- Email: [email protected]
The use of brief psychotherapy in a pediatric practice
T h e Journal of P E D I A T R I C S
259
The use of brief psychotherapy in a pediatric practice R. Dean Coddington, M.D.* FAIR H A V E N , N. J .
A L L physicians use psychotherapy in the course of their medical practice by virtue of their close personal relationship with the patient, and pediatricians, in particular, because they expect to act as counselors and advisers. Giving reassurance that there is nothing to worry about is the pediatrician's most frequent psychotherapeutic activity? But he can do much more. An attempt to deal with the interpersonal relationships within the family, which so intimately affect the child in health or disease, is the subject of this paper. It was with this aim in mind that I began my practice. I invited a discussion of emotional factors with my own patients and began to receive frequent consultations from my colleagues as my practice developed. Time was allowed for adequate discussion and appropriate fees charged, i.e., the equivalent of 3 ordinary office visits for an hour-long interview. Brief, direct psychotherapy is not new to pediatrics. Hilde Bruch 2 used the method
From the Department o[ Child Psychiatry at the New York State Psychiatric Institute and the Columbia-Presbyterian Medical Center, New York City. ~Address, 45 Laurel Dr{re, Falr Haven, N.J.
in a pediatric clinic in 1949 and Joseph B. Cramer and John B. Reinhart 3 have used it extensively in the psychiatric clinic of the Children's Hospital of Pittsburgh. Cytryn, Gilbert, and Eisenberg, ~ while studying the effects of drugs in children, found symptomatic improvement in 90 per cent of the patients with neurotic traits 6 months after the use of a placebo plus 5 psychotherapeutic sessions. Later Eisenberg and Gruenberg 5 state that "diagnostic .consultation and brief psychotherapy appear to produce results, at least at a symptomatic level, comparable to those attainable with more intensive methods of treatment." There is no doubt that many other centers also utilize the method. The term "brief psychotherapy" lacks clarity. T o be explicit we should look more objectively at the methods used. The most common technique I employed was that of encouraging the mother to express her attitudes and feelings in the course of an ordinary office visit. This requires: (1) rather rigid adherence to the appointment schedule so that there will be an unhurried, relaxed atmosphere, (2) a sympathetic pediatrician who is interested in hearing the mother tell her story in her own words, and (3) the use of certain introductory comments designed
2 6 0 Coddington
to get her started. For instance, as the baby squirms across the table during the physical examination one might comment, "He certainly is an active fellow--I bet you have your hands full" or " I ' m sure this tyke doesn't give you much time to yourself." To the mother of a child with a mild upper respiratory infection and a temperature of 102 ~ F. one might say, "I guess it kind of scares a mother to see the temperature go up" or "when a child gets sick the parents begin to worry about all kinds of things." Similar methods were used on house calls to allay the anxiety of the parents of a sick child. The effectiveness of this type of care can be seen in the self-assurance the parents develop and their ability to cope with the mildly ill child without making undue demands upon the pediatrician. Another technique of a preventive nature is the preparation of a child for operation. An effective method is to discuss the situation with the child while the mother watches. The patient's knowledge of the anatomy and physiology of the area involved and his concepts of the indications for operation are fascinating to hear, and his misconceptions can usually be readily corrected. With the use of a surgeon's cap and mask and a small anesthesia mask, some of the more mysterious and frightening aspects of the procedure can be elucidated. There is nothing more gratifying than to watch a child sail through a tonsils and adenoids operation with selfassurance, an appropriate amount of fear, and with no eating or sleeping sequelae, and furthermore, able and willing to discuss the experience in a rational manner 6 months later. The parents of children with some pediatric problem will often appreciate an opportunity to sit down with their doctor for an unhurried and uninterrupted discussion. Increasing their understanding of the illness and helping to work out other aspects of the problem, such as special school placement, can, in a sense, be broadly classed as psychotherapy. These 3 techniques, i.e., helping the mother of a well baby to express herself, preparing
February 1962
a child for operation, and counseling the parents of a chronically ill child, are discussed in every pediatric text and are generally considered within the province of the pediatrician. However, the resident is usually expected to learn them from experience without the benefit of organized teaching, the implication being that they are part of the art of medicine. My opinion is that the techniques can be understood best if they are considered as forms of psychotherapy and studied systematically as such. They are related to the 2 forms of brief psychotherapy that will be described presently, the first of which lends itself well to a pediatric practice while the second should probably be left to the child psychiatrist. These 2 forms of therapy are more clearly psychiatric techniques and might be termed (1) a diagnostic evaluation, which in itself is therapeutic, and (2) short-term psychotherapy. I used them primarily in the treatment of the patients referred specifically for the evaluation and/or treatment of an emotional problem. Of the 86 such referrals 50 were seen from 1 to 3 times and 13 from 4 to 10 times. In these cases a careful psychiatric history was taken from the child and one or both parents separately, then the child was seen alone on 2 or 3 occasions to give him further opportunities to discuss his problems in his own way. A summarizing visit with the parents alone followed. The primary goal was to find some areas of conflict in the interrelationships of the family with the hope that the parents could clear them up to some extent once they understood the problem. This type of psychotherapeutic endeavor can certainly be carried out by the pediatrician if some attention is paid to it in his training period. The pediatrician enjoys a unique relationship with the family and is often asked for advice of this nature since a visit to his office is not surrounded by the aura of mysticism and fear that clouds the layman's view of the psychiatrist. Some pediatricians, of course, develop an atmosphere of authority and prestige which tends to make it difficult for parents to really express themselves.
