Autumn: Thoughts On Commencing A Fourth Decade In Academic Psychiatry
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《精神病学术期刊》
To live one’s life is not as easy as to walk across a field.
—Russian proverb
What was it like for a woman to pursue a career in academic psychiatry in the last three decades of the twentieth century, when the field itself and the percentages of women involved were expanding geometrically?
Imagine, for one moment, how you would approach the question. Would you look for precursors, late effects, or the impact of intervention? Would you survey the women themselves? Their bosses, partners, children, or patients? The committee members who made decisions about their tenure and funding? What comparison groups would you choose? This imaginary research project reveals a great deal about the mind of the imaginary investigator.
For myself, the design that leaps to mind, instantly and unambiguously is the single case study. An entire subsection of my bibliography consists of revisits to such classics (1, 2): Psyche, Oedipus, Electra, Io, Dymphna, Cinderella, Thousandfurs, Snow White, Marquis de Sade, Mary Reynolds, Anna O, Hedda Gabler, Dora, and Kafka. These stories have colored my imagination, shaped theory, and bailed me out of clinical impasses. Those questions that Freud asked himself and his first patients and that oral historians continue to ask (3) have never lost their grip on my imagination. What happened next? What were you thinking? What surprised you? These are the questions I propose to ask myself in the following rough sketch of my journey through academic psychiatry in these turbulent years.
I was born in the American Southwest in the 1940s. Within the universe of historical cases, this represents only a small step back into history, but in the context of psychiatry as it is practiced today, it was a different world. Female physicians were rare, though we knew they existed. The psychiatric presence in the region was the state hospital where major tranquilizers, antidepressants, and lithium were then unavailable. Concepts like the battered baby syndrome or the battered woman syndrome were unheard of at that time. This story journeys through a sea change in psychiatry that was brought about primarily by the explosion in neuroscience research but also by the Women’s Movement, the Patients’ Rights Movement, and the struggle by Vietnam veterans to obtain respectful and appropriate treatment.
I have structured this case history sequentially by decades. Because I started psychiatric training in 1972, each decade of my career corresponds fairly well to the last three decades of the twentieth century. I also sketch beginning, early, and middle career phases, which may allow the reader to relate my experience to her own. Additionally, I’ve included an introductory section, in which I describe how I entered the field of psychiatry in the first place. I conclude by discussing what is important to me now as I enter a late career phase. What I have tried to highlight are career decisions, relationships with mentors, and the values and attitudes that seemed most important to productive and creative contributions in each phase.
PREPARATION
To make a prairie it takes a clover and one bee,
One clover, and a bee,
And revery.
The revery alone will do,
If bees are few.
—Emily Dickinson
Growing up on a ranch in North Texas taught me how to be alone and left me with no doubt that Earth is a dangerous planet where grownups are few. In what one of my mentors kindly referred to as my "atypical" family, we supported our cattle habit by freelancing for crime detective magazines. From about second grade on, my job in this cottage industry was to clip out newspaper stories about murders. Chores with the cattle and horses and chickens were also "atypical," in that many were performed in a manner quite similar to that of the nineteenth century. Even though the nearest neighbor was more than a mile away, we knew a lot about everyone on the far-flung party line, including some things that were sad and shocking. I would read about the fascinating and desperate characters in the country houses imagined by Eliot, Tolstoy, or Dostoyevsky and think that those folks would fit right in if they lived on our dirt road.
For someone accustomed to living as if it were the nineteenth century, going to Harvard was not a bad choice. The venerable university’s version of the nineteenth century was something my ancestors on the frontier had only dreamt of: a time-space where all phenomena could be explored and all mysteries were made accessible. It was the kind of space I imagined that Freud had inhabited. An anthropology major, I spent as much time in the musty corridors of the Peabody Museum as in the myriad stacks of Widener Library.
As my interests shifted toward biology and medicine, I was fortunate that my tutor, Albert Damon, a physician as well as an anthropologist, was more than capable of shepherding me into medical school (4). Dr. Damon was one of those extraordinary teachers whose steady but absolute insistence on excellence coexists with an atmosphere of utter support and acceptance. He also carried about him a whiff of the adventures that awaited us somewhere out there in the wider world. He had gone down the Rhine in a canoe, had fallen in love with the people of the Solomon Islands during World War II and then gone back to do field work. In his house was a secret room filled with books about Charles II and the Restoration. Jeffery Hudson, a court dwarf from those books, would provide the pen name for Michael Crichton, another Damon tutee, when he published his first novel (5).
Medical school dismayed me as thoroughly as college had delighted me. Some of the less attractive features of the nineteenth century became intrusive—elitism, paternalism, an idealism that was too scornful of practical realities. It did not help that I was one of a handful of females in my class. The Harvard Strike took place at this time as well as social unrest in cities throughout the country. The old order was toppling, and my classmates and I no longer sought solace from the older generation but from each other. David Spiegel, Jacquie Olds, Alex Murray, Sam Chase—these are friends and classmates who went into psychiatry and remain allies.
