Madeline Levine on Psychotherapy with Adolescents

Madeline Levine on Psychotherapy with Adolescents

by Keith Sutton

Learn from adolescent psychotherapy expert, Madeline Levine, the challenges and rewards of working with teens. CE credits available.
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Working with Teens

Keith Sutton: I'm very pleased to be speaking with you today about working with adolescents. Many therapists are trained to work with children or adults, but really, adolescents fall in between. How do you work with adolescents? Is it child therapy? Is it adult therapy?
Madeline Levine: I'm always slightly embarrassed or hesitant to talk about the way I actually work with teenagers. I think working with teenagers demands a degree of fluidity and flexibility very particular to teenagers. One of the things you need to do with adolescents is really enter into their world, because it is so profoundly different, both cognitively and emotionally, than the world of children or adults. I may take them out, feed them ice cream, go to their house and hang out in their rooms. I incline to bring in friends and boyfriends, and the people who matter in a teenager's life—something I wouldn't do ordinarily if I were seeing adults or children.
KS: So you really try to enter the teenager's world in a much more concrete way than you would with an adult or a child. Some people think of teenagers as a very difficult population to work with. What do you think?
ML: Well, they're my favorite population to work with, mostly because a lot of them are really angry. Give me an angry teenager any day over a depressed child, or a depressed teenager, for that matter, because they have the energy to help themselves. And I think one of the things you want to do is not necessarily pathologize their anger, but enlist it in the service of being used in a healthier way.

For example, a kid who's doing some dangerous risk-taking—that's worrisome. On the other hand, I think there is a healthy risk-taking that's imperative for adolescents. Usually the kid who's doing dangerous things sees no opportunity to do some risk taking. So we can take the anger that a kid brings in and try to turn it into part of the developmental task, which is to get out there and try new things and push your boundaries—and that often includes pissing a few people off, particularly your parents, from time to time. But that's okay -- as opposed to doing meth behind the school gym.

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KS: So channeling that energy into more appropriate or safer activities?
ML: Yes. I think one thing that's misunderstood about teenagers is that all this risk-taking is an indication of pathology. I think, in general, teenagers are horribly pathologized. And this started long ago with Hall's concept of Sturm und Drang -- Anna Freud basically said it was a period of pathology and you could be diagnosed as having adolescence. I don't think that's true—I think it's just another developmental stage with very major psychological tasks to be accomplished, and that if we could start looking at it and normalizing some of what adolescents do, making sure they're safe, then you'd have adolescents who are much more willing to talk to you. So this issue of, "How do you see teenagers? They never talk"—I don't find that really a problem at all in my practice.
I think teenagers are hungry to talk to adults who truly are interested in their internal lives.
I think teenagers are hungry to talk to adults who truly are interested in their internal lives.
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Trouble or Normal Development?

KS: I think often some parents want their kids to get through adolescence on a straight and narrow kind of line, and actually the normalcy of adolescence actually is not so straight and narrow. So can you talk a little bit about what is "normal" adolescence?
ML: That's like, "What's normal adulthood?"
KS: How can a therapist tell between a teenager that's got some big problems or big issues, and a teenager who is just going through the normal development of adolescence?
ML: Well, teenagers as a group do not have higher rates of pathology than any other group—so we think that they're more depressed and they're not. Are they moodier? Are they a little more labile? Sure. And I actually think we missed the boat a little bit about when that happens developmentally. My observation is that we think teenagers are going to be really difficult toward the end of adolescence when they can drive and have sex and stuff like that. But I actually think the height of their struggle with autonomy happens a lot earlier than that. So what I see is much more likely to be a 12-year-old who's running into trouble with their parents, and their parents are completely freaked out because they were waiting for the kid to be 15 or 16 before they were anticipating having autonomy problems. I think when we talk about it, we need to move down a little bit in terms of, is a 12-year-old who is saying, "Leave me alone and don't tell me what to do" and sneaking out and doing those kinds of things, is that way out of line? And I actually don't think so, because, like I said, I think the struggle for autonomy starts earlier than the popular perception.

