Podcast: Supporting Young Men’s Mental Health

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Scott: Alright, so good morning, good afternoon, everyone. Thanks for joining us today. My name is Scott O’Brien. I oversee McLean’s education outreach activities, and the topic today of young men’s mental health is an incredibly important one.

You know, we know that young people just as a whole are struggling at incredibly high rates these days, possibly more than ever before, and it should come as no surprise when I say that young men often do not know how to cope with the way that they’re feeling.

You know, young men, they struggle in many ways, and we may see it, but not be able to recognize it for what it is. We might see angry outbursts, withdrawal from friends and family, things like that, experimenting with substance use.

We see them as typical teen behaviors a lot of the times, but we also know these behaviors are often attempts to cope or maybe outlets for those struggling with maybe depression or anxiety, for example.

And in many countries around the world, we’ve created cultures that tell us that in order for all of us to be real men, we have to put our heads down and power through, you know. We’ve been conditioned to essentially be unhealthy.

We’re taught not to show emotion, don’t show weakness, never admit defeat, and these are things that run really deep in a lot of us, including myself. These are things that I can certainly say that I struggle with, and I know a lot of my friends and colleagues struggle with pretty much regularly every day.

So, you know, I’m glad everyone’s here with us today to talk about this topic. It’s really important that parents, educators, providers, everyone fully understand how to help support the young men in your lives, and those in your care.

They may need your help and not even know it themselves, or even worse, they may really need the help and be unable to reach out for fear of being considered less than or not a man for doing so. So, I’m thankful to Dr. Byron Garcia to help.

He’s here to help us better understand young men’s mental health. Dr. Garcia’s a child and adolescent psychiatrist who oversees medical care at McLean’s 3East program for young men. So, Byron, I can’t thank you enough for joining us today.

To get us started, would you do a, and just talk to us just a little bit about what’s important for us all to know about this topic?

Byron: Yes, thank you very much for the opportunity. I would like to describe a little bit my background.

I studied after my medical school a program in pediatrics in New York. However, I was very interested in human behavior, and I transferred to Pittsburgh to study child and adolescent psychiatry.

I graduated at the University of Pittsburgh 25 years ago, and I have been in the Boston area since I graduated. I have worked in child psychiatry in all of the different levels of care in the community.

That would be outpatient, partial programs, some of the CIPA beds or kind of acute residential, inpatient psychiatry, and now here at McLean working in a unit dedicated to work with young men and boys with emotional difficulties, depression, anxiety, and emerging personality disorders.

We recently became all-inclusive and with more of an inclusive language and tolerance in our unit, so we also admit non-binary patients to our unit. It really seems that there’s an increase in the manifestation of psychological issues in the LGBTQ community.

And after the pandemic in general, we have seen a tremendous increase unfortunately for the need of psychiatric care for children, teenagers, adults, because of course, the pandemic represents a very major struggle to all of us.

And of course, isolation, difficulties at work, financial issues, just the concern of health issues, either on our own or family members, bad outcomes, bad experiences, all of that has been accumulating, which has meant almost like a healthcare generalized issue.

Not only for health, more physical reasons, but also for emotional reasons, which keep us tremendously busy at all the different levels of care that we provide here at McLean Hospital.

Now, as a child and adolescent psychiatrist, I think that I could describe some of the challenges that boys and young men have nowadays. I think that the first concept is how important it is to be in school, not only from a learning point of view, but because of socialization.

As you know, is key for human beings to be able to work with other people, to interact with other people in order for us to have a healthy life and is usually in middle school when we start to see the most serious mental health issues in teenagers.

Of course, in childhood can also occur, but usually when there is such a strong need to have adequate or appropriate socialization, that usually starts taking place in middle school. That’s when some of the main problems are manifested.

I think that’s something that is overlooked sometimes in the community in general, is that many children, many teenagers do have some learning disabilities that could be more, very specific to the point that they cannot be very obvious to teachers or even during testing.

However, they’re struggling perhaps with math, perhaps with processing information, and of course, if they are underachieving and they’re getting bad grades and the parents tell them about it, and the teachers also tell them that the performance is disappointing over time, that kind of decreases their self-esteem.

And they can develop one of the most common conditions that we see in child psychiatry for teenagers, and that will be depression. Also, some of the children and teenagers who have difficulties interacting with others and have socialization issues from the beginning, of course, that’s a great deal of stress that they have to deal with on a day-to-day basis.

If they don’t like to go to be in a group of people, if their communication is inadequate, because in general, teenagers, they kind of clique together with people who they relate to, and if they find a teenager who is not up to par with their expectations, they kind of isolate them.

And of course, the youngster who is being isolated reacts either by becoming more elusive, more secluded, anxious, or depressed. So that’s another very common reason for us to have a consultation, is because of, especially middle school, when boys and girls, of course, for that matter, start struggling with the whole socialization phase.

