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Episode 37: Navigating A Professional Relationship That May Feel Personal
130 Plays3 years ago
Fara and Grant speak with Jacob Appel, psychiatrist, author, and bioethicist, about important ways that the therapist-patient relationships may feel like a friendship (or just feel confusing). Well-intentioned actions may have unintended consequences when they cross the boundaries between clinician and friend. Dr. Appel helps give us clarity on how to manage when these moments come up, and advises us on how to preserve the treatment and act in the best interest of the patient.
Find more on Dr. Appel here:
https://www.mountsinai.org/profiles/jacob-m-appel
Recommended
Transcript
The Importance of Boundaries
00:00:05
Speaker
people really aren't cognizant of the importance of boundaries. They don't think about there being a difference, being a professional or a social relationship. Hi, thanks for listening to Doorknob Comments. I'm Farah White. And I'm Grant Brenner. We are psychiatrists on a mission to educate and advocate for mental health and overall well-being. In addition to the obvious, we focus on the subtle, often unspoken dimensions of human experience, the so-called Doorknob Comments people often make just as they are leaving their therapist's office.
00:00:34
Speaker
We seek to dispel misconceptions while offering useful perspectives through open and honest conversation. We hope you enjoy our podcast.
Introducing Jacob Appel
00:00:43
Speaker
Please feel free to reach out to us with questions, comments, and requests.
00:00:47
Speaker
Hi, thanks for listening to Doordop Comments. I'm here today with my co-host, Grant Brenner, and very dear friend, Jacob Appel. Jacob is a bioethicist, writer, a psychiatrist, and a commentator. He's here to help us have a talk about violations of boundaries in psychiatry and outside of it. And Jacob, thanks for joining us today. Thanks for having me, though. I will add that introduction to my mother. I'm still her son, he's not the rabbi. So it's all contextual.
00:01:17
Speaker
A son who's not a rabbi. Yeah. But there's still time. That's true. She reminds me that often. Yeah, because you do have quite a few, we won't talk about it here because I don't want to embarrass you, but you have quite a few graduate degrees. So to get ordained would probably be like. I was going to say the only problem is I study malingering is one of the fields I'm interested in. And the time I mastered malingering was in Hebrew school as a kid. So yeah.
00:01:44
Speaker
I guess I get an MDiv and you can be a Jewish, you know, pastor. You don't have to go for the fall rabbinate. I mean, I don't think that would live up to my mother's expectation. Would it kill you, Jacob? Maybe consider the rabbinate. It would conspire with my mother. I don't even know your mother. We can send her a link. She'll know that we pointed you in the right direction.
Clergy vs. Psychiatry: Boundary Expectations
00:02:10
Speaker
I appreciate that. But it is interesting because rabbis in the clergy have very different sets of boundaries than physicians do. It's a good segue to the topic for today. If the rabbi invites you into his home for a cup of coffee to talk about a personal issue, that's usually a very productive endeavor. If your psychiatrist invites you into his home to talk about a personal issue, that is usually a red flag.
00:02:32
Speaker
Yeah, for sure. How much of that is convention? So I'm curious because I completely understand where you're coming from as a psychiatrist and a therapist. I get it. At the same time, as someone who's done disaster mental health work,
00:02:48
Speaker
And of course, the context is completely different. I have gone into different situations such as shelters and provided psychiatric treatment. In my mind, that's very similar to doing consultation liaison psychiatry, where you might visit someone in the hospital or doing a home visit. I think it's
00:03:09
Speaker
The rules around boundary violations, both the rules and the customs arose in a very particular historical context. And that was having to do with sexual boundary violations in psychodynamics. And that's where all the early cases arose. And the problem with that or the challenge with that was to concern both the courts and the bioethicists was not about inequalities of bargaining power or about
00:03:34
Speaker
Mis-treatment of patients is entirely about mismanagement of transference. The belief that if you became too involved with a patient or romantically involved with a patient, you wouldn't be able to provide the care. And if a paradigm is shifted dramatically now, so the issues are different. So what you're saying is a very good point.
