Through the Times With Paul Genova, M.D.

Psychiatric Times

May 2005

Vol. XXII

Issue 6

Colleagues and admirers of Paul Genova, M.D., have described him as a "voice of clarity, compassion and practicality," as a "kindred spirit" who "elegantly expressed some concerns about our profession" and as an advocate for "person-centered psychiatry that is analytically, neuroscientifically and politically informed."

After obtaining his medical degree from Dartmouth Medical School in 1979 and completing his psychiatric residency at Maine Medical Center in 1985, Genova began practicing general outpatient and community psychiatry in Maine. Until 2003, he was a staff psychiatrist at Tri-County Mental Health Services, treating patients with chronic, major mental illnesses and/or mental retardation, and from 1990 to 1996 was a contract psychiatrist with the Togus Veterans Affairs Medical Center, conducting disability evaluations of some 600 combat veterans. At the same time, he maintained a private practice focusing on individual psychodynamic therapy. In 1990, he joined the teaching faculty in the department of psychiatry at Maine Medical Center and four years later was appointed clinical associate professor of psychiatry at the University of Vermont. Beyond teaching about psychiatry and therapy, Genova has written about it in Psychiatric Times, Voices: the Art and Science of Psychotherapy and in book reviews for the American Journal of Psychiatry.

For more than a decade Genova's much beloved column "No Shows" graced the pages of PT. Many of the essays originally published in PT, together with retrospectives on some of the writings and more recent essays, appear in a revised and expanded edition of Genova's book The Thaw: Reclaiming the Person for Psychiatry (Analytic Press, 2002). The revised edition includes Genova's first column, "A Good Goodbye: Is American Psychiatry Terminally Ill?" in which he wrote despondently about psychiatry's movement "toward diagnostic and biological reductionism and away from the art of listening." In 2004, Genova informed PT's readers that he was being sidelined by cancer and unable to write. As part of our 20th anniversary celebration, PT asked Genova for some recollections and reflections about his own life.

PT: What drew you to psychiatry?

Genova: I have been fascinated with the mind ever since I was young. When I first got to college, I began reading [Carl Gustav] Jung. I was very excited, and that really got me started. Then, I had a brief detour into general medicine, working in general practice in Kentucky. After a couple of years of thinking about livers and kidneys, I realized that I didn't want to spend my life thinking about those sorts of things and wanted to go back to my original interests. So at that point, I bailed out of general practice and went to psychiatry residency.

PT: Tell me about your relationship with Psychiatric Times?

Genova: I showed my original paper, ‘Is American Psychiatry Terminally Ill?' to an acquaintance of John Schwartz, M.D., [who] showed it to John. He contacted me and asked to publish it in Psychiatric Times. That paper got many letters from readers, so John asked me to become a regular columnist.

I had been writing on my own for years and only published in very obscure journals. Although PT wasn't considered a "prestigious" journal, its circulation is enormous. It was really wonderful for me to write for it compared to writing for something that might be read by 10 people. I have loved being able to be in touch with the rank and file of the profession. I have found academic psychiatry, over my career, to be somewhat stifling. [Psychiatric Times] offered me a route around it directly to the practitioner. I, as a rank-and-file person, could write for rank-and-file people and get letters back, bypassing the baggage of doing research, writing it up and writing about things I wasn't really interested in. I love to write from my own experience. I love to write essays. I am not a scientist. There just aren't many vehicles for that in psychiatry.

I think PT pioneered a return to the essay with Peter Kramer, M.D., and then me and a number of other people writing in Psychiatric Times. Now, you see even the American Journal of Psychiatry has a regular feature that is kind of an opinion/essay. The New England Journal of Medicine has essays as do a lot of other medical journals. They have recognized that people want to read other human beings' writing about their experience.

PT: What major challenge is the profession of psychiatry facing?

Genova: I have said this before and a lot of other people have too, so it might sound trite, but I still think the biggest challenge is to hang on to our commitment and our expertise in our relationship with the patient. So many forces are pulling us toward a more technical state, whether it's medication treatment or manualized therapies. It has become much more of an "us" doing something to "them," the patients. Individual psychiatrists--I know, because I have supervised so many of them--really still yearn for contact with the patients or the experience of getting to know people over time and understanding them as individuals. But there has to be some kind of institutional sanctity about patient relationships instead of just having it be something that people do on the side on their own time. The relationship with the patient is what we could stand to lose.