One of my medical school interviewers told me to "[choose Harvard] so [that I could] marry one of [their] boys." This was kindly meant, and I took it kindly, and that was the way it turned out, and it was probably the most important contribution of medical school to my career. All of us need a home base in order to make adventuring possible. Mine is architected around the touching of inky fingers across the writing table. My husband is a natural scholar, and laughter is his best weapon against folly. He now has something of a reputation as a mentor; I consider myself to be his first and most successful victim (6).
I was astonished to find that I had a knack for psychiatry, since everything else in medical school had been a stretch and a strain. I also longed to perform the kind of magic that I saw the psychoanalyst Elvin Semrad conjure when he talked to patients (7). In his presence, people wept and spoke from the heart, even in silence. We joked about how different he was, as if from another planet. I was not surprised to learn that he came from Nebraska, from the prairie like me, and he wrote me the world’s shortest recommendation letter: "She’ll do."
THE SEVENTIES: MY LOVE AFFAIR WITH PHENOMENA
Blow up your TV. Throw away the paper.
Go to the country. Build you a home.
Have a lot of children. Feed ’em on peaches.
You can find Jesus on your own.
—John Prine
One could say that I spent this decade barefoot and pregnant and in the country. I took 1 year off to earn a degree in public health epidemiology. I had four babies, and I stopped working full time after my first 2 years of residency in Washington, D.C. That’s when my husband and I decided that we could not face another big city, so we sent off applications to complete our residencies in the most rural medical schools that we could find. When two Chairs in New Mexico called us one evening and told us in a chatty way how much they would like for us to come, we were at their mercy. We spent 11 years there and it still feels like home. So, one might say that I spent this decade in environments that optimally fostered my brand of creativity and that the time gestating and at home was more my own than the time spent in my career track has ever been.
I was fortunate to have been taught psychiatry by passionate idealists. At Georgetown, the faculty committed to the idea that a day hospital could do whatever a state hospital could and more. Police cars would bring us "violent" patients, chained hand and foot, and we would have them unmanacled and sent to group therapy. I still believe that this and other versions of "moral treatment" constitute the ideal therapeutic milieu. We continue to reinvent it because it is too costly, too difficult, and too alien to the technological solutions currently sanctioned as "scientific" (6).
In New Mexico, I worked with Robert Kellner (8) who had fought with the free Czechs in World War II through Africa and into Italy. When I knew him, he was happily measuring and cataloging virtually the entire world of psychological phenomena. Bob Bergman (9) was another mentor. His gift of empathic immersion had already subdued the entire Navajo Nation before he turned it into the training of psychiatrists and psychoanalysts.
Looking at my notebooks from those years, I realize that I was curious about everything. Why were the schizophrenics at the veterans’ hospital so different from the ones in civilian venues? Why were they maintained on antianxiety medications rather than antipsychotic drugs? How could a woman become so confused about her body as to believe herself to be pregnant when she is not? At the opposite pole, how could someone come into the emergency room for a stomachache and then deliver a baby on a gurney without ever having an inkling that she had been pregnant (10)?
More vital than the mentors and the questions, however, was my good fortune in encountering a brilliant patient. My first outpatient was a bright 17-year-old who was unable to decide where to go to college. The triage worker believed that I could handle it. In my first session with the teenager, she sobbed silently for what seemed to be forever, then blurted out that her father had sex with her, and then she ran out of the room. I telephoned her, and she said that she could never tell me the rest. I said that she could give herself a chance to try. My supervisor requested that I read Freud’s footnotes about incest fantasies. The patient’s family therapist called to ask if all this was due to schizophrenia. She did not seem schizophrenic to me, but then neither did all those combat veterans. She and I kept working in our own intense but persistent way, and somehow she figured out what she wanted to do in college, and I got a glimpse of what I would do with the rest of my career. This patient continues to write to me.
This was how I knew the correct answer when a child protection worker asked how psychiatrists could be so sure that children’s stories about sexual abuse were only fantasies (11). "I have no idea," I said. "Let’s write a grant and study it."
THE EIGHTIES: PUTTING TOGETHER THE JIGSAW PUZZLE OF TRAUMA
I hold that one should not make theories. They should arrive unexpectedly like uninvited guests, while one is busy investigating details.
—Sigmund Freud
So, against all odds, the pieces of my career flew together, and by age 35 I was a funded, tenured training director presenting papers around the world on childhood sexual abuse. In this era of my career I was told on several occasions that I was the first woman this or the first woman that. Such news always made me feel uncomfortable and unlucky. The only such designation I recall clearly is "first pregnant full professor," perhaps because the phrasing had a certain pleasing redundancy.
