What If Psychotherapy Required Physician Referral?

I didn't think much of it when my own physician wrote me some kind of order or prescription for 12 sessions of physical therapy a couple months ago, maybe just whether my medical insurance would claims for additional sessions differently. But a few days ago I was surprised to read in a physician forum a discussion of possible ramifications if physical therapists were allowed to treat patients directly, that is without referral from a physician. I had always assumed that patients could self refer to physical therapists in much the same way they can to psychotherapists.

This led me to wonder what it would be like if one could only engage the services of a psychotherapist with an order from the physician, maybe not necessarily even a psychiatrist. Maybe this would only apply to reimbursement. In other words you could self refer at will provided you paid cash, but perhaps there would be reimbursement from healthcare payers only with physician referral. Maybe it already works this way for some carriers.

How would this impact a typical psychotherapy practice? How would physicians determine whether to refer for psychotherapy? Would they get to know better the psychotherapists to whom they referred? It already seems to me that even psychiatrists might find it difficult to find a local psychotherapist who provides the type of psychotherapy best suited to a patient's particular problem. I suspect most physicians lump it all together as psychotherapy or counseling and don't know the difference between psychoanalysis and dialectical behavior therapy or between family system psychotherapy and primal scream. Certainly it would seem that physicians might be inundated with marketing efforts by psychotherapists clamoring for referrals. Maybe physicians would thus learn something about psychotherapy methods. Or would busy physicians just ignore it all and blindly authorize whatever treatment they are patients requested?

Under such a system might there be more communication, real collaboration, between physician and psychotherapist? Would it be easier or more difficult for patients to get treatment? What would be the impact on health care costs overall? Would such a policy solve problems or just create new ones?

The Good Med Check IV: Getting Physical

(Continued from The Good Med Check III: Time Is Money)

Critics of the med check often equate the abandonment of psychotherapy by psychiatrists with tragic abandonment of the biopsychosocial model, viewing psychotherapy as a necessary ingredient of every patient encounter (if only for psychiatric patients). You might think they were invoking the bio-psychotherapy-social model. But in fact when psychotherapy in the form of psychoanalysis stuck it's foot in the psychiatric door a hundred years ago was it not the "bio" that was abandoned? Back then  few drugs competed with non-"biological" treatment modalities, but as the model of psychiatrist as psychotherapist (or just "therapist") evolved psychoanalysts pronounced the physical examination, so long an integral part of patient-physician encounters, incompatible with analysis, and eventually any psychotherapy, citing potential boundary violation: talk, but don't touch. (Thankfully, we do not hear protests that psychotherapy should accompany electro convulsive therapy.)

To be sure physicians of many specialties have abandoned the physical exam in favor of laboratory tests and imaging studies. If your non-psychiatrist physician lays hands on you at all, she will likely limit or direct the examination to only that which relates directly to your complaint or diagnosis. Admittedly, at least at first look, few aspects of the physical (other than the mental status exam) seem directly related to psychiatric complaints or disorders, unless the psychiatrist assumes the role, as some do, of primary care provider. But a psychiatrists probably could do a better job by attending to a few physical findings, whether part of a med check or a psychotherapy session. A few examples follow:

• Monitoring blood pressure in patients taking venlafaxine, and some other drugs
• Weighing eating disorder patients or patients taking drugs that affect weight
• Pupil diameter when you suspect unadmitted drug use
• Examination for cogwheel rigidity in patients taking dopamine antagonists
• Neurological examination to rule out neurological causes for psychosis or conversion

One could argue that the psychiatrist needs to "see" the patient more than the patient needs to see the psychiatrist. In some ways physical examination of a psychiatric patient stands at the opposite end of the spectrum of clinical tasks from psychotherapy, but it is at least as legitimate.

Digital Diagnosis Duo for DSM

I have found that turning ideas upside down often leads to truth. An example from my personal experience follows while another pokes fun at those who thrive (and even profit from) labeling any activity they deem excessive an addiction, then claim to offer treatment for it. (Nothing here should be interpreted as making fun of anyone who suffers from any psychiatric or substance use disorder or any professional or program intending to help such individuals.)