00:03:49
Speaker
Can you say a little more about the management of the transference for not psychodynamically knowledgeable listeners? Sure. I am not a psychoanalyst, I should add, but much of early psychiatry was based on
00:04:05
Speaker
models that relate people may associate with Freud or talk therapy, where you would, as a patient, put the provider in the stead of a figure like a father figure or someone who you could then reenact or reimagine certain psychological phenomena with. In order to do that, the provider had to remain neutral. But if the provider became romantically involved with you,
00:04:28
Speaker
then they were no longer engaged in a neutral reflection of your needs or your experiences, but also had their own apps to grind, so to speak. And therefore the care wouldn't be as good with the theory. There are some providers who still embrace that theory, but much of modern psychiatry involves either manualized therapies like cognitive behavioral therapy,
00:04:48
Speaker
or supportive therapies or medication management, where none of those theoretical principles really have a significant impact or care, but the rules designed are still the same rules we have today, which on the one hand protects patients in certain narrow areas.
00:05:03
Speaker
protecting them from sexual violation, for example. But the rules also and the customs aren't very good at protecting either patients or providers from a wide range of other endeavors that may have significant implications for the patient, but didn't really relate to psychiatry in 1950s and 60s. So is that what got you interested in, you know, and how do you write this paper? Most recently, like how did the inspiration come about?
Professional Entanglements
00:05:29
Speaker
Yeah, I'm particularly interested in the issue of entanglements.
00:05:31
Speaker
Most talk about boundary violations in medicine and psychiatry is about inequality of bargaining power. The doctor has much more power, has much more control, has much more knowledge. The patient is much less so. There's a risk the patient will be taken advantage of.
00:05:45
Speaker
Almost nothing has been written about the concern that simply being too involved with the patient's life breaks down the relationship between the professional and the social, even if the patient is interested, is willing, has bargaining power, understands, and the result can be deleterious to care. So you can imagine a patient of yours who actually has a lot of power. A doctor is a celebrity who is very interested in having their doctor more involved with their lives, who invites you out to dinner, invites you to see a Broadway show with them,
00:06:14
Speaker
The concern is not that you're taking advantage of the patient in some concrete way, but the concern is it becomes harder to think about their interest and their psychological benefit once the relationship is quasi-social.
00:06:25
Speaker
I remember, I think George Washington had some political advice along the lines of avoid entangling alliances. When you talk about entanglement in psychiatric treatment, what is your definition? I mean, I think there isn't a good concrete definition in the law or in custom, but the definition I would use is a situation where there are no longer clear lines as to what actions you're taking that are in the patient's interest.
00:06:54
Speaker
versus what actions you're taking better in either in mutual interest or also in your interest. If you start looking forward to seeing the patient in a social setting because you enjoy their company, you're becoming entangled with them in a way that makes it much harder to provide good care for them.
00:07:07
Speaker
So as a psychoanalyst, then if you notice, I'm trained psychoanalytically, if I notice that I'm starting to have those sorts of feelings about a patient, I treat it as counter-transferential. I treat it as, in some sense, a fiction that is a sort of a figment of the imagination of the treatment, and I confine it to the work with the patient, and I dedicate myself to using whatever experiences I have
00:07:37
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to help the patient with their own issues rather than playing it out in the external world. So with entanglement, that would mean that I was getting internally blurred sense of what my roles were and mixing up my professional and my personal identities.
00:07:57
Speaker
exactly. And the next step is then you start doing that in an active way rather than simply a psychological way. I can give you a couple of examples of entanglement. I think that may seem like they're in the interest of a patient but actually are not. There's a prominent case in New York City, I won't use the names just to there's no reason to, where a prominent doctor clearly well-intentioned tried to fix up two of his patients and the patients either had a bad date or a bad series of
00:08:21
Speaker
romantic encounters, and then they sued him. And that would be a crime. He tried to serve as a matchmaker. He said that both of them were having a hard time meeting people. He didn't want to subject them to the vagaries of personal ads. He thought they had a lot in common. Now, well-intentioned, the patients were receptive, and yet that entangled him to such a degree in the patient's lives in a way that crossed the boundary from professional to social. A very concrete way this might come up, I always offer an example,
00:08:46
Speaker
is the law of unintended consequences. So there are consequences for you as a provider, but also consequences for other providers and the profession as a whole. So let us say a patient who's a victim of intimate partner violence knocks on your door one day and says that she has left her spouse. She has no place to stay. She needs a couple of days before she can get out of state to stay with her family.
