The Demons in Our Heads
A reflection on the mental health struggles of our youth
Trigger warning: Suicide is briefly discussed. If you’re experiencing mental health struggles, it is important to seek professional help. This brief article is by no means a substitute.
Dear Evan Hansen,
It turns out this wasn’t an amazing day after all. This isn’t going to be an amazing week, or an amazing year. Because… why would it be?
Evan Hansen
I recently watched Dear Evan Hansen, a musical that chronicles the life of struggling teenager Evan Hansen, and his central role in the events which unfolded after a schoolmate commits suicide. Later on, it is revealed that Evan had also attempted suicide previously. We also see other characters struggle in their own ways.
I left the theatre feeling a little weird. Dear Evan Hansen was tragic, funny, heartfelt, and unlike many gravity defying musicals that invite you to suspend belief, it feels painfully real. We’re deep in the throes of a global mental health crisis, particularly with our youth in the wake of the COVID-19 pandemic. A recent meta-analysis of 29 studies involving over 80,000 youth worldwide found that 1 in 4 have clinically elevated depression symptoms and 1 in 5 have clinically elevated anxiety symptoms. These are not trivial numbers. And if the numbers feel too distant, the social psychologist Jonathan Haidt and his collaborators have been doing important work in placing faces and stories to those numbers. Here’s the most recent example:
A core aspect of this suffering is the thoughts and beliefs that capable, beautiful, resourceful, perfectly normal youths have of themselves. In the musical, Evan holds deeply flawed beliefs about himself—he sees himself as a nobody, a loser, and not enough. In short, he’s just like many of our youth.
Our gift of language allows us to communicate, collaborate, and create on an unprecedented scale, but has also left us vulnerable to a uniquely human kind of suffering—we suffer because of the things we say to ourselves. But how did these thoughts and beliefs come to be? Thinking is incredibly complex, and we don’t have all the answers, but we have gathered some clues along the way that have allowed us to understand the origins of these inner demons, and potentially to alleviate some of this suffering.
Clue 1: Thoughts are triggered by something
Often, we can readily trace the origins of a thought. An orange cat chases its own tail → I NEED TO POST THIS ON TIKTOK!!; no one signs on Evan Hansen’s arm cast → I don’t have any friends.
Pay careful attention and sometimes we can even trace how one thought leads to another. For example: No one signs on Evan’s cast → I don’t have any friends → No one likes me/I am a loser; hears parents arguing downstairs → They’re fighting again → Is it because of me? → I’m a burden to this family → Everyone would be better off without me.
In all these examples, an antecedent stimulus cues the thought (which cues the next thought, which cues the next thought). This is the stimulus-response (S-R) view. In Pavlovian talk, a stimulus elicits a response1.
We can summarise the S-R view as such:
Identify the relevant antecedent stimuli to understand and predict thoughts. All the rest is commentary.
The parsimony of such a view carries a certain appeal. It is also useful in many situations. We can predict what a youth will do next when their phone buzzes. We can understand a teenager’s suffering as we watch them sit alone in the canteen. We can alleviate some of that suffering by recruiting peer buddies to engage them during recess.
However, the S-R view lacks completeness in some critical ways. Most crucially, it doesn’t seem to fully explain how we come to hold certain beliefs—a set of thinking tendencies that are latent (they seem to lurk beneath, waiting to surface), generalised (they surface under various circumstances, typically as follow-on thoughts), and carry emotional weight. It’s one thing to describe how stimuli induce salivation in dogs (and ourselves). It’s quite another to claim our youth hold deep beliefs that everyone would be better off without them because their parents argued.
Clue 2: Thoughts are motivated
Recall the times you laid in bed wrestling with your thoughts, unable to sleep. What kept you awake? Was it about the social life of pharaohs? Unless you’re an Egyptologist, probably not. Rather, they’re likely related to important events in your life.
Thinking is behaving, and all behaviours are motivated2. The evolutionary social scientist David Pinsof wrote about what some of these motivations are:
What we’re pursuing is not good vibes in our heads, but the (often unflattering) things in the world that evolution programmed us to pursue, like sex, status3, yummies, moral superiority, and high-status offspring. Instead of revealing the unflattering things we actually want, we say we’re pursuing happiness, because it sounds better.
