Psychologist Madeline Levine has been counseling teenagers for over 25 years, but recently Levine has begun to see a new breed of unhappy teenagers—smart, successful, and privileged kids who feel utterly lost and empty. For Levine, one client in particular typified this kind of unhappy teenager. Late on a Friday afternoon—the last appointment of her week—Levine saw a 15-year-old girl who was "bright, personable, highly pressured by her adoring, but frequently preoccupied … parents." The girl was also "very angry."

Levine quickly recognized the girl's "cutter disguise"—a long-sleeve t-shirt pulled halfway over her hand, with an opening torn in the cuff for her thumb. Such t-shirts are used to hide self-mutilating behaviors: cutting with sharp instruments, piercing with safety pins, or burning with matches. When the young girl pulled back her sleeve, Levine was startled to find that the girl had used a razor to carve the following word onto her forearm—"EMPTY."

Levine commented:

I tried to imagine how intensely unhappy my young patient must have felt to cut her distress into her flesh …. The most common thing I hear in my office from the kids is, "I'm fake." The surface of [their family life] always looks good …. The lawns are always perfectly manicured, the houses always look beautiful. But when you get to what's going on beneath these kids' T-shirts, there's not much happening inside.