“I always wanted to be a writer,” retired forensic psychiatrist Mark Rubinstein told Westport Sunrise Rotary last Friday. “People were telling me stories all the time … that’s partially why I went into psychiatry.”
Now he’s the storyteller, enjoying his second career, recalling 42 years of “listening to people’s tales of woe,” and working on his fifth novel.
Storytelling, he said, “makes us who we are … the novelist seeks to capture the reader, to take him from his prosaic world to one that gives him an experience he couldn’t hope to have in his daily life.”
Rubinstein spoke to his audience about his practice, about his genre, thrillers, and about writing.
As a forensic psychiatrist he often served as an expert witness, for criminal and civil cases, from the mundane to “some of the most horrific of human behaviors.” He evaluated and treated over 300 survivors of 9/11 — people fleeing, seeing dead bodies carried down the stairs, and firemen rushing up into billowing smoke, and “knowing, retrospectively, that these men never survived.” He helped survivors of air crashes from 32,000 feet (yes, “there are survivors”), of concentration camps and from the Vietnam War, as well as victims of rape and false arrest.
He mentioned divorces in which both sides told him the other was an unfit parent. “It makes it difficult to believe that these people were married, were in love, had children, made a life together. The accusations they hurl at each other are beyond anger, beyond rage, they qualify as hatred bordering on murderous impulses.”
This took him to “the thin line between love, obsession, hate and even murder … love is a state of mind with which we are all familiar. Obsession is something else, but there’s only a thin line separating them,” as we learned from the recent Jodi Arias case and the older one of Herman Tarnow and Jean Harris. Obsession became “love gone awry.”
He moved on, talking about his genre. “I write thrillers!” Thrillers are different from mysteries, Rubinstein said. Mysteries are “who done its,“ thrillers keep the protagonist in imminent danger and the reader on the edge of his seat in the well written ones.
Popular culture is rife with thrillers, with depictions of murder — of love turning to obsession, then murder, as in movies including “Fatal Attraction and “Misery,’” and novels like “Sophie’s Choice,” “a horrible kind of story about the most inhumane and inhuman things that can happen to people, beautifully written in the gorgeous style of William Styron.”
While thrillers get a bad rap, as “fluff,” he noted that Homer’s Iliad and Odyssey were thrillers — “You don’t know what’s going to happen next.”
He brought his newest novel, “Love Gone Mad,” a story about a young doctor and a nurse who met casually, fell in love, then were put in danger by their personal baggage. It is their downward spiral that puts the reader in suspense, takes him out of his everyday life, and keeps him turning the page. But it’s not a mystery, Rubinstein said, because it’s obvious early on who did it. But, sorry, no spoiler. Buy the book to learn what happens.
Talking about writing, Rubinstein said, “The only way a book can hold me is that I have to keep wondering what’s going to happen next … it has to have some element of suspense, where is this story going — where is the human tug?”
He added that as a psychiatrist he “turned the meter off as soon as I went out the door of my office … however as a novelist my meter never goes off.”
A Life Changed in an Instant
Phil was a 40 year old cop with 18 years on the force. I saw him in consultation after an incident one night in Bridgeport.
While on patrol, Phil and his partner received a radio call about a fire in a clothing store. With Phil driving, they arrived at the scene and saw a burning carton inside the darkened store. Fire trucks were on the way.
Before the call, they’d stopped at a Dunkin’ Donuts for coffee. As his partner got out of the patrol car to investigate, Phil took a sip of the coffee, set the cup on the dash and leaned back. The front window of the patrol car exploded. Phil felt a sledgehammer-like blow near his right armpit. His body slammed back and he fell onto the seat. He was shot. He reached for the radio, but couldn’t get to it. About to lose consciousness, he realized his partner was shoving him over in order to hop into the patrol car and take off. The vehicle stalled.
Bullets hit the car’s hood and doors. Phil’s partner got the vehicle started and raced to a nearby hospital, where Phil underwent a series of surgeries for severe nerve and muscle damage to a group of nerves in the armpit.
Weeks later, Phil had only limited use of his weakened right arm, could barely lift things, and felt burning sensations down the arm. He felt severe pain, especially in cold weather. He could no longer work as a police officer. He was forced to take a disability pension. He’d always wanted to be a cop and had planned on a 25 year career. But it was not to be.
The perp was caught after committing another crime. He confessed to having shot Phil from the roof of a four-story building across the street. He’d set the small fire, hoping to ambush police and firefighters.
