The Best Treatment or Just the Most Expensive?

$600 an Hour for Treatment

No, $600 for a 45 minute psychotherapy session.

On July 7, 2008 The New York Times published an article (Age of Riches: Challenges of $600-a-Session Patients by Eric Konigsberg) describing the psychotherapy practices of psychiatrists Michael Stone and Byram Karasu.

At first read this looks like another story about the wealthy getting the best treatment. Not necessarily. This article tells us a little about what is probably a very unrepresentative sample of the rich and famous but raises many questions about the practice of psychiatry, or at least the practice of some forms of psychotherapy.

The article begins with an example in which Dr. Karasu criticizes a “therapist” for encouraging a patient to go ahead with an expensive purchase despite his misgivings rather than “explore” the patient’s anxiety. He labels the purchase as a manifestation of an “addiction” involving “excesses and consumption.”

The average psychiatrist today may charge more than $100 for a medication management visit that may last five minutes. Cram 12 of those into an hour and you easily exceed Dr. Karasu’s fee. Of course it takes many more patients to fill your practice. Or fewer psychiatrists can treat the same number of patients, depending on your perspective. The $600 fee is exorbitant, and indeed few can afford it, especially twice a week, but the economic law of supply and demand determines how high a fee such a professional can command.

Regardless of fees much of importance is conspicuous by its absence. There are references to treatment, neurosis, patients, doctors, and psychoanalysis, but there is no mention of illness, of mental disorder. The rich “patients” described in the article seem to want only help for life problems, for “unhappiness or emotional anguish,” or just someone to talk to.

If this is not just an example of the richest patients buying the best doctors, we need to look further for an explanation. Perhaps it is the rare wealthy narcissist (Narcissism also afflicts the poor and can lead to failure.) who gravitates to a treatment that is expensive, if easily afforded, and makes him feel special. Perhaps these doctors are no better than the next “therapist” at helping them, but they may become skilled in attracting them to and keeping them in “therapy” even when they fail to “make progress.”

Sometimes many of us like to think all that money and success would not have made us happier anyway, and indeed the wealthy suffer from many of the same mental disorders as the rest of us. Antidepressants and other medications, and psychotherapy methods like cognitive behavior therapy, effectively treat most mental disorders today. The notion of “neurosis” was long ago abandoned by the diagnostic manual of the American Psychiatric Association, but psychoanalysts, Freudian and otherwise, cling to it stubbornly. The few who seek psychoanalytic psychotherapy from the likes of Drs. Stone and Karasu may be less ill and more in search of someone to listen. They may even like the idea of a “treatment” that can go on for years, regardless of whether it is effective.

Ambivalence about whether to bid $8 million for a painting is not likely a manifestation of a mental disorder, nor is the success of “treatment” likely to hinge on whether to give the patient permission to buy rather than force him to explore his anxiety. The mentally ill, wealthy or not, deserve effective treatment. The worried well are all too happy to pay someone with lofty status to listen to their complaints. Psychoanalysts like Drs. Stone and Karasu need only a few such patients to fill their practices.

If you are wealthy and need treatment that works, find a family or cognitive behavioral psychotherapist, or take psychiatric medication. They work just as well for the wealthy as for the rest of us.