Now, being a child psychiatrist means that I have to dedicate my time to be able to diagnose all of the different conditions, psychiatric conditions that you see in teenagers and young men in this particular case for today’s talk.

So that means that we have to identify what we call comorbidity, other conditions that take place during adolescent years and for young adults.

We get many referrals for young patients who actually have symptoms of autism and not the complete condition, but more like traits. Usually when the autism is very severe, it is diagnosed very early in life, three, four years of age.

Some of the high-functioning autistic boys and young men, they’re able to go under the radar into middle school or high school, and some of their characteristics really gets in their way to be able to function, which are a great deal of difficulty with socializing with others, very poor eye contact, obsessive thinking about very specific things.

For example, Japanese anime, they cannot have enough thinking about it, reading about it, watching movies, everything related to these Japanese, very specific comics, for example, or it could be also repetitive motions or repetitive behavior, and of course, that is considered odd and very quickly interferes with the capacity to be able to function at school.

However, in the general population, what we see the most as being a challenge for teenagers and young adults is substance use. It’s very easily, readily available.

Unfortunately, you know that now the marijuana use is legal, and from there they can have access accidentally even to some other drugs with some of the most deadly effects from heroin, and the fentanyl epidemic unfortunately has penetrated many layers in the Massachusetts society and have created many, that have caused many deaths.

And then I will say also that teenagers and young adults can struggle with regulating their mood. I talk first about depression, anxiety.

I have mentioned autism, learning disabilities, substance use, but there’s also a subset of teenagers and young adults who have difficulties regulating their mood, and they can go from being happy to being incredibly moody, angry, and even racial and aggressive, and that’s some of the other characteristics of these patients that come to our units.

Now, why don’t we talk more about communication? I think that, like Scott was mentioning, traditionally, boys have been expected to behave in a different way.

What I can tell you is that now that society has become more open-minded, more accepting, I think that we see more expression in different ways, sometimes maladaptive, of people’s individuality.

And one of the things that we practice here in our program, which is DBT, dialectical behavioral therapy, which is a skill-based therapy, and we’re able to teach or train teenagers and young adults to be able to understand their emotions, to be able to describe them in a more accurate way.

Because oftentimes because of a lack of instruction, because of a lack of language, sometimes teenagers and young adults, they just say generic words, trying to describe how they feel.

However, with more detail, with more therapeutic, with additional therapeutic interventions and being able to get to know them better and talking to them about it, you can identify the true meaning of what they’re saying.

Just to cite an example, if a teenager, this is a very common thing, says that he, that a situation is boring or they’re very bored, and then when you start asking more questions, little by little, you start finding out that something else is going on.

For example, they see they are failing in a class, then after that they find it boring, perhaps what it really means is that they’re feeling frustrated because the class is too challenging or they don’t like the social context in class, or they don’t like the teacher’s approach, and of course, they, the only word that they can come up with is to say that they’re bored, for example.

Sometimes they say something more drastic. They can say that they don’t want to be around anymore or very quickly when they don’t like the situation, they just don’t show up, right?

Or they walk away because obviously avoidance, pretty much not being there is a very common coping skill for everybody, frankly, in order to be able to avoid a situation that is not welcome, something that they really don’t like doing.

And moving a little bit more towards treatment, I think that for many teenagers and young adults, when they’re struggling with psychiatric or emotional difficulties, we have many different ways how we can help them. Everything can start at school.

A good guidance counselor can definitely help if the problem is educational, if learning issues is part of the factor for them to be having challenges in terms of their behavior and emotions at school.

Of course, a good psychological testing that would be originated at the same school, they can identify some areas of weakness that they can have accommodations or modifications at school.

And they can help them be able to learn in a better way, in a more appropriate way, because we also have to consider that traditionally, education in this country as many others, it’s kind of very, it’s a very standardized process, right?

Pretty much they teach every single child the same way, and they expect that everybody’s going to do well, but the reality is that human beings, we are very diverse in terms of how we learn, in terms of interest, in terms of capacities, learning style.

So, the traditional method only captures, only works with a percentage of the population, and I have had so many cases over the years of children and teenagers and young adults who were failing at school.

And in reality, what they needed was to be attending the right school with the right orientation, with the right choice of subjects, with the right number of students per class, or even different style how they teach.

Just to mention two examples, some high schools allow the students to pick what subjects they want to study throughout the year. Sometimes they give more time for homework.

Sometimes they allow the test to be taken an extended period of time, and sometimes very simple accommodations help many of these students to be more successful at school.

I was forgetting a very important diagnosis that we see very frequently in child psychiatry and pediatrics as well, and it is ADHD, attention-deficit/hyperactivity disorder, which is a psychiatric condition characterized by difficulties with concentration, difficulties with persistence, and poor organizational skills.