00:09:06
Speaker
and you have an empty apartment over your garage and you say just for a couple of days you can stay there you have the best of intentions no ulterior motives now even though there's no nefarious intention you're entangled with a patient in a way that can endanger you because your partner may show up and not
00:09:22
Speaker
understand the dynamics of this relationship and they assume the worst. But also other patients out there may then understand that they can make these expectations of their providers when their providers are not interested in that level of entanglement with negative consequences for them. The next patient will show up at someone's door or even your door and you won't have a garage for them. And then what do they do?
00:09:43
Speaker
not to mention the liability that probably that psychiatrist's business insurance doesn't cover the garage above his house.
00:09:54
Speaker
That is a very good point. I think entanglement, most people's malpractice insurance covers them for professional endeavors only. And when you become entangled enough, it suddenly becomes unclear what is a professional endeavor versus a social endeavor. And really, the point of my article is less to define specific rules, though I do think there is some guidance to be offered, and more to get people to really think about entanglement and non-sexual boundaries. In psychiatry, it's important. It's even more important in medicine, because in general medicine, the boundaries are even far blurrier.
00:10:24
Speaker
There are plenty of people who have social relationship to their patients. I'm not going to say that it's always inappropriate, but I think you really want to think carefully about the nature of that relationship because it can lead you down a path you don't want to be on. Well, what factors lead someone to become entangled on the caregiver side? Well, I think the most important thing is people really aren't cognizant of the importance of boundaries. They don't think about there being a difference, being a professional or a social relationship, and they let the patient think of their relationship as social.
00:10:50
Speaker
So when the patient calls them and they don't have time for the patient, the patient, rather than thinking, my doctor is busy, thinks I've been slighted by my friend. That leads to a dynamic that isn't hardly unhealthy. And then there are some very concrete things, mingling of finances or becoming invested in other areas of the patient's life rather than their medical care. Now, the thing is most people are not going to say, you know, I'm going to join to a joint business venture with my patient. People have enough common sense not to do that. But there are other areas that are entangling that people don't think
00:11:20
Speaker
A patient says, you know, I don't really have any close friends. I'm looking to someone to list to be the trustee for my children, for my inheritance, something happens to me. Now that may seem entirely innocuous, but it's really not because it changes significantly your dynamic with a patient. Serving on a board or a foundation for the patient in some circumstances may then raise expectations for the patient better, not healthy for the therapy.
00:11:43
Speaker
Well, sometimes I get invited to collaborate on something or to do this or that because I have identities outside of my clinical practice. I'm a business owner, I'm a writer too, not as good a writer as you are, but nevertheless, I guess I was trained, but maybe my upbringing too, to really be very, very clear about it. People don't always like, but you have to learn how to handle things with tact and diplomacy. What I'm wondering is if there's any personality factors because
00:12:11
Speaker
Part of my understanding of boundary violations is that sometimes it's driven by the personality of the clinician. No, that's absolutely true. It is rare that someone engages in boundary violations or boundary entanglements with one patient. It's also often people running...
00:12:29
Speaker
Yeah, a fast and loose practice are very different in a wide range of areas, and that leads them into a place they don't want to be. So yeah, so I think it's hard to make a hard and fast rule you should not do this, so much as making sure that each endeavor you engage in, you're really thinking about the implications for the patient. The people who get in trouble, the people who don't think about these things. A good standard, I think I always say, for relation to boundary violations,
00:12:51
Speaker
and particularly non-sexual, is if I went before the medical board and I explained what they did, I did, would they say, you know, a reasonable well-intentioned doctor could find themselves in that situation? Or would they say only a deeply misguided person could end up doing that? And if the answer is the latter, then you want to step back. Interesting. That's a good, I think that's a good way to look at it because really things are changing so fast.
