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Pitfalls in Psychotherapy*
Pitfalls in
402.
Psychotherapy~
Believing that one can easily inflict damage on children, or their families, by attempting superficial supportive psychotherapy, even though the physician is not trained in psychotherapy. In fact, the physician should be able to handle mild personality and transient adjustment problems. More complex, serious problems requiring a great deal of time should be referred to specially trained personnel. Children whose character development or behavior is sociopathic and those with serious learning disability, school phobias or serious neurotic symptoms, including those severely depressed or suicidal, should be referred elsewhere. In the case of isolated symptoms (tics, stuttering, and so forth) the response to therapy may be a reasonable guide as to whether the general practitioner or pediatrician should continue management or whether the patient should be referred to a psychiatrist.
403.
Failing to communicate with psychiatrists. This is an error on the part of the family physician, the pediatrician or the general practitioner and the child psychiatrist, but more often of the psychiatrist. Without communication there may be inadequate knowledge of all factors which relate to the problem.
The material in this section was exceedingly difficult to encapsulate, there being many variations and exceptions to all of the material. (I
237
238
PITFALLS IN PSYCHOTHERAPY
404.
Failing to recognize and manage excessive erotic stimulation (gross overstimulation, seduction, parent-child or intersibling incest).
405.
Discouraging natural emotional outlets a child might have if the situation or environment were appropriate.
406.
Attributing academic failure to deficiencies in the school (teachers, teaching methods). In fact, most cases are related to social-cultural deficiencies or emotional imbalances within the family.
407.
Failing to inquire about school attendance in a child with recurrent somatic complaints. The underlying cause may be separation anxiety or school phobia.
408.
Failing to appreciate that children can handle adverse material in an adult manner if they are given a factual but sympathetic explanation.
409.
Attributing illness to emotional problems. Some commented that the current preoccupation with psychologic pediatrics sometimes hampers a good medical work-up. The example of a five-year-old boy with delayed speech
PITFALLS IN PSYCHOTHERAPY
239
was noted. He was seen by a psychiatrist for five months without notable success. Eventually an abnormal electroencephalogram and clumsiness were noted. A diagnosis of brain damage was made. A 12-year-old boy with decided behavior disorder, apathy and school failure was seen almost daily by a psychiatrist for seven months until the boy suddenly became moribund. He was found to have Addison's disease (with pigmentation developing over a year).
410.
Failing to recognize a specific reading (language) disorder as a factor in learning disorders. Although uncommon, this is an important condition requiring specific remedial care. The secondary emotional disturbances often obscure the primary condition.
411.
Failing to advise parents to set sufficient limits for the activities and behavior of their children, or failing to suggest that they are setting unreasonable limits or limits which cannot be controlled. Limits must be realistic and controllable.
412.
Subjecting a toddler (two years old) to evaluation for possible mental retardation because he fails to speak.
413.
Believing that mild corporal punishment (or spanking) is detrimental or that minor deprivations (no movies, no television) or exposure to adult television programs, erotic
,'
240
PITFALLS IN PSYCHOTHERAPY
movies, and the like, are critical determinants relative to the behavioral development of children. The total life experiences are fundamental, and occasional minor (less than ideal) experiences are probably not very important if the basic emotional needs of children are satisfied.
414.
Failing to differentiate social problems from psychiatric problems. The result is referral to psychiatric facilities rather than to more appropriate social service facilities. Certain "reality" problems should be referred to the social service agencies. For example, the impoverished child who is malnourished should be referred to a social worker who will give relevant social service consultation and make provision for food. The family should not be sent to a psychiatrist simply because the child is anxious. In many instances, however, social and psychiatric needs are hard to separate. If psychiatric facilities are temporarily unavailable, the patient can be referred to the social agency for initiation of evaluation.
415.
Failing to recognize the variability of normal behavior. Examples: Enuresis is found in about 50 per cent of four-year-oIds; most two- to four-year-old children have phobias; 50 per cent of children lie, steal, cheat on occasion; sleep disturbances are common in toddlers; the majority of adolescents practice masturbation; and so forth.
PITFALLS IN PSYCHOTHERAPY
241
416. Assuming that retarded children should be removed from the home and be institutionalized. Basic reasons for this pitfall are lack of interest or training in the behavioral sciences, and failing to seek consultative help from psychiatrists, neurologists or paramedical personnel, particularly psychologists and social service workers.
417. Abandoning terminally ill children (and their families) and failing to meet their emotional needs. The physician fails to realize that this may be due to anxiety on his part and to his failure to seek psychiatric consultation for the child or his family, and possibly for himself.
418. Placing far too much burden (blame) on parents whose children have behavior problems. The implication is that if the result of the neurologic examination is negative, then the behavior disturbance is emotional and family-derived. In fact, only a small part of the nervous system can be examined, and considerable evidence has been presented that organic brain disease may be manifested only by a behavior disorder or a learning disorder. The most common behavior disorders are not organic and are remediable by a family-oriented psychiatrist.
419. Failing to evaluate family relations, particularly motherfather, parent-child and sibling relations, during routine well-baby visits.
242
PITFALLS IN PSYCHOTHERAPY
Identifying imbalances at this time may well facilitate therapy which might prevent subsequent emotional difficulties in the baby.
420.
Referring a patient to a psychiatrist without having obtained a social history. This would appear to be symptomatic of the widespread disregard for psychologic pediatrics.
421.