PT: Can you describe an incident or insight that changed the way you practice psychiatry?

Genova: There is a story I can tell. I was in my first year of psychiatry residency, and I had a very ill, borderline patient, a woman. She eloped from the unit, and then we got her back. She told me she had spent the afternoon out on a park bench, crying. I was relating the story to my supervisor, who was the head of the department, and I guess I was relating it in kind of a dispassionate way. He said, ‘Paul, don't you realize she was out there crying for you?' It suddenly became clear to me how important we can get to be to our patients. I hadn't really let that fact in before. I was much more at a distance from patients, and at that point, his comment made me put myself in her place. This was someone I was doing therapy with, and it made me realize for an instant what it must be like being her and depending on this one figure, this young psychiatry resident, who for her is an enormously important figure at this point in her life. That, of all the stories I could tell, let me know what I was getting myself into.

PT: In your column ‘Boundary Violations and the Fall from Eden' (PT June 2001, p64), you said that most psychiatrists start out as idealists eager to care for others, but few remain deeply engaged with large numbers of very needy patients. Did you go through that process, and how did you deal with it?

Genova: I had about 15 years of that idealistic, very intense immersion in other people's lives, unconscious processes and transference relationships, and trying to work with those. But I got to a point where it did feel overwhelming to continue that level of involvement with that many people. At that point, I backed off and really limited both the number of the patients that I saw and the kinds of patients that I worked with. I think most people do that, although I don't know that everyone admits it. There are some few people with a kind of stamina I don't comprehend who can be involved at that level for an entire career, but in talking to a lot of therapists, 15 to 20 years seems to be about the average that one can devote to that intense level. It is like a calling, like being a parish minister or priest. If you are really wholeheartedly doing that, you can't do it forever without something suffering, possibly your family life or your health.

PT: What insights have you gained from the experience of cancer, and how are you doing?

Genova: I had a stem-cell transplant about a year ago, and I am back doing chemotherapy again. I am stable but still have active disease, so I am very conscious of my mortality. Even though I had backed off from a really intense practice several years before, at first when I got sick, my thoughts went to ‘Did psychiatry do this to me?' For the first six or eight months, I just never imagined being in psychiatry again. I had this enormous reaction of wanting to flee from it. But as time went on, I realized this is what I had done with my life, and if I fled from it, I was saying that I had made a misguided choice for the bulk of my life. I didn't like the way that felt.

I came to value the fact that this is who I am, and this is what I do. I stand behind what I did, what I wrote and the work I did with patients, and that was one of the most meaningful things about my life, no matter whether I got dealt a bad hand physically or not.

So, I ended up getting back into psychiatry in a different way, and have been doing mostly supervision groups for psychiatrists and therapists and a little part-time work at a college. I am working less than half time.

In August, we are moving to England for two years. My wife, Noel, who is a PA-C, will be helping the National Health Service in the United Kingdom get their own PA-like ‘mid-level' profession off the ground. She'll work both as a clinician and educator of native trainees in Birmingham, England. As my health permits, I'll try to get involved with psychiatry and/or therapy.

PT: What has been the gift of psychiatry to you?

Genova: More than anything else, it is the people, the patients. It is having a thousand eyes on the world, seeing the world from so many different points of view. And I have met so many just wonderful people. Inherently, I am a pessimistic, doom-and-gloom person, and I had a very cynical attitude toward human nature when I came to the field. I can honestly say I now have a much better opinion of human nature and the possibilities of love and contact with other people than I did when I started. It really restored my faith in people.

I know that is not the trajectory that a lot of psychiatrists experience, but that has been my experience. Seeing what people can endure and the kind of integrity that people can maintain facing terrible situations, it is inspiring. I just never believed that human love was real, until I saw it, and I needed to keep seeing and seeing every week. That's what kept me going and in a small way still does, in the context of these groups and things I am doing. Just the experience of sitting with someone and having a wonderful conversation is life at its best.