We can probably throw in a few more, including predictability, sensory stimulation, avoidance of aversive stimuli, and such. But on the whole, it’s a pretty good list! Thinking is costly. It makes sense to be spending this energy on events that we perceive as important.
Antecedent stimuli gain the ability to evoke thoughts (and actions) by being predictive of such important events. They guide thoughts with respect to these events. Hunger is what makes the bell chime matter. Without hunger, the bell means nothing. The absence of anyone signing Evan’s cast (except another misfit) cues thoughts of social isolation because social connection is important. These thoughts, accompanied by that palpable, sinking feeling of utter loneliness, move the individual towards resolving (or avoiding) social isolation, sometimes through, alcohol, drugs, or other worse means.
In other words, important events motivate thoughts under conditions that predict these events. An updating of our original statement is warranted:
Identify the relevant antecedent stimuli and motivational variables to understand and predict thoughts. All the rest is commentary.
With that, we’ve brought motivational variables into the equation, somewhat. We still haven’t quite addressed how the same antecedent stimulus can trigger wildly different thoughts for different individuals, or how wildly different antecedent stimuli can trigger similar thoughts.
Let’s rewind the clock: Once upon a time, Pavlov’s dog did not salivate to the chiming of bells; our youth did not think about TikTok when they saw an orange cat; nor did Evan Hansen think of himself as a loser. Something happened in the intervening period that established such S-R relationships. Our final clue ties it all together.
Clue 3: Thoughts are learnt
Important events are important because, well, they impact our survival and reproduction. When stimuli present as predictive of these events, we learn to pay attention to these stimuli—Pavlov’s dog becomes attuned to bell chimes because they predict food; Evan Hansen becomes attuned to silence because it predicts rejection. In the presence of these stimuli, insofar as certain behaviours allow us to contact (or avoid) these events, we learn to replicate these behaviours.
Learning, as I’ve previously written about, is just another name for the process of adaptation by an organism to its environment.
We think the way we think because these thoughts serve some adaptive function, or have done so in the past. We call generalised thoughts that serve particularly important adaptive functions beliefs.
We could update our statement as such:
Identify the relevant antecedent stimuli and motivational variables in the individual’s present and historical context to understand and predict thoughts. All the rest is commentary.
Which just sounds great. The trouble is, accessing an individual’s historical context is not always possible. Even when we manage to do so, it often through error-prone methods (verbal reports) and often lacks granularity. That isn’t to say such information is useless. Even without granular details, just knowing an individual experienced trauma when young goes a long way in helping us understand how they think.
Beyond that, the true value of taking an adaptive view, in my opinion, it allows us to believe that thoughts can be changed, and new thoughts can be learnt, and offers a pathway for such change to occur.
Confronting These Demons
When I was young, we did a science experiment in school which involved gluing together cardboard strips to create a plant maze. We then placed a seed at the bottom of the maze and watched it germinate. As the seedling grew, it had to navigate the maze to reach the light source at the end of the maze. Thus, its shape would conform to the structure of the maze.
If one were to remove the maze after the experiment was over and allow the seedling to continue to grow, one could guide and reshape the stem4, and importantly, direct its future growth trajectory.
In many ways, each individual is like one of those seedlings, shaped by our environments. Our past experiences shape who we are and how we think today. Our present experiences are layered upon that to shape our future self. With that, let’s consider the two broad ways in which we have tried influencing how individuals think, with a focus on alleviating their suffering.
Approach 1: Harnessing the power of language
Probably to the surprise of no one. Just as language can cause suffering, it has tremendous power to also absolve suffering. My favourite example of this is from the psychiatrist Viktor Frankl’s book, Man’s Search for Meaning—An elderly doctor, struggling with the loss of his wife, sought Frankl’s help:
Frankl: “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?”
Doctor: “Oh, for her this would have been terrible; how she would have suffered!”
Frankl: “You see, Doctor, such a suffering has been spared her, and it was you who have spared her this suffering—to be sure, at the price that now you have to survive and mourn her.”
He said no word but shook my hand and calmly left my office. In some way, suffering ceases to be suffering at the moment it finds a meaning, such as the meaning of a sacrifice.