00:13:14
Speaker
And especially now with people having gone remote for a long time and different modes of communication, I feel like the lines are more blurred than ever. And it's really, really hard to maintain, you know, certain boundaries, like for example,
00:13:31
Speaker
If people will text about an appointment, you know, running five minutes late, you know, that's okay. But if they want to send me like memes or like a house listing for something, then that's something that we have to talk about in session. And I think there's a lot of nuance there because you don't want to sort of slip into something that feels more social and less professional. Right. It's a hard balance because you also don't want to lose your humanity. So an example I always use is a number of years ago, I was actually giving up book reading.
00:13:59
Speaker
And one of my patients, who was a woman in her early 90s, a geriatric patient, came into the bookstore with her daughter. And I noticed her there. And then afterwards, the woman said to me like, oh, I didn't know you wrote books. I want to buy one. And I said, don't be silly. And I bought her a book, and I gave her a copy of the book. Now, I wouldn't do that with every patient. But with a 90-something-year-old woman where there clearly was no ulterior motive on my part or her part, it would have hurt her feelings not to do that, perfectly acceptable. There are patients with borderline personality disorder
00:14:27
Speaker
or for that matter patients under a great deal of duress, I would never think of doing that with. So attuning yourself to the patient also matters. I guess that's sort of the point of all of this is that it's our job to make sure that the best interest of the patient and the treatment, you know, is the priority.
00:14:43
Speaker
Yeah, and we often, because of the way medicine works, having bright line rules, like don't sleep with your patients makes it easy. But having discretionary rules that have a lot more gray area make it much more challenging. The example I always use is every teenager understands you must be 21 to buy a drink. For fewer of them understand you can't get a drink if you're intoxicated because it's a discretionary rule with a continuum. I didn't even know that.
00:15:08
Speaker
Well, in your example of buying the book, I think that that's a good example, because I think people have a lot of trouble around things that aren't so egregious, like your, you know, your rule of thumb getting in front of a medical board. Would that, you know, would that be sort of a very disturbing thing to do? A lot of things are in the in the gray zone and maybe there's generational differences, you know, giving someone a book versus
00:15:33
Speaker
sort of in maybe an overly harsh boundary way, telling them that they have to buy a copy of the book if they want it, and maybe implying that they have poor boundary management, because they wanted you to give them a copy, really wouldn't work very well for the therapeutic alliance. And of course,
00:15:51
Speaker
perception is really important because something that even if you've thought it out and it seems like no big deal, like Farrah's example, well, we were just texting about the appointment time, but then the next thing the patient sends you a text at three in the morning that they're in clinical crisis and you don't check your text messages. That could easily cause problems and you've led the person to believe that it's okay to text you with whatever.
00:16:18
Speaker
I find a lot of clinicians use just regular text messaging without any real guidelines around it. Their treatment agreement may not spell out how to use text messaging, setting aside the question of privacy. I also sometimes find that when I insist on people using encrypted
00:16:39
Speaker
HIPAA compliant channels of communication, they often don't understand. And even if I explain why that's to their advantage and also because I'm obligated to follow those rules in some ways, it also isn't always comfortable for people. They don't always like it.
00:16:56
Speaker
What it makes me want to ask you about either of you is whether the nature of relationships is changing in our society, where there's just generally more fluidity in relationships, de-centering of traditional authority, and how does that affect non-sexual boundary violations and the concept of entanglement?
00:17:17
Speaker
a great question and I want to flip it on its head a bit. I do think things are changing but they're reverting back to in some ways the way they were before the modern psychiatric revolution. It's important to think about what psychiatry and what medicine were like in the 19th century. In the 19th century there's that famous scene from Anna Karenina where the doctor comes to treat Kitty Levin and he has this radical idea that he actually wants to meet the patient and examine her.
00:17:41
Speaker
because usually what the doctor does is they sit down with the family and have a conversation about the symptoms over a meal and offer a prescription. A number of very prominent psychiatrists over the years either had romantic relationships with their patients or married their patients. There was a time not that long ago where dialysis units would have parties when long-term dialysis patients married dialysis nurses.
00:18:02
Speaker
people they saw every day or three times a week, um, some intensity. So it is only in the last 40 years, really since the case of Roy B Hartog's and attention to the role of women and their treatment by psychiatrists in the seventies and a number of other specific conversion factors that the boundaries of sort of solidified in this way. Um, so now we're seeing a drift back to a much looser framework, but hopefully with better parameters and a better understanding of power.