Phil became depressed and dreamed nightly about the incident and its profound repercussions for his career and life. Every twinge of pain reminded him of the shattering glass, the shots in the dark, the blood, his fear and confusion, and the frantic ride to the hospital. He’d developed PTSD in addition to depression.
During the consultation, Phil said, “You know what, Doc? The guy’s rifle had a four-power scope and the cross hairs were targeted right on my heart. But when I leaned back after putting the coffee on the dashboard, the bullet hit me near the right armpit. If I hadn’t leaned back when the guy pulled the trigger, he’d have shot me in the heart. I was saved by a cup of Dunkin’ Donuts coffee.”
A few moments passed, and Phil continued, “And now…because I can’t take the cold weather, we’re moving to Florida.”
Tears welled in his eyes and he looked away.
“You know what they call Florida?” he asked.
“God’s waiting room,” Phil said, taking a final sip for the container of Dunkin’ Donuts coffee he brought into the consultation room.
I was in a restaurant having lunch with some psychiatrist colleagues. As is often the case, we talked about our practices, psychotherapy, medications, and other issues relating to the field of mental health. One man, a guy who fancied himself a bit of a bon vivant, made an interesting comment.
“I have this woman patient who’s extremely seductive.”
“Welcome to the club,” said another therapist.
“She has a terrible sex life with her husband…it’s virtually non-existent.”
“What do you think is behind it?” I asked.
“I don’t know,” he said. “But I’m very tempted…”
“It would be the easiest thing in the world to have sex with her.”
Two other colleagues and I exchanged glances. “Have sex with your patient?” one asked with widened eyes.
“Every therapist can be tempted by some patients. It’s part of the landscape. But sex with a patient…? You can’t be serious.”
“I am. She’s seriously considering having an affair with a guy in her office. It could be terribly destructive if she did…”
“And if she had sex with you?” I asked, barely believing my ears.
“Actually, it could be therapeutic, he said.”
“Therapeutic?” asked a colleague, nearly choking on his sandwich. “How?”
“Well, it would prevent her from getting involved with an office colleague. That could have disastrous repercussions at work; and in her relationship with her husband. It could get very sticky and complicated.”
“And sex with her therapist wouldn’t get complicated?” I asked. My incredulity was difficult to contain. I inwardly dubbed this guy Lothario.
“Well…” he said, “With me, the relationship would have specific times and certain boundaries. It would be controlled.”
“But it’s a serious boundary violation,” said another colleague.
“This whole thing about boundary violations is overblown,” Lothario said.
“But you’d be taking advantage of the transference,” I added.
“I’m not sure of that,” he replied.
“You’re not sure? She no doubt views you as someone from her past—maybe a powerful father figure. And you’d be taking advantage of a power disparity in the relationship. It’s malpractice…and in some states, having sexual relations with a patient is viewed as criminal. A therapist can be charged with rape…as though he’s an adult having sex with a child.”
“The law is arbitrary,” Lothario countered. “And it could be therapeutic for her.”
“Therapeutic?” asked a colleague. “Sounds like you want your needs satisfied. How’s your sex life at home?” he asked, not so jokingly.
“That’s none of your business,” said Lothario. “And I think it would be therapeutic for her.”
“Let me ask you something,” I said. “What does your patient look like?”
“Oh…she’s tall, with blonde hair and blue eyes…Scandinavian-looking. In fact, she was a model in her twenties…now she’s 35.”
“So, she’s good-looking…?”
“Very good looking,” he said.
I nodded my head. “Let me ask you this…” I paused.
He looked at me quizzically.
“Do you do this kind of therapy with your ugly patients, too?”
He turned beet red as the rest of us laughed.
As a physician and psychiatrist, I certainly have nothing against medications. Over the years, I’ve prescribed them, and have had a great deal of success when they’ve been used appropriately. But over the last few years, there’s been a dramatic change in the way we Americans view medications of all kinds. It’s worrisome.
Many of us know that certain bacteria have become resistant to antibiotics and now pose dangerous threats to hospitalized people. Infections with MRSA (Methicillin-resistant Staph aureus) and C. diff (Clostridium difficile) have become major health hazards for hospitalized patients. These infections run rampant through hospital wards, and patients who came for some other problem can develop life-threatening infections. Other strains of bacteria are now difficult to eradicate once they take hold within the human body. They, too, are a considerable risk for anyone hospitalized.
The root of this problem lies in the fact that for decades, physicians have prescribed antibiotics for various ailments not caused by organisms susceptible to antibiotics (such as viruses). This over-prescribing is often caused by doctors yielding to patient pressure to “give me something, doc.”
