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THE BASIC FUNCTIONS OF A CHILD PSYCHIATRIST IN ANY SETTING
THE BASIC FUNCTIONS OF A CHILD PSYCHIATRIST IN ANY SETTING
]. Cotter Hirschberg, M.D.
This paper has as its thesis that there are distinguishing characteristics in the functioning of a child psychiatrist because of his being a child psychiatrist and regardless of the setting in which this functioning as a child psychiatrist takes place. It is true that adult and child psychiatrists have much in common and much which is basic in their functioning, just as it is also true that there are certain basic similarities between a child and an adult. However, there are sufficient differences between the actual functioning of a child psychiatrist and an adult psychiatrist in any particular setting that it should be possible to describe the relatively unique contributions which the child psychiatrist may make in his work. The order of listing the differences described in this paper bears no relationship to any implied order of importance of these relative differences. 1. The child psychiatrist brings to any setting his awareness of the importance of the child's age in relation to the child's thinking, feeling, and behaving. The child psychiatrist is continually aware of the importance of growth and maturation in the child's functioning. He is also especially aware of the importance of the relationship between the child's age and any particular traumatic experience. The same event, for example, the death of the child's mother, has strikingly different meanings to the child, depending on whether Dr. Hirschberg is Director of Training in Child Psychiatry, The Menninger Clinic, Topeka, Kansas. This paper was presented at the Conference on Training in Child Psychiatry, Washington, D.C., 1963.
360
Basic Functions of a Child Psychiatrist
361
this event occurs in the first few weeks of life, the early months of life, late infancy, when the child is two and a half or three, when he is four to five years old, during the school-age period, in puberty, early adolescence, or late adolescence. The examples are numerous and each of us could supply many. 2. The child psychiatrist helps to delineate the vast differences between the nondevelopment of a function in a child or an arrest in development, as compared with the loss of a once acquired function in an adult. The child psychiatrist can help those in a significant relationship with a child understand the consequences which such a delay or arrest in psychological development will have for the emergence of new and ongoing functions. The child psychiatrist also has some awareness of the ways in which children compensate for this difficulty within their capabilities. 3. Since the child psychiatrist is always a physician, particularly aware of the physical aspects of the physical being of the child, he can aid others in becoming aware of those aspects of malfunction or emotional illness which are related primarily to organic difficulty, and thus place the role of organicity into proper relationship with psychogenicity. To many the child psychiatrist can bring his awareness of pediatric neurology as well as his awareness of emotional disturbance in children. 4. The child psychiatrist brings to any evaluation of a child his awareness that the child cannot be considered only as an individual but must always be viewed in a larger family, social, and cultural context. The relationships of the child with his parents are real, necessary, and immediate, and the necessity of this reciprocal relationship for the child's very process of growth is a part of the psychiatrist's basic knowledge. It is not merely that the child needs to be studied and understood in the setting of his family, but that the very concepts of the parent regarding the child are crucial to his total development. This is especially so since the child is "caught" in a particular situation or setting to a much greater extent than is true of adults. He is caught not merely because of his limited freedom of movement within the total situation, but because the total situation is continually contributing, for good or bad, to his growth pattern. No child's situation can be evaluated without con-
362
]. Cotter Hirschberg
sidering his constitutional and biological givens, his own internal dynamics, and the dynamics of the family, and the larger social-cultural complex. Further, the importance of a continuous and intact relationship between the child and his parents or parent surrogates emphasizes that the child cannot be viewed as existing as an independent person. 5. Adult psychiatrists may work closely with others and be meaningfully involved in a collaborative treatment process. However, the essential use of collaborative disciplines differs in child psychiatry in a qualitative, not merely quantitative, way. One such qualitative difference involves the child psychiatrist's awareness of the necessity for professional role definition and the necessity for various professions in any particular setting to be aware of and to contribute according to their particular roles. Such a case in point would be that a child receives greater help when the role of the therapist or the role of a teacher in a particular setting is clearly understood to be a separate role by the child himself. In addition, the child psychiatrist can contribute to formulating what role the entire setting as such plays in the child's life and his progress toward health. 