# 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.