In fact, when a patient actually needs an antibiotic to treat bronchitis, it’s difficult to find a medication that will kill what was once a common bacterial infection. The bacteria have become resistant to standard treatment and are morphing into “super bugs.” Couple that with the over-use of anti-bacterial hand sanitizers, and we are presented with a new generation of bacteria that cannot be killed.
Pharmaceutical companies are racing to develop new drugs to stave off these invaders.
Another area of concern is the growing use of amphetamine-like substances prescribed to treat an expanding population of kids and adults diagnosed with Attention Deficit Hyperactivity Disorder. Yes, there are people for whom such medication is appropriate and very helpful, but many patients do not have this disorder, but they are labeled as such. They are then prescribed these potent medications, which pose mental and physical dangers of many kinds, including elevation of blood pressure, palpitations, stroke and anxiety. There is an over-diagnosing of this disorder, and some pediatricians and psychiatrists far too quickly reach for their prescription pads. The number of people consuming Central Nervous System stimulants is growing explosively each year. And so are the problems associated with these drugs.
The difficulties aren’t limited to antibiotics and amphetamine-like substances. The Center for Disease Control and Prevention reports that in 2010, the number of drugs ordered or provided to patients during office visits was 2.6 billion. (Yes, 2,600,000,000 prescriptions or samples of medication were given to patients!) Seventy-five percent of patients visiting doctors’ offices were provided drug therapy. The three most frequently prescribed were potent painkillers, various lipid-lowering medications, and an array of antidepressants.
It’s particularly discouraging to see the explosive increase in the prescribing of psychiatric medications by physicians in nearly every specialty. It’s as though we’ve become a nation where the “answer” to every life problem is to swallow a pill. And we may very well be encouraging our doctors to overprescribe everything from antidepressants to amphetamines to mood stabilizers because we dislike the fact that life is complicated, can be messy, and often leaves plenty of loose ends lying around.
This brings us to something that very likely plays a large role in the numbers and types of medications prescribed today. For years now, pharmaceutical companies have been allowed to advertise their vast array of products directly to consumers.
We’ve all seen television advertisements for a variety of prescription medications. These ads offer treatment for a host of problems. For insomnia, there are sleep medications (Ambien and Lunesta — the butterfly ad). For depression — not necessarily clinical depression, but for common human misery, or for unhappiness about what life invariably throws at us — there are Cymbalta, Pristiq, Effexor and Zoloft (the one where someone is followed around by a dark cloud hovering over her head). For psychosis, there is Abilify.
There are medications for people with rheumatoid arthritis. For atrial fibrillation, there’s Pradaxa. For erectile dysfunction there are Viagra and Cialis (showing loving, sexy couples, or a man and woman in separate outdoor bathtubs). For men with decreased testosterone (“Low-T”) there’s AndroGel. There are medications for people with bladder control problems or enlarged prostates — think Flomax, where a man runs to the men’s room during a sporting event.
There are medications for diabetes, for excess stomach acid (not over-the-counter pills, but a class of medicines known as proton-pump inhibitors such as Nexium).There’s Lyrica for aches and pains. There’s Neulasta for patients with low white counts while on chemotherapy. There’s Requip for those suffering from Restless Legs Syndrome. For asthma, there are Singulair, Symbacort and a host of others — all depicted in well-produced, visually-provocative or enticing ads.
These ads heighten people’s awareness of medical conditions and of medications available for them. But they do far more than that. Patients come into doctors’ offices asking for something they’ve seen on TV. Big pharma’s advertising blitz, coupled with its aggressive marketing to physicians (who all too often are readily seduced to prescribe), results in the ever-increasing number of prescriptions offered to patients. Grabbing the prescription pad and writing a script have become the initial treatment for too many conditions. Patients want a quick fix, and doctors are all too ready to comply.
Making lifestyle changes or learning to live through stressful times are becoming things of the past. Instead, we seem to want pills to cure all ills. If only it were that simple to do without negative consequences.
Yes, we’re well on our way to becoming a medication nation.
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I was an unmarried practicing psychiatrist living in Manhattan. My best friend and nearly constant companion was Sidney, a 27 pound, adorable mutt I’d rescued from the pound. When I had a break between patients, I’d run back to my apartment—six blocks away—to walk him and keep him company. Aware that dogs are socially-oriented animals, I hated that Sid spent so much time alone, but I had to work.
One day, I was faced with a dilemma.
My apartment was being painted. I couldn’t leave Sid there because he’d get in the way. Having no other choice, I brought him to my office, where he’d stay in the consultation room during patients’ sessions. Secretly, I felt great about having him with me; but I had deep reservations. This was an unusual arrangement, but I had little choice since I could find no one who would take Sid for the day. I rationalized that Freud often kept one of his beloved dogs in the consultation room during sessions.