6. The child psychiatrist brings to any setting his awareness of the differences in thinking between the child and the adult, and particularly his awareness of the characteristics of the child's thinking at various stages of growth. The prominence of prelogical, archaic thinking in the child's early years makes the child psychiatrist's presentation to the setting of the normal timelessness of infantile thought, the concreteness of it, the animistic nature of it, the omnipotence of it, an important aspect of work with the child in any setting. That children respond in early years as if the world were an extension of themselves, and that differentiation comes about only as a part of growth, are further examples of the contributions which the child psychiatrist brings to the thinking of any group concerned with helping a child. The child not only is dependent upon outside figures (which become internalized later) for his learning process, but this reciprocal relationship between the child and parent figures achieves both the process of self-realization for the child and his developing of object relations. The child psychiatrist who is aware of this process of individualization can help others realize the nee-
Basic Functions of a Child Psychiatrist
363
essity of optimal satisfaction for the child's very growth, and can also clarify how necessary restitution may become to certain children before growth can proceed. For a normal child to initiate and sustain developmental change, the relationships with the outside objects must be real and adapting as well as appropriate to the child's developmental level. 7. Interviewing children requires not only specialized knowledge of children, but also specialized knowledge of the particular language and modes of every age group. As a result, the child psychiatrist brings to any setting a specialized kind of interviewing skill and a specialized awareness of the use that individuals make of themselves in both the interviewing and the therapy of children. 8. The child psychiatrist brings to any setting not only a concept of the importance of regression in a child's health and illness, but also the fact that regression occurs more frequently and more readily in children and can be moved out of with greater ease than is true with adults. The fact of regression is one reason why it is possible to make direct restitution to a child in a greater degree than with adults. Because of this the child psychiatrist can help the people in any setting recognize that in any helping relationship there is both a transference phenomenon and a genuine object relationship involved. Empathy and libidinal investment are part of the responsive feelings required of a setting as well as responsive understanding of the child, and this again represents the help that a child psychiatrist can be to the thinking of those involved in the helping process with this child. The child psychiatrist aids the setting in being aware that help for the child means not only the relief of the immediate presenting problem but aiding and freeing the child for future developmental growth. 9. Another special contribution of child psychiatrists to any setting is the understanding of the importance of limits and controls based upon a particular understanding of the psychological development in various age groups. The therapeutic use of limits and controls can be a contribution of the child psychiatrist whether such awareness be applied to a specific interview or to the work of the setting as a whole. 10. The child psychiatrist helps any setting be aware of how fre-
364
]. Cotter Hirschberg
quently motivation for change is felt by a child as a threat and thus is always to some degree resisted by the child. To some degree all children view help as authoritarian, feel change as imposed upon them from the outside, and cling to the status quo. The child often feels the threat of change as a threat of separation, a threatened loss of love, or as expressing dissatisfaction with him as he is. The child psychiatrist helps the setting to realize that this ingredient of the "necessity for change" must be achieved and continually redefined. Although the resistance to change is many times greater in a child than in an adult, fortunately the drive to change, the impulse for growth is greater also. The child psychiatrist helps any setting realize that it is not enough to be a friend but that for change to be initiated and sustained, it is essential that the genetic and defensive meanings be worked through in the therapy relationship. These expressive and defensive aspects are essential parts of therapy, and a child psychiatrist helps the setting remain continually aware of them. II. The child psychiatrist continually brings to any setting his awareness of playas a mastery and learning process and as a method of communication. The child psychiatrist helps the setting see play, as well as symptom behavior, as ways in which the child expresses feeling, communicates fantasy, represents the life about him and himself, or distorts and symbolizes and projects. The child psychiatrist helps the setting be