Career milestones felt peripheral to the fascination of watching theoretical patterns emerge as, one by one, my perennial questions found their answers. Again and again my questions about combat veterans and about abused children had kept turning up in parallel. Now I saw there was good reason for this. Both groups had experienced overwhelming stresses that left them with posttraumatic symptoms (12). It was because the mind copes with trauma by walling it off and refusing to deal with it that their stories were so fragmented and de-realized as to invite incredulity. The part of the mind determined to believe that nothing really terrible had happened was reassured when complaints were minimized or dismissed. That had been its strategy all along (13). This dissociation of traumatic experiences and affects from the everyday self could become so extreme as to leave entire segments of bodily and personal experience in unattended limbo. This was the mechanism that allowed some women to become entirely clueless about what was happening to their bodies.
The effort to document, probe, and put these connections into context was like riding a phenomenological juggernaut. Only several books and dozens of articles later did I come up for air. It was a relief that so many other minds were on the case: Judy Herman, Bessel van der Kolk, Richard Kluft, Onno van der Hart (14). Their more extensive studies made sense of my observations on single cases and small series.
Meanwhile I was navigating the perils of psychoanalytic training at the Chicago Institute. That decision to leave New Mexico to undertake training remains the most fraught of my career. Here personal and professional priorities reached almost absolute impasse. No one in our family fit comfortably into the new environment. On the other hand every class in Chicago left me with some small revelation of instant relevance to my clinical and theoretical puzzles. I remember Lou Shapiro, an analyst in his nineties, routinely saying things that hovered just beyond my understanding but were instantly recognizable as truth. "It doesn’t matter what you say to the patient," he told me one day in class. "What matters is how you breathe."
THE NINETIES: LIVING WITH CONTROVERSY
Hope ... is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out.
—Vaclav Havel
Readers who practiced psychiatry in the nineties will have guessed already how hopelessly out of step I was. For some biological psychiatrists both trauma therapy and psychoanalysis fell into the same deplorable category as voodoo dolls. The False Memory Syndrome Foundation went further, describing trauma therapy as not only erroneous but damaging and possibly criminal. Worst of all, my allies themselves were often at each others’ throats, with trauma therapists and psychoanalysts still squabbling over those footnotes of Freud’s that I had wrestled with so long ago (15). What this meant in practical terms was the near disappearance of funding for trauma research, of reimbursement for trauma therapy, and of space in the psychiatric curriculum to teach about trauma. In some venues, a rebuttal speaker had to be enlisted whenever I presented new findings.
I reacted largely with bewilderment. Did no one else recall the cruel and helpless ignorance that these new ideas had replaced? Especially for the multi-problem patient caught up in compulsive self injury, trauma assessment sometimes made the difference between perpetual patienthood and reclaiming one’s own real life (16).
I also tried to cope, becoming a forensic psychiatrist in order to more capably represent my point of view. As so often before, I turned to history, humor, and literature. If the hypothesis is that accounts of sadistic abuse are urban legends collaboratively produced by psychotic patients and their credulous therapists, how do we explain the exploits and writings of the Marquis de Sade (17)? If the premise is that dissociation is the invention of misguided American psychiatrists, why is it so well described in exorcism cases from 16th-century France (18)?
Mostly, I got by with a little help from my friends. My husband accepted a job that took us back to Texas where pickled peaches, Mariachi music, and other assorted micro-cultural delights were available to soothe whatever slings and arrows might arise. After many years of this dispute, often more destructive than enlightening, what remains luminous are the many kindnesses of friends and allies.
THE NEW MILLENNIUM: WHAT’S IMPORTANT TO ME NOW
We will have to give an account on the judgment day of every good thing we refused to enjoy.
—Rabbinic Text
I have never been good at doing what I did not want to do. At this point in my career, those occasions seldom arise. Fate has shot so many of its dreadful bolts already, including cancer. There is not that much left that might intimidate.
Fortunately, my complex job description covers a garden of delights. At the University of Texas Medical Branch and at the Houston-Galveston Trauma Institute I teach in the context of a trauma clinic, working shoulder to shoulder with trainees doing interviews, assessments, and treatment with survivors of interpersonal trauma (19). As faculty at the Houston-Galveston Psychoanalytic Institute I get to re-read Winnicott every year and discuss his ideas with wise trainees still innocent enough to grasp them (20). As a psychiatrist and psychoanalyst in solo practice I get to polish the old walnut desk and walk along the beach to the grocery store to buy sunflowers for the waiting room. The day’s only administrative hassle is how to manage my lone employee and ancient nemesis, which is to say, myself.
Writing has become more and more a communal endeavor. I schedule a writing weekend in New Mexico with Reina Attias or in Cat Springs, Texas, with Naomi Rosborough and Rosalie Hyde. We discuss metaphysics, share clinical problems and soothe post-traumatic burnout over good food and good movies. In the process, essays, articles, even books appear (21).
I have always been prey to enthusiasms. Now that I am older and know how much time there is in life, I abandon myself to them even more completely. Already in pursuit of my latest case history project I have stood amazed in front of dozens of Victor Brauner’s surrealist paintings. There will be time to search out the rest, even those in Europe and in museum basements. There will be time as well to hike Moundbuilder sites in the Mississippi Valley, and time to finish writing my murder mystery, styled for the moment as "Nancy Drew of Galveston." When students ask for advice these days I tell them to spend as much time as they can wondering and laughing and as little as possible doing things they hate.
