Tuesday, February 12, 2019

Under Pressure (Part 1): Interview with Lisa Damour, Ph.D.

[Episode 122] Today's episode of the Social Work Podcast is the first of a two part-series about Dr. Lisa Damour’s 2019 text Under Pressure: Confronting the Epidemic of Stress and Anxiety in Girls. In today’s episode we talk about the difference between stress, anxiety and trauma; what “good” and “bad” pressure look like; and how schools, parents, and providers can think about pressure. In part two we move the conversation into issues of rape culture and how society criticizes the way girls speak as a cover for criticizing girls.

Dr. Damour and I first spoke in February 2016 about her book, Untangled: Guiding Teenage Girls Through the Seven Transitions into Adulthood. I thought Untangled was a fantastic combination of empirical insights and practice wisdom and I loved our interview.

Download MP3 [34:06]


Lisa Damour, Ph.D. is a psychologist, author, teacher, speaker, and consultant. Dr. Damour writes the monthly Adolescence column for the Well Family section of the New York Times and is a regular contributor at CBS News. She serves as a Senior Advisor to the Schubert Center for Child Studies at Case Western Reserve University and is also the Executive Director of Laurel School’s Center for Research on Girls. Dr. Damour wrote the award-winning New York Times best seller Untangled: Guiding Teenage Girls Through the Seven Transitions into Adulthood and her 2019 book, Under Pressure: Confronting the Epidemic of Stress and Anxiety in Girls

Link to Dr. Damour’s articles: www.drlisadamour.com/articles/



It was a cold evening on the last day of November 2017. I was in Naperville, IL giving a talk to parents and community members about youth suicide. Naperville is one of the best school districts in Illinois. Like most top school districts, it has the reputation of being a high-pressure academic environment. Whether that reputation is warranted or not is up for debate. What wasn’t up for debate was the fact that the community was reeling from a cluster of student suicides. The school district was doing the right thing by having a community forum where people could learn about what to do to youth suicide and talk about solutions. I wanted to do right by Naperville by delivering the goods. So, I looked into Palo Alto, CA another community with a reputation for having a high-pressure academic environment which had also had a cluster of youth suicides. I came across an article written by Adam Strassberg, a Palo Alto psychiatrist. He had a piece of advice for parents that I loved. And when I shared it with the hundreds of folks who showed up that night, they seemed to love it too. He wrote, “Want the best for your children, not for your children to be the best.” When I said that line I saw dozens of parents nodding their heads. I also saw some teenagers smile.

After the talk a high school student approached me. He was from the school newspaper.  He referenced Adam Strassberg’s quote. And doing what a good journalist does, he asked me the question that I had not answered: Is pressure killing kids in Naperville? Here’s what I said: Pressure can be good or bad, so I wouldn’t say that kids are killing themselves because of pressure. If a kid feels pressure to measure up to peers, then he might isolate himself. Isolation is a known contributor to suicide risk. If parents are telling their child they have to be the best, if their child is struggling in schools, they might not be willing to talk to their parents. High conflict / low support parent-child relationships are a known risk factor for suicide. If a kid is putting pressure on himself to succeed academically because they think that will make peers and family accept them, then poor academic performance might make them feel like they have failed their most important social groups. Failed belongingness is a known risk factor for suicide. So, pressure is related to suicide because of what pressure means for a child’s relationship with herself, her peers and her family. I don’t know if the student reporter believed me, but he left with a smile on his face.

I’ve thought a lot about pressure since that conversation. Lucky for me, today’s guest, Dr. Lisa Damour wrote an entire book on the subject. Lisa is a psychologist, author, teacher, speaker, and consultant. She writes the monthly Adolescence column for the Well Family section of the New York Times and is a regular contributor at CBS News. She serves as a Senior Advisor to the Schubert Center for Child Studies at Case Western Reserve University and is also the Executive Director of Laurel School’s Center for Research on Girls.

In today’s episode, Lisa and I talk about pressure. We talk about the difference between stress, anxiety and trauma; what “good” and “bad” pressure look like; and how schools, parents, and providers can think about pressure. Spoiler alert: she has a great analogy about lifting weights. Because Lisa is so interesting, we talked for a long time. So long in fact that I decided to divide up the interview into two parts. In part two the conversation moves away from pressure at home and at school, to pressure in the broader society. We talk about rape culture, the problem with the word “consent” and how society’s criticisms of the way girls speak is really just another way of criticizing girls.