But I want to answer a little more clearly your question of, "How do you know if a kid is really in trouble or not?" Aside from all the obvious things—you'd want to look for the same things you'd look for in anybody, which would be severe depression or an eating disorder, self-mutilation, or anxiety disorders, or a family history of bipolar; none of that is any different for teenagers than it would be, I think, for adults. I think what is different is that, in spite of the fact that, in early adolescence, cognitively kids are at the stage of abstract reasoning—they actually can think more or less the way an adult does, which gives the impression that they're older than they actually are, so they have the cognitive skill, but they don't have any experience.

So a parent comes in and says, "Well, my kid argues all the time, and he's rude." But that's what a young teenager's supposed to do, because how do you go from having the cognitive skill with no experience to having the cognitive skill and some experience, if you don't get it by being out in the world and trying things out and banging up against parents? So I always tell parents, "That's a great thing that your kid is arguing. Think of it in the same way you would think of practicing pre-calc or soccer—that it's a skill that needs to be honed and not pathologized." And I think the parent's job is to stay reasonably calm, which can be very difficult because kids want the argument—it's their way of expressing their growing autonomy, so they want it to be an argument. And they're like Jedi masters at knowing where to get you.

So the fact that a kid is arguing, the fact that a kid is moody, the fact that a kid is doing some risk-taking that doesn't endanger them in any way—none of those things are particularly worrisome to me.
I'm most worried about a kid who has really retreated into themselves and has no capacity for self-reflection.
I'm most worried about a kid who has really retreated into themselves and has no capacity for self-reflection. With all the demands for academic and athletic success, the standard task of adolescence -- which is solidifying a nascent sense of self -- tends to get lost because you don't have the time to daydream and you don't have the time to hang out and all that kind of stuff. I think kids are absolutely overwhelmed with the amount of structured activity and the demands for academic excellence, particularly in upper-middle-class communities. And I don't think you can forgo the period of time of learning how to think about oneself.
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Developing a Sense of Self

KS: In your book, The Price of Privilege, you talked about developing that sense of self. Can you talk more developing that strong sense of self that as a developmental task in adolescence?
ML: If we go back and think in our own lives about the experiences that added to a sense of self, I mean, what comes to my mind is very visual— lying out in the backyard with my dad and looking at the clouds, and making up… The Rorschach test of childhood is looking at the clouds. The teachers who I had a relationship with who actually encouraged me to write. The hundreds of hours spent listening to Bob Dylan records and trying to figure out what he was saying. These were all sort of slow, internal activities without any particular evaluation.  My parents might have said once or twice, "Shut off the Bob Dylan," because I listened to him obsessively. But in general, they were internal, they were tolerated, because adults weren't in teenagers' lives all the time—not in the way they are now, and I'd like to be clear about this particular point.

I think we're way overinvolved in the wrong things and underinvolved in the right things.
I think we're way overinvolved in the wrong things and underinvolved in the right things. So moms stand at the door when their kids come home from school and want to know how they did on their math test that day. We know every teacher, every grade, every pop quiz, but we don't provide the space or the container for that kid to come home, sit at the kitchen table, have a glass of milk and a couple cookies, tell you or not tell you what their day was like. And I think that those are the spaces in which an internal sense of self develops. And it's much harder to develop if you're constantly being evaluated. So the kid down the block is smarter, or somebody has better grades, or your sister's daughter got into Harvard. What I hear in my office over and over again is, "I'm only good as my last grade." And that is an incredibly sad comment on the internal life of the kid. You know, kids walk into the office and I say, "Tell me a little bit about yourself," and they rattle off their metrics: "I get an A in this, and I get a B in this, and my parents are really mad because my SAT scores..." It's like, "No, tell me about yourself." I think one of the things that work pretty successfully with teenagers is absolute boredom with their metrics. You know, I look at my watch, I look out the window. I'm not interested in that. And every therapist knows the line where the kid says something that's really authentic. "I was so pissed, I went to my room and I listened to Sublime," or, "I took out my drawing pad..." And that's the moment you want to jump all over. You're not interested in the metrics—you're very interested in the part of the kid that feels authentic. And I think kids are a little suspicious of that at first, but very quickly get that you're interested in something entirely different about them than what they're used to adults being interested in.
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Building Rapport