Digital Gaming Aversion Disorder (DGAD)

About two years ago, while sitting at my desk, I realized that there was really nothing I wanted to do. A friend had been playing solitaire on her computer, and that was all it took to get me going. Within a few days I was hooked. Almost every time I got done with whatever computer task I had been engaged in, I started playing solitaire. After a couple weeks I realized my skills were improving gradually. I began to develop winning strategies. Maybe I wasn't addicted yet, but I certainly might have been headed in that direction.

Then one day I noticed that some of the pleasure had gone. I almost had to force myself to finish a game. Next time I thought about starting another game I simply could not do it. I have not played solitaire since. When I see my friends playing, the screen looks totally two dimensional, unlike previously when it was as though I could see into the game. I cannot even imagine myself starting a game. The thought of how it works, the different suits, the different colors, the different numbers, all are blocked from my mind.

To be honest I cannot say this has interfered substantially with my social or occupational functioning. I cannot say that I am particularly distressed about this aversion to solitaire. However, should I want treatment, I have two approaches to propose, both probably requiring double blind studies to prove their effectiveness.

Psychotherapy of Digital Gaming Aversion Disorder

Cognitive behavior therapy will be the first line psychotherapy for this disorder. I believe a sufficient and appropriate reward will quickly overcome the aversion. I suggest rewarding the patient with $1000 for each game played to conclusion will rapidly reverse the aversion. I of course expect this to be covered by medical insurance.

Pharmacotherapy Of Digital Gaming Aversion Disorder

I believe a similar approach to that proposed for psychotherapy will lead to rapid resolution of this disorder using cocaine as the first line agent. A small dose after completing each solitaire game should lead to rapid resolution.

Digital Media Avoidance Disorder (DMAD)

For years now people have admonished those who, in their minds, use computers and/or the Internet "too much," calling these behaviors, like almost any other behavior they can label excessive, "addiction." It occurs to me, however, that those who engage in this "addiction addiction" simply want to deflect attention from their own dysfunction. This clever but pathological strategy, based on severe denial, has enabled them to avoid needed treatment, often for many years, for the condition I address below.

Today we must all face the fact that we can only experience true reality through digital media, using devices like computers, smart phones, and other devices, regularly, if not continually, connected to the Internet. Avoidance of this reality can be compared to intoxication with drugs or alcohol, which we all know provides an escape for the user who wants to avoid the realities of day-to-day life.

To address this problem first we must confront the denial, rejecting the notion that we can experience reality without digital media. This dangerous idea will certainly lead to impairment of social and occupational functioning and probably distress as well. In particular, avoidance of social media can lead to digital social isolation. A disturbing percentage of the population may have never communicated with another person via email or texting with resulting alienation from digitally connected friends and family!

Treatment of Digital Media Avoidance Disorder

Due to its similarity to chemical dependence, treatment requires admission to inpatient rehabilitation where a holistic approach involving staff of numerous disciplines will immerse the patient in (digital) reality with gradual elimination of escape into non-digital media euphoria. Cell phones with non-removable ear buds will start the detoxification process. Only in the first hours will staff allow patients gradually diminishing access to analogue devices such as harmonicas, nose whistles, and, for more severe cases, ukuleles to ease the transition. At first specially trained staff even engage in face to face conversations with them. Motivated patients will work the (binary) 1100 step program. They will gradually learn that  ordinary feelings associated with life in the real digital world are normal and they they can tolerate them or even to appreciate them, that feeling them affirms life. They will learn to turn them over to Google (as they know it, their higher power). Patients who can tolerate tweeting and blogging while simultaneously listening to streamed audio, playing computer games and shopping on ebay will participate in a ritual upload to YouTube of a digital video showing their dysfunctional pre-digital escapest functioning followed by scenes showing them leading a fully sober digital life one virtual day at a time. They are ready for discharge. Most will continue working the binary 1100 steps in video-conference meetings for years after discharge, starting with 1001010 meetings in 1001010 days. After working the program for a year or more, some individuals can play World of Warcraft non-stop for 11000 hours without face-to-face contact with another human. Rarely do such individuals relapse.

