In Falling into the Fire: A Psychiatrist’s Encounters with the Mind in Crisis, clinical psychiatrist Christine Montross discusses the professional, ethical, and moral difficulties of treating troubled patients.

How did writing this book affect you as a psychiatrist?

Physicians often don’t have the luxury of taking months and months to consider a patient’s condition. Our charge is to intervene and ease suffering as quickly as we can. Writing allows me to return to the patients and cases that I feel I have incompletely understood. It offers me the chance to research clinical questions from many perspectives and disciplines and to really pore over the details of a case. I love diving into questions like that, and my hope is that the conclusions I reach strengthen and deepen my abilities and my practice.

In your own practice, do you ever feel impelled to step outside the role of doctor?

The challenge for young psychiatrists is often to stay in the role of doctor. Many of our patients have endured significant boundary violations. Perhaps they have been physically or sexually abused. Perhaps their delusions are such that they do not trust the world around them to be safe. My charge as a psychiatrist is to maintain a consistent, professional presence that creates safe and reliable boundaries for my patients. In training, we are taught that feeling the urge to step outside of that role is a sign to exercise caution and examine the impulses within us that are leading to that urge.

You write that “it is often impossible to separate our patients’ psychiatric symptoms from social circumstances.” What does this mean?

My patients often endure inconceivable life circumstances: prolonged homelessness, chronic sexual violence, agonizing loss. Separating circumstances from symptoms is like asking: which is more significant, the external stress or the internal response to it? Is it worse to witness combat trauma or to suffer from the flashbacks of it? But I don’t think we can measure significance. Nonetheless, I’ve seen countless examples of patients who have regained or retained mental health in spite of devastating social circumstances. That kind of endurance is incredibly inspiring.

In the book, you discuss feeling pressured to have an effective plan, to seem competent. Does that anxiety influence how you treat a patient?

Hopefully not much! Any anxiety or discomfort I might feel is my problem, not my patients’, and I must recognize and deal with it accordingly. That said, the majority of physicians—myself included—struggle when our treatments fail to bring relief or cure. And if, when our success is called into question, we charge forth in ways to assure ourselves of our own competence, the best course of treatment for the patient can be obscured.