If you like what you hear, please consider buying her book, Under Pressure: Confronting the Epidemic of Stress and Anxiety in Girls. In Under Pressure Lisa does a fantastic job balancing empirical research with clinical wisdom. She wrote the book for the general public, but mental health professionals will get miles of mileage out of this one. Check out some of these section titles: sleep vs. social media, finding comfort with competition, gendered sex ed, the truth about hookup culture, the downstream effects of mainstream porn, school is supposed to be stressful, battling test anxiety, coping with the thirty-hour day, speaking while female, the verbal toolkit.

And now, without further ado, on to episode 122 of the Social Work Podcast: Under Pressure (Part 1): Interview with Lisa Damour, Ph.D.


JONATHAN SINGER: Lisa, thank you so much for being here, again, on the Social Work Podcast to talk to us, this time about your book Under Pressure.

LISA DAMOUR: Thank you so much for having me. I love being on with you.

JONATHAN SINGER: Wonderful. Your 2019 book Under Pressure: has the subtitle Confronting the Epidemic of Stress and Anxiety in Girls. Are girls really more stressed now than in the past?

LISA DAMOUR: Good question. One of the things that’s always tricky about a title is that it’s got to be grabby. It’s got to get your attention. There’s sort of a commercial element to the titling of books. But here is what we do indeed see, which is when we look at self-reports, the rates at which young women are talking about feeling stressed, there has been a steady rise. For your academic audience, what I will say is a lot of this data actually comes from college counselling center surveys. Since stress is sort of a sub-clinical phenomenon, it’s not something that traditional clinical literature is measuring so carefully. But, college counselling centers are keeping eyes on this, and collecting good data and putting it out. They have seen a very steady rise in terms of the young women in their care, describing feeling overwhelmed by stress and then also much more than the young men in their care. They’re 43% more likely by some measures, than the guys in college, to talk about becoming feeling overwrought or over-whelmed in the last year [note: see the National College Health Association Reference Group Executive Summary for more details].

JONATHAN SINGER: I think the first thing that you said was really important for social workers, mental health professionals, as well as parents to understand. That this concept of stress is different than what we as mental health professionals think about as a clinical issue.


JONATHAN SINGER: The most common disorder is anxiety, sort of, a category in part because there’s a bajillion of them [laugh].

LISA DAMOUR: There’s a lot in that category.

JONATHAN SINGER: There’s a lot in that category. But there’s also this thing that happened when the DSM-5 was published in 2013, that they carved out trauma from anxiety. So you used to have anxiety and then post-traumatic stress disorder [it] was subsumed under anxiety but now it has its own chapter in the DSM of trauma. I think it’s really important for people to know about stress being maybe sub-clinical or different but... Could you talk about the difference between stress, anxiety, and trauma?

LISA DAMOUR: Absolutely. But you’re putting your finger on one of the main reasons I even wrote this book, which is there is a great deal of misconception in the popular culture about stress and anxiety. And so, let’s think about these phenomena, sort of as an object looking from two sides. We’re looking at it from our clinical side and we have our understanding of pathological anxiety, trauma, things that happen that actually cause traumatic reactions. Stress when it’s completely off the chart levels. And that’s how we clinicians are thinking about it.


LISA DAMOUR: As we should. This is what we’re responsible for. This is our job. What I think we have not paid close enough attention to, or something that I’m worried terribly about, is that the popular culture looks at every variety of stress and anxiety right now and sees it all as pathological. I’m making a huge overstatement. I’m sure I could walk pieces of that back. But, for the sake of argument, we have come to a place in our culture where anxiety is seen as a bad and stress is seen as a bad, and there is not a broad awareness of the fact that anxiety up to a point is a totally normal and healthy and protective function. And, stress up to a point is a totally normal healthy and productive function. It is our job to parse it clinically and to get into the details of this and I want to do that. I love thinking clinically with you. But, there is a bigger issue here that compelled me to write this book, which is: In the broader culture, no distinction is being made between having a really anxious moment and having pathological anxiety. That in it of itself has created more anxiety and more stress.

I would say that chapter one of my book is my attempt at a giant public service announcement to say: much of what happens in the day-to-day that is in fact anxiety and is in fact stressful, falls into the normal range. And we can manage it as such. Even in the book, and this is interesting to me as someone who’s a clinician for so long, I basically breeze past the anxiety disorders. It is a very tiny section and I even relegate PTSD to a footnote. [Jonathan laughs] I don’t get into it because it is so far in the outer limit and from parents who need help with the day-to-day. I just want to get that out there because then we can get into the details of the clinical.