Short Psychotherapy

No, not "short term," short, as in short sessions.

Who says psychotherapy requires 45-50 minute sessions and a formal commitment? Although I cannot claim to know the history I suspect the almost-an-hour session originated with psychoanalysis, and the 45' session allowed psychotherapists to pack more patients into a day, and make more money. Modern psychiatric visits started out as psychotherapy sessions. The medication management piece snuck in slowly and now threatens to take over entirely. Despite the numerous advantages of independent provision of medication management and formal psychotherapy a compromise model offers a few advantages that might quiet some of its critics.

Since I ostensibly stopped offering psychotherapy I have noticed that the patient and myself often wander off the subjects of symptoms, medications and side effects, and almost as often I yield to the temptation to offer a systemic intervention, even when I know the patient is "in" psychotherapy in the more formal sense with a non-physician professional.

When I reflect, I realize this is nothing new. My family systems perspective lends itself to this less rigid approach to psychotherapy. I have done this all along. There is no real contract. Patients appreciate it, possibly partly because it's one-stop shopping and I charge no more for the added time.

There's always that dilemma over whether to charge a flat fee whether the visit lasts only five minutes or requires twenty five. The payer, whether a third party or the patient herself, likes to know in advance how much any visit will cost. I don't like to have to worry about whether the patient can afford an extra ten minutes with me. Besides, my fee always covers much more than actual time with the patient: office rent, staff, billing services, postage, telephone calls, malpractice insurance, contacts with other treating professionals, writing medical records, copying medical records, reading some other provider's medical records, ordering prescriptions, etc, ad infinitum.

CBT, which can be directed at specific symptoms and disorders also may lend itself to this model. Read High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide or the article in the October, 2010 issue of Psychiatric Times.

Pitfalls do exist:

• The psychiatrist risks working at cross purposes to the independent psychotherapist treating the patient formally.
• Without a contract patient expectations may exceed reality.
• It's a lot easier to say "time's up" when you both see the minute hand on ten. In this model you decide when to stop based on when you want to go home or how many patients are in the waiting room. There's no entitlement to the full 50'.
• Some patients may not feel permission to bring up a matter they want help with.
• That matter the patient wants your help with might require referral for formal psychotherapy. But you can figure that out with the patient and steer them in the right direction.
• Some interventions benefit from follow-up within a few weeks, but for medically stable patients the next regularly scheduled appointment may be months away.

The notion that psychotherapy must be an all or nothing proposition may prevent you from providing the best treatment to your patient. If you the psychiatrist include a psychotherapy intervention now and then, you may increase efficiency, cost-effectiveness, and your chances of success.

How Many Psychiatrists Does It Take?

In his article in the most recent issue of Psychiatric Times Daniel Carlat, M.D. estimates that we need 45,000 more psychiatrists in the United States. In the article Pharmacists Take Larger Role on Health Team we read that pharmacists could be part of the solution to that problem as they assume roles that were once the sole province of physicians. What is missing from Carlat's article (but may appear in his references) is an estimate of how many patients a single psychiatrist can treat. Carlat advocates at the same time for psychiatrists to do more psychotherapy, but we can't have our cake and eat it too. A psychiatrist who attempts to do traditional psychotherapy and 45-50 minute sessions while also treating patients with medication or other biological interventions will not be able to manage nearly as many cases as a psychiatrist who delegates psychotherapy duties to non-prescribing professionals.

Carlat's solution to the problem of too few psychiatrists, training psychologists in the role of psycho pharmacotherapist, will perpetuate the inefficiency of psychotherapists attempting to manage biological treatments at the same time, though there will likely be more of them. In his article Carlat's justification for training psychologists to do medication management rather than recruiting more advanced practice nurses and physician assistants is his unsubstantiated notion that psychologists will be better able to handle what he calls "tough cases." If by tough cases he means the ones that do not improve with first line treatments, it is unlikely that more psychological training will help. If he means patients whose personalities interfere with their treatment, we need to keep in mind that personalities can interfere with all kinds of medical treatment. Perhaps we should train psychologists to treat diabetes and do knee replacements and colonoscopies, too.