Challenge of Modern Medicine
00:18:32
Speaker
I think just in general, the way that medicine is and the availability of information, even though I know that some people find it very annoying or some doctors might find it very annoying, people go on and they look at their symptoms and they bring that in. I think it's good for patients to have access to the information and then we can work with them and helping them to understand it and come up with a treatment plan that works. I don't know that
00:19:02
Speaker
doctors are gonna maintain this aura of power or authority because I think that the world is a little bit more casual and that's probably a good thing. Yeah, I mean, we have this false belief, I think, that these boundaries automatically make medicine better. When my grandfather was a psychiatrist in the early 50s in New York City, he would both take patients from a state hospital out on his boat and bring them home to have dinner with his family to test whether or not they were in a good enough psychiatric condition to be released.
00:19:31
Speaker
Now we would look aghast at that, but it was actually a fairly effective tool. So we shouldn't confound the familiar with the essential.
00:19:37
Speaker
That reminds me of there are areas where interacting with patients and you referenced cognitive behavioral therapy has a role like in vivo exposure therapy. A therapist might travel with a patient who has a fear of airplanes as part of their final work. What you described your grandfather doing doesn't sound so different as long as it's framed as a clinical exercise.
00:20:04
Speaker
The problem is when you're traveling with a patient for their fear of flying but your real goal was a vacation in California. Yeah. Well, then there's a different motive. My understanding though maybe it's overdone is that one of the big personality factors is is narcissism.
00:20:20
Speaker
and particularly grandiosity or certain unmet personal needs that a psychiatrist or another clinician might have, that they're seeking to gratify in clinical relationships rather than in their personal life. That's one of the big danger zones. There's a lot of data for that. What I always like to emphasize, because we do conceptualize it that way, those are what I like to think of as the bad actor.
00:20:45
Speaker
in a way. There are people who are to some degree aware they're doing something inappropriate, but they don't really care. My interest in my paper is more to you guys than people who actually are trying to be good doctors, but they're still grappling with these questions. I think a lot of us sort of face that dilemma. I want to be an accessible, likable person, but I also don't want to be the person who gets a 3am phone call or the patient shows up at my doorstep.
00:21:08
Speaker
Well, I think you've picked a wise example to focus on the people who want to do the right thing rather than the quote unquote bad actors, because it's very easy to say, well, that happened because he or she was narcissistic. And I'm not like that. So it couldn't happen to me. I think the point you make of expectations is also really important. And I want to emphasize that. One point I make in my paper
00:21:34
Speaker
is engaging in activities that are likely to occur once. It's far more justifiable than activities that are likely to repeat themselves. So a patient dies and the spouse asks you to come to the funeral and say something. I think it's generally fine because obviously you're not going to have another opportunity to do this again. But a patient asks you to come to their Christmas dinner, that sort of raises an expectation you'll come the following year too. And if you don't, they may take it the wrong way. Yeah, good point. And I think a lot of these things can be talked about upfront.
00:22:02
Speaker
I know there are plenty of examples of people wanting their psychiatrists to be there at weddings or bar mitzvahs or whatever it may be because they feel connected to their doctor and really genuinely want them there. The doctor may want to be there and it may be disappointing for both of them that it's probably better if we don't.
00:22:25
Speaker
cause real harm to the therapeutic relationship. If you set a precedent and then the therapist decides, you know, I don't want to go to the third thing. Right. And there's a therapeutic rupture and the treatment alliance can be irreparably damaged.
00:22:41
Speaker
And that's one of the strong justifications for holding those boundaries. But sometimes it can feel uncaring, depending how you handle it. So if you say, I'm not allowed to go to weddings, I don't go to weddings, it's not appropriate for you to ask.
00:22:58
Speaker
I hear a lot of that, quote unquote, it's not appropriate versus something like it's so generous of you to invite me. What a wonderful idea as a rule in order to make sure that our work together is protected. I have to decline, but let's talk about what that means for you.
