Dr. Paul Hokemeyer in The Wall Street Journal: What your therapist is really thinking?

In the following article, Dr. Paul shares the intimacies of the psychotherapeutic process with The Wall Street Journal’s Elizabeth Bernstein.


What Your Therapist Is Really Thinking
Yes, therapists sometimes get bored; excerpts from an interview with psychotherapist Paul Hokemeyer
Dr. Paul Hokemeyer, a psychotherapist, says ‘a large part of the value of psychotherapy comes from the thoughts that go through the patient’s mind in anticipation of the session.’ ENLARGE
Dr. Paul Hokemeyer, a psychotherapist, says ‘a large part of the value of psychotherapy comes from the thoughts that go through the patient’s mind in anticipation of the session.’ PHOTO: NICK DABAS

Dec. 14, 2015 12:56 p.m. ET
Ever wonder what your therapist is thinking?

Paul Hokemeyer, a psychotherapist and licensed marriage and family therapist, discussed what goes through the mind of someone paid to help people with their most private problems. Dr. Hokemeyer specializes in relationships and treats people for issues such as anxiety, depression, narcissism, addiction and infidelity. He also serves as a senior clinical fellow for the Caron Treatment Centers, an inpatient facility in Pennsylvania and Florida.

Dr. Hokemeyer was a corporate bankruptcy lawyer for seven years before getting his Ph.D. in psychology. He uses several approaches in his practice including cognitive behavioral and dialectal therapies. He has private practices in New York and Telluride, Colo., a research office in Malibu, Calif., and also Skypes with patients. Here are edited excerpts from an interview with Dr. Hokemeyer.

WSJ: How long do you typically see someone?

Dr. Hokemeyer: One to two years. I don’t believe psychotherapy should be a lifelong endeavor.

How has your therapy style evolved?

When I first started, I was terrified of making a mistake and I made patients nervous. When I was in training a woman came to see me to deal with an abusive relationship. She sat terrified in a chair across from me, while I forced her to answer a series of rote questions. I should have thrown the questionnaire out and sat with her in the weight of her pain and talked. But I didn’t, and she never came back. I still get sad when I think about her, and I think about her often.

I’ve come to see psychotherapy as an art grounded in science. The art consists of connecting with a patient where he or she is, then using solid evidentiary methodologies and interventions to move the patient toward a reparative experience.

My brand of psychotherapy operates on a number of levels. The first requires me to be hyper-aware of the physical and emotional feelings the patient brings up in me. How do I feel in their presence? Am I anxious, bored, entertained, manipulated?

Then I focus on what they are saying, verbally and non-verbally. Do I feel the heaviness that comes from depression, yet the patient is saying everything is fine or trying to distract me with superficial details?

Once I have the data gleaned from our personal connection, I formulate clinical interventions.

What do you write down about a patient?

I find note taking during the session by a therapist to be rude. The goal is to be fully present for the patient. I jot down notes after the patient leaves to remind me of issues to discuss and insights made by the patient.

If the patient is being treated for depression and made his way out into the yard the past weekend to garden I would write that down and encourage the patient to continue. My files contain basic contact information, releases, an assortment of legally required forms and brief notes that indicate where we need to go and how we are doing.

What do you hope a patient will do between sessions?

A large part of the value of psychotherapy comes from the thoughts that go through the patient’s mind in anticipation of the session and when they leave. The goal is for the patient to internalize the reparative relationship with their clinician. This means that they hear their therapist’s voice and anticipate what their therapist would say when they are confronted with a real-life situation.

I love when patients make a confession about falling down on a commitment and tell me: “I know exactly what you’re going to say…” That means they are internalizing a nurturing, affirming voice.

I give homework when it is appropriate, but I tend to do the opposite of what a patient requests. The super-A types want lots of homework. This is a red flag. I don’t give it to them. Their homework is to sit with their emotions and feelings rather than intellectualizing them.

Some patients can be very treatment resistant. They say they want to change but don’t take action. These are the people I’ll assign homework to and discuss why they refuse to do it.

