Desafios dos pacientes de US$600/sessão

Challenges of $600-a-Session Patients
NY Times
Published: July 7, 2008

Not long ago, a young titan of New York real estate sat in his psychotherapist’s office. An art collector, he was thinking of bidding about $8 million for a painting, and something about the deal made him uneasy.

Dr. Karasu said the rich could awe some therapists.

The therapist thought the patient was merely trying to impress him. This happened whenever the man felt unsure of himself, which was most of the time.

But instead of trying to explore the patient’s anxiety, the therapist encouraged him to buy the artwork: “This is what you want; you should go get it.”

T. Byram Karasu, a Manhattan psychiatrist whom the therapist consulted about the patient, was appalled. “That was precisely the wrong treatment,” he said. “The doctor forgot that addiction cannot be satisfied by its object. The therapist’s job is not to comfort and validate the patient’s excesses and consumption. Those are neuroses.”

Dr. Karasu, known as an expert in treating the wealthy and powerful, recognized a common pitfall among his peers: Rich people can be seductive. “The therapist wants to identify with the patients and comes to see it as his role to help them get more wealthy,” he said. In the process, the doctor risks becoming the patient’s “alter-id.”

Wealth reminiscent of the Gilded Age has encouraged a thriving business for a small and highly specialized group of therapists in New York and elsewhere. Their daily work gives them an intimate view of an elite who differ in some ways from their predecessors, and who can test the therapists who treat them.

More than a dozen therapists who are respected by their peers in the counseling of extremely wealthy patients said in interviews that, as with the real estate mogul, it can be hard to resist the temptation to sycophantically adopt their point of view.

In some cases, the patients treat their therapists as but another member of their entourage of servants. Some therapists also cited a heightened difficulty with frustration and setbacks for people used to getting what they wanted. And they are resistant to opening up, to showing vulnerability.

Dr. Karasu said the past few years had felt different to him.

“The problems are the same, but the scale is different now,” he said. “Hedge funds — there is no product, only wealth. It is flabbergasting to my patients, too. They can make so much money at once and then lose it.”

Dr. Michael H. Stone, a psychiatrist affiliated with Columbia, said that the preponderance of patients with self-made fortunes, many made at a relatively young age, marked a striking shift.

“It used to be that my patients were the children of the rich: inheritors, people who suffered from the neglect of jet-setting parents or from the fear that no matter what they did, they would never measure up to their father’s accomplishments,” he recalled. “Now I see so many young people — people in their 30s and 40s — who’ve made the money themselves.”

Dr. Stone said those two kinds of patients tended to have different problems: “In my experience, there was a high incidence of depression in the people who were born rich. And by contrast, the people today who are making a fortune are so often narcissistic in a way that excludes depression.”

Dr. Karasu is chairman of the department of psychiatry and behavioral sciences at Albert Einstein College of Medicine in the Bronx. He also has an office for private practice on 88th Street near Fifth Avenue. He charges $600 for a 45-minute session, seeing most of his patients at least twice a week.

It was during his first week in practice, in 1969, that he inherited a famous patient from a psychoanalyst who had recently passed away, and from that point on, he said: “My patients trained me in these issues. There’s a real school for it.”

King Ludwig Syndrome

A couple of years ago, Dr. Karasu received a call on behalf of an entertainment executive who wanted to reschedule an appointment at the last minute.

Dr. Karasu said the only time he had available that week was at 7 one night. The executive’s assistant said: “He’s having dinner then. How about 10 p.m.? He’s flying out to the Hamptons, but we’ll send a car for you and you can ride with him and do therapy on the helicopter, and then we’ll send you home in the morning.”

On and on it went. “If I would say I am busy on Saturday, the assistant would offer to pay me extra, as if that would be the answer,” Dr. Karasu said, adding that he declined the request. “For the average patient, the 45 minutes with a therapist is the most precious time. For this patient, it was just another activity superimposed on his schedule, and the therapist has to accommodate his way of being — like his trainer, his cook, his pilot, his administrative staff.”

