Privilege and adolescent addictions

This article will address the treatment of affluent adolescents with substance use disorders through a family systems approach. This approach considers not just the “problem adolescent,” but also the family dynamic within which the adolescent is raised. To accomplish this objective, the major psychosocial risks unique to adolescents from affluent families, as well as the challenges that the professionals who treat them face, will be addressed. Finally, through a case study, this article will provide a real-life example, thus offering suggestions for working with this population.

High-risk group
Although it is commonly believed that children from highly educated, affluent families constitute a “low-risk” population, several studies have found that these youngsters are as susceptible to substance use disorders as adolescents from lower socioeconomic “high-risk” populations.^1,2 There are several reasons for this. The first maintains that children from affluent families must manage achievement pressures from their successful parents and siblings. In this context, the message that affluent children receive from their perfectionist parents is that failure to succeed equals personal failure.

This overemphasis on accomplishments while under emphasizing personal character and resiliency leads to increased rates of anxiety and depression, which in turn lead to higher rates of substance use. The theory is that these pressured children use substances to “self-medicate” intolerable emotions.³

The second reason offered for increased rates of substance abuse among affluent youth is that these children frequently are isolated from the parental figures in their lives. This isolation manifests itself both in a literal and emotional context. While wealthy parents are out of the house pursuing their careers and the trappings of wealth, their children frequently are left alone or in the care of professional caregivers. Without parental figures in their lives, these children are hungry for firm yet authentically compassionate role models.²

In addition, studies show that affluent children frequently feel emotionally isolated from their parents even when their parents are physically around. In their own self-absorbed drive to succeed, affluent parents fail to provide their children with the unconditional nurturing that is so essential to their growth as assured and confident human beings. Again, this isolation leads to increased levels of anxiety and depression, which in turn lead to unhealthy ways of coping with unacceptable feelings.^4,5,6

Just as affluence is too frequently celebrated as a substantive quality possessed by the privileged, substance abuse and imperfection are still too frequently stigmatized as a moral failing or character weakness that affects lower socioeconomic classes. As a result, affluent parents feel a great deal of shame in admitting that there may be a substance abuse problem in their family. This view keeps the problem hidden deep behind the family’s manicured façade, impairing the willingness to seek treatment.²

This misplaced belief that “if it looks OK, then it is OK” leads to affluent families turning a blind eye to telltale signs of problems and denying when problems exist. One of the most common ways this denial manifests itself is in overscheduled days and additional academic pressures. Although often grounded in the family’s genuine concern to see the child succeed, these pressures continue in spite of the child’s cries for help. In these families, an idle mind and body are seen as the “devil’s playground.”

At the heart of this hyperactivity is the fear that if they slow down or stop, family members will be overwhelmed by the truth and will be forced to address issues that they are unwilling or unprepared to handle. So instead of addressing nascent problems when they emerge, families driven to succeed try to cover unwelcome tracks with a whirlwind of activity.

And it is not just the affluent family system itself that is challenged by wealth and success. The outside systems that treat affluent adolescents are often faced with obstacles to effective care. These challenges include dealing with the families’ exaggerated privacy concerns, overly pressured lifestyles, and denial of the problem.^7,8 As a result, these professionals frequently hesitate to report their concerns to affluent parents for fear of resistance, intimidation, or even the threats of a lawsuit.

As a result, research has found that affluent youth too frequently have less access to school-based counseling services than economically disadvantaged students.⁹

Case study
Several months ago I received a call from a 46-year-old mother of an adolescent son and daughter. The mother requested a family session “to get her husband into treatment.” In a pressured voice, she told me her husband was using cocaine and she saw his use as a negative influence on “her” children. Apparently, the 14-year-old son had been caught smoking marijuana in the bathroom of his exclusive prep school and was in serious academic trouble.

The mother warned me that her husband was “difficult” and that they “had been down this road before.” Although she had never met me, she asked during our initial call “if I thought I could handle [her husband].”

The father was a handsome, successful physician with a thriving Park Avenue medical practice and a solid gold Rolex. He was charming and in charge, angry for being called to task, but willing to “do what he could” to resolve his wife’s “hysteria.” The mother was a fit, blonde and immaculate stay-at-home Mom who showed up at our session clinging to an expensive handbag and two perfectly manicured children. She was brittle to the point of breaking, and her anxiety manifested itself in the look of terror deep within her children’s eyes.

When asked why it was the father’s drug use we were focusing on instead of the son’s, both parents were quick to dismiss me. The husband placed the blame on his wife and dismissed our meeting as an obligation he had agreed to in order “to keep the peace.” The wife’s dismissal was more painful. She directly attacked my credentials and me. According to her, I lacked the experience and clinical acumen “to see that the problem was not with the son, but with the husband.”

“Look,” she said in a harsh and pointed tone. “If you aren’t up for this, I can find someone who is.” She continued, “Don’t you get it? My son is fine. It’s my husband who has the problem here. You need to put him into treatment.”

Somehow this very intelligent and sophisticated woman thought I could throw a net over her husband and send him away to treatment for 30 days while she and her children returned to their affluent nirvana. Essentially, she saw me as a pawn in a game that she paid for and controlled.