While Carlat and others push for combining psychotherapy with medication management another trend would seem to push in the opposite direction. As more and more prescribers give up psychotherapy some would seem to take on the role of primary care provider (We don't seem to have enough of them either.) for their psychiatric patients. This role arguably demands physical examination of patients which the vast majority of psychiatrists gave up as soon as they finished residency. Of course physical findings have little if any bearing on any psychotherapy, but psychodynamic and psychoanalytically oriented psychotherapists seem to have particular difficulty with the so-called "transference" implications of so much touching and seeing on the psychological treatment.

I believe we have plenty of non-prescribing psychotherapists now and that those professionals are at least as capable as their physician counterparts. I believe physicians remain the most capable of prescribing. I also believe that much of the impetus for psychiatrists to continue providing psychotherapy comes from the psychodynamic school and that for many psychiatric patients such an approach is either completely unnecessary or maybe inferior to cognitive behavior therapy or other psychotherapies. However, I believe that improved psychotherapy skills will make for better psychiatrists. We need to develop greater efficiency in incorporating psychotherapeutic interventions into psychiatric contacts. This will require us to relinquish the traditional 45-50 minute session (Today much of such sessions is already occupied by administrative activities anyway.) in favor of a model that incorporates directed psychotherapeutic interventions into a 5-20 minute medication management visit. Furthermore, all physicians would probably benefit from learning some of these interventions.

Which direction will psychiatry take? Will it return to psychotherapy as a core service or become even more medical with performance of physical exams? Or will psychologists, nurses and pharmacists take care of the psychiatric patient of the future?

Maybe we won't need psychiatrists. If we don't make psychiatry more attractive by eliminating burdens from regulation, low fees and payer contracts we won't have psychiatrists.

Unhinging Dr. Carlat

No, this is not a review. I have not read the book, and I don't entirely disagree with Dr. Carlat's ideas.  I did, however, read a review, which I cannot now locate, but which included a short case said to have come from the book. A brief look may demonstrate the extent to which a different perspective can influence a psychiatrist's approach and challenge the notion that psychiatrists prescribing medication should also provide psychotherapy to most patients. (Let's not blame Dr. Carlat for any of this. The reviewer may have misread Carlat, and I may have misread the reviewer. If I didn't get it right, apologies to Dr. Carlat.)

As I recall the case involved a patient prescribed zolpidem for insomnia. Because of oversedation he nearly or actually wrecked his car. The patient had not been able to muster the courage to contact the doctor about the sedation because of his reluctance to confront authority figures, such as physicians. According to the reviewer Dr. Carlat argued that had he been treating the patient with psychotherapy the patient might have overcome his reluctance, telephoned the physician, and avoided the accident.

Here's how I would approach the case: First, I never prescribe zolpidem. Even if I prescribe a drug for insomnia I prefer melatonin, gabapentin, or a very sedating antidepressant like mirtazapine or trazodone. But before prescribing I want to know the source of the insomnia, and in some cases will recommend a sleep medicine consultation. I also like to address sleep hygiene (behavior) before resorting to a drug. Why would I want to prescribe a drug like zolpidem that can lead to dependence and has been associated with patients eating a buttered cigarette or driving while asleep?

But suppose, against my best professional judgment, I do prescribe zolpidem. I would do so only after warning the patient about the risks involved. And in fact the pharmacist would probably offer the same warnings orally and in writing when dispensing the drug.

But let's say it still boils down to that problem of psychological reluctance to call the authority figure. Successfully addressing such a problem in psychotherapy could take months or years, and there's no reason to believe it would happen any faster if the psychiatrist were providing the psychotherapy rather than a non-physician. Furthermore, we should not assume that psychotherapy would address said reluctance. Many kinds of psychotherapy don't address such problems at all, at least not directly. What would make a difference, however, is how often the patient visits the physician, even for a short visit to talk about medication effects, wanted and unwanted, and even with no psychotherapy.