The way how we reach a diagnosis is by providing very standardized testing, both at school and at home, and to be able to compile all of this information, and we have a rating system.

And then according to how the rating goes, then you can determine that the person has attention-deficit/hyperactivity disorder, and of course, this condition requires very specific treatment in terms of school accommodations, also therapy and medication management.

What I can tell you is that when it comes to attention-deficit/hyperactivity disorder, the response, the medication response is incredibly strong, and most of these children can actually improve how they do at school and be quite successful.

The condition doesn’t stop at the end of high school, and many college students need to continue taking medications and receiving therapy and also adults. However, having said that, in general, patients with ADHD do well.

Medication does not interfere with their functioning, actually enhances how they do in general, and they can be well adjusted adults, and most people don’t even know that they have a condition.

So, I think I’m going to stop there, Scott. I wonder if you have other questions that you want to ask.

Scott: We do. Thank you so much for that. That was great. You know, I think there’s definitely expectations of each gender out there.

I don’t think any of us can deny that, and we’re all raised to think that how, you know, maybe girls should behave, and boys should behave, and I’m not saying that’s a good thing. I’m just saying, I think most of us would probably say that’s the reality.

How should we think about the differences in expectations as far as it goes with, I guess, interfering with the way that we evaluate a young person or see a young person in terms of their potential to be struggling, if that makes sense? How does that typically get in the way?

Byron: Well, Scott, I think I was, when I was asked that question initially, I was a little bit surprised.

I think that the staff that we work with, everybody here at McLean, I think that we have such a degree of dedication and professionalism and open-mindedness that I really don’t think that at all when we are interviewing any of the teenagers or young adults in terms of what are the expectations dictated by society in past times in terms of the gender role.

And also, because we see such a degree of diversity in terms of roles that frankly, it would be very hard for me to say, okay, what is an average well-adjusted boy compared to an average well-adjusted girl?

Because we see so many different layers, there’s such a degree of granularity, so much nuance that it would be very hard for me to tell right now that that’s part of what we have in mind when we are evaluating a patient.

Scott: How would you say for the layperson, for the average person who sees maybe a young man struggling with anger, something like that, or, you know, things that I guess we would typically say, oh, this is typical teen angst, or this is the way young men might normally behave, or we expect this kind of behavior.

When can people know that something is typical teen behavior versus it’s actually problematic?

Byron: Thank you, yes. That’s a very good question. I think that the key is functioning. Does the dysregulation in the teenager’s mood interfere with how they do at school, with how they do with their classmates or their friends and how they do at home?

If there is a significant change in their functioning, then that degree of emotionality definitely is out of the norm. All of the teenagers, by nature, are moody.

Most teenagers don’t want to talk to their parents, but then when the level of anger escalates to yelling, screaming, insulting for hours at a time with property destruction, that’s definitely not normal, normative teenage behavior, and it has to be addressed.

Now, it is true that most boys and also girls do not know how to express their emotions, and because they don’t feel comfortable talking about it, then all of that internal stress comes out in the form of behavior.

So, the behavior can be externalizing, breaking things, yelling, screaming, behaviors that people do not tolerate, taking the family car, for example, doing impulsive things.

Some others direct the stress and internal turmoil towards themselves so they can start presenting self-injury behaviors, for example, cutting or scratching their arms or their legs, and it can happen both in boys and girls.

It is true, we see it more in girls, but we also have boys who self-injure like that, and the other thing is also true. Boys are more likely to be aggressive. However, we also see that type of behavior in girls as well.

Scott: Would you keep speaking just for another minute about this exact topic? I think this is an incredibly important one.

You’re talking about essentially a lot of these behaviors are essentially because of a lack of being able to cope and also not having the skills or maybe even the language to help understand the way that we’re feeling.

Byron: Yes, I think that many of those behaviors are called maladaptive because obviously they interfere in the regular functioning at home or at school.

So, the idea is to help them understand where these behaviors are coming from and modify how they conceptualize their frustration.

And to be able to express through words some of the interior anguish that they have or sadness or despair that they might have, and in order to do that, they have to, the current treatment that we have is called skills-based treatment.

Dialectical behavior therapy is one of those forms of skill-based therapy. CBT would be another one, cognitive behavioral therapy.

What it is is that you teach patients different steps and different skills, how they can control their anger, their sadness, or their anxiety in ways that are more manageable and tolerable and help them feel better, and they do not interfere with their day-to-day functioning.

Scott: Are there behaviors that we, I guess, as a society that we accept in young women that we don’t accept in young men or the other way around? Are there, I’m wondering about that essentially like, are there those things that we are just kind of conditioned to think are, are okay for some, but not for all?

Byron: Hmm, I have to think about that a little bit more.