So, anxiety versus stress versus trauma. For us, anxiety is just an alarm system. For everybody, it’s an alarm system; it alerts us to something amiss. It becomes pathological, the way we want to think about it: when the alarm system is not working properly, when it’s ringing all the time in response to nothing or in response to utterly minor concerns. Or, when it’s blaring over something that should be manageable, when a person’s having a panic attack over a test. That’s where we step in as clinicians.

And the cool thing and also this is not well-known is that we are great at treating this! [laugh] We are really good at treating anxiety! When we talk about the DSM-5, if you made the list of stuff that we really don’t know what we’re doing with, I don’t think stress and anxiety would be on that list. I think about Bipolar. We need a way better treatment for schizophrenia. There’s a lot we can describe but not treat as well as we want to. Whereas I feel like certainly with anxiety and increasingly with things like trauma, we’re making phenomenal headway at treating those. So, there’s anxiety in its normal and it’s on a continuum and it’s passed normal forms. And then there’s stress in its normal forms, which is basically any experience of change, anything that requires adaptation, and this is where it’s so fun to talk about it clinically. The Holmes Rahe Scale has been around forever, and that’s the scale that rates life events in terms of stressfulness and things on that are getting married, getting a new job…


LISA DAMOUR: …Moving, you know? This is old in our field. This total clarity around the idea that stress comes with change. And it also comes with bad change, your spouse dies: that’s a really bad change that’s enormously stressful. But that’s high on the list with other things that we would see as positive life events. Stress in it of itself just comes with change, and then my favorite thing and the thing I’m working really hard to make sure people understand is capacity building. When people go through a difficult experience and have something stressful happen, if it doesn’t mow them down, and we end up taking care of people from a mowing down experience, there are a lot of people who have really horrible experiences and it doesn’t mow them down and we just don’t see them. Then, the upshot is that they’re more durable. The next thing that comes their way actually bothers them less, as a function of having expanded their capacities for dealing with difficulty.

JONATHAN SINGER: Does your experience suggest that we should not be so protective of kids.

LISA DAMOUR: Well definitely yes to that. [laugh] Let’s start there. That’s easy. Let me back up and let me come back to that. One way that I have learned to think about stress is in terms of resources. What constitutes as a stressor depends on who it falls on and the resources they happen to have at hand. We have people who go to war and it’s a devastating experience and we have people who go to war and they fight side-by-side with the person who’s devastated by it and they somehow seem to come back not undone by it.

JONATHAN SINGER: Or stronger or more committed or more focused.

LISA DAMOUR: Yeah, it is all very relative. We can’t really say, “This is stressful or not stressful”. But what I do think about, trying to put it in the box of the adolescent experience because that’s an experience of its own, I do try to be careful about not thinking like “oh what doesn’t kill you makes you stronger, this is great for you”. One way we want to think about it is that it’s very hard to maintain perspective as a teenager. Neurologically their perspective maintaining systems can be knocked offline pretty easily. Even in difficult times, adults are just neurologically better equipped to think, “Okay, this isn’t as serious as a bunch of events. I’ve been through this before, I’ve been okay before, I will be okay again”. Teenagers just don’t have that life experience and they don’t have the neurology to do that when they’re at the height of emotions. We have to be careful not to seem invaliding or dismissive of how powerful events are for them. The other thing, just to bring it to the garden variety stress of teenagers, to move it away from trauma and from extraordinary experiences to the day-to-day: the model I talk about a lot in Under Pressure of stress is it’s like a weight-lifting program. You can’t get stronger unless you’re lifting uncomfortably heavy weights. Students don’t become more capable at school unless they’re doing work that is demanding and unpleasant. One of the things we have to be careful about is that people can make the assumption that if it doesn’t feel good, it can’t be good for you. Anyone who ever exercises knows that’s not true [laugh]. Just because it doesn’t feel good doesn’t mean it’s not good. The weightlifting model also points out that you only expand capacity, from stretching, if you have a chance to recover. You cannot lift weights non-stop without injury. And so, one of the things at the day-to-day level that I am worried about, and largely Under Pressure is a very reassuring book …

JONATHAN SINGER: I would agree.

LISA DAMOUR: … Good! I want it to be. There is a lot of reassurance to be had. But, I also was looking at the research and the data on the most ambitious high school students, kids who are applying to ivy league schools or their equivalent, and they’re taking an average of eight AP classes and as many as thirteen AP classes in high school. Which is just terrible. Here’s the thing, they can do the work, it’s not that the work is too hard and it’s not that they don’t have the work ethic; they can’t do the work in the time allotted. And so, what we create with students like that are conditions where they’re basically lifting constantly. In those conditions, I think we’re more useful to teenagers when we pivot the conversation away from what they could actually do. I mean, they can actually do these things, they can bear that much stress. It’s just that they cannot bear it in the absence of recovery. I have really been pushing schools and students to think less about how do we lighten the program for you, and more about how do we make sure there’s opportunity for recovery because this program is within your capacity, it’s just a matter of time frame in which it’s being delivered.