Dr. Karasu and several of his peers voiced a concern that a rich person today was ever more inclined to view his or her psychotherapist as nothing more than a highly skilled member of his personal army.

Most of his patients have been “mega-successes, in very public industries,” he said. A good many work in the highest reaches of the financial sector, and some have been “celebrities in the movie business.” He also travels to Washington every Tuesday to counsel a couple of patients with high-profile jobs in politics. (“We’re not talking about congressmen,” he said.)

Dr. Karasu, 73, is a slight and measured fellow who, much like the patients he describes, possesses an immediately apparent curiosity and ambition. He grew up in a prosperous Jewish household in Istanbul, where his father was a newspaperman and wrote thrillers. Dr. Karasu has written several books, including an autobiographical novel, a forthcoming collection of poetry, and “The Art of Marriage Maintenance,” co-written with his wife, Sylvia, who is also a psychiatrist.

Dr. Karasu acknowledged that he was not immune from taking satisfaction in the success and fame of his patients. “Wealthy people bring about a degree of awe, even in their therapists sometimes,” he said. “This is the biggest problem I see in the doctors I supervise. And these are fully practicing doctors, doctors making $400, $500 an hour.”

He added: “It’s King Ludwig Syndrome. In the 19th century, Bernhard von Gudden was the psychiatrist for the Bavarian royal family and began to treat King Ludwig II, who was psychotic. In the end, the two of them drowned in a boat. So I teach my people who are treating wealthy people, ‘Don’t get in your patients’ boats.’ ”

Wealthy patients find Dr. Karasu — and others of his ilk — as they would other providers of goods and service: through word of mouth and through a general insistence on being referred to therapists with high academic credentials. For example, friends of Stephen A. Schwarzman, chief executive of the Blackstone Group, say that he has referred them to Dr. Karasu. A Blackstone spokesman said, “Mr. Schwarzman does not comment on personal conversations.”

It is the extremely rare member of this circle who does not acknowledge struggling with complicated and contradictory feelings about superrich patients. The therapists admitted to feeling jealous or contemptuous on occasion, and though Dr. Karasu said of his patients, “They are, almost all of them, smarter than I am, and certainly more competent,” he rarely missed an opportunity in interviews for a joke or aside about the absurdity of talking about wealth as an affliction.

Janet L. Wolfe, a Park Avenue psychologist and the co-author of a paper about difficulties in counseling “women of the ‘upper’ classes,” said she considered a rich person’s unhappiness or emotional anguish no less serious than anybody else’s, but acknowledged how trivial some of her patients’ problems could sound.

“One of the things that drew a very wealthy woman to see me was that she was an inadequate tennis player,” Dr. Wolfe recalled. “She was very serious about this. She felt that the other wealthy women she played with would think she was an inadequate person. It’s easier for rich patients to take problems like this seriously.”

Slow to Trust

The politician would not listen to his therapist.

In fact, nobody — not the Harvard-educated foreign policy specialist who was supposed to be advising him, and certainly not Dr. Karasu — could persuade him that he was wrong. About anything.

It was anxiety that had brought the man to therapy , and both the cause and the symptoms followed a pattern. “He had learned how to maneuver everyone to come around to his point of view,” Dr. Karasu said. “He had removed the foreign policy consultant from his circle after the man had disagreed with him.”

Dr. Karasu saw this as an opportunity to press the patient. “But this person knows more than you,” he told the elected official, a wealthy businessman who had turned to public service, yearning for a greater challenge, after quickly making a fortune in the private sector.

“But I’m his boss,” the patient insisted.

“The issue wasn’t foreign affairs; it was control,” Dr. Karasu recalled. “That was his attitude to me as well: ‘I know what is best because look at who I am.’ ”

While it is common for a patient to resist treatment, Dr. Karasu said, “There are some people who, no matter how intelligent they are, they think they know my business better than I do. And they are very difficult to reach.”

