Some Thoughts on My Psychiatry Practice

I’ve no­ticed a marked change in my clien­tele af­ter go­ing into pri­vate prac­tice.[1] Of course I ex­pected class differ­ences—I charge full fee and don’t take in­surance. But there are differ­ences that are not as pre­dictable as ‘has more money’. Dur­ing res­i­dency I worked at a hos­pi­tal Med­i­caid clinic and saw mostly poor, of­ten chron­i­cally un­em­ployed peo­ple. While mon­e­tary prob­lems were a source of stress, they were not nearly as pre­sent in peo­ple’s minds as some­one from a mid­dle-class up­bring­ing might think. Th­ese peo­ple were used to go­ing with­out. They were not try­ing to get more. The types of things they talked about were fam­ily prob­lems, health prob­lems, and trauma. So much trauma. Peo­ple’s ego-iden­tity crises cen­tered less on their ac­com­plish­ments and more on their re­la­tion­ships.

The pa­tients I see now are mostly highly suc­cess­ful, highly ed­u­cated, weathly peo­ple, most of whom care a lot about their ca­reers. Their ego-iden­tity crises cen­ter around their work and their po­si­tion in life rel­a­tive to oth­ers. There is a lot of con­cern about ‘the path’. ‘Did I go down the right path?’ ‘Did I make a wrong turn?’ There seems to be a great fear of mak­ing or hav­ing made a wrong de­ci­sion, which can par­a­lyze their abil­ity to make fu­ture de­ci­sions. While this group is not with­out trauma, it is not what they wish to fo­cus on. They will of­ten be dis­mis­sive of its effects on them, not­ing that they clearly got over it in or­der to get where they are now. Which is, you know, in my office.

Many of my new pa­tients do NOT want to take med­i­ca­tion. This is a large change from my pa­tients at the Med­i­caid clinic who were always re­quest­ing more and differ­ent pills. And this differ­ence is not be­cause my new pa­tients are less un­happy. They de­scribe in­tense mis­ery, even a wish to die, go­ing on for months if not years, and yet they strug­gle through each day in their sisyphean or­deal. They ‘power through’ un­til they can’t. Un­til some­thing gives. Then they come to me.

I can think of sev­eral good rea­sons to have con­cerns about us­ing med­i­ca­tion. What are the long-term effects? Could this change my iden­tity? What if this makes me ok with a shitty situ­a­tion and then I don’t fix an un­der­ly­ing prob­lem? But these are not the typ­i­cal con­cerns I hear raised. What most of my pa­tients say is that they don’t want to ‘rely’ on a med­i­ca­tion. They don’t want to be the type of per­son who takes it. ‘That would mean there is some­thing wrong with my brain.’ Even though they are clearly very de­pressed, clearly suffer­ing and hat­ing ev­ery day, so long as they can push through with­out tak­ing a pill they must be ‘ok’ in some sense. Tak­ing the pill would con­firm there is ac­tu­ally some­thing wrong. Tak­ing the pill might mean they are more similar to the pa­tients at the Med­i­caid clinic than they want to con­sider.

What struck me about this was how peo­ple’s de­sires to as­sume a cer­tain iden­tity – that of some­one who didn’t take med­i­ca­tion – was more im­por­tant to them than their ac­tual lived ex­pe­rience. ‘This is your life.’ And this is broader than to take or not take med­i­ca­tion. Peo­ple will suffer through hor­rible work situ­a­tions in or­der to be the type or per­son who has that job. ‘If your job makes you want to kill your­self, shouldn’t you con­sider quit­ting it be­fore kil­ling your­self?’ ‘But I’m good at it.’ Iden­tity seems to be ev­ery­thing. Ex­pe­rience is there to tell you if you’re on the right way to as­sum­ing the proper iden­tity. If you go through the mo­tions prop­erly you can look the part. What’s the differ­ence be­tween look­ing the part and be­ing the per­son any­way?