Scott: I guess I was asking for, I’m asking you because I’m thinking about, you know, if you’re working with a family, and especially if it’s a young man and you’re saying that like, oh, well, you know, other people in the household exhibit a certain behavior, but it’s unacceptable coming from a young man, and that’s okay if you want to think about that one.

Byron: Well, I think that yes, boys are more expected to be aggressive. I think that if a boy doesn’t know how to express his emotions, I think that nobody would make much of it because of societal expectations.

However, this could be kind, can sound a little bit judgmental as well, and kind of typecasting boys or girls because of the gender. So, I think that talking about it feels to me more like judgments more than facts, for example, thinking that women by nature are more sensitive, right?

Well, some, I have met many women who are not, and I have met many boys who are incredibly sensitive and emotional. They’re able to talk about their emotions without any difficulties. So, I think that the lines are getting more blurred.

I think that it’s more helpful to be able to understand each person individually and to understand where they’re coming from, and also to help parents because it’s true previous generations, they have other assumptions.

And that’s why when you’re trying to help a patient, a teenager or young adult, especially teenagers, you need to, as far as possible, try to get some buy-in from the parents to help them learn some of those skills as well, because then they’re going to be able to be more supportive to their children.

In DBT for example, we talk a lot about validation and invalidation. I think that the previous generation was not a very validating one.

For example, if a teenager, boy or a girl, are doing their chores, are doing, they’re getting good grades, sometimes they don’t give any type of praise because they say, oh, that’s your job. That’s what you should do anyways.

Instead of saying, oh, that’s great, you really put all of your heart into it. Look at what kind of results you got. That’s awesome. Sometimes if we parents, many of us are more oriented in terms of problem solving.

So, if you are sensitive, a teenager comes home and says, many kids are picking on me and I’m feeling terrible because they’re calling me names, many parents say, you have to take a stand and hit the other boy in the face, right?

That will be one very invalidating statement, or no worries, I’m going to go tomorrow. I’m going to talk to a principal, I’m going to tell them that this is not supposed to happen, and we have to fix this.

So, trying to help, sometimes parents can be invalidating because a validation would be to tell the teenager, oh, I’m so sorry you’re having such a bad time at school. I can understand why you’re feeling so terrible today. I’m so sorry. Why don’t we think about something that we can do together so you can feel better?

That would be very validating instead of what I just described that was very invalidating, and although it sounds very simple, it is trouble for many parents to be able to learn how to validate the teenagers and how to help them.

Scott: That was perfect. So, thank you so much for that. I’m glad you really, you brought up validation.

I think it’s such an incredibly important topic as we talk about, especially around, you know, around adolescents and just all the things that they’re struggling with and you know, the adults in their lives, especially people that are caring for them, whether it’s parents, educators, things like that.

I mean, I just think it’s such an incredibly important topic and I do think I can, it’s very difficult to go from the way that some of us were raised to, you know, validating all kinds of things that traditionally we were not taught were acceptable things about ourselves. So, thank you for that.

Byron: Sure.

Scott: On this topic, how do you suggest that people, whether they’re providers, educators, administrators, how do you suggest approaching this topic with a parent who may not understand the importance, either of validation or the importance of…

Look, I’m so glad you brought this up and you used these words, looking at each person as an individual and not what, you know, what they should be in your mind, but treating them as an individual and accepting them for who they are.

How do you approach someone about that? And maybe their mindset is a little more, is a little different.

Byron: Yes, I think that it’s very difficult for a person to very radically change how they were raised, and if they have very strong views and they consider them to be their value system, it would be very self-defeating if the therapist wants to change it all from the very beginning.

It’s easier if you break down many different behaviors that the teenager is having and see if they make progress and then help the parents start validating small portions of the teenager’s behavior.

So, it’s more like a puzzle, like little pieces here and there in their interactions with the family to describe other ways how to look at things and other ways how to validate teenagers. I think that that works better than anything else, and without realizing the parents have started doing it, it’s very possible that you’re not going to change some of the parents’ core values.

However, you can still help them have a better communication with a teenager and have a better communication with a young adult and help them by supporting them, many different aspects to what they do.

Just to give you an example, we have a family that very strongly dislike the fact that their teenage boy had an online friendship with a girl of the same age who lived across the country in Los Angeles.

That specific point we were not able to break, even though nowadays it is not uncommon that a teenager will have an online friendship with somebody in a different state or a different part of the country, I’m sorry, in a different part of the world, even if it’s a benign relationship and there is no harm for either side.

However, we were able to help the family validate the fact that this boy had social phobia and that he was able to start interacting with more boys and in a crowded place without feeling uncomfortable, that he was able to communicate his feelings and his emotions better, that he was able to be, to have direct communication and tell the parents, listen, this is what I really want to do when I finish my high school.