KS: How do you build rapport with teenagers? How do you approach them? It sounds like this is one approach, where you're interested in some authentic part of themselves rather than the metrics. What else?
ML: I think in order to be an adolescent therapist, you have to really like teenagers, and you have to have a pretty good relationship with your own adolescent self. So I'm real knowledgeable about the culture, and I'm real knowledgeable about the music, and I'm real knowledgeable about the language. I'm not so good on the technology because it goes faster than I can possibly keep up with. But I'm knowledgeable and not in the least dismissive of adolescent culture. Your own authenticity is incredibly important.
The standard classical therapeutic position of not revealing about yourself, absolutely does not work with teenagers.
The standard classical therapeutic position of not revealing about yourself, absolutely does not work with teenagers. They want to know, and from their position, rightfully, so: "Who the hell are you? Why should I tell you anything? I tell my teacher at school and he tells me to work harder. I tell my parents and they tell me they're disappointed in me."

I would say the majority of the teenagers who come to see me really want to be in therapy. They're desperate to be in therapy. And talking, for them, is no issue—which is just surprising to me, and is still surprising to me. Then you have the kid who's dragged in by a parent who's worried, either appropriately or not so appropriately, about some kind of bad behavior. With those kids it takes a period of time of hanging out.  I had this one teenage boy who just was really difficult, but he had a passion for tropical fish, and we ended up doing—I saw him for about three years—we did his whole therapy through tropical fish. I went to his house, and I saw his tropical fish, and I learned about tropical fish, and we talked about the habits of tropical fish. It's a mistake to push teenagers into the model that most of us were most comfortable with, which is, "Well, what do you think about that?" Because I think when a parent says to a child, "What were you thinking?" the real answer is, "Nothing." I mean, nothing like what the parent wishes the child was thinking. It's kind of like a freight train going on in there.
KS: Things are moving so fast they're not really paying attention to what they're thinking.
ML: That's right. Now we have the neuropsychology, and we know a lot about how active the adolescent brain is. You have to take that brain where it is and be respectful. The other thing is adults aren't respectful of teenagers. Things they would never say to another adult I hear all the time in my office. A parent will come in and say, "Look at what he looks like." You wouldn't say that to your spouse or your best girlfriend, but it's kind of okay to be disrespectful towards teenagers. And that same parent turns around and is shocked when the child is disrespectful to them. So I try to stay very respectful, and very curious. I talk a lot more than I do with an adult patient. They know a lot more about my life. I have a hard time bringing out some of it in case conferences, but I think it works. I think they need to know that you're the real deal. And that can take a while.
KS: How do you deal with the issue of self-disclosure? Because in general, in children, adults, adolescents, people approach that very differently.
ML: I think it depends on the case. So there are kids who know absolutely nothing because I don't think it would be helpful to them. I use self-disclosure when kids have really become convinced that, and are treated as if, there's something incredibly wrong with them that isn't.

For example, I have three sons – two of whom are very academic and one who is less so. I will use the notion that people are good at different things. "Yeah, well, what do you mean by that? I'm not good at anything except noodling around in my car." And that's your way in to this client. I'll show that I want to know about cars; I want to come up with anything I can remember about cars; I'll  want to engage them in cars. And then I might say, "Well, it's interesting, because one of my kids is at a hands-on college because that was how he learned." It becomes not only normalized but valuable. For a lot of kids, especially in a community like ours, that experience of somebody saying, "You know, being a mechanic—everybody needs their car fixed. What a great skill. You must be good with your hands, you must really be able to see things...." And I may add something like "My spatial relations are absolutely awful." Teenagers, are like children in that they look at adults and we appear incredibly confident. That's because we get to do what we're good at. There's a whole bunch of stuff that teenagers don't see that we're not good at. So often I'll say to a kid like that, "You know, I have a trip coming up and I really can't visualize where I'm going. Can you help me?" The whole notion that there are things I'm good at and things I'm not is just a revelation for some of these kids.
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Nobody's Perfect