Most of the therapists interviewed said the rich were also far more able than the average patient to not show up for a session or give up on therapy altogether. “It starts with the way it’s so easy for them to not show up for an appointment because it means nothing to them if they’re out the $300 or $400,” said Dr. Stone, who is also known as a forensic psychiatrist and is the host of a show on the Investigation Discovery network.

Part of the therapeutic model for many practitioners involves charging whether the patient shows up or not: The idea of obligation — and the notion that there be some cost incurred for not meeting it — becomes essential to the treatment.

“Superbly well-to-do people tend to have much less of an impetus to work through things now,” Dr. Stone said. “They have so many opportunities to seek gratification that they’re not hurting in the same way. I’m thinking of a narcissistic and unmarried patient in his late 40s who, in another time and under most circumstances, you’d have said missed the boat. He could get gratification through his wealth and move from one model to another, so that he didn’t really need to maintain a relationship.”

That patient, Dr. Stone said, terminated therapy abruptly by way of a call — from his secretary — informing him that the man had left for Africa on a spontaneous vacation.

Moreover, the environments in which a lot of these patients have become successful do not necessarily leave them well equipped to benefit from the talking cure. “To generalize, it’s not the priority of people who are successful on Wall Street to be intimate,” Dr. Karasu said. “It is their priority to be aggressive. Many will not open themselves up to intimacy even in love affairs. They are slow to trust anyone — even the therapist.”

One patient with whom he had been making progress, Dr. Karasu said, walled himself off from him ever more after a business accomplishment made him famous and pushed his considerable wealth to stratospheric levels. “I said, ‘What is happening to you that you are regressing now, when you are thriving?’ ” Dr. Karasu recounted. “He said, ‘The higher up the monkey goes,’ ” the easier it was for the public to catch a glimpse of his posterior. “He was terrified that the world was out to make a fool of him,” Dr. Karasu added.

Great Disenchantments

It is not uncommon to find in wealthy and powerful patients an extremely low tolerance for frustration, the therapists said.

Dr. Seth Aidinoff, a NewYork-Presbyterian Hospital psychiatrist who practices on the Upper East Side and also consults for hedge funds and Wall Street firms, illustrated the consequences with the Saturday-afternoon choice faced by “your typical master of the universe,” who can either play outside with his 7-year-old or stay inside to complete a business deal on the phone.

“The phone call might involve the most important and interesting people in the world, being well compensated for his time, and the chance to handle it with A-plus skill,” Dr. Aidinoff said. “Whereas playing with his 7-year-old might be sort of boring, or unsatisfying; his son might not fully express his appreciation, or the child could even be in a bad mood. So this person might find himself terrified of spending time with his child because it’s not an activity he can control or succeed at the high level of accomplishment to which he is accustomed.”

Because so much of ordinary life is built on small failures and frustrations, therapists see among this patient group a great disenchantment. The therapists cited familiar tropes of the new gilded age: the three-year renovation of a country house that becomes its own “infrastructure of entrapment,” as one therapist put it; the man so accustomed to travel by private jet and chauffeur that he develops a fear of airports and taxis. “It results in a fear of chaos and vulnerability” Dr. Aidinoff said.

“These people have to win,” Dr. Karasu said. He described another patient, a tennis enthusiast, who was so humiliated when his 16-year-old son began beating him that he gave up playing.

“He said: ‘It’s a silly game. You just hit the ball, they hit it back. What is to be gained from this?’ ” Dr. Karasu said. “After that, he tried to discourage his son from playing.”

A patient’s inability to accept his own limitations is not without beneficial side effects, he said. “I see this in the way my patients are consumed by the idea of their deaths, or their attempts to counteract death,” Dr. Karasu said. “All of the philanthropy you see — the buildings named after people for giving $50 million to this museum or to Columbia — is a result of one man after another trying to conquer his mortality.”

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