What is unhelpful for patients to do between sessions?

Beat themselves up. We all make mistakes in life. The key is to learn from them and move on. I tell my patients it is OK to look back at the past but don’t stare.

Is it helpful for patients to discuss their therapy with loved ones?

It depends. It can be helpful if you feel they have your best interest at heart.

What should patients do to prepare for a session?

Come into the room focused and motivated. Don’t come to me because you’re trying to get your spouse off your back or are more concerned with the text messages you’re receiving during our session.

What do you think about during a session?

I focus on the immediate, my feelings, thoughts, what the patient is saying, then step back and put it in a global context. Is what they are saying congruent with what I’m feeling? What patterns are emerging?

I also need to keep track of time, which is tricky. The last thing I want my patient to see me do is glance at the clock. I have three clocks in my office and I’ve taken to wearing an iWatch, but I still screw up.

Does your mind wander?

Frequently. Most of the time it wanders back to the session I had with the last patient and what I should have done differently.

It can also wander if the patient is avoiding connecting and filling the time with superfluous details. I’ll start to think about the dry cleaning or what I can have for dinner. This is important clinical data as it lets me know that just as I’m not feeling connected to the patient, the patient isn’t connected to me because they don’t feel safe enough to share the intimate details of their life.

Do you fire clients?

I will refer a patient out if I don’t feel we have a good connection or if their issue is outside of my scope of competence. I also refer out if I feel that our work is creating a financial strain on the patient.

Do you judge patients?

I’m constantly judging. It is my job. This notion of unconditional positive regard is a fantasy. Yes, I need to accept the patient for who they are, but to pretend that I won’t bring my humanness to the equation is unrealistic.

I need to know how and when to deliver my truth. The best example I can give is around issues of fees. Discussions around money are wonderful illuminators of personality. Typically, people who are miserly with money are miserly with emotions. People who throw money around have poor interpersonal boundaries.

Do you go to therapy?

I’ve been in individual and couples therapy off and on for 20 years. I started when I was practicing as a young lawyer, miserable and desperate to change my life. Recently, I’m focused on my marriage and so I’ve been investing in couple’s therapy.

I can be a very difficult consumer of psychological services. It takes me forever to find a therapist I trust.

What are your pet peeves?

I get annoyed when patients cancel at the last minute because of traffic or some other minor annoyance. This tends to be a chronic situation with the affluent. For them, what’s a few hundred dollars for the late cancellation? I view this issue as a clinical one and address it. I tell them it feels like they are hiding behind their money to avoid intimacy.

What if someone isn’t making progress?

Some patients love to play games. They are masters at manipulation and avoid connection at all costs. They will dominate the conversation with tales of great bravado, tales that illuminate their personality but keep us from connecting. I tell them to cut it out.

Do you dislike patients?

I dislike traits my patients display, but my job isn’t to like or dislike my patients. It is to give them a new way of relating.

My awareness of myself and my own issues enables me to relate to and feel compassion toward the vulnerability of being human. It is the thing we share and it gives us a strong foundation to build upon.

Write to Elizabeth Bernstein at elizabeth.bernstein@wsj.com or follow her on Facebook or Twitter at EBernsteinWSJ.

Write to Elizabeth Bernstein at Bonds@wsj.com

Entitled Teens and Addiction Treatment

In this article that was published in Addiction Professional Magazine, Dr. Paul discusses the unique challenges presented in treating upper middle class and elite adolescents and their families:

Privilege and Adolescent Addictions

By Paul L. Hokemeyer, J.D., PhD.

Perhaps the most prevalent cultural myth in America is that money and professional success are salves that heal what ails us. When substance abuse strikes in a culture of affluence, the American dream of wealth and power quickly turns into a seemingly unmanageable nightmare.

This article will address the treatment of affluent adolescents with substance use disorders through a family systems approach. This approach considers not just the “problem adolescent,” but also the family dynamic within which the adolescent is raised. To accomplish this objective, the major psychosocial risks unique to adolescents from affluent families, as well as the challenges that the professionals who treat them face, will be addressed. Finally, through a case study, this article will provide a real-life example, thus offering suggestions for working with this population.