My job as psychotherapist and psychoanalyst, I conceptualize now as being a kind of mountain guide for those on pilgrimage to reality. That trip is never as easy as walking across a field. There are always precipices, pitfalls, quagmires, not to mention trauma monsters and resistance ninjas waiting in ambush. The voyage can be touch and go some hours in the consulting room, as suspenseful as my favorite novels. I try to remind myself that it doesn’t matter so much what we say as how we keep on breathing, as those creatures from the psychic depths emerge gasping into the hopeful silence. No longer exiled and excluded, these aspects of the self prepare to join us on the journey.
CONCLUSIONS
The real voyage of discovery consists not in seeking new lands, but in seeing with new eyes.
—Marcel Proust
This narrative traces one woman’s career in academic psychiatry through almost four decades. Early in this story mentors and colleagues are exclusively male physicians, and the nature and types of family violence are only beginning to be conceptualized. At the end of this interval colleagues and trainees are mostly women psychotherapists from many disciplines, and assessment of prior trauma and treatment of stress response syndromes have become standard aspects of psychiatric care. In both configurations, mentorship is portrayed as central to the academic enterprise.
This career trajectory patterns itself into four stages: exploration, hypothesis-building, hypothesis-testing and revision, and clinical applications. Certain conflicts seem to recur through all four phases: tensions between personal and professional priorities, between the scientific method and the values of the humanities, and between an attitude of humor and hopefulness and a grim view of the limitations of the human condition. Are these stages and themes peculiar to the singular voice of this narrative? Inherent to the task of teaching psychiatry? More salient for women? Or for members of the narrator’s generation?
The weakness of the case history method is that it provides only one viewpoint, one fragment of a larger story. Its strength is its capacity to bring alive an experience in a way that motivates the reader to search for the missing pieces of the puzzle.
REFERENCES
McClung J: Mischief and Mercy: Tales of the Saints. Berkeley, Calif, Tricycle, 1993
Goodwin J: Rediscovering Childhood Trauma: Historical Casebook and Clinical Applications. Washington, DC, American Psychiatric Press, 1993
Chin EL: This Side of Doctoring: Reflections from Women in Medicine. New York, Oxford University Press, 2003
Damon A, McClung J: Previous pulmonary disease and lung cancer—a case-control study. J Chron Dis 1967; 20:59–64
Hudson J: A Case of Need. New York, New American Library, 1968
Goodwin JS, Goodwin JM: The tomato effect: rejection of highly efficacious treatments. JAMA 1984; 251:2387–2390
Rako S, Mazer H: Semrad: The Heart of a Therapist. New York, Aronson, 1983
Goodwin JM, Goodwin JS, Kellner R: Psychiatric symptoms in disliked medical patients. JAMA 1979; 2410:1117–1120
Goodwin J, Bergman R, Simms M: Hysterical seizures: a sequel to incest. Am J Orthopsychiatry 1979; 49:698–703
Silverblatt H, Goodwin J: Denial of pregnancy. Birth Psychol Bull 1983; 4:13–25
Goodwin J: Sexual Abuse: Incest Victims and Their Families. Littleton, Mass, Wright-PSG, 1982. Second Edition, Chicago, MosbyYearbook, 1989
Goodwin J: Post-traumatic symptoms in incest victims, in Post-Traumatic Stress Disorder in Children. Edited by Eth S, Pynoos RS. Washington, DC, American Psychiatric Press, 1985, pp 157–168
Goodwin J: Credibility problems in multiple personality disorder patients and abused children, in Childhood Antecedents of Multiple Personality. Edited by Kluft R. Washington, DC, American Psychiatric Press, 1985, pp 1–20
Goodwin J, Attias R: Splintered Reflections: Images of the Body in Trauma. New York, Basic Books, 1999
Goodwin J: The seduction hypothesis 100 years after, in Treatment of Adult Survivors of Incest. Edited by Paddison P. Washington, DC, American Psychiatric Press, 1993
Goodwin J, Cheeves K, Connell V: Borderline and other severe symptoms in adult survivors of incestuous abuse. Psychiatr Annal 1990; 20:22–32
Goodwin J: Sadistic abuse: definition, recognition and treatment. Dissociation 1993; 6:181–187
Van der Hart O, Lierens R, Goodwin J: Jeanne Fery: a sixteenth century case of dissociative identity disorder. J Psychohist 1996; 24:18–35
Goodwin J: Snow White and the seven diagnoses, in Attachment, Trauma and Multiplicity. Edited by Sinason V. New York, Brunner Routledge, 2002
Goodwin J: DW Winnicott (book review). J Psychohist 1997; 24:302–304
Goodwin J, Rosborough N, Hyde R: The Trauma Model, Rituals in Psychotherapy, Psychic Envelopes (book reviews). Trauma and Dissociation 2002; 3:133–140[(Jean P. Goodwin, M.D., M.)