I also knew by having Sid at my office, I was “telling” patients about myself—a therapeutic no-no, since the therapist should be something of a “blank screen” to patients during insight-oriented psychotherapy. But, I had to make the best of an unusual situation.
So Sid was in the consultation room as each patient entered for a 45 minute session.
I wasn’t surprised when he greeted each one robustly with wagging tail, plenty of sniffs and kisses, and begged to be petted and adored. That was Sidney.
To my great surprise, whether the patient was using the couch or sitting face-to-face during the session, each one gushed over Sidney and engaged my canine companion.
Then, something unusual happened: each patient began talking either about having had a dog as a child, or having wanted one. And each began dredging up memories of parents, friends, wishes, fears or strivings from years earlier. Some cried, some laughed, and even those who had trouble talking freely about themselves, poured forth a cascade of thoughts and feelings, revealing unresolved wishes or fears from childhood which encroached on their present lives.
It was obvious: Sidney’s presence was a powerful catalyst for a deep, emotional engagement by patients with the therapeutic process. And it was clear that Sid—much more than I—was instrumental in getting them to dig more deeply into their emotional lives.
Sidney was such an incredibly powerful therapeutic “instrument”, I briefly thought of keeping him in the office as a regular practice. But, it was too unusual for the times.
Nowadays, pets are a regular part of the therapeutic process at nursing homes and assisted living facilities. I fully understand why.
Were Sidney alive today, he’d be my co-therapist.
As a psychiatrist and human being, I understand the complicated swirl of emotions people felt and still feel about the horror of Newtown, Connecticut. This is especially true for those with young children, though I think most of us reel in revulsion when we think of that terror-filled day. It’s a natural human reaction.
One tries to comprehend the profound sorrow of those who lost children that day. The ripple effect spreads—widely and deeply. On the day it happened I was in a supermarket where many employees were from Newtown and the surrounding area. They were in a state of abject shock, and some ran home for fear their children were victims.
I’m asked frequently to provide insights about Newtown—how to understand that tragedy, and how to learn something from it. It’s impossible to provide some psychiatric nostrum or unitary explanation for what happened, but I do have some thoughts. And they don’t all relate to psychiatry.
The horror of Newtown calls into question who we are as a society and how we relate to our children. We must look more closely at our schools, the entertainment our kids watch, and at our very culture itself—who and what we are as a nation. And, we must examine our mental health delivery system.
It’s clear that the young man who committed these crimes was a disturbed and tortured soul whose inner demons exploded that day. I’m struck by the fact that in each of these mass killings—whether in Aurora, Colorado; Arizona; Virginia Tech; a shopping mall; a high school; an elementary school in Newtown; or wherever these killings occur—the shooter is always a young, loner male with deep-rooted mental problems that were either ignored or inadequately treated. And invariably, he gave many warning signs of his mental state before acting.
Usually, after a few weeks of media frenzy and renewed debates about gun control and mental illness, we go back to our daily lives and concerns. The horror of it all fades into the background.
But these terrible events are a cause for deep, probing soul searching about many issues, some not pleasant to examine: access to assault weapons; the depersonalizing effects of some video games and CGI action films; our music; and the coarsening of our culture with its desensitizing influences on those who are emotionally vulnerable. Looking into these worrisome concerns can make us feel uncomfortable.
But if we don’t address them, these tragedies will occur again and again.
I’ve sometimes been asked what it is about crime fiction I love, and why I write about it. I must say though, I read much more than crime fiction, and am now reading “Gone Girl” by Gillian Flynn. Though it involves crime, it’s not pure crime fiction.
But I do love crime fiction. There’s something elemental about it–something universal and intriguing about a good crime story–either with or without violence, though most depict violence to one or another degree.
About violence: violent–even murderous impulses–reside within us all. You come across them in news items about wars or murder. You certainly see bloodlust when people rubberneck while passing an accident, or go to some sporting events (mixed martial arts, boxing matches, hockey games, football and wrestling contests). Or, when you read some of the world’s greatest literature, or view the foul arc of history.
As a psychiatrist who’s done forensic work, I’m aware that violent impulses are universally present. So to pretend they aren’t part of human nature is disingenuous.
Sex and violence sell, and there’s a reason for that. Despite my years of training in medicine and psychiatry, and no matter how peaceful a life I lead, I’m still intrigued by violence and crime. And so are most people, whether they admit it or not. And that’s partly why the best-seller lists are populated by novels about crime and violence.