Beyond Bedlam’s Door
The Book Brigade talks to clinical psychiatrist Mark Rubinstein.
Posted Jun 29, 2017
Whether behind the closed door of a consultation room or facing the public on a witness stand, psychiatrists must balance the need to preserve their patients’ trust with the responsibility of making judgments that could change their lives. In his wide-ranging career, clinical psychiatrist Mark Rubinstein has worked with people at their most pivotal moments—facing divorce, dementia, or criminal charges. In his new book he chronicles the daily drama of mental health.
What led you to write this book?
Psychiatry is unlike any other medical specialty. I don't palpate an abdomen, listen to someone's lungs, or look down a patient's throat. People come to me—most of them willingly, some involuntarily—and the most intimate details of their lives are explored during the course of their treatments.
Experience has taught me that most of the time, even the most baffling of symptoms could be understood if time was spent and attention was paid.
In a sense, I wrote Beyond Bedlam’s Door for the same reason I wrote my last book, Bedlam's Door: to demystify mental illness while paying tribute to the people I've been privileged to treat.
You write about a case in which a patient became convinced that his therapist was recruiting him to take part in a murder plot, which ended with the two men in court. At its core, that episode was about doctor-patient trust. Why is that so vital for those living with mental illness?
Trust is the foundation of the relationship between a therapist and patient. Someone in treatment must feel comfortable revealing to the therapist anything troubling, no matter how embarrassing or difficult that may be. Whether one seeks help for severe mental illness or to deal with everyday problems, the therapist must never undermine confidentiality or engage in behavior that will compromise the patient’s willingness to discuss any problem or difficulty. In a very real sense, a patient and therapist must have an inviolable therapeutic alliance.
More than one story in the collection hinges on the boundaries that must be maintained between therapist and patient. Should readers be surprised at how often violations, or at least temptations, arise?
A therapist occupies a uniquely powerful position. A patient makes an enormous mental and emotional connection with the therapist by virtue of transference, attributing to the therapist thoughts, feelings, and expectations deriving from childhood. It’s akin to a parent-child relationship. Some unscrupulous therapists may take advantage of this relationship and commit boundary violations by engaging in an inappropriate relationship with the patient, but most mental health professionals maintain appropriate boundaries between themselves and their patients.
You include several stories about your role as a mental-health expert witness in court and the pressures you experience from both sides in testimony. How do you remain a reliable witness even when hired by just one side?
My role as an expert witness is to provide the court with an unbiased opinion about a mental health issue in litigation. The only way I can do this work while retaining my self-respect and sense of both personal and professional integrity is by telling the clinical truth. There have been times when my refusal to shade or distort the medical facts has cost me business with some attorneys, but in the long run, my approach has served me well. Juries have a collective wisdom, and most know when a witness is being dishonest or evasive. My commitment to telling the clinical truth has favorably impacted most juries, and it has allowed me to sleep well at night, knowing I haven’t become a hack for hire.
Your stories take readers behind the scenes into places they may never go themselves, or if they do, only under the most dire circumstances. What do you hope to reveal to laypeople about the medical and legal professions?
Whether I place the reader inside the World Trade Center on 9/11 as a survivor details his harrowing ordeal or bring the reader with me into a nursing home as a once-brilliant middle-aged man is left with no memory other than that of art, I want to share with the reader the sometimes awe-inspiring—but at other times devastating—true life stories I’ve been privileged to hear. I want to demystify what happens when someone’s in therapy, debunk some of the misconceptions surrounding psychiatry, and bring the reader into a world where the most intimate thoughts, feelings, fears, and expectations are explored.
One story, “Double Agent,” involves the dilemma of potentially reporting a patient who appeared to have the motivation to commit violence. What should people know about how clinicians make those crucial judgments?
Every therapist hears things patients will never tell other people. During sessions, a patient may express angry or violent thoughts and feelings that would be deemed “unacceptable” anywhere else. A therapist must evaluate these verbalizations carefully, realizing they can be figures of speech but may sometimes presage actual acts of violence. These utterances must be evaluated in the context of the patient’s history, judgment, impulse control, and life stresses.
What is the most important message you want to get across through your book?
I simply want to relate true stories about people who have touched me deeply. I think these stories reflect the richness and diversity of the human condition.
Who would the book appeal to?
I think Beyond Bedlam's Door would appeal to anyone who enjoys reading true stories that are stranger than most fiction and to anyone who has an interest in mental health issues or a curiosity about what a psychiatrist actually does.
About THE AUTHOR SPEAKS: Selected authors, in their own words, reveal the story behind the story. Authors are featured thanks to promotional placement by their publishing houses.
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