Believing that obtaining a social history is the sole province of the psychiatrist.
402.
Psychotherapy~
Believing that one can easily inflict damage on children, or their families, by attempting superficial supportive psychotherapy, even though the physician is not trained in psychotherapy. In fact, the physician should be able to handle mild personality and transient adjustment problems. More complex, serious problems requiring a great deal of time should be referred to specially trained personnel. Children whose character development or behavior is sociopathic and those with serious learning disability, school phobias or serious neurotic symptoms, including those severely depressed or suicidal, should be referred elsewhere. In the case of isolated symptoms (tics, stuttering, and so forth) the response to therapy may be a reasonable guide as to whether the general practitioner or pediatrician should continue management or whether the patient should be referred to a psychiatrist.
403.
Failing to communicate with psychiatrists. This is an error on the part of the family physician, the pediatrician or the general practitioner and the child psychiatrist, but more often of the psychiatrist. Without communication there may be inadequate knowledge of all factors which relate to the problem.
The material in this section was exceedingly difficult to encapsulate, there being many variations and exceptions to all of the material. (I
237
238
PITFALLS IN PSYCHOTHERAPY
404.
Failing to recognize and manage excessive erotic stimulation (gross overstimulation, seduction, parent-child or intersibling incest).
405.
Discouraging natural emotional outlets a child might have if the situation or environment were appropriate.
406.
Attributing academic failure to deficiencies in the school (teachers, teaching methods). In fact, most cases are related to social-cultural deficiencies or emotional imbalances within the family.
407.
Failing to inquire about school attendance in a child with recurrent somatic complaints. The underlying cause may be separation anxiety or school phobia.
408.
Failing to appreciate that children can handle adverse material in an adult manner if they are given a factual but sympathetic explanation.
409.
Attributing illness to emotional problems. Some commented that the current preoccupation with psychologic pediatrics sometimes hampers a good medical work-up. The example of a five-year-old boy with delayed speech
PITFALLS IN PSYCHOTHERAPY
239
was noted. He was seen by a psychiatrist for five months without notable success. Eventually an abnormal electroencephalogram and clumsiness were noted. A diagnosis of brain damage was made. A 12-year-old boy with decided behavior disorder, apathy and school failure was seen almost daily by a psychiatrist for seven months until the boy suddenly became moribund. He was found to have Addison's disease (with pigmentation developing over a year).
410.
Failing to recognize a specific reading (language) disorder as a factor in learning disorders. Although uncommon, this is an important condition requiring specific remedial care. The secondary emotional disturbances often obscure the primary condition.
411.
Failing to advise parents to set sufficient limits for the activities and behavior of their children, or failing to suggest that they are setting unreasonable limits or limits which cannot be controlled. Limits must be realistic and controllable.
412.
Subjecting a toddler (two years old) to evaluation for possible mental retardation because he fails to speak.
413.
Believing that mild corporal punishment (or spanking) is detrimental or that minor deprivations (no movies, no television) or exposure to adult television programs, erotic
,'
240
PITFALLS IN PSYCHOTHERAPY
movies, and the like, are critical determinants relative to the behavioral development of children. The total life experiences are fundamental, and occasional minor (less than ideal) experiences are probably not very important if the basic emotional needs of children are satisfied.
414.
Failing to differentiate social problems from psychiatric problems. The result is referral to psychiatric facilities rather than to more appropriate social service facilities. Certain "reality" problems should be referred to the social service agencies. For example, the impoverished child who is malnourished should be referred to a social worker who will give relevant social service consultation and make provision for food. The family should not be sent to a psychiatrist simply because the child is anxious. In many instances, however, social and psychiatric needs are hard to separate. If psychiatric facilities are temporarily unavailable, the patient can be referred to the social agency for initiation of evaluation.
415.
Failing to recognize the variability of normal behavior. Examples: Enuresis is found in about 50 per cent of four-year-oIds; most two- to four-year-old children have phobias; 50 per cent of children lie, steal, cheat on occasion; sleep disturbances are common in toddlers; the majority of adolescents practice masturbation; and so forth.
PITFALLS IN PSYCHOTHERAPY
241
416. Assuming that retarded children should be removed from the home and be institutionalized. Basic reasons for this pitfall are lack of interest or training in the behavioral sciences, and failing to seek consultative help from psychiatrists, neurologists or paramedical personnel, particularly psychologists and social service workers.
417. Abandoning terminally ill children (and their families) and failing to meet their emotional needs. The physician fails to realize that this may be due to anxiety on his part and to his failure to seek psychiatric consultation for the child or his family, and possibly for himself.
418. Placing far too much burden (blame) on parents whose children have behavior problems. The implication is that if the result of the neurologic examination is negative, then the behavior disturbance is emotional and family-derived. In fact, only a small part of the nervous system can be examined, and considerable evidence has been presented that organic brain disease may be manifested only by a behavior disorder or a learning disorder. The most common behavior disorders are not organic and are remediable by a family-oriented psychiatrist.
419. Failing to evaluate family relations, particularly motherfather, parent-child and sibling relations, during routine well-baby visits.
242
PITFALLS IN PSYCHOTHERAPY
Identifying imbalances at this time may well facilitate therapy which might prevent subsequent emotional difficulties in the baby.
420.
Referring a patient to a psychiatrist without having obtained a social history. This would appear to be symptomatic of the widespread disregard for psychologic pediatrics.
421.
Believing that obtaining a social history is the sole province of the psychiatrist.