Before the completion of the session, however, the husband left the room. He had a standing poker game with his friends and didn’t want to keep them waiting. With the father out of the room, the mother realized that her attempts to control him through me were pointless. In response, she too decided to end the meeting and regain control. With ice literally dripping from her lips, she told me how “disappointed” she was with the session and me. Several days later, she called my supervisor to complain about the “service” she received.

Fortunately, my supervisor had been down this road many times before and had a deep understanding of the dynamics in affluent families. So instead of taking sides, he simply suggested that she schedule another appointment and talk this out alone with me. Recognizing that her ego would prevent her from making such a call, he advised me to wait a day and call her myself. I followed his advice. Although my call was received with an indignant tone, the woman agreed to another appointment.

When I met her this time, however, she was nearly unrecognizable. Without her family around, the stress of her life was apparent. Instead of hiding behind a façade of perfection, she revealed the frayed edges of her pain. In the privacy of my office, she allowed herself to talk honestly about her fear of failing as a mother and wife, and also how she loved her son and her husband but felt betrayed and devalued by them. She felt alone and mute, angry and sad, humiliated and defeated.

This honest admission by the mother was a huge step in her family’s recovery. It was my professional responsibility to provide her a safe space where this transformation could occur. By removing my pride and ego from the equation and allowing the mother to express her concerns about my “performance,” I modeled the vulnerability and humility that enabled her to reveal the pain around hers. In so doing, we formed an alliance based on truth, empathy and trust that we were then able to take into the family system.

It took a while, but eventually each family member joined in our weekly therapeutic sessions and became willing to express fears, vulnerabilities and concerns with one another. Instead of operating from a hard and shallow veneer, the family began to cultivate care and compassion that provided the nurturing soil that allowed them to heal as individuals and as a family unit. It was a long and often rocky road, but one they were able to travel together respectfully.

Conclusion
I relay this experience to illustrate how challenging working with affluent families can be and how important it is to stick with the process and to be alert to one’s own hostile reactions.

In this case, the family system initially refused to acknowledge the true origin of the problem or to allow an outside intervention. Because the family was successful and rich, the family members viewed the people they paid as the “hired help” who were there to do their bidding. In so doing, they undermined the therapeutic process and perpetuated a self-destructing family order. But by honoring the mother’s voice and meeting her in her reality, we were able to move forward to a place where honesty, vulnerability and healing could occur.

As professionals who treat these families, we must remain open and available for this process to happen. To do this, we must watch our own egos and be aware of our own feelings and reactions toward wealth and power. It is easy to fall into a cultural trap and either deify these people for their wealth or resent them for it. Both ends of the spectrum present problems.

Effective treatment requires clarity and focus, and remaining grounded in our talents and purpose. We must remain aware of the power of wealth and not be distracted or seduced by it. By remaining grounded in our ethical and personal goal to help those in need, we will be available to provide the empathy and compassion these families require while modeling vulnerability, authenticity and truth.

We must be tough and kind, flexible and firm, and understanding while expanding awareness. In short, we must honor the professionals that we are and not fall into the cultural trap that these families erect around them.
The work is challenging. The work is frequently tough on our own egos. But like most challenging things in life, the rewards from persistence and honest effort are great. I encourage you to allow yourself to stick with an uncomfortable process and fully engage in the endeavor. Here are some suggestions:

•    Give the process time. Don’t be discouraged if the first few sessions are rocky.
•    Bring a colleague into the process to check your reality and support your interventions. Wealth and power can be blinding. Constantly check your vision with another person through supervision.
•    Look beyond the veneer. The pain lies hidden deep within. Be patient in your exploration.
•    Model vulnerability, compassion and empathy. People heal in nurturing relationships. Provide one for the family.

Paul Leslie Hokemeyer, JD, PhD, is a nationally recognized expert on treating substance use disorders in affluent populations. His research has been published by Lambert Academic Press, The Journal of Wealth Management, and Family Therapy Magazine. Based in New York City, he maintains a private practice and also serves as Senior Clinical Adviser to Caron Ocean Drive, a residential treatment facility in Boca Raton, Fla. His e-mail address is phokemeyer@yahoo.com.

References
1.    Luthar SS, D’Avanzo K. Contextual factors in substance use: a study of suburban and inner-city adolescents. Dev Psychopathol 1999 Fall;11:845-67.
2.    Luthar SS, Latendresse SJ. Children of the affluent: challenges to well-being. Curr Dir Psychol Sci 2005 Feb;14:49-53.
3.    Luthar SS, Becker BE. Privileged but pressured? A study of affluent youth. Child Dev 2002 Sep-Oct;73:1593-1610.
4.    Csikszentmihalyi M. If we are so rich, why aren’t we happy? American Psychol 1999;54:821-7.
5.    Kasser T. The High Price of Materialism. Cambridge, Mass.: MIT Press; 2002.
6.    Myers DG. The American Paradox: Spiritual Hunger in an Age of Plenty. New Haven, Conn.: Yale University Press; 2001.
7.    Puura K, Almqvist F, Tamminen T, et al. Children with symptoms of depression: what do the adults see? J Child Psychol Psychiatry 1998 May;39:577-85.
8.    Wolfe JL, Fodor IG. The poverty of privilege: therapy with women of the ‘upper classes.’ Women Therapy 1996;18:73-89.
9.    Luthar SS, Sexton C. The high price of affluence. In Kail RV (ed.), Advances in Child Development. San Diego: Academic Press; 2004.