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Problems around psychotherapy with children
PARIKH ET AL
THE JOURNAL OF PEDIATRICS VOLUME 137, NUMBER 4 wall thickness and major risk factors: the atherosclerosis risk in communities (ARIC) study, 1987-1993. Am J Epidemiol 1997;146:483-94. 26. Mykkanen L, Zaccaro DJ, O’Leary DH, Howard G, Robbins DC, Haffner SM. Microalbuminuria and carotid artery intima-media thickness in non-
diabetic and NIDDM subjects: the insulin resistance atherosclerosis study (IRAS). Stroke 1997;28:1710-6. 27. Kimball TR, Daniels SR, Khoury PR, Magnotti RA, Turner AM, Dolan LM. Cardiovascular status in young patients with insulin-dependent diabetes mellitus. Circulation 1994;90:357-61.
28. Gotzsche O, Sorensen K, McIntyre B, Henningsen P. Reduced left ventricular afterload and increased contractility in children with insulin-dependent diabetes mellitus: an M-mode and Dopplerechocardiographic evaluation of left ventricular diastolic and systolic function. Pediatr Cardiol 1991;12:69-73.
50 Years Ago in The Journal of Pediatrics PROBLEMS AROUND PSYCHOTHERAPY WITH CHILDREN Szurek SA. J Pediatr 1950;37:671-8 Fifty years ago, psychotherapy with children was in its infancy; Szurek wrote critically about its theoretical basis and its practice. He described the tendency for child psychotherapy to be focused entirely on children’s difficulties with insufficient focus on their families. He also decried the typical psychotherapeutic approach as being critical and sometimes abusive of parents, implicitly seeing “the parent as the enemy of the child… the child must be protected against the bottomless hatred of the parent.” He pointed out in contrast that “few if any parents deliberately or with conscious malice deprive their children of essential affectional nutriment. They do for them only what they can do, no more and no less.” He cautiously introduced the notion that “the most effective psychiatric help in parent-child problems is simultaneous concomitant psychotherapeutic work with both parent and child.” These ideas presaged the early work of family therapists such as Virginia Satir, Nathan Ackerman, and Murray Bowen, who highlighted the dynamic qualities of family systems and the benefits of working with distressed children within the context of their families, often taking account of the emotional lives of multiple generations. The theories and practice of family therapy have created a radical re-envisioning of the role of both therapists and pediatricians in the lives of distressed children and their families. The narrative therapists of the past decade1 have emphasized the opportunities that become available when the strengths of both parents and child are acknowledged and the family system is encouraged to use them to create a more successful equilibrium. Szurek also acknowledged the growing recognition, led by Anna Freud, that play is the “natural medium of expression for the child, rather than the collaborative self-revelation in speech as with adults.” Critical of the current practice based on these ideas, he pointed out that responsible “play therapy” requires long and rigorous training and that “unrestricted freedom in the playroom has little in common with a serious effort to allow the child to experience himself in a new kind of relation to an adult.” In the age of “managed care,” increasingly limited access of distressed children to experienced therapists, in concert with the growing success and availability of effective psychopharmacologic agents, threatens to restrict both the supervised education and practice of this aspect of therapeutic work with children. The concerns of 50 years ago are still the concerns today. Ellen C. Perrin, MD Division of Developmental-Behavioral Pediatrics University of Massachusetts Medical Center Worcester, MA 01655
REFERENCES 1. White M, Epston D. Narrative means to therapeutic ends. New York: WW Norton; 1990. 2. Freeman J, Epston D, Lobovits D. Playful approaches to serious problems. New York: WW Norton; 1997.
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THE JOURNAL OF PEDIATRICS VOLUME 137, NUMBER 4 wall thickness and major risk factors: the atherosclerosis risk in communities (ARIC) study, 1987-1993. Am J Epidemiol 1997;146:483-94. 26. Mykkanen L, Zaccaro DJ, O’Leary DH, Howard G, Robbins DC, Haffner SM. Microalbuminuria and carotid artery intima-media thickness in non-
diabetic and NIDDM subjects: the insulin resistance atherosclerosis study (IRAS). Stroke 1997;28:1710-6. 27. Kimball TR, Daniels SR, Khoury PR, Magnotti RA, Turner AM, Dolan LM. Cardiovascular status in young patients with insulin-dependent diabetes mellitus. Circulation 1994;90:357-61.
28. Gotzsche O, Sorensen K, McIntyre B, Henningsen P. Reduced left ventricular afterload and increased contractility in children with insulin-dependent diabetes mellitus: an M-mode and Dopplerechocardiographic evaluation of left ventricular diastolic and systolic function. Pediatr Cardiol 1991;12:69-73.
50 Years Ago in The Journal of Pediatrics PROBLEMS AROUND PSYCHOTHERAPY WITH CHILDREN Szurek SA. J Pediatr 1950;37:671-8 Fifty years ago, psychotherapy with children was in its infancy; Szurek wrote critically about its theoretical basis and its practice. He described the tendency for child psychotherapy to be focused entirely on children’s difficulties with insufficient focus on their families. He also decried the typical psychotherapeutic approach as being critical and sometimes abusive of parents, implicitly seeing “the parent as the enemy of the child… the child must be protected against the bottomless hatred of the parent.” He pointed out in contrast that “few if any parents deliberately or with conscious malice deprive their children of essential affectional nutriment. They do for them only what they can do, no more and no less.” He cautiously introduced the notion that “the most effective psychiatric help in parent-child problems is simultaneous concomitant psychotherapeutic work with both parent and child.” These ideas presaged the early work of family therapists such as Virginia Satir, Nathan Ackerman, and Murray Bowen, who highlighted the dynamic qualities of family systems and the benefits of working with distressed children within the context of their families, often taking account of the emotional lives of multiple generations. The theories and practice of family therapy have created a radical re-envisioning of the role of both therapists and pediatricians in the lives of distressed children and their families. The narrative therapists of the past decade1 have emphasized the opportunities that become available when the strengths of both parents and child are acknowledged and the family system is encouraged to use them to create a more successful equilibrium. Szurek also acknowledged the growing recognition, led by Anna Freud, that play is the “natural medium of expression for the child, rather than the collaborative self-revelation in speech as with adults.” Critical of the current practice based on these ideas, he pointed out that responsible “play therapy” requires long and rigorous training and that “unrestricted freedom in the playroom has little in common with a serious effort to allow the child to experience himself in a new kind of relation to an adult.” In the age of “managed care,” increasingly limited access of distressed children to experienced therapists, in concert with the growing success and availability of effective psychopharmacologic agents, threatens to restrict both the supervised education and practice of this aspect of therapeutic work with children. The concerns of 50 years ago are still the concerns today. Ellen C. Perrin, MD Division of Developmental-Behavioral Pediatrics University of Massachusetts Medical Center Worcester, MA 01655
REFERENCES 1. White M, Epston D. Narrative means to therapeutic ends. New York: WW Norton; 1990. 2. Freeman J, Epston D, Lobovits D. Playful approaches to serious problems. New York: WW Norton; 1997.
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