KS: Pointing out that you're not perfect.
ML: That nobody's perfect. I do a tremendous amount of speaking at the Young Presidents Organization -- these are the Young Turks of business, they have big corporations. If you talk to them and ask them how they did in high school, they, for the most part, were average students who went to state universities. I'm very interested in dispelling the notion that there's this one way that people get successful. It just isn't true.
KS: That's an interesting area that I'm looking more into, which is around resilience. On the one hand, in working with adolescents, oftentimes I'm trying to help them better their family relations. But I also know extremely successful people who went through a lot of hardship. What do you think about that, especially how that translates to the work we're doing as therapists with adolescents, trying to decrease the hardship in their lives?
ML: So this is the topic of the new book I'm writing, and I'm very interested in it. If you look at who's successful where they went to school, what their grades were, what their IQ is, none of that stands out. But someone said, "Success is how high you bounce after failure." I think that's true. I think what people forget is that we all hit terrible bumps in our lives. There are losses, there are deaths, there are divorces, there's heartbreak. That's life. So parents run around like crazy trying to make sure that their kid isn't kicked off the team, and if it was a B- it should really be a B and they're going to go up and talk to the teacher, and they're going to help them write the essay to get into the college they want them to get into, thinking that they're giving their kid a leg up.

Bad stuff is going to happen to you in life. And it's going to happen no matter what you do with your kids. Instead of all this focus on protecting kids from age-appropriate challenge, stay out of your kid's grade in the fourth grade or the sixth grade or the eighth grade. Teach them to talk to the coach if they're not getting enough playing time. We're really busy protecting kids in that way, which is a tremendous loss for the kids, because then they don't know. And side by side with that, by the way, I think we're not busy enough saying to our 16-year-old, "It's Saturday night and I want you home by 1:00 or midnight because nothing good happens after midnight," or, "Where are you going?"

So what are the components of resilience? I'm interested in this. I think things like perseverance, self-management, autonomy, self-reflection are all part of becoming resilient. But if I had to pick the most important one, it's the ability to tolerate mistakes. And I think that's exactly what we're not tolerating in kids.
KS: Can you give me an example of what you mean?
ML: I was speaking in New York, and I'm walking down Fifth Avenue, and there's a mom with a very well dressed four-year-old boy, and he jumps in a puddle of water right in front of Bergdorf Goodman. And it's kind of muddy and he's splashing. And the mother has an absolute meltdown on Fifth avenue, just a meltdown—she's screaming at the kid and crying. And of course with the grandiosity of a famous psychologist, I walk over and go, "Hi, I'm Madeline Levine, I'm a psychologist. Are you okay?" And what happened? They were on their way to a preschool interview, and now she couldn't decide, did she have enough time to get him home and spiff him up again, or would she be late and would that be a strike against him? It sort of breaks your heart because now the four-year-old looks like a four-year-old instead of like little Lord Fauntleroy. But she's yelling at him—"How could you make a mistake like that? How could you get dirty?" So it's a little bit of a dramatic example, but I think that goes on all the time. The normal parts of mistake making aren't tolerated.
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Collaborating with Parents

KS: How do you decide whether to do individual therapy or family therapy? Because a lot of your book is geared toward parents -- helping parents change their thinking or behavior.
ML: Again, this is just how I work—I wouldn't think of seeing a teenager without their parents. Not necessarily together, but parents are -- and should be -- a really big part of an adolescent's life. The research is that teenagers want more, not less. They may not tell you that, and they may roll their eyes when you say, "It's family day," but all the research is pretty consistent, that kids want more contact with their family.

What's the reality of working with the family and a teenager? About two-thirds of the families I see, I continue to see the parents—we're collaborative. You have to be pretty good at boundaries and at issues around confidentiality, and those have to be clear up front. And I would say with maybe a third of the parents, the reality is they're not going to collaborate with me, they don't especially like what I'm doing with their children, they don't like being told, "Back off." I had one dad who had this really nice daughter, very mild level of difficulty, and she wanted a small nose piercing. A very wealthy guy. And he said, "If you encourage her in that, I will cut her out of my will."

