Spencer: Let’s talk about some alternatives to this narrative. You’ve talked about taking a broader view of youth mental health struggles. As you wrote in your article about smartphones, “There’s a need for public awareness campaigns and social policy initiatives that promote nurturing home and school environments that foster resilience as youths navigate the challenges of adolescence in today’s world.” What would that entail?
Abi-Jaoude: We need to be thinking about policy initiatives aimed specifically at social and environmental and economic factors that underpin family well-being and nurture youth resilience. The reference that I used for this is basically an open statement from the former UN Special Rapporteur on the Right to Health, Danius Puras. He talks about when we talk about good mental health and well-being, it’s not about the absence of a mental illness. We need to be thinking about the factors that allow people to live life fully, with dignity, with rights, and equitable pursuit of their potential. And this is key here.
One way I think about it is as if someone has stepped on a nail and they’re in pain as a result of that. So is the problem that there’s pain, and that’s what we should be addressing, or is the pain a sign or an indication of something else? We should be addressing the nail, not so much the pain. So when youth are struggling so severely, what does it say about society at large? There’s something off in a society when the future generation is experiencing so much struggle, I mean, what does it say about what’s happening with the adults? Their parents, their families, their teachers and other adults in their community? [Any mental health] campaign should address the issue of social inequality.
There’s been some clear-cut policies in much of the western world since the early ‘80s that have resulted in increased stress on individuals, with increased death, lack of job security, increased productivity expectations and such. There are studies that show that teachers’ mental health and well-being is associated with students’ mental health and well-being. So, if the teachers are in precarious job conditions, if the teachers are going through life hardships, the parents are going through these hardships, [the solution] cannot be just empty campaigns or rhetoric. It has to be clear-cut policy initiatives that address these things.
And we need to be thinking about communities. Part of the issue is with the focus on individuals and maybe even individual freedom and liberty, which I think are good things. But has it come at the cost of connectedness? Of a sense of belonging and community that goes beyond the individual? And I think it’s important that people feel a sense of belonging to something. It might be based on racial or ethnic belonging or might be based on religious belonging, some worship community. Might be based on their physical location, their neighborhood. It might be based on a cause, but I think it’s important that people feel that their lives are meaningful. And there’s some bigger purpose that they are part of.
Spencer: Have you looked at the Surgeon General’s report?
Abi-Jaoude: Well, I would say it’s a mixed bag. I was very impressed with a lot of the things, especially in the beginning. They named some of the issues that have been going on [that may lead to mental ill health in youth]. They identify people who are disenfranchised or have difficulties, people [with] disabilities, racial and ethnic minorities. Low-income youth, immigrant households, homelessness. They also talk about social inequality. They talk about mental health being shaped by many factors: genes and brain chemistry, fine, but they also emphasize the role of relationships with family, friends, neighborhood, conditions such as larger social forces, and policies. They talk about systemic changes [as] essential and he says “Our obligation to act as not just medical, it’s moral.” So all of this I thought was excellent and really set the stage for something very nice rather than just focusing on the individual or “something’s wrong with you,” thinking in these broad terms.
Early on, [though], he says mental challenges are “real, common, and treatable.” I’m not a big fan of this idea that it’s something treatable, again medicalize[ing] mental health challenges [as being] the pain in your foot from the nail. No, the problem is not the mental health challenges or the pain in the foot. The problem is the context that’s leading to that. And then when they give suggestions for what people can do, suggestions individual young people, parents and families, care providers, educators. I thought generally these were very good, too, a holistic approach, looking at the big picture.
Where it broke down is when it came to suggestions at the more macro level. When it comes to talking about the workplace and at the government, what did these guys forget? They use the term social inequality maybe a dozen times in the intro of this report, but then when it comes to the government interventions, not even once does it mention the term. But the specific remedies they were suggesting there, as well as the governments at all levels I thought fell short because there the emphasis was more targeted at individuals. Ran along the themes of screening, diagnosing, treating, increasing access to care, that kind of thing. It came back to the individual as opposed to looking at, okay, what can government do in terms of socio-economic inequality?
Spencer: If you were the U.S. Surgeon General, what would your recommendations be?
Abi-Jaoude: We need to do something, but we don’t want to do things for the sake of doing them. We need to be careful about where do we have enough evidence? We need to understand what the issues are and what are the consequences of our actions.
I keep coming back to socio-economic inequality. That says a lot in terms of things that can be done, just by maybe reversing some of [the] neoliberal policies that have been dominant and the last four decades now. If we go to 50, 60, 70 [years ago], the balance of power between corporations and workers was very different. You had much more labor rights. So these things are not having to reinvent the wheel [that] make for a much more healthy and more equitable and fair society.
I’d say [to] parents, the key is what I said earlier: talk to your kids, maintain open communication, maintain a relationship with your young person, making sure to spend quality time together. Not just time dealing with things that need to be done. We often forget, parents grow apart from their kids. So reconnecting, maintaining a relationship. If you’re not talking regularly to your kid about things that really matter to them, then [if] your kid is struggling [with] some things that are very difficult emotionally, maybe embarrassing, you can’t expect that all of a sudden they’re going to talk to you about it easily.
Don’t be afraid for your kid to be in distress. I think it’s important that they [get to] experience distress at a young age. We should not be depriving them of the opportunity to learn to regulate, and to work through it. And guess what, if they experience that at a younger age, it prepares them better for adolescence, because [it] ain’t an easy ride. And then when they experience distress as an adolescent, learning to work through that will prepare them for later on too. Again, there’s no need to panic about it. It’s okay. You can tolerate that.
There’s no need to be perfect as a parent. You’re going to get it wrong often. I regularly get it wrong. It’s okay, as long as you work through it, that’s how growth happens.
In terms of the young people themselves, I would encourage young people to have real relationships, not just digital relationships. If there’s bullying in your life, whatever form it is, if you see it happening, stand up for others— that can make a big difference. Again, basics, living a healthy lifestyle, making sure you attend to your academics, physical activity, in-person social activities, your sleep. If you’re chronically sleep-deprived, it makes it harder to deal with challenges.
But also think about anything that you can do to be helping others. When you’re caring towards others, that helps you feel better. It’s volunteering, being more active in your community. And then I would say, and this is key, talk to the adults in your life. They really want to listen.