JONATHAN SINGER: I think it’s really such a great metaphor and I love your metaphors, I know for Untangled you have the swimming pool metaphor, which is just been so great for me and all the mental health professionals I’ve shared it with. But this metaphor of lifting weights, I think there are analogies; I’m a drummer and one of the things that we always talk about in playing music is that you know, you can’t practice playing fast slow, if you want to play fast, you just have to play fast. But also, you can’t just play fast all the time, and you can’t just lift weights all the time or else you’re going to injure yourself. And this idea that schools are allowing or encouraging or making it possible for kids to take thirteen AP classes, seems like there is a structural responsibility. There’s something that as adults as professionals, we need to recognize this and step in and say, maybe this is something that we as adults should say no to. Would you agree with that or is there a different way of thinking about it?

LISA DAMOUR: Totally, and I think my mind goes off in ten different directions but absolutely! One of the things that can do, and do, which I really appreciate, some schools put a limit on how many AP students can take, which then actually gives the student room to work. Because for colleges, they can say, “I’ve done the most demanding program at my school”, and that’s what colleges want to know. When adults do take that responsible step and say, we’re going to give you a structural out here from this ridiculous expectation, those things matter. I also think and I spend a lot of time in Chapter Five about girls at school, I think that the assumptions underpinning the idea that kids need to go to dazzling colleges, those assumptions don’t hold up very well. And I know it’s really hard for adults and kids to let go of the idea that if you’re really ambitious in high school, it’s going to set you up for life. The data don’t support that, don’t support the ambitious in traditional school ways that we talk about. So, what I tried to do in the book was to really take it layer by layer. That stress and anxiety are normal but there’s still a lot of stress and anxiety and we then need to respond to it well. Just because it’s normal doesn’t mean we ignore it, we just have to respond to it effectively and try to work my way through the domains of, in this case, girl’s lives. But a lot of it applies to boys, of where these stresses and anxieties crop up and how adults can respond to it in ways that push things in a positive direction. And then, I want to get back to your question about, “Should we let kids do things that are stressful?” Yes, it is durability building, it is capacity building, and all we want to monitor is we never want it to hit chronic levels, where they never stop lifting. Obviously we don’t want it to become overwhelming, we don’t want it to be more of a constitute trauma for that person. But, there’s a wide range between, having everything cared for on your behalf so you never feel stress and becoming overwhelmed, and we want kids hanging out in that zone.

JONATHAN SINGER: Yes. And I know that one of the things that we have been talking about is this difference between sub-clinical and clinical which I think is really important for what I think mental health professionals, maybe not as day-to-day useful for parents, although maybe … I don’t know. I should know because I’m a parent also [laugh]. But you do a really nice job of balancing the kind of scientific information that clinicians need and the clinical wisdom for how to do things like, in the section “girls at home”. So you write, “I start by reminding myself that the stuff of life can be divided into three categories: things we like, things we can handle, and things that constitute a crisis”. Anyone who spends time with young people knows that when children and teenagers become upset, they can forget about that middle category, which is the things we handle. I love that sort of piece of clinical wisdom, how you divided that, it reminds me of what my kids learned when they were little about problems being pebbles, rocks, or boulders. Can you talk about some things that you do that you’ve found would work to help girls, or teenagers in general, remember that there are things they can handle.

