‘Don’t Get in Your Patient’s Boat’

I was pointed to this New York Times article on the pitfalls of psychotherapy with the superrich from kottke. As a psychiatrist myself (who never, alas, treats the superrich), I was interested by the number of notable psychiatrists who seem to be making it their niche. True, treating the superrich overlaps with the issues, long considered very challenging in psychotherapy, of treating the very narcissistic. But the article is, I think, too polite about what I assume are added ingredients of a mix of therapists’ voyeuristic and purely mercenary interests in taking on the extremely wealthy in particular. The patients and their struggles are not inherently more interesting; in fact, they are probably less so, on the whole, despite the pat statement quoted by a therapist of the rich that she “considered a rich person’s unhappiness or emotional anguish no less serious than anybody else’s”. As the writer correctly points out, most of these patients have less of an impetus to work things through than the rest of us, and even than the rich patients of days past, more and more insulated from a recognition of personal dissatisfaction in an ever more materialistic and spiritually vacuous society as they are. Thus, a therapist treated more often as just another member of the client’s personal entourage flirts with being readily disposed of if s/he too readily emphasizes unpleasant aspects of these clients’ lives, which is after all what therapy is all about. And if the therapist refrains. s/he of necessity becomes a sycophantic supporter of self-indulgence.

In fact, arguably, psychotherapeutic practice originated with the treatment of the affluent, and the psychoanalytic style of practice inherited by those in Freud’s lineage has remained expensive, largely unreimbursed by health insurance, and only affordable by the wealthy. (Perhaps that has shaped the compelling focus of this school of treatment on narcissism as a central issue?) Only relatively recently in the lifespan of psychotherapy has it migrated down to other strata of society, its techniques and the nature and extent of the problems upon which it focuses morphing in the process. This in large measure helps to explain the two divergent cultures of the modern practice of therapy and psychiatry — the rarefied, isolated and often interminable world of the psychoanalytic psychotherapy practice, and the urgent unsystematic intensity of community mental health aimed at the lower and middle classes. Only as psychotherapy transmuted to deal with the ‘real world’ problems of the rest of us has there been an impetus to incorporate consideration of social, economic and political factors urgently impacting on patients’ lives and welfare. Ironically, only the superrich can afford the possibility of change from lengthy depth analysis, and only they can afford not to change…

Related:  While we’re on the topic of unethical mercenary behavior among psychiatric luminaries, the name Alan Schatzberg will certainly mean something to any psychiatrist FmH readers.