I'd love to tell you that all the families come around and they're really helpful. Some of them aren't. And then part of what you do is, you never really diss the parents, but you're allied with the child's perception that there's something crazy here. Those can be really tough cases. But most of the time there is enough of a good parent in there, which is what you're always calling for: "I know you want to be a good parent. I know that you've been a great mom. I know you want to do best. But this is how I see it" So
in a best-case scenario you work collaboratively with parents, mostly trying to teach them some really basic skills about adolescent development
in a best-case scenario you work collaboratively with parents, mostly trying to teach them some really basic skills about adolescent development—not to flip out at the wrong things, and not at the right things. I still will get calls from time to time that say, "I found cocaine in my daughter's room. Should I do anything?" That's when you flip out. Well, you don't flip out, but that's when you do something. The parent who says, "My kid keeps coming in ten minutes late and why won't they listen to my authority"—that's the not-flip-out stuff.
KS: How do you manage the different relationships and the rapport with both parent and adolescent at the same time, especially if they have very competing interests?
ML: Good question. I don't see the teenager and the parent together frequently. Maybe I'll see them together twice a year. But I'll see the parents once a month, because, again, it's an hour a week or two hours a week, and you're trying to make some systemic change in the house around things like chores. You know, none of these kids have chores. They're supposed to have chores. There's good reason for kids to have chores. Optimally you get buy-in. But I don't see them in the same room more than once or twice a year for a very particular reason, and that is that I think the teenager has to feel that your alliance is primarily with them, that you don't have this split alliance. And you can run into some of that when everybody's in the room together. And, again, as a point for therapists, I think the fastest—I don't know how good this will sound—but the fastest way to get buy-in from a teenager is to get something for them. You want a teenager to come back the next week. It doesn't matter if it's ten minutes on their curfew. It doesn't matter if it's just a quarter on their allowance. You get something, you can be useful to a teenager in some way, you at least have a beginning relationship. So I don't bring them all in together that frequently, and I bring friends in but not that frequently. It has to be very clear that your main allegiance is to your teenage patient and that you use other people selectively to be helpful, to provide a better environment, and things like that.
KS: I'm wondering about countertransference with the adolescent and the parent. I know a lot of young therapists tend to identify with the adolescent over the parents, and I'm wondering, as you became a parent of adolescents yourself if that changed your experience with your teenage clients and their parents?
ML: Did I change when I had teenagers of my own? Not so much. I mean, I always liked teenagers, and if I have to really think about it, it's probably somehow related to the fact that I was one of those really, really goody-two-shoes teenagers. I didn't lie and I didn't do any of those things. So there's something about the spiritedness of adolescence that intrigues me. And my own kids' adolescences were not particularly difficult. So I think certainly I have a greater tolerance or more empathy for parents. I had three boys. That's a challenging period of time.
KS: Did you change how you worked with the parents after gaining that greater empathy?
ML: I think I use a tremendous amount of humor in working with parents. Maybe what I learned in having teenagers is that they grow out of it—and they grow out of it really pretty quickly. It seems interminable in the middle of it, but it's not. We think of these kinds of things in young children as kind of dear. You have young children, right? Your child starts to learn how to walk, and they totter and they fall down, and they totter, and we love it. We don't get mad at them and we don't say, "If you keep falling down, you're going to be flipping burgers for the rest of your life." We don't do that. We find their motions toward independence and autonomy…the word that comes to mind, is "dear." And I think that's how I found my own kids' adolescence—the stories in The Price of Privilege, of mistakes and times my kids got in trouble and stuff like that. But if you frame it as kids really trying to do their best and they're not out to get you, that the tasks of adolescence are so multiple... When I talk to parents, and it's usually about college and grades and all this stuff, and what they've forgotten in their pursuit of all of this is these kids have to learn how to talk to each other, they have to learn social skills, they have to learn how to ask a girl out, they have to go to school in spite of the fact that they've got acne all of their face or a boner when they go up to the blackboard, or one girl's bust... I mean, just all the physical, physiological and social changes and all that is happening, and you want your kid to get straight A's also? So I think that what changed for me in having teenagers of my own was seeing on how many multiple fronts they had to deal with change, and that instead of being pissed at some of it, I started to see it more like the two-year-old who's stumbling.
KS: That's a good metaphor for it. In your book, you write about the authoritarian, authoritative, and permissive parenting styles. How do you deal with the issue of one parent that's over-involved? I find, at least in my practice, that the parent who's very strict is a little bit easier to slow down. But the parent that's so worried if they step back that everything's going to fall apart—how do you work with that?
ML: That's our toughest dilemma, isn't it? That, or the divorced family where there are entirely different sets of rules. I don't have any magic words for that, because I think it really is very difficult. In my experience, it's usually the mother that's over-involved. Sometimes I'll have a session or two with Mom alone. My take on mothers is this: I'm practicing thirty years. I've never, ever had a mother come to therapy and say, "Would you help me screw up my child?" That's just not what moms want to do. So I think usually a mom's over-involvement is coming out of anxiety.