Volume 60 Number 2
In my experience diagnostic evaluation is often therapeutic. By setting aside certain hours for patients with emotional problems, the regular office practice is not upset, and through a realistic discussion of fees one can expect adequate compensation. These 2 factors are the major stumbling blocks that most pediatricians feel prevent them from devoting so much time to one patient. On the other hand, however, I found that over a period of time the parents became so much more willing to take the responsibility for the care of their children that they could confine their consultations to the office schedule. House calls definitely became less frequent during my 5-year experience in private pediatric practice, and late night calls became almost nonexistent. Another point favoring the use of these psychiatric techniques is the enjoyment the pediatrician feels as he sees the parents look at their child in a new light and with greater understanding accept him as an individual, with his own ideas and an ability to reason logically at a childish level. They try to see the reason behind his strange behavior, and the message he is trying to communicate. And they are often successful. With 23 of the referred cases I entered into longer term treatment on a once-a-week basis because of my special interests. Success was not common in these cases and consisted only of helping passive children learn to express themselves a little better. Even this improvement might be attributed more to changes in the parental attitude than to psychotherapy per se. This type of treatment should probably be left to the psychiatrist. Psychoneurotic traits were by far the most common type of cases referred, and overt anxiety leads the list of symptoms. Thirtyfour out of 86 referred patients had welldefined neurotic traits of one kind or another (nail biting, feeding disorders, enuresis, thumbsueking, etc.) and would commonly be described as "tense," ';nervous, . . . . easily upset," or "frightened." The anxiety was recognized by the child and his parents, and both seemed interested in professional help. This is probably the reason why almost all of them
Brie[ psychotherapy in pediatrics
261
felt there was some improvement regardless of the number of interviews they had. It was usually not difficult to find on the first visit at least one aspect of the family relationship that was anxiety provoking. The parents could often work it out by themselves after it was brought to light. Sixteen of these children were seen less than 4 times, 5 were seen from 4 to 10 times, and in 13 more prolonged treatment was carried out. Personality disturbances were the next most common entity (19 cases). These children demonstrated a well-defined pattern of behavior, a type of conduct which had become a source of difficulty in their relationships with their parents, peers, school authorities, and others. They had all developed some type of passive-aggressive character disorder and can be subgrouped as (1) passive-dependent (2 cases)--these are rather quiet, withdrawn, shy children; (2) passiveaggressive (14 cases)--hostile children who revealed their anger in a passive manner such as refusal to hear a command or to obey, forgetting to obey a rule, or directing their hostility toward an innocent younger sibling or playmate; and (3) outwardly aggressive children (3 cases). Many of them were also anxious, but their conduct problem was by far the most outstanding feature and seemed to be the primary problem. This diagnosis was made more commonly in boys, and examination of the parents' ideas about discipline revealed their different points of view. Since these viewpoints were well established in the parents, it was difficult to change them, but some benefit resulted from working with the child and showing him what he was doing. The passive-agressive boys usually became worse at first, acting more outwardly hostile toward the parents themselves, rather than displacing their hostility toward others. The parents were prepared for this, and, if they were able to accept it, the children would then begin to improve. In 18 of the referred cases the major problem seemed to lie in the psychopathology of the parents, and I was not able to cope with the situation. No attempts were made to treat the parents. In some instances advice
262
Coddington
was given or referral to a psychiatrist made, but few disturbed parents were able to accept the suggestions. The remainder of the referrals were psychophysiologic disturbances, developmental variations, and congenitally handicapped children with secondary behavior disorders. All of these are fascinating from the pediatrician's point of view, and some can be handled by the methods described while some cannot. Case 1. Jeffrey was a 12-year-old boy, who had been "nervous" for 4 to 5 years. Intermittently for 3 years, he had rubbed his tongue against the lower canine teeth with resultant ulcerations which the pediatrician found very refractory to treatment. He was seen 3 times and his parents twice. He discussed his anxiety regarding the need to compete as a pitcher in Little League baseball, of the high standards he had set for himself in athletics and in school, and of his inability to satisfy his father's expectations. Jeffrey's father was a state police officer and took great pride in his son's athletic and intellectual prowess. When his boy pitched a winning game he followed his congratulations with advice on how he could have done even better. The parents denied wanting him to do better but the boy felt he could never satisfy them. He continued to strive even higher and was depressed and anxious when he got a "C" on a report card for conduct. Our discussions were focused on the need for more open communication between the members of the family and on the value systems used. As a result, the symptom stopped abruptly and has not recurred in 2 years. He is now in high school and competing successfully in football and baseball but much more rationally and without the neurotic drive that had at one time made him so anxious. Case 2. Ricky, a 9-year-old boy, was suspended from school. His father was an engineer, a very rigid, compulsive individual, a personality characteristic which was an asset in his work but a disadvantage in his role as a husband and father. His wife, a warm,