So, there were many gains and then we work with those gains hoping that they’re going to be very important, they were going to be more important to him in the long term, and then in DBT we also have a concept called radical acceptance.

We can only change so many things, right? So sometimes unfortunately we hit the wall and we realize that situation, there’s not much that you can do about that specific situation. So, we just decide to radically accept, it is what it is, and then work in areas that can be better.

So, I think that all of these different concepts and skills help not only the patient or the parents, but also clinicians themselves to know their limitations.

Scott: So, my next question, you know, I think some people understand this and I think a lot don’t, in just terms of how common it is for young people, young men to struggle with symptoms related to depression, anxiety, emerging personality disorders, trauma disorders, things like this.

Would you speak briefly about how common these things are, even if they’re not formally diagnosed? I’d like to, for parents and educators to really hear about how often they may be seeing these things, even though they might not know exactly what they are.

Byron: Yes, definitely. Depression, anxiety, and substance abuse are extremely common. Just to say numbers, I would say anxiety would be 15, 20% of children, teenagers, young adults, depression about 20, I’m sorry, about 10% of teenagers.

They say that any person can be depressed in their lifetime up to 30 to 40%, and then finally, substance abuse is very rampant, 30 to 40% in all high schools across the country. So those conditions are incredibly common.

Not all of them come to the child psychiatry office, unfortunately. Many of them are underdiagnosed or they’re not diagnosed, or they’re treated in a partial way by nurse practitioners or pediatricians, sometimes with some success.

Many times, they get misdiagnosed, or they’re given medications that are the wrong dose, unfortunately, and then of course if they come to us, we correct that.

Let’s see, and then in terms of personality disorders, there has been such a kind of a bias against personality disorder, and it was believed to happen only in women, and it was believed to only happen after 18 years of age.

But the reality is that many girls and also boys do present borderline personality features very early in life, 13 or 14 years of age, for example. Now the presentation in girls is a little bit different compared to boys.

This is not coming from publications, it’s more based on our own empirical experience here at McLean because we have two very intensive units for boys and girls. So, we can compare with our colleagues how is that other patients are presenting in each one of these two units.

I could perhaps describe more in the case of boys if, I mean that that could be part of what I talk about today, how borderline personality presents in teenagers and young men.

Scott: It’s like you can read my mind, Byron. This is great ‘cause my next question was going to be, would you tell us about a couple of conditions that may present very differently in young men versus young women?

Byron: Yes, and I think that that’s the one that I would like to talk about today.

Borderline personality disorder in young men and young women present in a different way. In young women, usually it’s very straightforward combination of impulsive behavior, mood dysregulation, self-injurious behaviors, depression, feelings of abandonment, for example, and a great deal of ambivalence between liking a person or disliking a person very, very easily.

So those are pretty much like the main characteristics, and in general that has been kind of the profile that has been described for borderline personality, traditionally, historically. They do have some level of comorbidity, so it’s not uncommon that they have teenagers, I mean girls and young women, who have borderline features and they also have depression.

Sometimes they have a history of trauma, post-traumatic stress disorder, and eating disorders. So that’s pretty much the cohort. That’s pretty much like the description of this particular condition in women and girls.

Now, when it comes to boys, it is very interesting because there’s more comorbidity. We don’t see the same degree of impulsivity. We do see the mood dysregulation and difficult interpersonal interactions. We don’t see as much self-injurious behaviors.

We do see kind of chronic suicidal ideation, and I think that the main feature is that we see tremendous amounts of comorbidity.

We see many children, I’m sorry, many boys and young men with attention-deficit/hyperactivity disorder, with obsessive compulsive disorder, also with autistic behavior and also with other conditions, some eating disorder as well and medical conditions.

So, it is very interesting, a very diverse, diverse population in terms of teenage boys and young men that we see here at McLean.

Scott: What are other really important things for teachers, educators, and parents, the things for them to look out for that signal someone may be seriously struggling?

What are the, I’m sure there’s a lot of those different kind of signs and things, we recognize some things, but I’m sure there’s other things that you could help us, you know, keep in mind from where we’re dealing with a young person.

Byron: Yes, that’s a very good question. I think that the first thing to teachers would be if they see a sudden change in the teenage behavior.

If they were bubbly, a bit friendly, involved in many activities, have good grades, and then all a sudden they don’t want to talk to anybody, they’re in the corner, they’re not looking, they’re keeping downcast with the hair over the eyes.

That’s kind of the classic thing that we see. They’re kind of, they’re not any more in any particular group of the kids at school and the grades go downhill. I think that usually in children and teenagers you don’t see like a very gradual getting worse.

It’s more like kind of sudden, right, like something happened and then the last two, three weeks the kid is not doing is not the same, is not doing well. I think that an early evaluation by the school psychologist or send them to the pediatric office, or if they have access to a child psychiatrist.