00:23:20
Speaker
I think one of the hardest challenges is when the doctor and the hospital are in conflict, and you're seeing more and more of this. When you have well-off patients who clearly want to do something for the welfare of health care of the hospital, and the hospital would like to make this happen, but the doctor doesn't want the patient to be given a doubt chair at his or her honor because then there's no therapeutic relationship. I've heard a number of colleagues over the years treating patients, often in medicine, but I've seen it in psychiatry raise this question, and it's a really hard issue to navigate.
00:23:48
Speaker
Does the doctor have a lot of say and how that unfolds or? Often because the patient may say to you, I want to find a way to thank you for all the years of treatment. I'm going to reach out to the development office. You say, no, you shouldn't do that. And yet.
00:24:05
Speaker
For good therapy, sometimes you do want to say, no, you shouldn't do that because let's say the patient says to you, we've had a great relationship for the last 10 years. I'm moving to Florida. I want to thank you. I want to endow a chair. And then a year later, the patient moves back to New York. Can you resume care with the patient or the patient's friend calls you up and says, I heard Fred donated $4 million and you treated him. I'm only doing $8 million. Um, I'm suicidal and have addiction problems. And I only come on Thursdays. Um, I'd like you to treat me to do with that.
00:24:34
Speaker
Why is that problematic in terms of the power relationship around the money or could you spell it out a little more?
00:24:40
Speaker
Yeah, so on the one hand, once money becomes involved in a way beyond the agreed upon reasonable fee for treatment, the patient may feel they're entitled to special services or they may also second guess whether or not you're treating them in their own best interest or for ulterior motives. One thing I always try to emphasize when I give a book to a patient or something like that is I try to make it seem like it's routine to them so they don't see anything special in it. I also, when my patients learn that I write about
00:25:08
Speaker
I don't write about patient learn, I write, I write, I always make a point of telling them that I would never write anything about them. So they don't ever think that I may be using them for a purpose other than Yeah, I think that's one of the questions. I know there are a lot of issues in terms of like getting consent from patients to, you know, publish certain papers or write about cases. But I think the bigger question is,
00:25:33
Speaker
you know, is my therapist interested in helping me or are they minding my life for their next, you know, their next book or their next case write up. There can be so many unconscious like motives. It's hard to know.
00:25:51
Speaker
If it's something I write about and talk about a lot, what do you do if your patient is a celebrity or the president? To what degree do your obligations to the public interest conflict with your obligations to the patient, which can become fairly complicated? If the patient says to you, as we know happened in New York, I'd like to dictate my statement about my health care, please release it to the public. Should you do that? Can you do that? If you don't do that, how does it affect your relationship?
00:26:12
Speaker
Absolutely. I think now, at least lately in the media, we've seen a few different cases of these bad actors or have heard about them maybe through the Britney Spears case, or there was this wildly popular podcast called The Shrink Next Door. And now that's coming out as a mini series. You know, I think really the question is, do psychiatrists, you know, set out to cause harm or to, you know, take over people's lives? Most of them don't.
00:26:42
Speaker
But there are things that happen and because of I guess the nature of the relationship how intimate it is and also how private it is, people don't usually speak openly about it. I think one of the challenges psychiatry faces is
00:26:57
Speaker
It's hard to have a professional field with a worse reputation and psychiatry unfortunately has earned it because many of the things psychiatry did in the 40s, 50s and 60s, both in the interventional sense from lobotomies and insulin comas to the boundary violations and egregious misconduct in the 70s of a number of high profile providers, have tarnished many people who think that's what psychiatry is like today.
00:27:20
Speaker
And obviously it is not, I'm a psychiatrist, I believe very much in what we do, but how to message that in the right way and on the one hand control bad actors, but on the other hand, not draw too much attention to bad actors is really one of the challenges. The media, the culture loves finding quote unquote evil psychiatrists to parade through the media, even though there are very few of them. But I think they probably are more exciting than the rest of us.
00:27:44
Speaker
Oh, absolutely. Yeah. Well, what is the allure? Well, I think it's sort of on one hand allows people to avoid the psychiatry therapy, um, because they can say, well, things are bad now, but I don't want to be exploited. I saw a psychiatrist once and he was super intrusive. And I guess it's a way that people can on one hand believe that they're protecting themselves, but on the other hand, avoid something.