LISA DAMOUR: Yeah, I think for me especially that handle piece, if you’re in loving touch with a kid who becomes overwhelmed and they feel like something’s a crisis, it’s very easy for adults to feel like it’s a crisis too. That’s when we do things that we’ll probably later regret, like picking up the phone and calling the school right away about something, as opposed to letting it all settle down a little and letting our child relax a little bit and then figuring out if they can handle it on their own or if they can handle it with our help. I think we really want to be careful not to, ourselves get caught up in a young person’s view of things. The other thing I write about and I think about a lot is that there’s a section in the book about a glitter jar that I was introduced to on a trip to Dallas. I won’t re-hash the whole thing, but the bottom line is that I was in Texas meeting with a bunch of counselors down there, and one of them introduced me to this concept of the glitter jar. Initially I was extremely skeptical because it sounded really girly to me, it sounded like pop psychology to me, I kind of hated it already. But what she showed me is that when she’s taking care of a girl at school who becomes very overwrought, she shakes her glitter jar and says to the girl that it turns into a snow globe, a sparkling purple snow globe of glitter. She says, “Look! This is your brain right now! First, let’s settle your glitter.” It’s so corny and it’s so brilliant, because it really is good model of the neurology of the adolescent brain and adolescents do become overwhelmed by emotions. And then, they actually do reset, that their brains are gawky but their brains can actually get themselves back online pretty effectively, if a grown-up can be patient. The more I thought about the glitter jar, the more I’ve come to think: you can teach teenagers about how their brain works, that’s fine if you want to. The glitter jar is actually issuing instructions to the adult, which is just relax for a minute and sit with this child if she wants your company. Make it clear that you are fully confident that if everybody just takes a minute, the emotion that has saturated the brain will flow back to where it belongs, and then we can figure out what needs to be done, if anything, about this problem. What I have become attuned to is a misunderstanding about emotion in our culture, especially with a super upset teenager. If you have a really upset teenager, it can feel like the kid’s on fire and the fire has to be put out fast. Grown-ups need to jump in with suggestions or solutions or phone calls or tutors, who knows what. What we need to help ourselves understand and the people we care for understand, is that actually emotions are pretty self-regulating. They have life-cycles. They’re more like waves: they rise and they crest and then they flow away. In some ways, we can think about the definition of mental health is that that is what happens, and the definition of people in trouble psychologically is that it doesn’t flow down. It doesn’t crest and then recede. But for most people, it does. Part of our job as adults is communicating this to teenagers and kids that they are already in possession of a self-correcting system. When they’re having a huge big feeling, that doesn’t mean they’re broken or that we’re worried they’re broke or their worry is just going to get bigger and bigger and bigger. It is a moment for them to discover that, one of the ways I was taught clinically was with hard feelings, the only way out is through. Just have it! And then, you’ll be okay again. That piece to me feels so essential in how we respond to really intense affect, how we teach kids about the internal systems already in place to help them regulate really intense affect. And we have to model that and remember that all the time.

JONATHAN SINGER: This is so beautiful because it really connects with this idea that if we think about the stuff that’s happening in kids’ lives as too much, then we take away the opportunity for them to sit with the things that are happening. But it doesn’t mean that we should create experiences for kids that are perpetually overwhelming. Because it’s that time, it’s that recovery that is part of the growth.

LISA DAMOUR: Yeah! And the discovery that, and I think in psychodynamic terms, “Oh, I am in possession of sudden defenses that come to my rescue before this gets too big”. And they work. The mind does regulate itself. The mind does not usually allow people to become overwhelmed. Sometimes, I’ll have a child who’s really, whatever just happened is huge, and they can’t get perspective and their glitter is just going to take a little more time to settle and maybe more time than we have, maybe the appointment or the encounter we’re in. And I will say, “I want to see you tomorrow” or “I want you to call me tomorrow and let me know how you are”. I have to say, almost invariably happens is that they’ll call and say, “Oh no, I’m fine!” or they’ll text me and say, “No, never mind I don’t really need to talk. Everything is okay.” This gets to something so important for your work, and the audiences and your clinicians. I feel like one of the things I do a lot is that I consult to a school here two days a week, so I have exposure to a large number of kids.  There will be a really rough patch with the kid, or a really rough day that is alarming to grown-ups and alarming to the kid. And so, from that moment on, I’m walking this really interesting and tricky line of responding directly to the child or the teenager as if like, “Well that was rough, but I think you’re okay”. Sort of a confidence that they’re going to reconstitute while watching very closely to make sure that’s true. What I find is that it breaks both ways. There’s some kids that go, “That was a day: It was an ugly day.” And you never see anything like it again. It is a real gift to that child and probably a really helpful thing that no one ever reacted, that we didn’t throw that kid into therapy, we didn’t take him to the ER. We just said, “you’re having a moment, we’re here, we’re going to ride it out with you. And we think you’re going to be all right”, and it turns out to be true. Maybe self-fulling but definitely turns out to be true and it is left in the rear view mirror. There are other times that it happens with the kiddo, and then a week later, she’s undone again and then of course, we really start to put all wheels in motion around all of the clinical support that need to be put into place. I’m not saying this elegantly, but I think it’s an interesting thing that both transmitting confidence that they will be okay while watching really carefully.

--END PART 1--

Transcription generously donated by Fatima Lee, a BSW student of Douglas College in British Columbia, Canada. 

APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2019, February 12). #122 - Under Pressure (Part 1): Interview with Lisa Damour, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2019/02/underpressure1.html

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