There's usually something in that mom's background that needs some exploration, and if you don't get to it, you can say over and over, "It would be better for your kid if you backed off," but I think the anxiety becomes so overwhelming that it's really impossible. If you can bring that mom in—and I've never had a mom not do that, because mothers in communities like this are very lonely and are very eager for connection—and if you can find out what the anxiety is about, that's your best chance at effecting some change with the mother.

Here's a personal example of what I'm talking about. My youngest kid was a hands-on, nonverbal kind of kid, and I found myself, in spite of knowing so much better, giving him a hard time with English—that was where his learning disability was. So I went, "I know better, what the heck am I doing?" I really had to think long and hard about it, but what I came up with was my father died when I was the age that Jeremy was when I was giving him a hard time, and we had no money, and I got to college on my verbal skills. I had a scholarship. So when I was yelling at him about his English grades, it wasn't him. I was just remembering my own sense of whether or not I was going to make it at all.

So I think it's like those ghosts in the nursery—Selma Fraiberg's ghosts in the nursery kind of stuff—that if you can get to with the parent, you can, first of all, strengthen your relationship with that mother because she feels understood and I think you have a better chance.
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Dangerous Issues

KS: How do you deal with the dangerous issues that you run into with adolescents in therapy, like drug or alcohol abuse? Or other issues like cutting, or suicidality, or sexual acting out. How do you deal with these?
ML: That's the hard part. It's not just stressed-out kids that we see. We see some sick kids and some kids who are doing very dangerous things. I probably have a divergent point of view about some of this, and I think along some of what you're talking about, I'm as much a mother as a psychologist. If my kid was in danger and was seeing a therapist and I didn't know about the danger, I would be really pissed. Now what constitutes real danger? Is smoking marijuana real danger? Not if the kid's experimenting and he's 15 or 16 years old. If he's high all the time, yes. Is cocaine a real danger? Well, you think you're going to say yes, because it's a much more dangerous drug, but if the kid's tried it twice as experimentation and they're done, then no. So I think you look at several things. You look at the age of the child, because we do know that the younger kids experiment with drugs and alcohol and sexual relations, the more at risk they are. There's a huge difference between an 18-year-old smoking a couple of doobies and an 11-year-old doing that. That's one thing you look at. The other thing you look at is whether or not it's being used for experimentation or self-medication. So the kid who's self-medicating is at much greater risk than the kid who's out with their friends and they're 12 years old and somebody has a beer.

If I have a kid who's actively suicidal, I have to tell the parents. And because teenagers are so sensitive to issues of trust, those things have to be laid out really early. "If I feel that you're a danger to yourself or others, I will tell your parents. Do you still want to do this with me?" Clearly, you want the teenager, if possible, to be the person to say, "I'm having a problem." I think for me, personally, the hardest moments as a therapist have been when I've had to decide whether or not I'm going to give the kid the week -- when I'm worried about them -- to talk to their parents themselves. I tend to keep in a lot of contact with the kid over that week. If somebody's actively suicidal in my office, I take them to the hospital. If there's a clear and immediate threat, obviously I know what to do. But I think there's this little bit of a grey area where you're worried about a kid, you think they're going to be able to talk to their parents, but you're not sure. You have to know the kid you're treating really well. And for me if I'm going to err, I'm going to err on the side of involvement.
KS: What about sexual acting out, especially for male clients versus female clients?
ML: Well, I see almost all girls, so I can talk more about girls than boys. I think the thing that I find troubling for girls is disengagement of sexual activity and affect—you know, the twelve-year-old girls who have given blowjobs behind the gym at the middle school here. So as a therapist, once you get over the shock of that—because it is shocking the first couple times you hear it—what you find is an incredibly frightening lack of being there. They don't feel much of anything—they don't really care much about whether what they're doing is right or wrong or a good idea or a bad idea. For most of them, depending on the status of the boy, it accrues to either their popularity or sense of self.I see that as really quite troublesome, as one of the more distressing things about the kids I see.