aware of the nonverbal as well as verbal communications. The child psychiatrist also aids any setting in its awareness of the maturity necessary to be involved in the child's life without overidentifying with the child, without competing destructively with the parents, and without responding to the child from the individual's own unresolved infantile needs. The child's play always involves dynamic response to immediate reality as well as to the dynamic past. Thus the child psychiatrist helps a setting base its work on a theoretical sound purpose, not merely expediency. An example would be the following. A setting may be considering taking a specific action in relation to a particular child because it seems the expedient and practical thing to do. The child psychiatrist helps the setting consider the specific psychological meaning of this
Basic Functions of a Child Psychiatrist
365
action to the particular child in all of its ramifications to the individual and to the group, and thus helps the setting look beyond expediency so that a healthy balance results between what is useful in a practical way and what is necessary in the child's or the group's dynamics. In addition, the child psychiatrist enables any setting to be aware of how play in children can be used for: (a) the need to concretize fantasy, that is, to act it out through direct representational means; (b) the substitution of active mastery for passive experience; (c) the displacing of destructive and restitutive impulses; (d) the acting out of socially reprehensible impulses through identifying with the bad evil play figures; (e) the sublimation of impulse into acceptable activity; (f) the motor discharge of tension. 12. The child psychiatrist brings to any setting his awareness of the relative lack of a stabilized symptom picture in many children, and the fact that, as compared with adults, there are less definite, clear-cut neuroses and psychoses but more deviations in social behavior. In addition to helping the setting recognize and absorb the frequent role of secondary gain in a child's symptoms, the child psychiatrist also functions to help the setting be aware of the more direct gratificatory nature of children's symptoms. The setting needs to realize that symptoms can be satisfying and satisfactory and bring therapeutic work to an impasse. The child psychiatrist can help the setting tolerate areas of reality in which the illness manifests itself to a child as a disability, so that the child himself feels motivated toward change. It is here, however, that the child psychiatrist also helps a setting by enabling it to realize that an adult can tolerate greater amounts of anxiety than a child. In work with adults the crucialness of someone else's opinion is never as vital to the helping process as it is with a child. A setting not only needs to know the child's concept of the people in the world about him; it must also be aware of the importance of its own concept of each particular child within that setting. Children not only show a relative lack of stabilization of their symptoms but may show different symptoms with different persons in the same setting, and the child psychiatrist with his knowledge of transference and the ways in which children can split their objects into good objects and bad ones can enable
366
]. Cotter Hirschberg
the setting to understand the phenomenon rather than to react to it in inappropriate response. The child psychiatrist can help a setting move away from absolutism by realizing that in one case the relationship alone may therapeutically deal with the problem, but that in another child, working through genetic content may be essential.
]. Cotter Hirschberg, M.D.
This paper has as its thesis that there are distinguishing characteristics in the functioning of a child psychiatrist because of his being a child psychiatrist and regardless of the setting in which this functioning as a child psychiatrist takes place. It is true that adult and child psychiatrists have much in common and much which is basic in their functioning, just as it is also true that there are certain basic similarities between a child and an adult. However, there are sufficient differences between the actual functioning of a child psychiatrist and an adult psychiatrist in any particular setting that it should be possible to describe the relatively unique contributions which the child psychiatrist may make in his work. The order of listing the differences described in this paper bears no relationship to any implied order of importance of these relative differences. 1. The child psychiatrist brings to any setting his awareness of the importance of the child's age in relation to the child's thinking, feeling, and behaving. The child psychiatrist is continually aware of the importance of growth and maturation in the child's functioning. He is also especially aware of the importance of the relationship between the child's age and any particular traumatic experience. The same event, for example, the death of the child's mother, has strikingly different meanings to the child, depending on whether Dr. Hirschberg is Director of Training in Child Psychiatry, The Menninger Clinic, Topeka, Kansas. This paper was presented at the Conference on Training in Child Psychiatry, Washington, D.C., 1963.