High-risk group
Although it is commonly believed that children from highly educated, affluent families constitute a “low-risk” population, several studies have found that these youngsters are as susceptible to substance use disorders as adolescents from lower socioeconomic “high-risk” populations.1,2 There are several reasons for this. The first maintains that children from affluent families must manage achievement pressures from their successful parents and siblings. In this context, the message that affluent children receive from their perfectionist parents is that failure to succeed equals personal failure.

This overemphasis on accomplishments while underemphasizing personal character and resiliency leads to increased rates of anxiety and depression, which in turn lead to higher rates of substance use. The theory is that these pressured children use substances to “self-medicate” intolerable emotions.3

The second reason offered for increased rates of substance abuse among affluent youth is that these children frequently are isolated from the parental figures in their lives. This isolation manifests itself both in a literal and emotional context. While wealthy parents are out of the house pursuing their careers and the trappings of wealth, their children frequently are left alone or in the care of professional caregivers. Without parental figures in their lives, these children are hungry for firm yet authentically compassionate role models.2

In addition, studies show that affluent children frequently feel emotionally isolated from their parents even when their parents are physically around. In their own self-absorbed drive to succeed, affluent parents fail to provide their children with the unconditional nurturing that is so essential to their growth as assured and confident human beings. Again, this isolation leads to increased levels of anxiety and depression, which in turn lead to unhealthy ways of coping with unacceptable feelings.4,5,6

Just as affluence is too frequently celebrated as a substantive quality possessed by the privileged, substance abuse and imperfection are still too frequently stigmatized as a moral failing or character weakness that affects lower socioeconomic classes. As a result, affluent parents feel a great deal of shame in admitting that there may be a substance abuse problem in their family. This view keeps the problem hidden deep behind the family’s manicured façade, impairing the willingness to seek treatment.2

This misplaced belief that “if it looks OK, then it is OK” leads to affluent families turning a blind eye to telltale signs of problems and denying when problems exist. One of the most common ways this denial manifests itself is in overscheduled days and additional academic pressures. Although often grounded in the family’s genuine concern to see the child succeed, these pressures continue in spite of the child’s cries for help. In these families, an idle mind and body are seen as the “devil’s playground.”

At the heart of this hyperactivity is the fear that if they slow down or stop, family members will be overwhelmed by the truth and will be forced to address issues that they are unwilling or unprepared to handle. So instead of addressing nascent problems when they emerge, families driven to succeed try to cover unwelcome tracks with a whirlwind of activity.

And it is not just the affluent family system itself that is challenged by wealth and success. The outside systems that treat affluent adolescents are often faced with obstacles to effective care. These challenges include dealing with the families’ exaggerated privacy concerns, overly pressured lifestyles, and denial of the problem.7,8 As a result, these professionals frequently hesitate to report their concerns to affluent parents for fear of resistance, intimidation, or even the threats of a lawsuit.

As a result, research has found that affluent youth too frequently have less access to school-based counseling services than economically disadvantaged students.9

Case study
Several months ago I received a call from a 46-year-old mother of an adolescent son and daughter. The mother requested a family session “to get her husband into treatment.” In a pressured voice, she told me her husband was using cocaine and she saw his use as a negative influence on “her” children. Apparently, the 14-year-old son had been caught smoking marijuana in the bathroom of his exclusive prep school and was in serious academic trouble.

The mother warned me that her husband was “difficult” and that they “had been down this road before.” Although she had never met me, she asked during our initial call “if I thought I could handle [her husband].”

To finish reading the article, click on the following link:


Infidelity: Defining the Narrative of Your Relationship

Infidelity: Defining the Narrative of Your Relationship

by Dr. Paul Hokemeyer

Susan was a beautiful and vibrant 54-year-old woman who had just celebrated 32 years of marriage to Steve when she found out he’d been carrying on a 10-year affair with Marsha, a 42-year-old business associate.