I think that to make, that could mean a big difference between getting treatment on time or letting that drag on and get worse. Sorry, I’m sorry. I just remember.

Scott: Go ahead.

Byron: Also, that would be for the, probably for the kid who is developing some degree of depression, anxiety, or even substance use, but you can also see the opposite, a kid who was calm and all of a sudden is impulsive, very angry, even threatening. That type of behavior should be also a red flag.

Scott: Any tips for parents, educators, or providers who are attempting to reach a young man who is, let’s say closed off?

Byron: Yeah, that, I think that the best way to do it is by sharing an activity that a young man or woman or teenager enjoys. It’s very hard to talk, right, to get into the substance pattern right away.

I think it’s important to develop some degree of relationship with that person to be able to have kind of a non-threatening calm situation that feels neutral to them, that feels enjoyable to them, and then you can have a conversation.

I think that to bring that boy to the principal’s office and to sit them in the chair and to have more like an interrogation-style conversation, of course that’s not going to go anywhere because they look down, they keep you outside very quickly, right? And then you’re not going to get that far.

On the other hand, in psychiatry, in child psychiatry specifically, we are able to connect the dots and we kind of, we can read the whole picture and kind of have at least a working diagnosis based on behavior, even if the person is not communicating in words how they’re feeling, right?

So, the same case scenario, you have a boy who was involved in sports and have many friends. All of a sudden, he’s not talking to anybody. He has kind of a very blunt expression. He stays in the corner.

And then you talk to the parents, and they say, well, I don’t know what is happening to Tommy, but we did tell him two weeks ago that we’re getting a divorce and he has seen us arguing in the kitchen and we had to cancel our vacation to Cape Cod this summer, and he had a problem with a girl.

Now his friends don’t like him. So usually, we kind of look at the background, right, and usually something that I didn’t mention before, before there is a break in any kind of psychiatric condition per se, many times, if not all of the times, there is a risk factor or a precipitant factor.

Something happen in that kid’s life recently that affected him or her or them, and is prompting a change in behavior, change in emotions, or if you see that the girl is downcast, she’s not eating, she’s not drinking well, she’s not sleeping, she has lost weight, all of those are symptoms of depression.

They don’t have the same energy or motivation. They’re not social. Those are also symptoms of depression. So, the girl doesn’t have to tell me, I am very depressed, right? I already know she’s depressed, right?

So, you can, when you’re talking to a girl or boy, you can say, well, your parents are very concerned. You seem to be struggling. I think that we can help you, right, and then go from there, and then of course the same goes after treatment.

If they buy into learning the skills or they’re taking the right medication, then you assess progress, the same thing based on their behavior.

Of course, it’s better they tell us that they’re feeling, they’re not feeling as sad, but for example, if they start talking to more people, they seem to be more present, more alert, they are participatory in the different meetings that we have here in our program.

If the nurse tells us that they’re sleeping through the night, if they seem to have a good appetite, for example, if they say that when they go back home, they have plans or they have a pass with the family, and they seem to have enjoyed.

So, all of those will be like points to tell us the depression is being lifted or they’re getting better. Of course, I’m kind of highlighting things to make it very clear.

But not, sadly, not every case goes so well, and it’s not uncommon that we have patients who don’t get better as soon as expected or there’s steps back and then they go forward. So, it can be a very fluid course for many patients.

Scott: You mentioned earlier the topic of stress, and I think it’s an incredibly important one when it comes to young people. I mean, you’re talking about the time in your life when, you know, you’ve got your parents and your, either their real or perceived expectations of you.

Some young people are trying to balance, you know, sports and expectations of, you know, excelling at those, already thinking about, you know, what’s next for me? Am I going to go to college? What’s my post high school life going to look like? Things like that.

There’s essentially so much pressure on young people, again, whether it’s perceived or it’s real, during those kind of key years of say, 13 to 18. Would you speak briefly about the impact of stress and also, you know, how much stress is on young people, just kind of in general without a diagnosis complicating that?

Byron: Oh, yes, that’s a very good question as well.

I think that we have been witnessing a shift in terms of culture in America, in terms of behavior in young adults and also in teenagers especially kind of forced by the pandemic, but I think that before it was already happening.

I think that many young adults don’t know what they’re going to do as soon as they graduate from high school and they have a very hard time deciding what major they’re going to be taking in college, and even if they graduate from college, they don’t know what to do next.

I think that the pandemic, because change, because of economic forces, because there are changes in the workplace, because of inflation that is happening right now, the high cost of things, that has paralyzed even further young adults, and oftentimes when in their 20s they don’t know what to do with their lives.

What we are seeing more is that many caring, supportive, conscientious parents, they’re allowing more young adults to stay home in their 20s just to help them out, because the old paradigm from the ‘50s on to the ‘90s that as soon as your child, as soon as your son or daughter is 18, is like, okay, I can wash my hands.

