'The kids I see have been flattened — lifeless, listless, bored.'
(Photo by Guilherme Yagui via Flickr/Creative Commons)
The phone rings at least three times a day with the same message from a distraught parent: my daughter needs someone to talk to (and it’s usually a daughter in middle school or high school). I ask what’s going on. They say she wants therapy, she is depressed and anxious. I say there is a wait list. For the first time in my social work career, doing private practice psychotherapy from home, there is a demand no one saw coming.
It's tantalizing to be valued suddenly in a field where starting salaries can, in some cases, be no higher than $35,000 a year. But it also underscores a crisis with no end in sight.
As the Surgeon General recently warned, children and teens are in trouble. Emergency room visits for suicide attempts are up more than 50% in girls over the last two years and 4% in boys. Shocking as these statistics are, they came as no surprise to mental health professionals working with teens. The question is: what will the country do about it?
Burning out on childhood
Our children make up the centerpiece of our lives and they have inadvertently become the subjects of emotional trauma right before our eyes. My colleague, Dr. Amanda Jacobs, an adolescent medicine specialist, told me that she believes girls with underlying anxieties and insecurities that bubbled up to the surface during lockdowns and other pandemic disruptions are now more fragile than ever.
This fits with a long-held model in our field: issues are rarely caused by just one trigger. They culminate from a hit to self-esteem combined with external (say, viral) or environmental stressors.
Say you’re an average kid with average grades and a couple of friends, and some history of depression and insomnia. Your parents are out scrambling to make a living and then, boom, add a global crisis and a family tragedy of some sort, and what is the outcome? It’s the intersection of distress and heredity at the most critical time of their lives. While it may not reach the level of PTSD, it drives a new kind of desperation for support.
Many of our children are living in a state of panic. Worry, languishing and depression would be putting it mildly. The kids I see have been flattened. Lifeless, listless, bored, you name it. I'm surprised there isn't a new diagnosis called “childhood burnout.” This seems to alternate with the other less passive states of “screw this” and “there’s no point.” Like going from sad to angry, all within an hour.
As parents, therapists, teachers and community leaders, we do not want them to go to school full of anxiety and dread. Stir in the worries of school shooters, climate change and the politicization of vaccines and masks, and the sense of cold cynicism is amplified: What next? Why me? Who cares? Where is my future? Vocabulary fails us. “Empty” is a word I hear from a lot of teenagers, and I am still struggling to understand it. “Empty” goes to numbing, cutting, searching, not feeling, wanting to feel, disassociating and clients begging for a diagnosis. What is this uncomfortable feeling? Is it existential dread or something unknowable and unnamable?
People blame social media. But that is only the delivery system, not the core problem. Yes, girls are inundated with images of perfection, and it makes them feel bad about themselves and their bodies. But there may be more to this.
My colleagues point to isolation. What actually happens when the dynamics of a family are locked down? I think we all know, even before the Surgeon General told us, that the answer is not good.
I had a middle school client who stacked several books on top of her chair, with a hat on top of that, and just lay down on her bed every day. Only after three weeks did the teacher catch on. Zoom school and Zoom fatigue are unlike other maladies. They just make you dull. Perhaps the authority figures were too zoomed out to notice.
A waiting game
While it’s important to have the Surgeon General call attention to the crisis facing our kids, where are the policies that would help them get care?
The gap between insurance companies’ policies and the need for support has widened. Most of my clients are low- and middle-income families who could not afford mental health care without their hard-earned benefits, so I continue to respect that. Practitioners who take only private clients charge double what insurance pays us. One company that serves a wide range of state employees, including many teachers, has paid $67 per session for the last 20 years, while private practitioners may charge $125 to $350 per 50-minute session.
If you happen to need a prescription along with that, an initial psychiatric evaluation can start as high as $650 out of pocket. Finding a psychiatrist who takes insurance is considered a feat.
Because insurance sets rates so low and requires so much time and paperwork, more therapists, understandably, choose to go private, putting more pressure on the demand. In addition, "prior authorizations, lack of reimbursement, constant resubmissions to obtain payment for service” create a massive barrier for therapists and clients alike, said New York therapist Jennifer Rowe.
When the incentive is the bottom line, and not care, everyone suffers. Health care becomes a privilege, not a right. The neediest get the least help. Most of my peers are "out of network" because they themselves can't live on the fees the network pays. The system favors those able to pay out of pocket. Everyone else waits, often for months.
I received a call from a girl who was suicidal, self-harming, and deeply depressed. The insurance would not cover the immediate or long-term therapeutic care because of a convoluted loophole through which her policy was carved out to a subcontractor that denied the claims for no apparent reason. As if suicidal ideation wasn’t reason enough.
I spent 10 hours on the phone to no avail. The time I spend talking, arguing, pleading with insurance companies is unpaid. I saw her for free. For using 30 years of experience and skills to intervene in this young life, making a judgment call to her parents to have her hospitalized, I was reimbursed zero. What was I going to do, drop her in the middle of it all as if I were shopping and my credit card was inexplicably denied?
My job is not for the avoidant — it is hands-on, day after day. Insurers slow down the process by micromanaging our decisions, cutting back on covered services and making us justify continued care. They actually call you, mid-treatment, to say, are you sure this is necessary? Or more commonly, can you fill out this form and fax it, like it’s 1990, to show that you want to continue? Finding the right person is like finding a contact lens on the pavement.
Like nurses, teachers, clergy, and doctors, we do it because we care. We have kids of our own.
The changes we need
While the pandemic has triggered today’s mental health crisis, its roots run deep. “We ignored and stigmatized mental health for too long,” said my colleague Gayle Skovron, a licensed clinical social worker in Nyack, New York. “This is the fallout of torn families, lack of community and greed."
With this massive break from normalcy, no policy changes were made besides a brief covering of copays and telehealth. Max Benezra of South Shore Counseling on Long Island told me, “We experienced such an increase in referrals during the pandemic, especially with teens, that we hired more therapists and still did not have enough therapists to meet the demand.”
The changes we need can be innovative if we have the will: offer incentives to therapists who take insurance, demand that insurance companies adjust rates for the 21st century, do away with middlemen, reduce time-consuming billing hassles, and give more discretion over treatment plans to the mental health care professionals themselves.
Our teenagers are in desperate need of help. They feel lost, tired and alone. We could do so much more. Yet we wait.