Psychologists, counsellors, and other mental health professionals employ therapeutic conversations to help alleviate suffering. Through these conversations, the professional identifies maladaptive thoughts/beliefs, their triggers (antecedent stimuli) and motivations, and work toward changing these thoughts, the client’s relationship with their thoughts, or fostering new ways of thinking. To give you some idea of how these processes are like, here’s a conversation between the psychologists Kelly Wilson (who is the co-developer of Acceptance and Commitment Therapy) and Diana Hill:
Approach 2: Changing the environment
Most people imagine therapy to be like this—the client sits in a room on a comfy chair, possibly a recliner, and spends an hour or so talking it out with the therapist.
In fact, therapy often involves a great deal of working towards changing an individual’s circumstances. For an individual presenting with depressive symptoms and who has stopped leaving home, a therapist might prescribe spending time outside (behavioural activation). For an individual presenting with trauma or severe anxiety in the presence of particular stimuli/situations, a therapist might work on gradual exposure towards those stimuli/situations (exposure therapy).
The roles of mental health professionals are incredibly important, and becoming increasingly so. But relying solely on them to solve our youth mental health crisis is woefully inadequate for a number of reasons:
Mental health professionals mostly work in 1-on-1 settings, occasionally in small group settings. That’s highly resource intensive and there simply aren’t enough of them to go around.
Their influence over the individual’s environments is often limited. They may not be able to intervene in school bullying, and cannot control their client’s social media access. They certainly cannot remove their clients from their rough, impoverished neighbourhoods.
It’s just a terrible way of solving a systemic problem. Imagine a car assembly line with faulty machines that do a botched job of assembling cars. At the end of the assembly line is a final station that fixes all the prior manufacturing errors before the cars go out for sale.
We can do better.
Here’s a powerful example of what better looks like:
In the 1980s, researchers in Montreal identified 7-year-old boys with disruptive behaviours from low-income neighbourhoods and enrolled them in a 2-year programme social skills programme. The boys were placed in small groups with other boys identified by their teachers as highly prosocial, and learnt skills such as inviting others to play, giving compliments, offering help, reacting to teasing, and emotion regulation. 30 years later, these boys had significant increases in employment income and marriage, and a decrease in social transfers and criminality as compared to boys in the control group. The estimated return on investment was $11 in benefits for every $1 invested.
These boys came from environments where what we label as disruptive behaviours were adaptive. Simply by teaching them what adaptive behaviours in their new environments looked like, the researchers and stakeholders permanently altered the trajectory of these boys for the better.
Concluding Thoughts
We began with the thought.
We then traced the conditions in an individual’s past and present that led to their formation. In all honesty, if it isn’t yet clear, what we discussed about thinking today applies to all other behaviours5. We think what we think and do what we do because these behaviours are related to important events in our past and present environments.
The modern environments our youth find themselves in today resemble that assembly line in many ways. It is imperative (and way past time) that we fix those faulty machines6. The good news is, unlike cars, our struggling youths are not static objects, but dynamic, resourceful, resilient, and highly capable of healing and adapting. Just like for our little seedlings, we just need to shine some light.
For many, the word Pavlovian would of course elicit thoughts about salivating dogs and chiming bells, often with a negative connotation.
At this point, it should be mentioned that thoughts aren’t actually a thing. Rather, they are a descriptive shorthand for us to talk about the act of thinking.
Social validation is a powerful drug and our youth will do pretty much anything to obtain it.
Sometimes, the plant doesn’t fully straighten despite our best efforts, particularly if it has been kept in that maze for a long period and its stem loses some of its malleability.
The discussion on thought was, in a sense, a Trojan horse to talking about the environmental influence on behaviours more broadly.
Australia’s teen social media ban just came into effect. While the effectiveness of such a policy remains to be seen, their government’s courage to do so is commendable.
Interesting points. Personally never thought of thoughts as respondent behavior — and that was an odd interpretation for a selectionist, I thought, as Skinner proposed thoughts are operant behavior, selected by consequences (essentially intraverbal chains evoked by something in the external environment), but nevertheless, you brought it to environment and went an interesting direction after that. Understanding thoughts as VB traceable to external sources is essential, in my experience with si.