They’re on their own, they’re adults. They can function in life, but that’s not working so much anymore because it’s not true. They’re not ready to function in life. We all know how difficult it is to find a good job, to keep it, how expensive rents are, how difficult it is to stay in a job for an extended period of time for this new generation.

Scott, you and I, perhaps to us it was normal, it was the thing to do to stay in a job at least four, five years, right?

That’s pretty much the standard or is considered okay for a person in their working experience or their, the way how they go about their career, but nowadays, it’s not uncommon that younger adults or young adults, they change jobs after six months, right?

They have different expectations. Many of them are not thinking about being part of the corporate rat race. Many of them don’t have, they know cars, I’m sorry, they know that houses are so incredibly expensive, they know they won’t be able to buy one in their lifetime.

Rent is expensive and how many young adults are living with five other people in order to be able to afford housing. So, all of those are very important dilemmas nowadays. I wish I had an answer to that, but these are real, real stressors that young adults are dealing with.

What I can tell you is that for many families, especially in our practice, they have been able to go back to the older model where extended family lived together, right? Parents and two or three kids and everybody contributes, and everybody treats themselves respectfully and they’re able to make it work, right?

That wouldn’t work for everybody, but I think that more families are doing it. Parents with resources, sometimes they have started sponsoring young adults who are struggling, who have mental health issues and help them with their rent, for example, or pay for additional services so they can have a more structured life.

That would be the minority, and the other side of the coin is that unfortunately there are many young adults struggling because they don’t know what they’re doing, where they’re going, and they’re having difficulties with relationships with others, maybe substance use, and they’re barely making it, but they’re not receiving help.

So that would be the sad part. So, I think that we’re lucky in Massachusetts because we have better mental health compared to other states.

And people who have mental health issues, they can always contact their own health insurance and ask them for referrals, or they can also ask their pediatrician or primary care physician and ask for referrals. So, there are many different ways how they can have access to support.

Scott: That’s great. Thanks so much. Somebody wrote in and said, you know, for most families, and of course due to proximity, means, access for lots of different reasons, you know, getting to a DBT provider is inaccessible, or it’s inaccessible just in general.

How can folks working in schools and in the community help youth effectively express their emotions? This is a great question, by the way, so thank you to whoever asked this.

Byron: Well, yes. What I can tell you is that we don’t have that in place yet, but I think that that would be the way to go. Some of these skill-based therapies can be very costly because unfortunately not all insurances pay or only partially pay for this type of therapy.

However, if we are able to work with the school department, we were able to have many of the teachers learn more about mental health issues in childhood or for the teenager, teenage years.

They will be able to identify more what children are vulnerable and refer them to a specialist sooner, and also, they can learn some of the general CBT or DBT skills and teach them in class.

That would be tremendous if part of the U.S. education includes how to be able to deal with anxiety, for example, because anxiety happens to all of us, how to be able to conduct themselves on a day-to-day basis in terms of the interpersonal interactions with others, how to be able to communicate better with parents.

So, all of those different skills are learned in DBT and they’re universal. They can be helpful of course for teenagers and young men who have mental health issues, but actually they’re helpful to the therapist, they’re going to be helpful to the teachers.

They’re helpful in general to every person in terms of how to be able to enjoy their life better, and they’re not complex. They’re easy to understand. What it takes is for the person to put them into practice, right?

Scott: Is there anything that you would suggest, even something basic that someone like myself could essentially use as a skill for, say I’m working with a young man in some regard and he’s, there’s an anger as an outburst.

Is there anything in that moment you would suggest a layperson can do to help that young person kind of put into words how they’re feeling, aside from just recognizing it as being an angry outburst?

Byron: Well, it depends. If the person is having a very intense anger outburst, okay, so let me back up that. In DBT, we believe that there are three different ways how we could react given a stressful situation.

So, the most common thing that people do is to react in an emotional mind. When somebody crosses us in the road, we get angry in our car, we start yelling obscenities, and of course if the person gets so angry, they will probably speed and go and probably chase the other car, and then you can be in an accident. It could be tragic.

That would be to be behaving in an emotional mind, right, letting our emotions lead our behavior. Then there’s another way how some people can behave according to what the situation is at hand.

For example, your friend comes and tells you, Scott, my dad passed away last night, right? So, if the person has only a rational mind, you will say, well, your dad was kind of old and he was sick anyways. It was going to happen, get over it.

So of course, both kind of approaches, the emotional mind and the rational mind sometimes are not effective, right, because it leads to problems or losing a friend, for example. So, we talk in DBT about the wise mind.

So, the wise mind is to slow down what you’re doing, think through things, and try to include both emotion and rational thinking and try to come to what is called a middle path, and to be able to start saying what you’re thinking after you’ve been able to kind of digest and come with a conclusion, a synthesis.

