As a psychologist, I worked for many years at an HIV clinic in a major New York hospital, serving a catchment area in the Bronx. My patients there were what most of us would call poor. Many did not have jobs; some had spent significant time in prison, or had histories of drug abuse. These days, I work in private practice in midtown Manhattan—only a few miles from the Bronx as the crow flies, but socioeconomically a long way off. My patients now are bankers, brokers, surgeons, journalists, and small-business owners. You'd think it would have been a jarring transition, but the truth is, it wasn't. “Whether you’re rich or poor,” my father used to say, “it’s nice to have money.” To that I would add: No matter how much money you have, it’s good to have access to psychotherapy.
Outside of Hollywood movies—where poor people have been portrayed as more joyful and carefree than the cosseted, uptight rich—no one really believes America’s poor are better off than its wealthy. A 2010 meta-analysis found that in up to 79 percent of previous studies, poverty was positively associated with mental illnesses like depression and anxiety. The connection isn’t simple, but it’s obvious that money makes it easy to satisfy the basic needs of living, which stabilizes one’s sense of subjective well-being. Our least well-off Americans, then—like my old patients—are deeply frustrated by the challenges they confront each day, which can leave them feeling as if they’ll never be able to change their circumstances or achieve their personal goals. This frustration is a far cry from the stereotypical wealthy patient who can’t tolerate minor difficulties because he is accustomed to being given everything he wants.
Nevertheless, rich and poor Americans do suffer in similar ways.
Intimacy, for example, is equally difficult for rich and poor alike. T. Byram Karasu, former chairman of the Department of Psychiatry at Albert Einstein College of Medicine, reported that his wealthy patients were slow to trust people, and did not always prioritize intimacy—which can exact a steep emotional cost, damaging long-term relationships and hobbling new ones. But during my time in the Bronx, I found these same difficulties with intimacy to be just as common at the bottom of the socioeconomic ladder; it’s difficult to develop trust if you’re concerned that the people you are close to may take advantage of you. A former patient of mine was uncomfortable at family events because his impoverished cousins would steal items from his backpack when they had a chance. Another Bronx patient had problems finding love because her last serious relationship had been with a man who squandered her regular monthly checks to support a heavy drug habit.
Money itself, whether you’re rich or poor, is always a stressor. Many people I worked with in the Bronx were living on HRA benefits and making honest efforts to keep their refrigerators full, their electricity on, and their children warm and fed. These patients were often able to engage in deep, challenging self-examination, but sometimes they simply couldn’t afford to come to treatment—if, for example, bill-paying had eaten up their monthly carfare allotment. But wealthier patients feel stressed out by finances as well. Money doesn’t usually settle equally within families, or within marriages, and the disparity between a rich brother and a poor sister, or a wife with wealthy parents and a self-made husband, can create obvious gaps in power or influence that may generate resentment and harm relationships. Inherited wealth isn’t free of problems, either, in that it often comes with family expectations that can be extremely divisive.
Where families are concerned, people at every level of society care deeply about their children. Surprisingly, though, recent data suggests that the young children of America’s wealthy families may be worse off than those of the poor. One study of American teens showed that higher wealth and status was actually associated with lower emotional well-being—in other words, wealthy children described their lives as less happy than the children of the poor. This may be explained by the strong social connections that are found in inner-city communities, where dependence on neighbors and family members can be essential. Many of my Bronx patients lived close to their aging parents, on whom they depended for babysitting or emergency loans—even as their parents depended on them in turn. By contrast, the very rich may be quite a bit more independent from family members, from whom they need little, and thus the least likely to experience the security of deep social connectedness. This in turn means they should stand to benefit from forming a strong relationship in psychotherapy.
Freud once famously remarked about turning exceptional misery into ordinary unhappiness; psychotherapy, with the rich as well as the poor, can be about shoring up a patient’s emotional reserves in the face of the challenges of everyday life. The very wealthy may actually be less insulated against these difficulties than the working class, having suffered through fewer minor heartbreaks while growing up and thus building up less resistance to adversity. Sometimes, wealthy people feel less comfortable seeking help, fearing that a therapist might be privately rolling his eyes: “Her husband is rich. What’s she got to worry about?” But as it turns out, the opposite may be true: A well-documented 2016 study found that people with high-status, prestigious jobs show higher rates of treatment-resistant depression than their lower-wage colleagues. Despite their wealth—or perhaps because of it—they remain deeply unhappy and uncomfortable asking for help.
These patients deserve fair, compassionate treatment from the psychologists who choose to work with them, no matter what family circumstances they come from. Equally, the most impoverished inner-city citizens deserve to be treated as more than just the products of their upbringing or their environment. Skilled therapists will be able to offer all clients, rich or poor, the right amount of understanding and empathy—the real “active ingredient” in psychotherapy—without letting a patient’s financial condition affect the work. As therapists, we owe all of our patients our most sincere empathy, our strongest efforts to comprehend them from the inside out. All of our patients, rich or poor, need to be seen as “more simply human than otherwise,” with needs that we as therapists, and fellow human beings, can understand.