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A Life in Psychiatry:
Looking in, Looking out
When Dr. Paul Garfinkel started his career in psychiatry in the 1970s, psychoanalysis dominated the profession. Then the pendulum swung the other way. Psychoanalysis was discredited and drugs became the treatment of choice for mental illness. Throughout his career, Garfinkel has struggled to find a balance between these two poles, between compassion and human touch on one hand and the rigour of science and the prescribed drugs that have revolutionized psychiatry on the other. Though it was sometimes not popular, he held steadfast to his belief that medicines combined with psychotherapy are often better than either one alone.
In this deeply personal memoir Garfinkel writes about his journey through a 40-year career and life devoted the to the understanding, care, and advocacy of the mentally ill. He takes us through the many stages in his life, from his humble beginnings in Winnipeg as the son of Jewish immigrants, through to medical school, his internship at Toronto Western Hospital, his rise to leadership positions at many institutions and eventually as the first CEO of the Centre for Addiction and Mental Health (CAMH).
With candour, Garfinkel gives us insights into the life of a psychiatrist and reveals the challenges facing many practitioners, including “burn out” and the intense pain they feel when a patient commits suicide. He probes some of the most controversial subjects in the profession, such as the outrageous sexual abuse of patients. He shares his thoughts on the qualities needed to be a good psychiatrist and a good leader. He reflects honestly on some of his professional missteps and the breakup of his own marriage. Garfinkel passionately urges his colleagues to speak out, support the patients, and work toward removing the stigma of mental illness, hopeful for the day when people with mental illness are treated like anyone else who is suffering and in pain. A Life in Psychiatry is a fascinating insight into the world of mental health care from a devoted and compassionate pioneer.
CBC Radio – The Current with Anna Maria Tremonti
Following the news of the GermanWings crash, you’d be forgiven for thinking everyone’s a psychiatrist, busy with a diagnosis of Andreas Lubitz, the co-pilot who crashed GermanWings Flight 9525. In the media coverage, facts have been mixed with speculation and critics say the collateral damage is our understanding of mental health.
We can never forget that psychiatry, like all of medicine, is a helping profession that aims to improve the physical, mental, spiritual, and social well-being of human beings. Psychiatry is concerned with illness but also with the texture and drama of the human condition. Yet the art of medicine, the caring side, is easily dismissed in a scientific world. This was true then, and it still is true today. Caring in medicine can be neglected at a time when the pursuit of science has brought us powerful and effective new treatments. I believe this is a mistake for our profession. Practitioners need to be healers who connect to patients on a human level. Rather than just focusing on the illness, they need to see people as they are—multidimensional and complicated individuals. They must tailor their treatments to individual patients and never forget that the practice of medicine, while based on scientific evidence, is first and foremost a social interaction between someone who is suffering and a healer.
When we lose this caring side of medicine, we lose the ability to sit and be with people who are ill. A physician in one of our studies put it this way: “I think we have failed, somewhere along the line, to teach our residents how to cope with someone who is suffering. To sit in a room with someone who is crying, someone who is in pain, someone who is psychotic and confused and frightened of you, and I think we hide behind our pills. Because the pills become an interaction that says, ‘I’ll solve this problem for you quickly so that I don’t have to sit with your tears.’”
The challenge to balance caring and evidence-based science is not new. I’ve always been an admirer of Sir William Osler, the Ontario-born and McGill educated physician who was the first professor of medicine at Johns Hopkins and later the Regius Professor of Medicine at Oxford. A great man and an outstanding doctor, he fundamentally changed medical teaching in North America by introducing the clinical clerkship and medical residency. The idea of the residency, with its emphasis on bedside teaching, was borne of his insistence that students learn from seeing and talking to patients.
I have collected the first editions of many of his books and have loved to quote him in my addresses to psychiatrists, especially when I was at the Toronto General. The group there even came to expect it, and when I left they gave me a first edition of his The Principles and Practice of Medicine (1892). In his day, Osler used to complain that doctors relied excessively on treatments that had never been proven to be effective. Since they were not interested in proof, doctors often believed in a particular school of thought, which led to the growth of denominations. Members of denominations resisted the advances of knowledge because they were ideologically committed to particular therapies. Practitioners maintained their beliefs rather than applying new evidence when it was powerful, or testing or refuting it.
This description could fit psychiatry as it was in 1990. We had dichotomous value systems—clinical practice and scientific research. The clinicians were the humanists who tried to understand the complicated human beings in all their dimensions. The scientists thought the cure would come from the lab and the thrilling new insights about the workings of the brain. As the pendulum was swinging from the caring side of the profession to the power of science, the two camps were deeply split.