—Russian proverb
What was it like for a woman to pursue a career in academic psychiatry in the last three decades of the twentieth century, when the field itself and the percentages of women involved were expanding geometrically?
Imagine, for one moment, how you would approach the question. Would you look for precursors, late effects, or the impact of intervention? Would you survey the women themselves? Their bosses, partners, children, or patients? The committee members who made decisions about their tenure and funding? What comparison groups would you choose? This imaginary research project reveals a great deal about the mind of the imaginary investigator.
For myself, the design that leaps to mind, instantly and unambiguously is the single case study. An entire subsection of my bibliography consists of revisits to such classics (1, 2): Psyche, Oedipus, Electra, Io, Dymphna, Cinderella, Thousandfurs, Snow White, Marquis de Sade, Mary Reynolds, Anna O, Hedda Gabler, Dora, and Kafka. These stories have colored my imagination, shaped theory, and bailed me out of clinical impasses. Those questions that Freud asked himself and his first patients and that oral historians continue to ask (3) have never lost their grip on my imagination. What happened next? What were you thinking? What surprised you? These are the questions I propose to ask myself in the following rough sketch of my journey through academic psychiatry in these turbulent years.
I was born in the American Southwest in the 1940s. Within the universe of historical cases, this represents only a small step back into history, but in the context of psychiatry as it is practiced today, it was a different world. Female physicians were rare, though we knew they existed. The psychiatric presence in the region was the state hospital where major tranquilizers, antidepressants, and lithium were then unavailable. Concepts like the battered baby syndrome or the battered woman syndrome were unheard of at that time. This story journeys through a sea change in psychiatry that was brought about primarily by the explosion in neuroscience research but also by the Women’s Movement, the Patients’ Rights Movement, and the struggle by Vietnam veterans to obtain respectful and appropriate treatment.
I have structured this case history sequentially by decades. Because I started psychiatric training in 1972, each decade of my career corresponds fairly well to the last three decades of the twentieth century. I also sketch beginning, early, and middle career phases, which may allow the reader to relate my experience to her own. Additionally, I’ve included an introductory section, in which I describe how I entered the field of psychiatry in the first place. I conclude by discussing what is important to me now as I enter a late career phase. What I have tried to highlight are career decisions, relationships with mentors, and the values and attitudes that seemed most important to productive and creative contributions in each phase.
PREPARATION
To make a prairie it takes a clover and one bee,
One clover, and a bee,
And revery.
The revery alone will do,
If bees are few.
—Emily Dickinson
Growing up on a ranch in North Texas taught me how to be alone and left me with no doubt that Earth is a dangerous planet where grownups are few. In what one of my mentors kindly referred to as my "atypical" family, we supported our cattle habit by freelancing for crime detective magazines. From about second grade on, my job in this cottage industry was to clip out newspaper stories about murders. Chores with the cattle and horses and chickens were also "atypical," in that many were performed in a manner quite similar to that of the nineteenth century. Even though the nearest neighbor was more than a mile away, we knew a lot about everyone on the far-flung party line, including some things that were sad and shocking. I would read about the fascinating and desperate characters in the country houses imagined by Eliot, Tolstoy, or Dostoyevsky and think that those folks would fit right in if they lived on our dirt road.
For someone accustomed to living as if it were the nineteenth century, going to Harvard was not a bad choice. The venerable university’s version of the nineteenth century was something my ancestors on the frontier had only dreamt of: a time-space where all phenomena could be explored and all mysteries were made accessible. It was the kind of space I imagined that Freud had inhabited. An anthropology major, I spent as much time in the musty corridors of the Peabody Museum as in the myriad stacks of Widener Library.
As my interests shifted toward biology and medicine, I was fortunate that my tutor, Albert Damon, a physician as well as an anthropologist, was more than capable of shepherding me into medical school (4). Dr. Damon was one of those extraordinary teachers whose steady but absolute insistence on excellence coexists with an atmosphere of utter support and acceptance. He also carried about him a whiff of the adventures that awaited us somewhere out there in the wider world. He had gone down the Rhine in a canoe, had fallen in love with the people of the Solomon Islands during World War II and then gone back to do field work. In his house was a secret room filled with books about Charles II and the Restoration. Jeffery Hudson, a court dwarf from those books, would provide the pen name for Michael Crichton, another Damon tutee, when he published his first novel (5).
Medical school dismayed me as thoroughly as college had delighted me. Some of the less attractive features of the nineteenth century became intrusive—elitism, paternalism, an idealism that was too scornful of practical realities. It did not help that I was one of a handful of females in my class. The Harvard Strike took place at this time as well as social unrest in cities throughout the country. The old order was toppling, and my classmates and I no longer sought solace from the older generation but from each other. David Spiegel, Jacquie Olds, Alex Murray, Sam Chase—these are friends and classmates who went into psychiatry and remain allies.