“I was devastated,” Susan blurted out between tears. “I mean I know these things happen – but to other people. I never thought it would happen to me.”
Too ashamed to tell anyone, she came to me with her secret and laid it at my feet. It was a position of honor that I find myself in frequently and one that I never take lightly. As a marriage and family therapist who specializes in the treatment of addictive disorders, infidelity is a phenomenon I’ve become an expert in treating. Over the years I’ve found it’s one of the more common injuries that occurs where an addiction has corroded the intimacy bond that is crucial to healthy relationships.

And while no two cases are ever the same, an infidelity always involves three distinct features that must be addressed and treated.

Breach of Trust: When one person in a committed relationship goes outside its agreed perimeters to partake in emotional or physical intimacy with someone else, the foundation of the primary relationship is severely damaged. The passive party to the infidelity feels violated, completely confused as to how the person they trusted with their emotional and physical vulnerability could betray them.

Shame: The fundamental characteristic of shame is that it’s emotionally and physical painful. It feels like a punch in the stomach. Shame arises when we are given a demeaning label that we can’t eliminate through our actions. So the passive party to the infidelity gets labeled a victim while the active party gets labeled an aggressor and infidel.

Guilt: In contrast to shame, which derives from fingers pointing in towards us, guilt is an internal construct that arises when we point fingers at ourselves. It’s our internal and moral code of conduct that causes us to self-regulate our actions in the world. Like shame, guilt exists in both parties to the infidelity. The passive party feels like they did something “wrong” to cause their partner to wander, while the active partner feels diminished for their actions.
Treating Infidelity in Relationships

In treating infidelity, it’s important that the parties work with a therapist who they trust and who reflects back to them their own morals and values rather then dictating down to them notions of “right” or “wrong.” In this regard, therapy becomes a collaborative process where the individuals and the couple figure out how the infidelity fits into the complete trajectory of their marriage, their individual lives and the lives of their children.

To do this, they need to go back and look at what brought them together, what religious and community values they share, where they differ, and what they want for their future. It’s a process that requires a high tolerance for discomfort, the ability to process anger, resentment and hostility in constructive rather than destructive and punitive ways; and, a willingness to be open to incorporating a new reality into the narrative of their relationship.

For relationships exist as a narrative. They consist of a beginning, middle and an end. While an infidelity will certainly impact the story line of a relationship, it need not define its entirety. Parties to an infidelity need to make sure that they remain in control of their author’s pen and finish the script in a way that honors who they are and what they want in this world.

Processing an infidelity in their relationship requires couples to let go of fantasies of what they thought their lives should be and integrate the truth of what is. Is this a difficult and humbling process? Yes, it unquestionably is, but it’s also a process that enables individuals, couples and families to embrace richer and more meaningful lives. Need it be humiliating? Absolutely not.

In this regard, the parties need to make sure they work with a therapist who helps them work through the shame and guilt of the breach of trust in a way that gives them a voice while working towards a solution that results in a happy and rewarding ending to their relational story.

Narcissism: The Character Pathology Underlying Addictions

Narcissism: The Chronic Character Pathology of Underlying Addictions

by Dr. Paul Hokemeyer

I was closing down my Manhattan office late last Friday afternoon when my phone began ringing. I looked at the caller ID to see if it was someone I knew, but I only recognized the Aspen, Colorado area code. Thinking it was a friend with whom I skied last winter, I eagerly answered the call.

“Well hello!” I said with more enthusiasm than appropriate for a professional encounter. The silence that followed indicated my caller was a bit put off.

“Um. I’m calling for Dr. Hokemeyer,” a soft-voiced woman tentatively responded.

I pooled out the professional composure I had tucked away for the weekend and responded as officiously as I could, “This is he.”

“Oh.” The woman sounded shocked. “I wasn’t sure I had the right number. I’m calling from Aspen.”

“Yes, I recognized the area code. What can I help you with?”

“I need to hire you.” Now she spoke with the strength and confidence of a seasoned trail lawyer.

“Ok. But you’re in Aspen and I’m in Manhattan. I only do phone sessions after we’ve had some time to establish a face-to-face relationship. But before we even get to that point, why don’t you tell my what prompted your call. What are you struggling with?”