February 1962
friendly person, had adjusted to her husband's ways but didn't agree with his inflexible attitudes regarding child rearing. As a result Ricky was confused, being told on the one hand to be friendly and relaxed while being instructed to fight and stand up for his rights on the other. He became very aggressive at school and at play. H e told me his story so clearly and sincerely that it was surprising that the parents could have failed to understand. He was accepted back in school immediately when the parents arranged weekly visits with me, and 2 weeks later the principal gave a glowing report of his behavior. They were seen regularly at first, then irregularly with continued success. Ricky had his ups and downs but the parents' awareness now enabled them to look more objectively for the causes and interrupt the process before it became well established. Case 3. Toni Ann was 7 years old when she was referred for investigation of her nightmares, which consisted of somnambulism and obvious terror as she repeated an unintelligible phrase over and over again. The episode occurred frequently and lasted about half an hour. She was enuretic, as were all the children in the family, a thumbsucker, and afraid of the dark. A careful history revealed that at 2 ~ years of age she and her mother went upstairs to awaken a 6-month-old sibling and found her dead in bed. The mother became hysterical, shouted to her husband to "get the baby" (meaning the patient) and then ran into the bedroom to do what she could for the infant. The police and first-aid squad were called and much excitement ensued. The mother developed a severe depression with suicidal ruminations which lasted a year. It was also discovered that the patient was regularly sent to her bed as a punishment and that she was in the habit of repeating the bedtime prayer that goes: Now I lay me down to sleep, I pray the Lord my soul to keep,
If I should die before I wake, I pray the Lord my soul to take.
Volume 60 Number 2
Both parents had developed the belief that any child could suffocate in bed, regardless of age and state of health. They obsessively checked each child several times a night and were upset at Toni Ann's habit of pulling the covers over her head. It seemed clear that the child associated sleep, her bed, and darkness with punishment, death, mystery, and severe parental anxiety, and this was explained to the parents on the first visit. They returned one week later with a tape recording of a nightmare, and we could now understand the previously unintelligible cries. She was saying, "get the baby . . . CET T~IE BABY . . . GET T H E BABY" louder and louder as she walked around the house apparently searching for the dead sibling. I suggested that the parents alter the situation by (1) disassociating punishment from bed, (2) teaching her a new prayer, and (3) talking to her openly about the death of the sibling. In addition, an attempt was made to give the parents a more realistic attitude about sudden infantile deaths, suffocation, and the like. They were seen on just these 2 occasions. A 2-year follow-up revealed that the child had stopped the nightmares gradually within 2 or 3 months, had essentially lost her fear of the dark, and no longer caused her parents to be concerned. She was still enuretic and continued to suck her thumb, but the parents consider this familial and normal. The parents are still anxious about death from suffocation and still obsessively check the children. Case 4. A 2-year-old girl drank poisonous liquids, which the mother was using around the house, on 2 occasions in such a manner and with such swiftness that it seems unfair to accuse the mother of negligence. The parents were invited in for a conference in which the normal oral drives and consequent dangers were discussed, and the stress the child was undergoing in the process of toilet training was explained. They were quite appreciative of the opportunity and wrote a most gratifying letter a year later pointing out how it had helped them understand their
Brie[ psychotherapy in pediatrics
263
child so much better and that she made no further attempts to ingest poisons. DISCUSSION
An attempt has been made to define the role of the pediatrician in dealing with the psychologic problems which he often faces. Much satisfaction can be obtained from a limited effort without encroaching upon the area of the child psychiatrist. A few 1 hour visits can be devoted to the management of such problems and most middle-class parents can well afford the necessary cost. The evaluation of the results of psychotherapy is in itself a gigantic task and not within the scope of this paper. In m y opinion, however, two thirds of the referred cases and the great majority of the problems arising in m y own practice could be satisfactorily handled, at least on a symptomatic level, with the very brief, direct type of psychotherapy described. In addition, a creditable evaluation of the more severe personality and psychoneurotic disorders can be carried out, thereby enabling the pediatrician to make a more successful referral to a psychiatrist. There are pitfalls which must be avoided in these attempts and a consideration of them will lead to a discussion of the educational needs of the pediatrician. Reinhart 3 warns of the dangers of the transference and countertransference reactions, pointing out that patients seen irregularly still form close relationships with the psychiatrist, who must, therefore, be well trained in order to handle it. The statement itself is true but the emphasis should be placed on the need to teach pediatricians as well as all other doctors the meaning of these phenomena, rather than on the dangers of getting too closely involved with a sick patient. There is no doubt that pediatricians who do so much counselling should have a thorough basic understanding of the doctor-patient-parent relationships. The traditional doctor-patient relationship with the ubiquitous transference is more easily crystallized when dealing with children. The child expects the doctor to react as his parents