One of my medical school interviewers told me to "[choose Harvard] so [that I could] marry one of [their] boys." This was kindly meant, and I took it kindly, and that was the way it turned out, and it was probably the most important contribution of medical school to my career. All of us need a home base in order to make adventuring possible. Mine is architected around the touching of inky fingers across the writing table. My husband is a natural scholar, and laughter is his best weapon against folly. He now has something of a reputation as a mentor; I consider myself to be his first and most successful victim (6).
I was astonished to find that I had a knack for psychiatry, since everything else in medical school had been a stretch and a strain. I also longed to perform the kind of magic that I saw the psychoanalyst Elvin Semrad conjure when he talked to patients (7). In his presence, people wept and spoke from the heart, even in silence. We joked about how different he was, as if from another planet. I was not surprised to learn that he came from Nebraska, from the prairie like me, and he wrote me the world’s shortest recommendation letter: "She’ll do."
THE SEVENTIES: MY LOVE AFFAIR WITH PHENOMENA
Blow up your TV. Throw away the paper.
Go to the country. Build you a home.
Have a lot of children. Feed ’em on peaches.
You can find Jesus on your own.
—John Prine
One could say that I spent this decade barefoot and pregnant and in the country. I took 1 year off to earn a degree in public health epidemiology. I had four babies, and I stopped working full time after my first 2 years of residency in Washington, D.C. That’s when my husband and I decided that we could not face another big city, so we sent off applications to complete our residencies in the most rural medical schools that we could find. When two Chairs in New Mexico called us one evening and told us in a chatty way how much they would like for us to come, we were at their mercy. We spent 11 years there and it still feels like home. So, one might say that I spent this decade in environments that optimally fostered my brand of creativity and that the time gestating and at home was more my own than the time spent in my career track has ever been.
I was fortunate to have been taught psychiatry by passionate idealists. At Georgetown, the faculty committed to the idea that a day hospital could do whatever a state hospital could and more. Police cars would bring us "violent" patients, chained hand and foot, and we would have them unmanacled and sent to group therapy. I still believe that this and other versions of "moral treatment" constitute the ideal therapeutic milieu. We continue to reinvent it because it is too costly, too difficult, and too alien to the technological solutions currently sanctioned as "scientific" (6).
In New Mexico, I worked with Robert Kellner (8) who had fought with the free Czechs in World War II through Africa and into Italy. When I knew him, he was happily measuring and cataloging virtually the entire world of psychological phenomena. Bob Bergman (9) was another mentor. His gift of empathic immersion had already subdued the entire Navajo Nation before he turned it into the training of psychiatrists and psychoanalysts.
Looking at my notebooks from those years, I realize that I was curious about everything. Why were the schizophrenics at the veterans’ hospital so different from the ones in civilian venues? Why were they maintained on antianxiety medications rather than antipsychotic drugs? How could a woman become so confused about her body as to believe herself to be pregnant when she is not? At the opposite pole, how could someone come into the emergency room for a stomachache and then deliver a baby on a gurney without ever having an inkling that she had been pregnant (10)?
More vital than the mentors and the questions, however, was my good fortune in encountering a brilliant patient. My first outpatient was a bright 17-year-old who was unable to decide where to go to college. The triage worker believed that I could handle it. In my first session with the teenager, she sobbed silently for what seemed to be forever, then blurted out that her father had sex with her, and then she ran out of the room. I telephoned her, and she said that she could never tell me the rest. I said that she could give herself a chance to try. My supervisor requested that I read Freud’s footnotes about incest fantasies. The patient’s family therapist called to ask if all this was due to schizophrenia. She did not seem schizophrenic to me, but then neither did all those combat veterans. She and I kept working in our own intense but persistent way, and somehow she figured out what she wanted to do in college, and I got a glimpse of what I would do with the rest of my career. This patient continues to write to me.
This was how I knew the correct answer when a child protection worker asked how psychiatrists could be so sure that children’s stories about sexual abuse were only fantasies (11). "I have no idea," I said. "Let’s write a grant and study it."
THE EIGHTIES: PUTTING TOGETHER THE JIGSAW PUZZLE OF TRAUMA
I hold that one should not make theories. They should arrive unexpectedly like uninvited guests, while one is busy investigating details.
—Sigmund Freud
So, against all odds, the pieces of my career flew together, and by age 35 I was a funded, tenured training director presenting papers around the world on childhood sexual abuse. In this era of my career I was told on several occasions that I was the first woman this or the first woman that. Such news always made me feel uncomfortable and unlucky. The only such designation I recall clearly is "first pregnant full professor," perhaps because the phrasing had a certain pleasing redundancy.