Look, I grew up in the sixties. There was a lot of sexual activity, but it was "make love not war"—it was in the context of relationships. I think if I had to pick one thing that troubled me about young kids now, it is this kind of friends-with-benefits, very early sexual acting out. Kids going to school dressed sort of like hookers. Is some of this the media? Absolutely, some of it's the media. Why are parents tolerating it?
Why does the mother of a 12-year-old let her kid go to school dressed looking like a whore?
Why does the mother of a 12-year-old let her kid go to school dressed looking like a whore? So part of it is the community. But part of it, I think, is symptomatic of a de-emphasis on the value of relationship. Look at the times we live in. Our grandest people have no morals, and kids will say that all the time. Like, "What are you giving me a hard time for? I didn't steal money from my grandmother or anything like that." So we have to work extra-hard because these kids have grown up in a period, starting with Enron, of terrible disconnection between people. I mean, how do you steal all that money without being psychopathic and not really being connected to people?

So the work—and I see a fair number of these girls—the work with them is to start to restore some sense of self, because these girls have awful self-esteem. They have a very poor sense of self, based entirely on their sexuality, and for somebody like me, it's challenging. Anybody who went through the women's movement and has a girl in her office saying, "All I want to do is give head to the cutest boy because then maybe he'll marry me and I can lie back and be rich," and it's kind of like, "What?! You want to do what with your life?" I'd have to think about whether this is fair to say or not... Anecdotally, a fair number of these kids come from divorced homes, so I don't know if it's true or not, but the whole issue of a father's involvement with an early adolescent girl's sense of sexuality is really, really important. So if Dad's out of the picture or hanging around with young girls... Again, it's purely anecdotal, but I do have a sense that it's an issue for these kids in the same way that work can be an issue for adolescent boys.
KS: In the same way as what?
ML: It seems to me, at least in my practice, that girls have issues around trust and sexuality, and boys seem to have issues around work.
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The Price of Privilege