2 64
Coddington
do and is, in fact, often told that he will; "if you don't behave the doctor will give you a shot," or "be good and you'll get a lollipop." The parents will often transmit their own reactions to their children. Their anxiety might appear as "don't be afraid," implying that there is cause for fear. Maternal anxiety was listed as the greatest problem in pediatrics by general practitioners of Washington state. ~ The pediatrician is in the unique position of being a surrogate parent of the child and the child's mother simultaneously; therefore, he appears to be both father and husband to the mother. Evidence that this is so is abundant. Some mothers act overtly seductive at times, wanting to be called by their first names, referring to the baby as the pediatrician's, and complaining that their husbands don't seem interested in them any more. At the same time some mothers seek the sort of advice from the doctor that they would ordinarily expect from a father. The pediatrician must certainly understand these aspects of his relationships with his patients. Lack of knowledge is, of course, another pitfall. Normal developmental psychology should be taught in all pediatric centers; c l i n i c s dealing with retarded children lend themselves admirably to practical experience and supplement the experiences in the wellbaby clinic. Enough descriptive psychiatry and psychopathology should be taught to pediatric residents so that they are able to evaluate accurately both .children and their parents. These subjects can be taught within the framework of a pediatric residency, if the teaching is limited to the techniques and goals described in this paper. The pediatric resident will not learn these things by rotating through the psychiatry service for a few months; the psychiatrist must come to him. David Levy, a psychoanalyst, has pioneered in this field in his work with pediatricians in the child health clinics in New York City. s He has demonstrated, for instance, that a psychiatric evaluation can be accomplished as part of the physical examination. He feels that the child's clothes are somewhat analo-
February 1962
gous to a defensive armor, and when naked, the child is more ready to discuss his body, growth, deficiencies, and sexual differences, s, 9 Some children, of course, resist the examination. The maternal attitudes, the child's dependency, and his fear of inoculations are subjects which can be studied by the same scientific principles of observation and inquiry that pediatricians have long applied to other aspects of child health. 6 Practical interviewing techniques can be taught within the framework of a pediatric residency. 1~ SUMMARY
An attempt has been made to describe various techniques utilized in my pediatric practice which I categorize as psychotherapeutic, and more specifically as brief, direct psychotherapy. Results of this form of treatment are very difficult to evaluate, but I believe that I was able to help, at least symptomatically, the majority of the patients treated. Some suggestions to the teaching profession have been put forward in the hope that more attempts will be made to teach pediatric residents systematically the type of psychiatry they need. Furthermore, I think that some of the dissatisfaction in modem pediatric practice results from the pediatrician's inability to cope with problems of an emotional nature that come to his attention. Indeed, the "anxious mother" is so often the thorn in the side of the pediatrician that she has become a clich6 and the butt of our jokes, but realistically she is as much a part of our specialty as the child himself.
REFERENCES
1. Levy, D. M.: Advice and Reassurance, Am. J. Pub. Health 14: 1113, 1954. 2. Bruch, H.: Brief Psychotherapy in a Pediatric Clinic, Quart. J. Child Behavior 1: 2, 1949. 3. Reinhart, J. Bo: Need for and Results of "Short Term" Psychotherapy, read at Thirty-eighth Ann. Meet. Am. Orthopsychiat. A., New York, 1961. 4. Cytryn, L., Gilbert, A., and Eisenberg, L.: The Effectiveness of Transquilizing Drugs
Volume 60 Number 2
Plus Supportive Psychotherapy in Treating Behavior Disorders of Children, Am. J. Orthopsychlat. 30: 113, i960. 5. Eisenberg, L., andGruenberg, E. M.: The Current Status of Secondary Prevention of Child Psychiatry, Am. J. Orthopsychiat. 31: 355, 1961. 6. Levy, D. M.: Observations of Attitudes and Behavior in the Child Health Center, Am. J. Pub. Health 41: 182, 1951. 7. Deisher, R. W.: Survey of General Practitioner's Opinions on Pediatric Education, J. M. Educ. 33: 579, 1958.
Brief psychotherapy in pediatrics
2 65
8. Levy, D. M.: Method of Integrating Physical
and Psychiatric Examinations, Am. J. Psychiat. 9: 121, 1929. 9. Levy, D. M.: Body Interest in Children and Hypoehondriasis, Am. J. Psychiat. 12: 295, 1932. 10. Korsch, B. M.: Practical Techniques of Observing, Interviewing and Advising Parents in Pediatric Practice as Demonstrated in an Attitude Study Project, Pediatrics 18: 467, 1956.