360
Basic Functions of a Child Psychiatrist
361
this event occurs in the first few weeks of life, the early months of life, late infancy, when the child is two and a half or three, when he is four to five years old, during the school-age period, in puberty, early adolescence, or late adolescence. The examples are numerous and each of us could supply many. 2. The child psychiatrist helps to delineate the vast differences between the nondevelopment of a function in a child or an arrest in development, as compared with the loss of a once acquired function in an adult. The child psychiatrist can help those in a significant relationship with a child understand the consequences which such a delay or arrest in psychological development will have for the emergence of new and ongoing functions. The child psychiatrist also has some awareness of the ways in which children compensate for this difficulty within their capabilities. 3. Since the child psychiatrist is always a physician, particularly aware of the physical aspects of the physical being of the child, he can aid others in becoming aware of those aspects of malfunction or emotional illness which are related primarily to organic difficulty, and thus place the role of organicity into proper relationship with psychogenicity. To many the child psychiatrist can bring his awareness of pediatric neurology as well as his awareness of emotional disturbance in children. 4. The child psychiatrist brings to any evaluation of a child his awareness that the child cannot be considered only as an individual but must always be viewed in a larger family, social, and cultural context. The relationships of the child with his parents are real, necessary, and immediate, and the necessity of this reciprocal relationship for the child's very process of growth is a part of the psychiatrist's basic knowledge. It is not merely that the child needs to be studied and understood in the setting of his family, but that the very concepts of the parent regarding the child are crucial to his total development. This is especially so since the child is "caught" in a particular situation or setting to a much greater extent than is true of adults. He is caught not merely because of his limited freedom of movement within the total situation, but because the total situation is continually contributing, for good or bad, to his growth pattern. No child's situation can be evaluated without con-
362
]. Cotter Hirschberg
sidering his constitutional and biological givens, his own internal dynamics, and the dynamics of the family, and the larger social-cultural complex. Further, the importance of a continuous and intact relationship between the child and his parents or parent surrogates emphasizes that the child cannot be viewed as existing as an independent person. 5. Adult psychiatrists may work closely with others and be meaningfully involved in a collaborative treatment process. However, the essential use of collaborative disciplines differs in child psychiatry in a qualitative, not merely quantitative, way. One such qualitative difference involves the child psychiatrist's awareness of the necessity for professional role definition and the necessity for various professions in any particular setting to be aware of and to contribute according to their particular roles. Such a case in point would be that a child receives greater help when the role of the therapist or the role of a teacher in a particular setting is clearly understood to be a separate role by the child himself. In addition, the child psychiatrist can contribute to formulating what role the entire setting as such plays in the child's life and his progress toward health. 6. The child psychiatrist brings to any setting his awareness of the differences in thinking between the child and the adult, and particularly his awareness of the characteristics of the child's thinking at various stages of growth. The prominence of prelogical, archaic thinking in the child's early years makes the child psychiatrist's presentation to the setting of the normal timelessness of infantile thought, the concreteness of it, the animistic nature of it, the omnipotence of it, an important aspect of work with the child in any setting. That children respond in early years as if the world were an extension of themselves, and that differentiation comes about only as a part of growth, are further examples of the contributions which the child psychiatrist brings to the thinking of any group concerned with helping a child. The child not only is dependent upon outside figures (which become internalized later) for his learning process, but this reciprocal relationship between the child and parent figures achieves both the process of self-realization for the child and his developing of object relations. The child psychiatrist who is aware of this process of individualization can help others realize the nee-
Basic Functions of a Child Psychiatrist
363
essity of optimal satisfaction for the child's very growth, and can also clarify how necessary restitution may become to certain children before growth can proceed. For a normal child to initiate and sustain developmental change, the relationships with the outside objects must be real and adapting as well as appropriate to the child's developmental level. 7. Interviewing children requires not only specialized knowledge of children, but also specialized knowledge of the particular language and modes of every age group. As a result, the child psychiatrist brings to any setting a specialized kind of interviewing skill and a specialized awareness of the use that individuals make of themselves in both the interviewing and the therapy of children. 