Vivian Rakoff, the chair of the University of Toronto’s Department of Psychiatry during the 1980s and one of the legends of Canadian psychiatry, used to say that psychiatry was both a science and an art, and the essence was to balance the two. More than four decades later, his words ring as true as ever.
So begins Dr. Paul Garfinkel in the chapter “Science and Care” of his newly released autobiography, A Life in Psychiatry: Looking out, Looking in.
It’s a nice observation, and there are many in Dr. Garfinkel’s book.
And that’s why I’m so pleased to offer this exclusive book excerpt — a full chapter — as the Reading of the Week, distributed with the permission of the author and his publisher, Barlow Book Publishing, Ltd.
You will recall that the Reading back in mid-October was from his book, a short excerpt on suicide. I noted at the time that Dr. Garfinkel has had a storied career — psychiatrist, prolific researcher, administrator — and that the former CEO of the Centre for Addiction and Mental Health can now add to the resume: published author of a moving and thoughtful memoir. Since then, I’ve had the chance to re-read his book, and strongly hold to this view.
This chapter, like the last excerpt, is highly readable and interesting.
In it, Dr. Garfinkel considers the state of psychiatry.
When I started in 1970, psychodynamic thinking and practice dominated psychiatry in the United States and to a lesser extent in Canada. Patients spent a great deal of time lying on the couch, or sitting face to face with their therapist as they explored their internal world, their dreams and fantasies, their past, and their relationships. Psychiatrists tried to help them see meaningful connections and relate these to their distress or disability. Psychoanalysts dominated academic centres and it was difficult to challenge their views, particularly if your critique was seen as a form of psychological resistance. They believed their ideas and treatment evaluations were beyond reproach.
And yet, as dominant and immovable as this situation seemed to be, just a decade later, he notes: “In 1980, two momentous events hastened psychiatry’s medicalization.” First: the 1980 landmark case involving a West Virginia nephrologist who sued after being psychoanalyzed instead of being given medications. (He had shown no improvement despite months of analysis.) The second? “The 1980 publications of DSM-III” — which changed the APA’s entire approach to diagnosis. Certain diagnoses were dropped, others were replaced. Neurosis gave way to personality disorders; “hyperkinetic reaction of childhood” was replaced by attention deficit disorder.
The dominance of psychotherapy was pushed further, as Dr. Garfinkel explains, by health economics and pharmaceutical companies.
Psychiatry had swung from the proverbial couch to the lab. In many ways, this was a good thing, but it raised a serious question for me in 1990 as I thought about my next move in the advancement of Canadian psychiatry: How do you balance science and caring?
Dr. Garfinkel struggles with this question in this chapter and in his book and in his career — as I suspect, we all do.
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I’m a big fan of Dr. Garfinkel’s book. For those of us interested in psychiatry, is a great read — part autobiography, part history, part observation on evolution of the field of psychiatry.
Dr. Paul Garfinkel
The details are fun. Consider: What do you really know about Dr. Charles Kirk Clarke (after whom the Clarke site of the Centre for Addition and Mental Health is named)? The book discusses his life and work, including the fact that he was nearly knifed to death by a patient; his brother-in-law, who was right beside him, didn’t survive that attack.
And the book is enliven by patient stories.
It’s also filled with strong observations.
During residency, I had the opportunity to attend a handful of Dr. Garfinkel’s lectures. Since then, we had a working dinner together (in which, for the most part, we debated income inequity — a debate I think I fought at least to a draw). What comes across in these encounters is his keen intellect and passion, exactly what comes across in his book.
I strongly suggest you get a copy.
You can find it at Caversham Booksellers. In speaking to their managing director yesterday, they offer the book at a 25% discount. Dr. Garfinkel’s book will be personally signed. Caversham, it should be noted, has a connection to the author: they sponsor the Caversham Booksellers-Paul Garfinkel Prize for Excellence in Resident Leadership, an annual award.
The book is also available through Amazon and at Indigo stores (or online).