259
The use of brief psychotherapy in a pediatric practice R. Dean Coddington, M.D.* FAIR H A V E N , N. J .
A L L physicians use psychotherapy in the course of their medical practice by virtue of their close personal relationship with the patient, and pediatricians, in particular, because they expect to act as counselors and advisers. Giving reassurance that there is nothing to worry about is the pediatrician's most frequent psychotherapeutic activity? But he can do much more. An attempt to deal with the interpersonal relationships within the family, which so intimately affect the child in health or disease, is the subject of this paper. It was with this aim in mind that I began my practice. I invited a discussion of emotional factors with my own patients and began to receive frequent consultations from my colleagues as my practice developed. Time was allowed for adequate discussion and appropriate fees charged, i.e., the equivalent of 3 ordinary office visits for an hour-long interview. Brief, direct psychotherapy is not new to pediatrics. Hilde Bruch 2 used the method
From the Department o[ Child Psychiatry at the New York State Psychiatric Institute and the Columbia-Presbyterian Medical Center, New York City. ~Address, 45 Laurel Dr{re, Falr Haven, N.J.
in a pediatric clinic in 1949 and Joseph B. Cramer and John B. Reinhart 3 have used it extensively in the psychiatric clinic of the Children's Hospital of Pittsburgh. Cytryn, Gilbert, and Eisenberg, ~ while studying the effects of drugs in children, found symptomatic improvement in 90 per cent of the patients with neurotic traits 6 months after the use of a placebo plus 5 psychotherapeutic sessions. Later Eisenberg and Gruenberg 5 state that "diagnostic .consultation and brief psychotherapy appear to produce results, at least at a symptomatic level, comparable to those attainable with more intensive methods of treatment." There is no doubt that many other centers also utilize the method. The term "brief psychotherapy" lacks clarity. T o be explicit we should look more objectively at the methods used. The most common technique I employed was that of encouraging the mother to express her attitudes and feelings in the course of an ordinary office visit. This requires: (1) rather rigid adherence to the appointment schedule so that there will be an unhurried, relaxed atmosphere, (2) a sympathetic pediatrician who is interested in hearing the mother tell her story in her own words, and (3) the use of certain introductory comments designed
2 6 0 Coddington
to get her started. For instance, as the baby squirms across the table during the physical examination one might comment, "He certainly is an active fellow--I bet you have your hands full" or " I ' m sure this tyke doesn't give you much time to yourself." To the mother of a child with a mild upper respiratory infection and a temperature of 102 ~ F. one might say, "I guess it kind of scares a mother to see the temperature go up" or "when a child gets sick the parents begin to worry about all kinds of things." Similar methods were used on house calls to allay the anxiety of the parents of a sick child. The effectiveness of this type of care can be seen in the self-assurance the parents develop and their ability to cope with the mildly ill child without making undue demands upon the pediatrician. Another technique of a preventive nature is the preparation of a child for operation. An effective method is to discuss the situation with the child while the mother watches. The patient's knowledge of the anatomy and physiology of the area involved and his concepts of the indications for operation are fascinating to hear, and his misconceptions can usually be readily corrected. With the use of a surgeon's cap and mask and a small anesthesia mask, some of the more mysterious and frightening aspects of the procedure can be elucidated. There is nothing more gratifying than to watch a child sail through a tonsils and adenoids operation with selfassurance, an appropriate amount of fear, and with no eating or sleeping sequelae, and furthermore, able and willing to discuss the experience in a rational manner 6 months later. The parents of children with some pediatric problem will often appreciate an opportunity to sit down with their doctor for an unhurried and uninterrupted discussion. Increasing their understanding of the illness and helping to work out other aspects of the problem, such as special school placement, can, in a sense, be broadly classed as psychotherapy. These 3 techniques, i.e., helping the mother of a well baby to express herself, preparing
February 1962
a child for operation, and counseling the parents of a chronically ill child, are discussed in every pediatric text and are generally considered within the province of the pediatrician. However, the resident is usually expected to learn them from experience without the benefit of organized teaching, the implication being that they are part of the art of medicine. My opinion is that the techniques can be understood best if they are considered as forms of psychotherapy and studied systematically as such. They are related to the 2 forms of brief psychotherapy that will be described presently, the first of which lends itself well to a pediatric practice while the second should probably be left to the child psychiatrist. These 2 forms of therapy are more clearly psychiatric techniques and might be termed (1) a diagnostic evaluation, which in itself is therapeutic, and (2) short-term psychotherapy. I used them primarily in the treatment of the patients referred specifically for the evaluation and/or treatment of an emotional problem. Of the 86 such referrals 50 were seen from 1 to 3 times and 13 from 4 to 10 times. In these cases a careful psychiatric history was taken from the child and one or both parents separately, then the child was seen alone on 2 or 3 occasions to give him further opportunities to discuss his problems in his own way. A summarizing visit with the parents alone followed. The primary goal was to find some areas of conflict in the interrelationships of the family with the hope that the parents could clear them up to some extent once they understood the problem. This type of psychotherapeutic endeavor can certainly be carried out by the pediatrician if some attention is paid to it in his training period. The pediatrician enjoys a unique relationship with the family and is often asked for advice of this nature since a visit to his office is not surrounded by the aura of mysticism and fear that clouds the layman's view of the psychiatrist. Some pediatricians, of course, develop an atmosphere of authority and prestige which tends to make it difficult for parents to really express themselves.