This wasn’t good for patients or for doctors, so I wanted to introduce a value system and an educational program that integrated both streams of thought. We need science and humanism together—together at the bench and together at the bedside.
Gerald Russell,The British Journal of Psychiatry,
Nov 2015, 207 (5) 462-463; DOI: 10.1192/bjp.bp.115.166843
For a psychiatrist to write an autobiography is a rare event. Professor Paul Garfinkel is a Canadian psychiatrist who has spent most of his professional life in Toronto. His account is presented in chronological order, beginning with information about his background and containing, to a degree, key self-revelations. For example, he felt he had been overprotected by his upbringing, within the cocoon of his Jewish family. He experienced prolonged grief after the deaths of his parents. He admits to a tendency to lose his temper when he thinks someone else is bent on personal gain.
He divides his 40-year career into two phases. During the first part he saw himself as a clinical psychiatrist with strong academic leanings. Indeed, his research was distinguished by key papers on the raised prevalence of anorexia nervosa among student dancers and fashion models, whose occupations entailed pressures to maintain a thin body shape. He also established through cohort studies that the historical period when these social pressures first appeared was from the late 1960s onwards. The second phase of his career was spent leading institutions at the forefront of the mental health revolution in Canada. He became more interested in management and executive leadership than the psychiatric issues reported in the profession’s journals.
In 1986, Garfinkel experienced the ‘biggest crisis’ of his career. His closest research colleague was accused by a female patient of having had a sexual relationship. After a while Garfinkel could no longer accept his colleague’s denials, and felt betrayed. He sought to understand why such professional lapses occurred. He reviewed the literature, and found that between 6 and 10% of psychiatrists succumb to what he calls ‘the slippery slope phenomenon’. He names several senior psychiatrists in Ontario guilty of such sexual transgressions. He also commits himself strongly against other colleagues who seek ‘excessive emoluments’ from drug companies for assisting in drug trials. They too are named in the book. In the foreword there is a sensitively written section by Dr David Goldbloom cautioning the reader against concluding that part of Garfinkel’s character is to be judgemental.
It is uncommon for clinical researchers to welcome having an additional managerial role. During the second part of his career Garfinkel chose to take on this role increasingly. He explains this new motivation by what he saw when regularly driving past the Queen Street Mental Health Centre on the site of the old Toronto asylum—homeless people who were clearly ill, talking to themselves or pushing grocery carts filled with their belongings. He sensed that these were people with the most serious psychiatric illnesses, living on the streets. Yet the medical profession was not taking care of them. Here was a sign of the gap between scientific achievements and society’s level of care. He quotes a 2004 survey in which it was found that only a third of people who needed psychiatric care succeeded in obtaining it. Queen Street Hospital had low staffing levels of psychiatrists, in contrast with the well-endowed Clarke Institute, where Garfinkel held his Chair, and the Toronto General Hospital where there were good psychiatric facilities. After this conversion experience he developed a fresh ideology, encapsulated in his phrase ‘research, education, health promotion and care are mutually enhancing’.
Garfinkel played a central part during a merger of the most significant mental health facilities in Toronto: the Clarke Institute, the Toronto General Hospital and the Addiction and Mental Health Services Corporation. He accepted the post of Chief Executive Officer for the Centre for Addiction and Mental Health. He made good use of his capacity for hard work and attention to detail including ways of reaching the hearts and minds of his more reluctant colleagues. Some of them became resentful because of changes to their roles. He felt he was becoming increasingly isolated as the influential leader of the Centre.
Unusual in an autobiography, the book has a strong educational content. For example, any psychiatrist faced with the task of planning a mental health merger would do well to follow the author’s advice on the logistics and the psychological problems that have to be overcome. The book also contains pearls of clinical wisdom. Garfinkel commits himself to a return to the psychiatric formulation as opposed to the narrower diagnostic procedure of following the DSM-5 criteria. His chapter on ‘DSM dysfunction’ is an insightful account of limitations of this DSM approach, including false multiplication of psychiatric disorders. Equally important, teaching of psychiatry has become distorted, leading trainees to diagnosing psychiatric illness by using the DSM checklists.
Professor Garfinkel ends his autobiography in a dramatic manner but, in order not to spoil his story, this reviewer will not disclose the ending. This most interesting book will repay detailed reading, made easy by the author’s pleasing narrative style.