00:28:13
Speaker
that's potentially uncomfortable. Yeah, I mean, I think we may reject the pull yourself up by your bootstraps theory of mental health and improvement. On the other hand, if you're an outsider and you've seen generations people talking about schizophrenogenic mothers and refrigerator mothers, and all of the horrific implications of having psychiatric illness, none of which are true, then you're really going to run from it at high speed.
Evolving Understanding of Psychiatric Blame
00:28:37
Speaker
If you're told that your psychiatric illness is due either to
00:28:40
Speaker
your personal shortcomings, your family shortcomings, which has really been the message of our culture for generations until very recently. You don't want to see me in office. I don't quite fully understand your last point because my sense is development significantly influences people's adult problems, but I think you're referring to maybe an overly simplistic message. Yeah. So it's sort of shaming or blaming.
00:29:05
Speaker
Yeah, so I mean there were theories where conditions we now want to be very complicated with heavily genetic and social influences were attributed to very specific malevolent or misguided choices in parenting and this became a culture of society. Bruno Bettelheim on radio and television in the 70s saying that if you had an autistic kid, it was because you were a bad parent.
00:29:26
Speaker
is very much simplistically blaming the parent. The psychodynamic mechanistic approach to psychiatry that many people still think is what we do. Yeah. And so that's not very appealing. But so I was asking, why is it so alluring as a media figure for a transgressive violator of boundaries? Why is it so alluring and seductive for the media to portray, for example, a psychiatrist
00:29:56
Speaker
who violates boundaries or transgresses I'm thinking of Harley Quinn, the joke, you know the Joker's sidekick now sort of a supervillain in her own right started out as a psychiatrist. She's got this kind of insight about people that she uses the wrong way, though she does have sort of a sense of justice.
00:30:17
Speaker
But I think we're also tend to be interested in other deviations when other types of caregivers transgress. And I'm wondering if either of you have thoughts about why we sort of love that disturbing situation so much, the mother who becomes a bad mother. You know, the media is full of stories like this. Well, I think a lot of it is the media is really interested in psychological manipulation. And Mr. Mingali, is that
00:30:46
Speaker
and the power of psychiatrists in that way. The psychiatrist who runs over his neighbor's dog, nobody's interested in. If you commit the kind of offense that anybody can commit, not interesting, but if you commit something that only the magic of psychiatry and the ability to see into the soul and twist it lets you do, that's really interesting to people. I think it's like anything else that there's some perian interest or some scandal there. You know, maybe people
00:31:10
Speaker
I don't know, they want to be aware of their own vulnerabilities in the face of someone who might be like trying to shrink their head a bit. So you think it might be sort of part of a general curiosity about like psychopaths and manipulators. And then the doctor, you know, psychiatrist is amplifies that interest in people who are powerfully charismatic and manipulative because there's kind of a contradiction as well.
00:31:39
Speaker
Absolutely. I mean, it's a combination of the Dr. Jekyll and Mr. Hyde effect with our more general fascination with serial killers, sociopaths of all sorts. And there's a whole culture of fascination with people. I mean, it disturbs me that many, many of these serial killers get thousands of letters of fan mail in prison. I mean, I can't imagine what it would take to sit down and write a fan mail letter to Charles Manson, but thousands of people have done it. That's interesting. That's probably a
00:32:09
Speaker
a slightly different phenomenon, but you're right. There's fascination around it, for sure, and probably a lot more interest than someone who's generally hardworking, tries to do a good job and help their patients, which is with the majority of the campus, I think. And at this point, now that there is information out there, and hopefully people
00:32:34
Speaker
who are listening have a bit more of an understanding of that these things are at times fluid, but can be talked about and can always try to be understood in the context of even something as small as how did that disclosure help me, right? Why did you tell me where you were going on vacation? I didn't ask, but maybe it was just something that slipped out or maybe it was something that
00:32:57
Speaker
the psychiatrist thought it was important for the patient to know. I'm not sure. I think it's a subject that can make psychiatrists anxious. I think we've made the point a few times that people who act this way, they're bad actors or people who make a well-intentioned mistake, it's quite rare.