Volume 60 Number 2
In my experience diagnostic evaluation is often therapeutic. By setting aside certain hours for patients with emotional problems, the regular office practice is not upset, and through a realistic discussion of fees one can expect adequate compensation. These 2 factors are the major stumbling blocks that most pediatricians feel prevent them from devoting so much time to one patient. On the other hand, however, I found that over a period of time the parents became so much more willing to take the responsibility for the care of their children that they could confine their consultations to the office schedule. House calls definitely became less frequent during my 5-year experience in private pediatric practice, and late night calls became almost nonexistent. Another point favoring the use of these psychiatric techniques is the enjoyment the pediatrician feels as he sees the parents look at their child in a new light and with greater understanding accept him as an individual, with his own ideas and an ability to reason logically at a childish level. They try to see the reason behind his strange behavior, and the message he is trying to communicate. And they are often successful. With 23 of the referred cases I entered into longer term treatment on a once-a-week basis because of my special interests. Success was not common in these cases and consisted only of helping passive children learn to express themselves a little better. Even this improvement might be attributed more to changes in the parental attitude than to psychotherapy per se. This type of treatment should probably be left to the psychiatrist. Psychoneurotic traits were by far the most common type of cases referred, and overt anxiety leads the list of symptoms. Thirtyfour out of 86 referred patients had welldefined neurotic traits of one kind or another (nail biting, feeding disorders, enuresis, thumbsueking, etc.) and would commonly be described as "tense," ';nervous, . . . . easily upset," or "frightened." The anxiety was recognized by the child and his parents, and both seemed interested in professional help. This is probably the reason why almost all of them
Brie[ psychotherapy in pediatrics
261
felt there was some improvement regardless of the number of interviews they had. It was usually not difficult to find on the first visit at least one aspect of the family relationship that was anxiety provoking. The parents could often work it out by themselves after it was brought to light. Sixteen of these children were seen less than 4 times, 5 were seen from 4 to 10 times, and in 13 more prolonged treatment was carried out. Personality disturbances were the next most common entity (19 cases). These children demonstrated a well-defined pattern of behavior, a type of conduct which had become a source of difficulty in their relationships with their parents, peers, school authorities, and others. They had all developed some type of passive-aggressive character disorder and can be subgrouped as (1) passive-dependent (2 cases)--these are rather quiet, withdrawn, shy children; (2) passiveaggressive (14 cases)--hostile children who revealed their anger in a passive manner such as refusal to hear a command or to obey, forgetting to obey a rule, or directing their hostility toward an innocent younger sibling or playmate; and (3) outwardly aggressive children (3 cases). Many of them were also anxious, but their conduct problem was by far the most outstanding feature and seemed to be the primary problem. This diagnosis was made more commonly in boys, and examination of the parents' ideas about discipline revealed their different points of view. Since these viewpoints were well established in the parents, it was difficult to change them, but some benefit resulted from working with the child and showing him what he was doing. The passive-agressive boys usually became worse at first, acting more outwardly hostile toward the parents themselves, rather than displacing their hostility toward others. The parents were prepared for this, and, if they were able to accept it, the children would then begin to improve. In 18 of the referred cases the major problem seemed to lie in the psychopathology of the parents, and I was not able to cope with the situation. No attempts were made to treat the parents. In some instances advice
262
Coddington
was given or referral to a psychiatrist made, but few disturbed parents were able to accept the suggestions. The remainder of the referrals were psychophysiologic disturbances, developmental variations, and congenitally handicapped children with secondary behavior disorders. All of these are fascinating from the pediatrician's point of view, and some can be handled by the methods described while some cannot. Case 1. Jeffrey was a 12-year-old boy, who had been "nervous" for 4 to 5 years. Intermittently for 3 years, he had rubbed his tongue against the lower canine teeth with resultant ulcerations which the pediatrician found very refractory to treatment. He was seen 3 times and his parents twice. He discussed his anxiety regarding the need to compete as a pitcher in Little League baseball, of the high standards he had set for himself in athletics and in school, and of his inability to satisfy his father's expectations. Jeffrey's father was a state police officer and took great pride in his son's athletic and intellectual prowess. When his boy pitched a winning game he followed his congratulations with advice on how he could have done even better. The parents denied wanting him to do better but the boy felt he could never satisfy them. He continued to strive even higher and was depressed and anxious when he got a "C" on a report card for conduct. Our discussions were focused on the need for more open communication between the members of the family and on the value systems used. As a result, the symptom stopped abruptly and has not recurred in 2 years. He is now in high school and competing successfully in football and baseball but much more rationally and without the neurotic drive that had at one time made him so anxious. Case 2. Ricky, a 9-year-old boy, was suspended from school. His father was an engineer, a very rigid, compulsive individual, a personality characteristic which was an asset in his work but a disadvantage in his role as a husband and father. His wife, a warm,