Career milestones felt peripheral to the fascination of watching theoretical patterns emerge as, one by one, my perennial questions found their answers. Again and again my questions about combat veterans and about abused children had kept turning up in parallel. Now I saw there was good reason for this. Both groups had experienced overwhelming stresses that left them with posttraumatic symptoms (12). It was because the mind copes with trauma by walling it off and refusing to deal with it that their stories were so fragmented and de-realized as to invite incredulity. The part of the mind determined to believe that nothing really terrible had happened was reassured when complaints were minimized or dismissed. That had been its strategy all along (13). This dissociation of traumatic experiences and affects from the everyday self could become so extreme as to leave entire segments of bodily and personal experience in unattended limbo. This was the mechanism that allowed some women to become entirely clueless about what was happening to their bodies.
The effort to document, probe, and put these connections into context was like riding a phenomenological juggernaut. Only several books and dozens of articles later did I come up for air. It was a relief that so many other minds were on the case: Judy Herman, Bessel van der Kolk, Richard Kluft, Onno van der Hart (14). Their more extensive studies made sense of my observations on single cases and small series.
Meanwhile I was navigating the perils of psychoanalytic training at the Chicago Institute. That decision to leave New Mexico to undertake training remains the most fraught of my career. Here personal and professional priorities reached almost absolute impasse. No one in our family fit comfortably into the new environment. On the other hand every class in Chicago left me with some small revelation of instant relevance to my clinical and theoretical puzzles. I remember Lou Shapiro, an analyst in his nineties, routinely saying things that hovered just beyond my understanding but were instantly recognizable as truth. "It doesn’t matter what you say to the patient," he told me one day in class. "What matters is how you breathe."
THE NINETIES: LIVING WITH CONTROVERSY
Hope ... is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out.
—Vaclav Havel
Readers who practiced psychiatry in the nineties will have guessed already how hopelessly out of step I was. For some biological psychiatrists both trauma therapy and psychoanalysis fell into the same deplorable category as voodoo dolls. The False Memory Syndrome Foundation went further, describing trauma therapy as not only erroneous but damaging and possibly criminal. Worst of all, my allies themselves were often at each others’ throats, with trauma therapists and psychoanalysts still squabbling over those footnotes of Freud’s that I had wrestled with so long ago (15). What this meant in practical terms was the near disappearance of funding for trauma research, of reimbursement for trauma therapy, and of space in the psychiatric curriculum to teach about trauma. In some venues, a rebuttal speaker had to be enlisted whenever I presented new findings.
I reacted largely with bewilderment. Did no one else recall the cruel and helpless ignorance that these new ideas had replaced? Especially for the multi-problem patient caught up in compulsive self injury, trauma assessment sometimes made the difference between perpetual patienthood and reclaiming one’s own real life (16).
I also tried to cope, becoming a forensic psychiatrist in order to more capably represent my point of view. As so often before, I turned to history, humor, and literature. If the hypothesis is that accounts of sadistic abuse are urban legends collaboratively produced by psychotic patients and their credulous therapists, how do we explain the exploits and writings of the Marquis de Sade (17)? If the premise is that dissociation is the invention of misguided American psychiatrists, why is it so well described in exorcism cases from 16th-century France (18)?
Mostly, I got by with a little help from my friends. My husband accepted a job that took us back to Texas where pickled peaches, Mariachi music, and other assorted micro-cultural delights were available to soothe whatever slings and arrows might arise. After many years of this dispute, often more destructive than enlightening, what remains luminous are the many kindnesses of friends and allies.
THE NEW MILLENNIUM: WHAT’S IMPORTANT TO ME NOW
We will have to give an account on the judgment day of every good thing we refused to enjoy.
—Rabbinic Text
I have never been good at doing what I did not want to do. At this point in my career, those occasions seldom arise. Fate has shot so many of its dreadful bolts already, including cancer. There is not that much left that might intimidate.
Fortunately, my complex job description covers a garden of delights. At the University of Texas Medical Branch and at the Houston-Galveston Trauma Institute I teach in the context of a trauma clinic, working shoulder to shoulder with trainees doing interviews, assessments, and treatment with survivors of interpersonal trauma (19). As faculty at the Houston-Galveston Psychoanalytic Institute I get to re-read Winnicott every year and discuss his ideas with wise trainees still innocent enough to grasp them (20). As a psychiatrist and psychoanalyst in solo practice I get to polish the old walnut desk and walk along the beach to the grocery store to buy sunflowers for the waiting room. The day’s only administrative hassle is how to manage my lone employee and ancient nemesis, which is to say, myself.
Writing has become more and more a communal endeavor. I schedule a writing weekend in New Mexico with Reina Attias or in Cat Springs, Texas, with Naomi Rosborough and Rosalie Hyde. We discuss metaphysics, share clinical problems and soothe post-traumatic burnout over good food and good movies. In the process, essays, articles, even books appear (21).
I have always been prey to enthusiasms. Now that I am older and know how much time there is in life, I abandon myself to them even more completely. Already in pursuit of my latest case history project I have stood amazed in front of dozens of Victor Brauner’s surrealist paintings. There will be time to search out the rest, even those in Europe and in museum basements. There will be time as well to hike Moundbuilder sites in the Mississippi Valley, and time to finish writing my murder mystery, styled for the moment as "Nancy Drew of Galveston." When students ask for advice these days I tell them to spend as much time as they can wondering and laughing and as little as possible doing things they hate.