KS: Interesting. Now, the premise of The Price of Privilege is that kids of affluent, upper-class and very affluent families, have more mental health problems than middle-class or poorer adolescents.
ML: Yes.
KS: And that seems against common sense—
ML: Counterintuitive.
KS: Yes, counterintuitive. Especially, working in my internships and practicum in Richmond, which is one of the most dangerous cities in California, with very poor families and adolescents and all those issues, I have a hard time wrapping my head—
ML: Buying it.
KS: Yeah, buying it.
ML: Well, okay. So, first of all, they don't have higher rates of mental illness across the board. They have higher rates of depression, anxiety disorders, and substance abuse. They do not have higher rates of the acting-out disorders—behavioral disorders.
KS: Yeah, that's what I was wondering. I imagine PTSD and things like that, too.
ML: Right. It's a perfectly legitimate question that comes up a lot. It's like, "What are you talking about? How could you possibly be more impaired coming from Kentfield than from Richmond?" You're impaired in different ways. And also I worked in Harlem when I lived in New York, so I had a lot of trouble with it, too. But the numbers are pretty consistent. And substance abuse among inner-city kids is a lot lower than among suburban white kids. But the big ones are the depression and anxiety—upper-middle-class adolescent girls have three times the rate of depression of the general population, and just slightly higher than inner-city girls. And what the research says is that their pressure to be successful and to be perfect is intolerable. I think girls have tremendous pressures on them. I think they have the wrong kind of supervision, and I think they don't feel known at all. My experience is that these kids come in and just don't know themselves. Now, teenagers aren't supposed to be done knowing themselves, but they're supposed to be starting to know themselves. And these kids have developed astounding facades. They look great, they...
KS: It sounds like especially for the girls, it's more on the outward appearance, either the metrics or the physical appearance, rather than the inward self.
ML: Right. There's not much value on going off by yourself and playing the guitar—unless you're a really cute boy and you can bring it to the party or something like that—just those kinds of experiences that nurture the internal sense of self. So there's this issue of academic pressure, there's this issue of appearances. And there's disconnection from adults. And you ask upper-middle-class parents if they're close to their kids, they overwhelmingly say yes, and you ask the kids, and they overwhelmingly say no. Because the parent says, "I took you to lacrosse and I took you to your coach, and then I took you to Kumon [Learning Center]," and the kid is going, "And so? You don't know anything about me." So certainly poverty has a huge range of different pressures and stuff on it, but there tends often to be more of a community. I grew up very working class. You didn't buy your way out of anything. Somebody had a problem in the neighborhood, every door was open, everybody came over. You didn't go down to the Woodlands and buy the frozen lasagna, you had to make the lasagna. So I think there are a lot of problems, clearly, and I think the issues of involvement are actually the opposite—inner-city kids, you want more involvement from their parents, not less, which we're trying to do. But I do think there's a broader net.
KS: So it sounds like it's different issues than the low-income areas or middle-class.
ML: It is different issues, but I thought it was really important to bring that information forward, because it is so incredibly counterintuitive. And I think a lot of upper-middle-class kids were not getting the kind of attention and the kind of services that they needed. You talk to counselors in schools around here, and they're afraid to refer a kid to therapy because they're afraid the parents are going to be angry and threaten to sue the school and all that kind of stuff. So I think the assumption has always been, "Well, these kids get services left and right," but I don't think that's entirely accurate.
KS: So they're somewhat neglected in that way, too.
ML: I think they are, yeah.
KS: Do you have any other words of wisdom or thoughts to pass on for therapists of adolescents that could be helpful?
ML: I think to be an adolescent therapist, like I said, you have to really like teenagers, and you have to have a pretty good capacity for uneven progress. So just when you think you've got that teenager stopping the blowjobs behind the gym or the cocaine or something, they get really stressed and they're back doing it. That's true in therapy in general, but I think kids are not very good drivers of their own cars yet, both literally and metaphorically. So
I think an important trait for an adolescent therapist is to be able to tolerate disappointment reasonably easily, because if you don't, you become just like everybody else in the teenager's world.
I think an important trait for an adolescent therapist is to be able to tolerate disappointment reasonably easily, because if you don't, you become just like everybody else in the teenager's world. And that's not to say that you don't have an authentic relationship. If that kid has really done something and you're disappointed, I think you get to talk about that with the teenager. But I think you save it for things that are critical in terms of their development, and you have to be able to take pleasure in the fact that these are really works in progress and not treat them like adults. I think people make a mistake when they treat teenagers like adults. You've got to be more forthcoming, you've got to be more fun, you've got to know something about the world in which they live. You don't look like them and you don't talk like them—that's not the point. You absolutely have to be the adult. So you walk a very different line. You're knowledgeable, but you don't come in dressed like they do or talking like they do. And I think, like any psychologist, you have to be really curious, because what you want is the development of that ability to reflect, so you have to value curiosity.
KS: Well, great. Thank you so much for the interview. I appreciate it.
ML: My pleasure.

Copyright © 2010 Psychotherapy.net. All rights reserved. Published March 2010.
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Madeline LevineMadeline Levine, PhD has been a practicing clinical psychologist in Marin County for the past 25 years. She is the author of several books including The Price of Privilege, Viewing Violence, and See No Evil. A frequent lecturer on child and adolescent issues, she lives in California with her husband and three sons.
W. Keith Sutton, Psy.D. is a psychologist in private practice in San Francisco and San Rafael, CA. He specializes in working with teenagers and families, was the founder of the Bay Area Therapists Specializing in Adolescents, president of the Association of Family Therapists of Northern California, and is part of the Bay Area Oppositional and Conduct Clinic. In working with clients, he uses a family systems (e.g., Structural, Strategic, Emotionally Focused Therapy) and Cognitive Behavioral Therapy approach based in a postmodern perspective (e.g., Narrative, Solution Focused). He also provides Eye Movement Desensitization Reprocessing (EMDR) and neuropsychological assessments. You can learn more about him at www.drkeithsutton.com.
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