February 1962
friendly person, had adjusted to her husband's ways but didn't agree with his inflexible attitudes regarding child rearing. As a result Ricky was confused, being told on the one hand to be friendly and relaxed while being instructed to fight and stand up for his rights on the other. He became very aggressive at school and at play. H e told me his story so clearly and sincerely that it was surprising that the parents could have failed to understand. He was accepted back in school immediately when the parents arranged weekly visits with me, and 2 weeks later the principal gave a glowing report of his behavior. They were seen regularly at first, then irregularly with continued success. Ricky had his ups and downs but the parents' awareness now enabled them to look more objectively for the causes and interrupt the process before it became well established. Case 3. Toni Ann was 7 years old when she was referred for investigation of her nightmares, which consisted of somnambulism and obvious terror as she repeated an unintelligible phrase over and over again. The episode occurred frequently and lasted about half an hour. She was enuretic, as were all the children in the family, a thumbsucker, and afraid of the dark. A careful history revealed that at 2 ~ years of age she and her mother went upstairs to awaken a 6-month-old sibling and found her dead in bed. The mother became hysterical, shouted to her husband to "get the baby" (meaning the patient) and then ran into the bedroom to do what she could for the infant. The police and first-aid squad were called and much excitement ensued. The mother developed a severe depression with suicidal ruminations which lasted a year. It was also discovered that the patient was regularly sent to her bed as a punishment and that she was in the habit of repeating the bedtime prayer that goes: Now I lay me down to sleep, I pray the Lord my soul to keep,
If I should die before I wake, I pray the Lord my soul to take.
Volume 60 Number 2
Both parents had developed the belief that any child could suffocate in bed, regardless of age and state of health. They obsessively checked each child several times a night and were upset at Toni Ann's habit of pulling the covers over her head. It seemed clear that the child associated sleep, her bed, and darkness with punishment, death, mystery, and severe parental anxiety, and this was explained to the parents on the first visit. They returned one week later with a tape recording of a nightmare, and we could now understand the previously unintelligible cries. She was saying, "get the baby . . . CET T~IE BABY . . . GET T H E BABY" louder and louder as she walked around the house apparently searching for the dead sibling. I suggested that the parents alter the situation by (1) disassociating punishment from bed, (2) teaching her a new prayer, and (3) talking to her openly about the death of the sibling. In addition, an attempt was made to give the parents a more realistic attitude about sudden infantile deaths, suffocation, and the like. They were seen on just these 2 occasions. A 2-year follow-up revealed that the child had stopped the nightmares gradually within 2 or 3 months, had essentially lost her fear of the dark, and no longer caused her parents to be concerned. She was still enuretic and continued to suck her thumb, but the parents consider this familial and normal. The parents are still anxious about death from suffocation and still obsessively check the children. Case 4. A 2-year-old girl drank poisonous liquids, which the mother was using around the house, on 2 occasions in such a manner and with such swiftness that it seems unfair to accuse the mother of negligence. The parents were invited in for a conference in which the normal oral drives and consequent dangers were discussed, and the stress the child was undergoing in the process of toilet training was explained. They were quite appreciative of the opportunity and wrote a most gratifying letter a year later pointing out how it had helped them understand their
Brie[ psychotherapy in pediatrics
263
child so much better and that she made no further attempts to ingest poisons. DISCUSSION
An attempt has been made to define the role of the pediatrician in dealing with the psychologic problems which he often faces. Much satisfaction can be obtained from a limited effort without encroaching upon the area of the child psychiatrist. A few 1 hour visits can be devoted to the management of such problems and most middle-class parents can well afford the necessary cost. The evaluation of the results of psychotherapy is in itself a gigantic task and not within the scope of this paper. In m y opinion, however, two thirds of the referred cases and the great majority of the problems arising in m y own practice could be satisfactorily handled, at least on a symptomatic level, with the very brief, direct type of psychotherapy described. In addition, a creditable evaluation of the more severe personality and psychoneurotic disorders can be carried out, thereby enabling the pediatrician to make a more successful referral to a psychiatrist. There are pitfalls which must be avoided in these attempts and a consideration of them will lead to a discussion of the educational needs of the pediatrician. Reinhart 3 warns of the dangers of the transference and countertransference reactions, pointing out that patients seen irregularly still form close relationships with the psychiatrist, who must, therefore, be well trained in order to handle it. The statement itself is true but the emphasis should be placed on the need to teach pediatricians as well as all other doctors the meaning of these phenomena, rather than on the dangers of getting too closely involved with a sick patient. There is no doubt that pediatricians who do so much counselling should have a thorough basic understanding of the doctor-patient-parent relationships. The traditional doctor-patient relationship with the ubiquitous transference is more easily crystallized when dealing with children. The child expects the doctor to react as his parents