8. The child psychiatrist brings to any setting not only a concept of the importance of regression in a child's health and illness, but also the fact that regression occurs more frequently and more readily in children and can be moved out of with greater ease than is true with adults. The fact of regression is one reason why it is possible to make direct restitution to a child in a greater degree than with adults. Because of this the child psychiatrist can help the people in any setting recognize that in any helping relationship there is both a transference phenomenon and a genuine object relationship involved. Empathy and libidinal investment are part of the responsive feelings required of a setting as well as responsive understanding of the child, and this again represents the help that a child psychiatrist can be to the thinking of those involved in the helping process with this child. The child psychiatrist aids the setting in being aware that help for the child means not only the relief of the immediate presenting problem but aiding and freeing the child for future developmental growth. 9. Another special contribution of child psychiatrists to any setting is the understanding of the importance of limits and controls based upon a particular understanding of the psychological development in various age groups. The therapeutic use of limits and controls can be a contribution of the child psychiatrist whether such awareness be applied to a specific interview or to the work of the setting as a whole. 10. The child psychiatrist helps any setting be aware of how fre-
364
]. Cotter Hirschberg
quently motivation for change is felt by a child as a threat and thus is always to some degree resisted by the child. To some degree all children view help as authoritarian, feel change as imposed upon them from the outside, and cling to the status quo. The child often feels the threat of change as a threat of separation, a threatened loss of love, or as expressing dissatisfaction with him as he is. The child psychiatrist helps the setting to realize that this ingredient of the "necessity for change" must be achieved and continually redefined. Although the resistance to change is many times greater in a child than in an adult, fortunately the drive to change, the impulse for growth is greater also. The child psychiatrist helps any setting realize that it is not enough to be a friend but that for change to be initiated and sustained, it is essential that the genetic and defensive meanings be worked through in the therapy relationship. These expressive and defensive aspects are essential parts of therapy, and a child psychiatrist helps the setting remain continually aware of them. II. The child psychiatrist continually brings to any setting his awareness of playas a mastery and learning process and as a method of communication. The child psychiatrist helps the setting see play, as well as symptom behavior, as ways in which the child expresses feeling, communicates fantasy, represents the life about him and himself, or distorts and symbolizes and projects. The child psychiatrist helps the setting be aware of the nonverbal as well as verbal communications. The child psychiatrist also aids any setting in its awareness of the maturity necessary to be involved in the child's life without overidentifying with the child, without competing destructively with the parents, and without responding to the child from the individual's own unresolved infantile needs. The child's play always involves dynamic response to immediate reality as well as to the dynamic past. Thus the child psychiatrist helps a setting base its work on a theoretical sound purpose, not merely expediency. An example would be the following. A setting may be considering taking a specific action in relation to a particular child because it seems the expedient and practical thing to do. The child psychiatrist helps the setting consider the specific psychological meaning of this
Basic Functions of a Child Psychiatrist
365
action to the particular child in all of its ramifications to the individual and to the group, and thus helps the setting look beyond expediency so that a healthy balance results between what is useful in a practical way and what is necessary in the child's or the group's dynamics. In addition, the child psychiatrist enables any setting to be aware of how play in children can be used for: (a) the need to concretize fantasy, that is, to act it out through direct representational means; (b) the substitution of active mastery for passive experience; (c) the displacing of destructive and restitutive impulses; (d) the acting out of socially reprehensible impulses through identifying with the bad evil play figures; (e) the sublimation of impulse into acceptable activity; (f) the motor discharge of tension. 12. The child psychiatrist brings to any setting his awareness of the relative lack of a stabilized symptom picture in many children, and the fact that, as compared with adults, there are less definite, clear-cut neuroses and psychoses but more deviations in social behavior. In addition to helping the setting recognize and absorb the frequent role of secondary gain in a child's symptoms, the child psychiatrist also functions to help the setting be aware of the more direct gratificatory nature of children's symptoms. The setting needs to realize that symptoms can be satisfying and satisfactory and bring therapeutic work to an impasse. The child psychiatrist can help the setting tolerate areas of reality in which the illness manifests itself to a child as a disability, so that the child himself feels motivated toward change. It is here, however, that the child psychiatrist also helps a setting by enabling it to realize that an adult can tolerate greater amounts of anxiety than a child. In work with adults the crucialness of someone else's opinion is never as vital to the helping process as it is with a child. A setting not only needs to know the child's concept of the people in the world about him; it must also be aware of the importance of its own concept of each particular child within that setting. Children not only show a relative lack of stabilization of their symptoms but may show different symptoms with different persons in the same setting, and the child psychiatrist with his knowledge of transference and the ways in which children can split their objects into good objects and bad ones can enable
366
]. Cotter Hirschberg
the setting to understand the phenomenon rather than to react to it in inappropriate response. The child psychiatrist can help a setting move away from absolutism by realizing that in one case the relationship alone may therapeutically deal with the problem, but that in another child, working through genetic content may be essential.