Laura B

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 go