This case also begs the question of whether psychiatrists should provide psychotherapy so patients can muster the courage to call between appointments about a side effect. I argue that psychotherapy should address a diagnosable mental disorder (however we choose to define it).

And wait. Suppose a sleep medicine physician, or heaven forbid an orthopedic surgeon, prescribed the zolpidem. Would we want all physicians to provide psychotherapy? Orthopods don't even do physical therapy.

This case provides little or no support for the position that psychiatrists should provide psychotherapy. It does underscore the importance of careful selection of medication, avoidance of medication when possible, and adequate patient education. In some cases there may be advantages to one-stop psychiatric shopping, but in this case the frequency of contact, rather than overcoming a psychological problem with psychotherapy might have made the difference.

Independent Treatment: The Whole Truth

Every article I have read in the psychiatric literature about "split treatment" (The psychiatrist prescribes medication while another professional provides psychotherapy.) reveals a bias against this practice. The article by Drs. Mossman and Weston (Splitting Treatment: How to limit liability risk when you share a patient's care Current Psychiatry 9:3) continues the tradition. While purporting to help psychiatrists avoid malpractice suits related to independent treatment, this article will likely send plaintiffs' attorneys scurrying to the authors' doors for expert testimony to support antiquated theories based in myth. I hope to provide the whole truth, which may appeal more to defense attorneys, not to mention patients.

Mossman and Weston would have you believe the story started "not long ago," when "insight-oriented psychotherapy was the primary treatment" provided by psychiatrists. Not so. The truth is that psychiatry's dalliance with psychotherapy has probably spanned less than half the time since psychiatry's birth; is already a thing of the past; and 100 years from now will probably be viewed as a little blip. There have probably always been many psychiatrists who eschewed psychological treatment approaches, preferring ECT or medication, but psychiatrists only became enamored of psychotherapy with the introduction of psychoanalysis by Freud, who was himself a neurologist.

The terminology betrays the bias in discussions of this subject. "Split treatment" implies inferiority to "whole" treatment (without foundation). More accurate, less pejorative terms include "joint treatment" (which the authors do mention at least once), "collaborative" and "independent" treatment. The authors use these latter terms to designate types of "split-care relationships," but I argue that these terms may in fact be synonymous with split treatment. Collaborative care implies coordination, but still the non-psychiatrist provides the psychotherapy. This term has also been used to designate treatment models in which a primary care physician, rather than a psychiatrist, provides medical management. The term "med check" likewise demeans the medication management or psychopharmacology visit.

Independent care, rather than designating a type of split care, accurately and without bias describes the reality: When a psychiatrist prescribes medication, and a psychotherapist provides psychotherapy, each is an independent, presumably licensed or registered, professional. Neither assumes responsibility for the actions of the other, regardless of who wears the deepest malpractice pockets. What Mossman and Weston fail to mention is that each of these professionals may be "treating" something different. The psychiatrist may prescribe paroxetine for panic disorder while the family psychotherapist treats marital conflict or parenting problems. Yet another psychotherapist, a psychologist perhaps, may provide cognitive behavior therapy for the panic disorder, but even when the two professionals thus treat the same problem for the courts to hold either responsible for the actions of the other is a grievous error. Frequently the psychiatrist may treat a "brain disease" with medication or rTMS while the psychotherapist helps with life problems, related or unrelated to the psychiatric -- or other -- illness.

Another erroneous assumption in the Mossman Weston article, and indeed most discussions of independent treatment is that the duration of the two treatments coincides. In fact many psychiatric conditions require lifelong medication either for symptom control or for prevention. Psychotherapy, however, usually stops after certain goals are reached. This may apply especially to cognitive behavior therapy. No patient should have to continue 45-50 minute sessions indefinitely to satisfy the needs of the psychiatrist who has become stuck in the rut of psychotherapy. And psychiatrists who require all patients to be "in" psychotherapy for the duration of treatment have an obligation to inform each patient that other psychiatrists may require only short medication management visits.