Now re­fus­ing med­i­ca­tion would be one thing if they wanted to come for weekly ther­apy and talk through their prob­lems. But many don’t. They com­plain they don’t have the time (and it’s time, not money that is the con­cern). They know some­thing is wrong. They were told by their pmd or prior psy­chi­a­trist that they should go on an an­tide­pres­sant. They didn’t like the idea, they came to me. For what? I sus­pect they wanted me to iden­tify the one thing that would help them in one 45 minute ses­sion and tell them how to fix it. It doesn’t work like that. In this sense, they are not that differ­ent from the pa­tients I worked with at the Med­i­caid clinic. Those pa­tients de­manded new meds to fix them, when they clearly had a lot of prob­lems med­i­ca­tion was not go­ing to fix. ‘This might make you feel less hor­rible, but it’s not go­ing to solve the prob­lems with your mar­riage.’ Th­ese new pa­tients es­chew be­ing iden­ti­fied in that class, but still in some sense want a ‘quick fix’. They want to feel bet­ter but keep their illu­sion of iden­tity in­tact.

So what’s the point of these ob­ser­va­tions? I’m not quite sure yet. I’m still work­ing that out for my­self, which is one of the rea­sons I de­cided to write them down. I find I iden­tify more strongly with my cur­rent clients, which is un­sur­pris­ing given we have more similar char­ac­ter­is­tics and back­grounds. I see some of my own iden­tity strug­gles in theirs, and it makes me re­flect how ridicu­lous the whole iden­tity strug­gle is. Every­one is Good­hardt­ing it[2]. All of the time. Peo­ple want to play a part and they want to be the type of per­son who plays that part, and their lived ex­pe­rience is a frus­trat­ing dis­ap­point­ment which doesn’t fit the role they told them­selves they have to play. And we live in a so­ciety that is vi­gor­ously re­in­forc­ing ‘iden­tity’ roles. One where 7 year olds are asked to write es­says on their ‘iden­tity’. Can we let go of these iden­tity con­structs? What is the al­ter­na­tive? Bud­dhism? Ego death? Self-refer­en­tial sar­casm? I feel like I’m onto some­thing but not quite there yet. Psy­cho­anal­y­sis is, af­ter­all, an at­tempt to be more hon­est with our­selves, and that, it turns out, is much more difficult to do than one might ini­tially think.

[1] * Just not­ing that I re­al­ize that money is not the only fac­tor in the se­lec­tion pro­cess. Pa­tients at the Med­i­caid clinic were of­ten wait­ing for months to be seen. A long wait will se­lect against pa­tients that are am­biva­lent about tak­ing med­i­ca­tion. In ad­di­tion, my web­site ad­ver­tises me as be­ing more ‘ev­i­dence-based’, which I think ap­peals to peo­ple who are more likely to have a sci­en­tific world-view. Another large differ­ence be­tween my cur­rent and former clients is be­lief in God. Al­most none of my cur­rent clients be­lieve in God, whereas the ma­jor­ity of my prior clients did. Reli­gion does an­ti­cor­re­late with class, but I think this is more ex­treme then one would ex­pect by class alone. I also have a large num­ber of peo­ple in fi­nance. How many hedge fund man­agers are there in NYC any­way? I have many first and sec­ond gen­er­a­tion im­mi­grants, who have ‘pul­led my­self up by the boot straps’ type sto­ries. The wealthy clients I got are ‘new money.’ Ba­si­cally I think my ad­ver­tis­ing cap­tured a de­mo­graphic that is un­usu­ally close to that of my friend/​peer group and not nec­es­sar­ily rep­re­sen­ta­tive of most ‘rich peo­ple.’ The fac­tors that caused them to se­lect me might very well be more rele­vant than rich v poor in terms of their psy­cho­dy­namic makeup.

[2] * Good­hardt’s law: “When a mea­sure be­comes a tar­get, it ceases to be a good mea­sure.” In other words – peo­ple are op­ti­miz­ing for the su­perfi­cial qual­ities by which suc­cess is mea­sured, and not the un­der­ly­ing struc­ture of the suc­cess.