Seminal thinkers in the field of mental health have often had to resort to self-exposure in order to advance their work. Sigmund Freud kicked off his theory of dream interpretation by using one of his own dreams as a specimen, exposing some highly unflattering material about himself in the process. In 2011, Dr. Marsha Linehan, the creator of a therapy for severely disturbed, self-harming and suicidal individuals, revealed she was hospitalized at 17 for cutting and burning herself. "I have to do this. I owe it to them," she told The New York Times. Such candour is not easy, but their personal example is enormously persuasive.
Joining the ranks of these enlightened exhibitionists is psychiatrist David Goldbloom, senior medical adviser at the Centre for Addiction and Mental Health in Toronto. In How Can I Help? A Week in My Life as a Psychiatrist, he presents himself as a model of a hospital-based psychiatrist, though not to advance a theory or treatment, but to "make our profession better understood … [by bringing] you to the front lines of modern psychiatry – the inside of the psychiatric hospital." His goal, shared by his co-author and fellow psychiatrist Pier Bryden, is to reduce public fear of psychiatrists by showing what it is they really do, the conditions they treat, the resources they deploy and the setting in which they work.
Tracking Goldbloom over the course of a hypothetical week greatly expands our knowledge of what a psychiatrist in a teaching hospital does and gives us a textured picture of its complexity. We watch Goldbloom observe and critique a diagnostic interview, meet with long-standing patients to monitor their symptoms and medication, teach residents, administer electroconvulsive therapy, confirm a diagnosis of Asperger's disorder by long-distance telepsychiatry to Kenora, Ont., and admit an involuntary schizophrenic patient to the acute care unit – and that's all by Wednesday morning.
The patients profiled – some of whom have given explicit permission to appear as themselves, some who are fictionalized composites – seem equally real. Goldbloom's genuine and sensitive engagement with his patients is moving to behold, even though this ongoing bond develops because there are no absolute cures for the three major psychiatric disorders: bipolar disorder, schizophrenia and depression, so he has seen many of his patients for decades. His challenge is to restore mental health when relapses occur, extend periods between episodes by facilitating emotional, vocational, cognitive and other strengths, bolster social supports where feasible and to offer hope.
"I've learned in my work that an inexhaustible capacity for hope is essential – for me and my patients," Goldbloom says. This capacity allows him to keep working with individuals such as the anorexic patient who, at five-foot-six, has weighed between 65 and 100 pounds for 25 years. His thinking on hope in the face of recurrent severe suffering verges on the genuinely philosophical. "Recovery means … a journey toward a meaningful life … and a focus on strengths despite limitations." This attempt to define the good life within devastating constraints is both wise and humane, deserving of the term used by psychoanalyst and philosopher Jonathan Lear: moral psychology.
Goldbloom might object to being compared with a psychoanalyst, though, even one as eminent as Lear, who is with the Committee on Social Thought at the University of Chicago. His claim to being "anything but neutral" about psychiatry is certainly evident in his stance toward psychoanalysis. It's puzzling that he feels compelled to mention this, given how long it has been since psychoanalysis was a force in hospital psychiatry, especially the dated caricature he targets, with Bruno Bettelheim (whom he incorrectly identifies as a German-American psychiatrist) as its straw man. His views on neuroscience as "razzle dazzle" and attachment theory as overly influential in theories on parenting are two other opinions with which many respected experts would disagree.
Even so, Goldbloom scores points for revealing some of the biases that exert internal pressure on him when he's trying to remain on an even clinical keel. More impressive is the manner in which he frames his professional story with his personal life. His week begins with the realization that his mother's cancer may have metastasized to her brain, and this unsettling awareness punctuates his work. While immersing himself in the moods, thoughts, worries and preoccupations of his patients, the same processes are pressuring him. All physicians are subject to emotional vicissitudes but most specialists are not trying to treat these same intense fluctuations in others while trying to cope with their own. Goldbloom's extra measure of personal exposure makes it clear that psychiatrists and other physicians are not exempt from the human condition, nor should they be. What should be expected is that a psychiatrist is willing to manage his or her internal challenges with introspection, insight and other techniques. When Goldbloom is shattered by the news that a patient has committed suicide, he rallies many resources to regain emotional equilibrium, including paying a condolence call to his patient's family in which their shared grief helps them heal. Freud and Linehan would approve.
Robin Roger is a registered psychotherapist and a founding editor of Ars Medica: A Journal of Medicine, The Arts and Humanities.