Did I mention the patient? I read the Mossman Weston article twice or more and found no mention of what the patient wants. I regularly encounter patients in my practice who do not want psychotherapy. We must respect what the patient wants, even if ultimately we must guide some patients in a different direction. Some patients, too, want only psychotherapy. And even if the patient wants both, how many psychiatrists can provide skilled psychopharmacological treatment as well as excelling at a variety of different psychotherapies. The patient who needs CBT in addition to medication deserves the best CBT psychotherapist, and that will not likely be the psychiatrist. The patient with a substance use disorder may need a chemical dependency counselor. The patient has a right to choose which psychiatrist and which psychotherapist or counselor from whom he or she wishes to obtain treatment.

Myth: Psychiatrists are the best psychotherapists. Psychologists, social workers and others can possess skills in psychotherapy equal to or better than many psychiatrists. Medical school may provide essential foundations for a psychopharmacology practice, but not for psychotherapy.

Myth: The psychiatrist should judge the competence or credentials of the psychotherapist. This is absurd. No medical school, internship or residency trains any physician in how to "credential" a professional of another discipline. Would this be expected of a primary care provider in the same situation? I think not. Mossman and Weston say "find out if the potential collaborator is credentialed." Even they, however, do not tell us what they mean by credentialed. Would a drivers' license suffice? If the patient's hairdresser or massage therapist provides advice or comfort, must the  psychiatrist confirm registration or licensure? This raises another question. Suppose the patient wants to use a clergyman as a counselor, a Rabi or priest perhaps. Should the psychiatrist then check with God about this individuals "credentials?" Should she "respectfully inquire" about malpractice insurance? The irony in this is that how the courts view this issue may hinge on whether this counselor bills the patient for services. And yet psychotherapists in training programs may provide service at no charge, not to mention other givers of advice in the context of completely informal relationships. Must the psychiatrist then inquire about financial arrangements? What about an alcoholic patient's AA sponsor? I say it's none of our business, and none of our responsibility.

Myth: "Psychiatrists have a duty to ensure that their patients receive good care." The psychiatrist only has a duty to provide good care himself unless there exists a formal supervisory relationship as in a clinic.

Logistical problems: From time to time a patient will have the audacity to consult a non-physician psychotherapist, counselor, or, the latest thing, life coach, without obtaining the psychiatrists permission. Now the abused psychiatrist must decide whether to punish the patient by discharging them on the spot (while carefully avoiding the appearance of abandonment of course), contact the psychotherapist to coordinate care, or ignore this new problem. Perhaps the psychiatrist should add language to the already encyclopedic policy statement each patient probably glances at before tossing in recycling, language demanding that the patient inform the psychiatrist before daring to consult any other professional. Then there is the matter of staying in contact. Assuming the psychotherapist has the courtesy to return phone calls, remember that patient authorization for release of information may expire after 90 days. This means you must make sure that each such patient reactivate written authorization at least that often even when stable treatment dictates visits only a few times per year. It also means that at the very time when communication would seem must critical, when the patient fails to keep an appointment or return calls, providers may not have a way to obtain authorization.

Liability wrongly attached to independent treatment is not a problem for the psychiatrist to solve by knowing through which hoops to jump to avoid liability, but for the courts to solve by attending to reality and obtaining competent expert testimony that supports reality, instead of sour grapes psychiatrists who can't stop living in the past and give up an unjustified bias in favor of integrated treatment. We had enough of a problem with scarcity of psychiatrists before health care reform that psychologists and nurses were able to convince legislatures to give them prescribing privileges. With millions of Americans newly able to afford psychiatric care we should make it easier, not harder, for psychiatrists to focus on what only they are able to do best, psychoparmacotherapy, and leave the psychotherapy to non-physicians.

See also: The Real Reasons Psychiatrists Want to Provide Psychotherapy

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.