The tone of my caller’s voice suddenly turned frosty. “I’m struggling with my complete jerk of a husband— soon to be ex-husband I hope. He’s a complete narcissist and falling down drunk. I’ve gathered from your work that you’re an expert on both topics and I need you to testify at our pending divorce trial that his narcissism led to the demise of our marriage— that he’s an alcoholic and unfit to have custody of our two boys.”

Now it was me who was taken aback. Yes, I’m an expert on a whole host of personality disorders that are endemic to men, women and families of wealth and power and that fuel a variety of addictions; and yes, narcissism typically heads the list, but the notion of testifying at an out of state trial for a couple I’d never treated was definitely outside my comfort zone. As a result, I graciously declined the engagement and referred her to several local resources that could help her navigate her anger towards her husband, and deal with his alcoholism and her frustration with the divorce process.
But her call made me stop and think about the incredibly destructive toll narcissism takes on relationships and families. It also made me appreciate the frustration that family members and partners feel when narcissism stands in the way of their loved ones’ recovery from a variety of addictions, including alcoholism, drug addiction, sexual compulsivity, and disordered eating. So what exactly is narcissism and how is it most effectively treated?

Narcissism Defined

Narcissism is a character trait that defines a person’s self view and view of others. Like the narrow lens in a microscope, it causes a person to focus on the world in a very self-centered way. It causes them to lose sight of notions like we, us and compassion for others. It’s a trait that takes hold early in a person’s life – typically as the result of a major breach of trust by a primary caregiver. Through this breach of trust, the person vows never to be vulnerable again and sets out to be a self-sustaining, autonomous entity.

Although narcissism is resistant to change, it can be “softened” through a variety of clinical interventions to a point where it no longer has a negative impact on the quality of the person’s life and relationships. Through this softening, the person can then embrace a comprehensive program of recovery for life, rather than feeling distant and detached from the healing force of others.

Recently, the diagnostic criterion for what constitutes narcissism was revised in the DSM-V. In looking for pathological narcissism, clinicians look for people who evidence the following traits:

They are what they possess: The person defines himself or herself from the outside in. They find their self worth in objects, external recognition, and adoration from others.
They are emotionally volatile: The person is only happy when they are being praised and acknowledged as special. They can’t tolerate being criticized and react with anger when they’re questioned.

They are externally driven: The person lacks a moral or intuitive compass. They are driven by commercial notions of success rather than spiritual principles.
They are emotionally shut off: The person lacks empathy and compassion. They only concern themselves with others when they feel their concern will advance their own narcissistic agenda.
They are manipulative: The person can be highly charming and charismatic, but only to manipulate and exploit others for their own gain.
They are grandiose: The person feels they are unique and special. Their condescending and critical attitude towards others is a tool they use to build themselves up.
They are entitled: The person feels they are deserving of special treatment and rewards without having to pay dues or earn them.
They need constant attention: The person is constantly seeking external validation and needs to be the center of attention.
Treatment Options

Although narcissism is difficult to treat, there are some highly effective clinical approaches that enable narcissistic patients to gain insight into their characteristics and learn new ways of relating to themselves and others. Unfortunately, the greatest obstacle to getting effective care is the very personal traits that got them into trouble in the first place.
Unlike other patients, who ask for help and are open to suggestions from professionals, narcissistic patients have a hard time admitting they are anything less than perfect. They have difficulty being challenged and frequently fail to attach to the clinical team who is treating them. As a result, it’s important that the professionals treating narcissistic patients possess an above average intellect, a persistent and compassionate heart and a deportment that will allow them to challenge the patient in a firm, yet flexible manner.