2 64
Coddington
do and is, in fact, often told that he will; "if you don't behave the doctor will give you a shot," or "be good and you'll get a lollipop." The parents will often transmit their own reactions to their children. Their anxiety might appear as "don't be afraid," implying that there is cause for fear. Maternal anxiety was listed as the greatest problem in pediatrics by general practitioners of Washington state. ~ The pediatrician is in the unique position of being a surrogate parent of the child and the child's mother simultaneously; therefore, he appears to be both father and husband to the mother. Evidence that this is so is abundant. Some mothers act overtly seductive at times, wanting to be called by their first names, referring to the baby as the pediatrician's, and complaining that their husbands don't seem interested in them any more. At the same time some mothers seek the sort of advice from the doctor that they would ordinarily expect from a father. The pediatrician must certainly understand these aspects of his relationships with his patients. Lack of knowledge is, of course, another pitfall. Normal developmental psychology should be taught in all pediatric centers; c l i n i c s dealing with retarded children lend themselves admirably to practical experience and supplement the experiences in the wellbaby clinic. Enough descriptive psychiatry and psychopathology should be taught to pediatric residents so that they are able to evaluate accurately both .children and their parents. These subjects can be taught within the framework of a pediatric residency, if the teaching is limited to the techniques and goals described in this paper. The pediatric resident will not learn these things by rotating through the psychiatry service for a few months; the psychiatrist must come to him. David Levy, a psychoanalyst, has pioneered in this field in his work with pediatricians in the child health clinics in New York City. s He has demonstrated, for instance, that a psychiatric evaluation can be accomplished as part of the physical examination. He feels that the child's clothes are somewhat analo-
February 1962
gous to a defensive armor, and when naked, the child is more ready to discuss his body, growth, deficiencies, and sexual differences, s, 9 Some children, of course, resist the examination. The maternal attitudes, the child's dependency, and his fear of inoculations are subjects which can be studied by the same scientific principles of observation and inquiry that pediatricians have long applied to other aspects of child health. 6 Practical interviewing techniques can be taught within the framework of a pediatric residency. 1~ SUMMARY
An attempt has been made to describe various techniques utilized in my pediatric practice which I categorize as psychotherapeutic, and more specifically as brief, direct psychotherapy. Results of this form of treatment are very difficult to evaluate, but I believe that I was able to help, at least symptomatically, the majority of the patients treated. Some suggestions to the teaching profession have been put forward in the hope that more attempts will be made to teach pediatric residents systematically the type of psychiatry they need. Furthermore, I think that some of the dissatisfaction in modem pediatric practice results from the pediatrician's inability to cope with problems of an emotional nature that come to his attention. Indeed, the "anxious mother" is so often the thorn in the side of the pediatrician that she has become a clich6 and the butt of our jokes, but realistically she is as much a part of our specialty as the child himself.
REFERENCES
1. Levy, D. M.: Advice and Reassurance, Am. J. Pub. Health 14: 1113, 1954. 2. Bruch, H.: Brief Psychotherapy in a Pediatric Clinic, Quart. J. Child Behavior 1: 2, 1949. 3. Reinhart, J. Bo: Need for and Results of "Short Term" Psychotherapy, read at Thirty-eighth Ann. Meet. Am. Orthopsychiat. A., New York, 1961. 4. Cytryn, L., Gilbert, A., and Eisenberg, L.: The Effectiveness of Transquilizing Drugs
Volume 60 Number 2
Plus Supportive Psychotherapy in Treating Behavior Disorders of Children, Am. J. Orthopsychlat. 30: 113, i960. 5. Eisenberg, L., andGruenberg, E. M.: The Current Status of Secondary Prevention of Child Psychiatry, Am. J. Orthopsychiat. 31: 355, 1961. 6. Levy, D. M.: Observations of Attitudes and Behavior in the Child Health Center, Am. J. Pub. Health 41: 182, 1951. 7. Deisher, R. W.: Survey of General Practitioner's Opinions on Pediatric Education, J. M. Educ. 33: 579, 1958.
Brief psychotherapy in pediatrics
2 65
8. Levy, D. M.: Method of Integrating Physical
and Psychiatric Examinations, Am. J. Psychiat. 9: 121, 1929. 9. Levy, D. M.: Body Interest in Children and Hypoehondriasis, Am. J. Psychiat. 12: 295, 1932. 10. Korsch, B. M.: Practical Techniques of Observing, Interviewing and Advising Parents in Pediatric Practice as Demonstrated in an Attitude Study Project, Pediatrics 18: 467, 1956.