So, in the case of the acting out angry youngster, you can say, I can see that you’re very angry right now. I’m just going to let you blow some steam. Just let me know when you’re ready and we can talk, and we can see how we can fix the situation together.

So that would be a way of validating that a person is angry, because being angry does happen, right? Anger is a part of life.

It depends on what you do with your anger, what can be a problem or not, and then of course, if you are with your friend and they, and he tells you, my dad died last night. Of course any person with wise mind would say, oh my God, I’m so sorry. That’s so, so sad. You might be feeling so terrible. How can I help you? Let me see what I can do for you.

Right, that would be a very honest, considerate, supportive way how to go about that. In both cases, that would be a wise mind way to do it. So of course I’m kind of oversimplifying, but those skills can be learned for each one of us how to be able to find the middle path and try to always behave using our wise mind instead of the emotional or the rational.

One, another very easy trick is try to slow down, because every time that you have a problem, if you react according to the first thing that comes to your mind, usually that’s not the best answer, right?

So you can say, oh, this is making me very angry, very frustrated. I’m not going to do anything right now. I’m going to think about it overnight, keep it, give it a couple of days, and then I can make a decision, right?

So that would be another way how to use your wise mind. Usually when you let the situation simmer down, I think that there’s more clarity. You can see what is the essence of that problem and how you can solve it, right?

So that would be another DBT example how to go about things, and of course the core of DBT that is called mindfulness.

Mindfulness is the capacity to be in the moment, and why is mindfulness, mindfulness helpful, because when you are able to only concentrate to what is happening in this instant, in this very instant, by nature, biologically, our brain is not able to focus on two or three things at the same time, right?

So if you’re focusing on this very moment, then this is a situation that you’re controlling, that you can be at ease, that you could be peaceful, and there were so many people who are always stressed out, right? So where does anxiety come from?

Anxiety comes from the lack of control of situations in your life and by anticipating a lot what is going to happen. So, the person that is always thinking, what is going to happen tomorrow? Usually, they’re going to be anxious.

If you don’t think about tomorrow, the anxiety is going to decrease tremendously, right? Of course, generalization, it has more detail to it, but I’m just giving just general information.

Now, thinking about the past, people who think a lot about the past, about negative things that happened in the past, they become depressed, right? Because for one, they might have been very sad or there’s not much that they can do about it, right?

So, they’re sitting ruminating, perseverating, going on and on, dwelling on things. Of course, that’s going to increase negative symptoms or depressive symptoms.

Again, going back, if you’re only thinking the here and now, right this instant, then if you’re not thinking about something that happened in the past, then it’s not going to hurt you, right? So that would be another way to use mindfulness in an effective way.

There are other methods, for example, relaxation techniques that people can learn. They’re very easy to learn and they can be very helpful.

So, like I said, anxiety is very common, and anxiety is actually a protective thing that not only human beings, but also animals develop with evolution, because it’s protective. Anxiety is what make us run when there is a dangerous situation and we notice, right?

We get very nervous and go, we run in the opposite direction, right? It’s the whole fight or flight response. However, when fighting with that response happens in the absence of a serious situation, of course that’s going to make us feel terrible.

Those are the episodes of anxiety or even panic attacks, and then relaxation techniques is pretty much to be able to learn how to make your body on purpose relax, right, how easy be going, easy on your muscle tension by being able to feel each part of your body, but on purpose relaxing each part of your body.

It could be done in your room, laying on bed, playing soothing music with dim light. You could even use aromatherapy and all of that conducive to kind of winding down all of your senses and then practicing mindfulness during that view of time, feeling your body, each part of your body, making out your muscles heavy, relaxed.

That definitely is going to make you in a better mind state, state of mind compared to the rest of the day if you had a very tough day. So that would be an easy method to be able to help your mental wellbeing that you can do on your own.

Scott: If it’s one thing I hope everyone takes away from today, I hope it is, slow down. As soon as you said it and you said, the first thing to come out of our mouths during these situations is usually not the best thing to put out there.

I think that’s one of the lessons I’ve had to learn the hard way over the course of my life is that my gut reaction is very rarely helpful and to, for all of us to kind of consider what we’re about to do if we’re going to, you know, we all want the best for the people in our lives.

But at the same time, we also want to be careful of what we’re doing in that moment not to escalate things or make things, you know, more challenging for ourselves and also for the person that we’re, that we’re working with.

On that note, I want to thank Dr. Garcia so much for joining us today. I think this has been a great session. I also want to thank the audience for being with us today. I really appreciate everyone, you know, being here and wanting to be better for the young men in our lives.

That’ll do it. This concludes today’s session. Dr. Garcia, thank you again so much for being with us.

Byron: Thank you very much for the opportunity. Bye-bye now.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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