The most effective forms of psychotherapy for the treatment of narcissistic personality disorder include the following psychotherapeutic approaches:

Interpersonal psychoanalysis: Through the patient and therapist relationship, the patient begins to explore his or her significant relationships and gains insight into how they perceive and are perceived by people.
Family therapy: An extremely effective form of therapy that involves the patient’s family. As a team, the family works to resolve conflicts and relationship problems.
Cognitive behavioral therapy: Gives the patient tools to change their thought distortions and negative beliefs. Through these tools, the patient replaces unhealthy and negative beliefs with healthy, positive ones.
Group therapy: Occurs in a group of other patients who share the same emotional and personality issues. Provides the patients with insights into how they relate to other people and as a member of a group.
Ideally, these treatment interventions will occur simultaneously and continue for as long as clinically indicated. In my experience, it takes at least one year for patients receiving treatment in a private office setting and at least 60 days in an intensive and comprehensive in-patient setting before they will begin to experience an improvement in their personalities and their relationships.

Is it worth the time and effort? Absolutely. Narcissism fuels the addictions that destroy lives and families. Are narcissists lost causes? Absolutely not. They are human beings who in spite of their external bravado are incredibly sensitive and terrified of being hurt. With the proper clinical care they can transform into loving partners and parents, sober men and women, who add great value to the lives of others and the world around them.

Luxury Treatment: Guidelines for Culturally & Clinically Competent Care

In the following article, which first appeared in Rehabs.com, I address what patients and families should look for when seeking addiction and mental health services from providers that hold themselves out as purveyors of “luxury” treatment.

Luxury Treatment: Guidelines for Culturally and Clinically Competent Care

Posted May 7, 2014 in Addiction Treatment Methods by Paul Hokemeyer

Addiction professionals are offered many opportunities for cultural sensitivity in treating the patients they serve. These can be broken down by a host of segments we can rattle off the tops of our heads: race, religion, gender, sexual orientation, disability and even diet. But what about wealth? When have any of us considered wealth, power and celebrity to be identity markers that require unique cultural and clinical interventions?

There are plenty of facilities that charge hefty fees and provide luxurious settings and amenities, but ask what they’re doing to address the unique issues elite patients bring into treatment and you’ll be met with a vacant stare.
Unfortunately, too few treatment professionals ever have. When it comes to women, men and families of wealth there’s huge resistance to acknowledging that these human beings bring unique issues into the realm of treatment. Yes there are plenty of facilities that charge hefty fees and provide luxurious settings and amenities, but ask what they’re doing to address the unique issues elite patients bring into treatment and you’ll be met with a vacant stare.

As a clinician whose research and clinical impressions on the treatment of elite substance abuse patients have been widely published, I believe that everyone, regardless of his or her place on the power and income spectrum, deserves care that meets them where they are, rather then where the clinician based on their limited knowledge and experience expects them to be.

The truth of the matter is that elite patients, and the systems in which they live, are exceedingly sophisticated, complicated and nuanced. Typically the patients and families I treat have been through several programs and clinicians before they find effective care. Their emotional lives and the lives of their families have been ravaged by what is known as Addictive Interactive Disorder – meaning, their addictions manifest in several forms.

These often include prescription drug dependence, alcoholism, stimulate abuse, gambling, sexual infidelities, disordered eating and other destructive compulsions. They frequently hide behind facades of bravado and entitlement and are masters at manipulating the people, places and things in their external lives.

These often include prescription drug dependence, alcoholism, stimulate abuse, gambling, sexual infidelities, disordered eating and other destructive compulsions. They frequently hide behind facades of bravado and entitlement and are masters at manipulating the people, places and things in their external lives. In addition, their addictions and destructive personality traits are supported by legions of enablers, “handlers” and other people who are financially dependent on the patient and terrified of change. In short, these patients with issues endemic to their socio-economic class must be treated with an appropriate clinical and cultural acumen.

Distinct Cultural Markers

Like other minority groups, elite patients have distinct cultural markers that are highly relevant to their treatment for substance abuse and mental health disorders. For starters, they are suspicious of outsiders and resist attaching to their clinicians.

This resistance to attach is perhaps the greatest hindrance to treatment and as such, requires clinicians to possess a keen mind, a honed intuition, a heightened level of maturity and an empathetic heart. In addition, elite patients occupy positions of power in the world. In contrast to other minority groups who occupy positions of powerlessness, elite patients enjoy high levels of external success and its accompanying influence. As such, they react negatively to authoritative clinical stances and must be approached collaboratively to acknowledge and build on their strengths rather than criticizing their weaknesses.