00:33:16
Speaker
But from a professional point of view, of course, it's a touchy subject to talk about transgressions. But the tendency, of course, is for any profession to want to present itself in the best possible light. Of course, the paradox is by doing so, there's a risk of not paying attention to the areas that need attention paid. And so I'm wondering what it's like for you, Jacob, as an educator and a writer, working with
Teaching Subtle Boundaries
00:33:46
Speaker
psychiatric trainees, as, as you try to teach people about these subtle nuances that don't have to do with, you know, being a Svengali, you know, who's the doctor from Silence of the Lambs, Hannibal Lecter type, but just
00:34:03
Speaker
you know, an ordinary psychiatrist who is learning how to navigate what can sometimes be surprisingly difficult situations, which in the moment, you know, maybe seems pretty obvious. What's the big deal? Like, you know, it's easy to text about a change in appointment time. Why? Why are you making such a big deal about it in class?
00:34:24
Speaker
Yeah, absolutely. That's a really good question. So I should add more context. I always try to emphasize that psychiatrists should go with the reputation rather than resist the reputation. So I always introduce myself in not the patients, but in professional settings with something like I'm a psychiatrist. I'm almost a real doctor because that's what a lot of people in the audience are thinking. And when you say that you disarm them and they realize that that's really an inappropriate way of looking at it. While if you become defensive about what psychiatrists do, then they think the worst. So with the students,
00:34:53
Speaker
I always emphasize, actually I tell the students, begin with a couple of very powerful stories about prominent psychiatrists in New York City who we've known.
00:35:01
Speaker
who've engaged in egregious boundary violations, probably without even realizing they were doing something wrong. And I start by telling these stories to give them a sense that it can happen to anyone. And then I tell them that most people don't mind boundaries. Most people just want fairness and equity. If they understand this is what doctors do and that you treat everybody like this and it's in their interest, they're very embracing it.
00:35:24
Speaker
If you think it's a special rule for them as a patient, that's when they get upset about it. And that's what I emphasize to my students. If you like flying an airplane, like running a psyche, or if you do the things the safe way every time, then when there's a loose part, you notice it. If you do things piecemeal each time, then there's a loose part, you don't notice it. And that's what I'm trying to avoid.
00:35:45
Speaker
It's a really good point and a great way to look at it. It sounds like we're coming to the end of our time together today. It's been very thought provoking. Where can people read your work or find out more about your perspectives, Jacob?
00:36:01
Speaker
Sure, so I have a website with my full name, JacobMAppell.com, or I have a recently, I have a fairly new book out, Who Says You're Dead, which is a compendium of ethical and legal dilemmas related to medicine, but not for psychiatrists, but rather for lay people. Who says you're dead? Who says you're dead.
00:36:20
Speaker
Yeah, it's a fantastic book. It really is. Is it true? Do you know that the term dead ringer comes from when people might have been accidentally buried alive so they could signal to the outside world because it was hard to tell when people were dead? Do you know? I've heard that, but I don't know if it's true or not, but I have heard that. I don't know if it's true either.
00:36:42
Speaker
But I mean, there's a whole, for many years, it was unclear what the definition of death was. And it's still possible to be dead in one state in the United States and alive in a different state in the exact same condition. That's true, sort of metaphorically as well. But I think you mean like- I mean, literally. New York. Yes. What happens if you're going through the Holland Tunnel, though, and your half of you is in New York and half of you is in New Jersey? That is a Talmudic question. That is if I become a rabbi, I could have answered.
00:37:11
Speaker
Good. We started where we ended and we ended. Farrah, anything you want to add? Thank you so much for doing this. It was a lot of fun. And yeah, I hope that we'll be able to have you on again. Thank you for having me. Thanks.
00:37:35
Speaker
Thanks for listening to Dornop comments. We're committed to bringing you new episodes with great guests. Please take a moment to share your thoughts. We'd love it if you could leave a rating and review on your favorite podcast platform. You can also find us on Instagram at Dornop comments. Remember this podcast is for general information purposes only and does not constitute the practice of psychiatry or any other type of medicine. This is not a substitute for professional and individual treatment services and no doctor patient relationship is formed. If you feel that you may be in crisis, please don't delay in securing mental health treatment. Thank you for listening.