My job as psychotherapist and psychoanalyst, I conceptualize now as being a kind of mountain guide for those on pilgrimage to reality. That trip is never as easy as walking across a field. There are always precipices, pitfalls, quagmires, not to mention trauma monsters and resistance ninjas waiting in ambush. The voyage can be touch and go some hours in the consulting room, as suspenseful as my favorite novels. I try to remind myself that it doesn’t matter so much what we say as how we keep on breathing, as those creatures from the psychic depths emerge gasping into the hopeful silence. No longer exiled and excluded, these aspects of the self prepare to join us on the journey.
CONCLUSIONS
The real voyage of discovery consists not in seeking new lands, but in seeing with new eyes.
—Marcel Proust
This narrative traces one woman’s career in academic psychiatry through almost four decades. Early in this story mentors and colleagues are exclusively male physicians, and the nature and types of family violence are only beginning to be conceptualized. At the end of this interval colleagues and trainees are mostly women psychotherapists from many disciplines, and assessment of prior trauma and treatment of stress response syndromes have become standard aspects of psychiatric care. In both configurations, mentorship is portrayed as central to the academic enterprise.
This career trajectory patterns itself into four stages: exploration, hypothesis-building, hypothesis-testing and revision, and clinical applications. Certain conflicts seem to recur through all four phases: tensions between personal and professional priorities, between the scientific method and the values of the humanities, and between an attitude of humor and hopefulness and a grim view of the limitations of the human condition. Are these stages and themes peculiar to the singular voice of this narrative? Inherent to the task of teaching psychiatry? More salient for women? Or for members of the narrator’s generation?
The weakness of the case history method is that it provides only one viewpoint, one fragment of a larger story. Its strength is its capacity to bring alive an experience in a way that motivates the reader to search for the missing pieces of the puzzle.
REFERENCES
McClung J: Mischief and Mercy: Tales of the Saints. Berkeley, Calif, Tricycle, 1993
Goodwin J: Rediscovering Childhood Trauma: Historical Casebook and Clinical Applications. Washington, DC, American Psychiatric Press, 1993
Chin EL: This Side of Doctoring: Reflections from Women in Medicine. New York, Oxford University Press, 2003
Damon A, McClung J: Previous pulmonary disease and lung cancer—a case-control study. J Chron Dis 1967; 20:59–64
Hudson J: A Case of Need. New York, New American Library, 1968
Goodwin JS, Goodwin JM: The tomato effect: rejection of highly efficacious treatments. JAMA 1984; 251:2387–2390
Rako S, Mazer H: Semrad: The Heart of a Therapist. New York, Aronson, 1983
Goodwin JM, Goodwin JS, Kellner R: Psychiatric symptoms in disliked medical patients. JAMA 1979; 2410:1117–1120
Goodwin J, Bergman R, Simms M: Hysterical seizures: a sequel to incest. Am J Orthopsychiatry 1979; 49:698–703
Silverblatt H, Goodwin J: Denial of pregnancy. Birth Psychol Bull 1983; 4:13–25
Goodwin J: Sexual Abuse: Incest Victims and Their Families. Littleton, Mass, Wright-PSG, 1982. Second Edition, Chicago, MosbyYearbook, 1989
Goodwin J: Post-traumatic symptoms in incest victims, in Post-Traumatic Stress Disorder in Children. Edited by Eth S, Pynoos RS. Washington, DC, American Psychiatric Press, 1985, pp 157–168
Goodwin J: Credibility problems in multiple personality disorder patients and abused children, in Childhood Antecedents of Multiple Personality. Edited by Kluft R. Washington, DC, American Psychiatric Press, 1985, pp 1–20
Goodwin J, Attias R: Splintered Reflections: Images of the Body in Trauma. New York, Basic Books, 1999
Goodwin J: The seduction hypothesis 100 years after, in Treatment of Adult Survivors of Incest. Edited by Paddison P. Washington, DC, American Psychiatric Press, 1993
Goodwin J, Cheeves K, Connell V: Borderline and other severe symptoms in adult survivors of incestuous abuse. Psychiatr Annal 1990; 20:22–32
Goodwin J: Sadistic abuse: definition, recognition and treatment. Dissociation 1993; 6:181–187
Van der Hart O, Lierens R, Goodwin J: Jeanne Fery: a sixteenth century case of dissociative identity disorder. J Psychohist 1996; 24:18–35
Goodwin J: Snow White and the seven diagnoses, in Attachment, Trauma and Multiplicity. Edited by Sinason V. New York, Brunner Routledge, 2002
Goodwin J: DW Winnicott (book review). J Psychohist 1997; 24:302–304
Goodwin J, Rosborough N, Hyde R: The Trauma Model, Rituals in Psychotherapy, Psychic Envelopes (book reviews). Trauma and Dissociation 2002; 3:133–140[(Jean P. Goodwin, M.D., M.)