Money is an Energetic

Money is a highly charged and complex energetic. Like electricity, money’s energetic has both productive and destructive qualities; and like electricity, money’s energetic must be properly used and contained. For example, the patients I treat often use money in the following ways:

To control and manipulate others
As a substitute for an authentic ego identity
To “buy” their way out of problems
To distance themselves from others
As a substitute for intimate connections with family and friends
To medicate over the guilt they feel from being absent parents and partners
However, most clinicians fail to address these unhealthy dynamics while the patient is in treatment. As a result, once back out in their lives, the patient resumes using their wealth and power in ways that continue to erode the integrity of their interpersonal relationships and ultimately lead to their relapse.

Money is a Taboo Topic

The denial, rationalization and minimization of a significant aspect of the patient’s life cheat the patient and perpetuate the destructive interpersonal and addictive cycles.
The failure to address these critically important issues is in large measure because of the fact that money remains a taboo topic in our culture. As a result, clinicians are resistant to raise issues of wealth, power and celebrity with their patients. Instead of addressing these topics as a dynamic that plays out in significant ways in their patients’ lives, they shy away from them and rationalize they don’t matter. The denial, rationalization and minimization of a significant aspect of the patient’s life cheat the patient and perpetuate the destructive interpersonal and addictive cycles.

Moreover, elite patients are resistant to discussing their wealth, power and celebrity with their clinicians; or, they use their elite status to impress, and distance themselves from their treatment team. Those who are resistant to discuss their wealth do so out of fear of being judged, objectified, manipulated and even extorted. Those who wear their wealth on a sleeve of bravado do so out of insecurities and low self worth. Both positions require smart clinical interventions that simultaneously honor, but also test the patient’s reality. Elite patients must be held, but they must also be challenged.

Elite Patients Require Distinctive Clinical Care

Elite individuals, their families and referents seeking effective treatment for substance abuse and mental health issues should look for clinically competent programs rather than those that merely provide luxury amenities. Central to this competency is the level of maturity and professional acumen of the entire treatment staff. A lovely view, gourmet food and high thread count sheets are good, but smart, committed and seasoned professionals are better.

First and foremost, look for clinicians who:

Understand the powerful energetic that wealth, power and celebrity interjects in their patients’ lives
Are not afraid of talking about money and it’s inherent energetic
Evidence clinical acumen and personal maturity
In my own practice, I look for dedicated and intuitive clinicians who have spent a significant portion of their professional careers and personal lives honing their craft. These are the men and women who have mastered the fine art and science of the psychotherapeutic process – not babysitters afraid of clinically confronting sophisticated and challenging patients.

The clinical team must be willing to use a variety of psychotherapeutic techniques that enhance, and at times will fall outside, the classic 12-step model. These include the Socratic Method of Inquiry wherein the clinician utilizes logical thinking and reason, Feminist Theory, which requires the clinician to work collaboratively with the patient, and experiential techniques that connect the patient with their emotions.

In addition the clinical team must be willing to use a variety of psychotherapeutic techniques that enhance, and at times will fall outside, the classic 12-step model. These include the Socratic Method of Inquiry wherein the clinician utilizes logical thinking and reason, Feminist Theory, which requires the clinician to work collaboratively with the patient, and experiential techniques that connect the patient with their emotions. Used together this mélange of treatment approaches will honor their patients’ intellect and external successes while showing them how they can benefit from change.


Clinically and culturally competent care does not have an economic threshold. All patients, regardless of their place on the socio-economic spectrum deserve addiction treatment that honors who they are in the world rather than pandering to or diminishing their existence. Addiction treatment programs that market to high-end patients have a moral and ethical responsibility to deliver this heightened level of care. Luxurious amenities alone are woefully deficient in meeting this standard. Clinical care must be delivered through a sophisticated team of clinicians trained in the unique needs of their unique patient population.


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