Child Psychiatry Perspectives Therapeutic Choice in Child Psychiatry
Saul I . Harrison, M.D.
Psychiatry is in the midst of a phenomenal burgeoning of available therapeutic modalities.’ In the course of reviewing and analyzing NIMH’s quarter century of active leadership in the field, their Research Task Force ( 1973) characterized psychiatric treatment as “vastly changed” and “revolutionized.” While it was no great challenge 25 years ago to be a versatile, all-encompassing psychiatric practitioner, today such an accomplishment is barely within the reach of even the most knowledgeable and gifted child psychiatrist. It would not be rash to predict that soon it will be utterly impossible for any one person to be a renaissance practitioner of child psychiatry capable of mastering all reasonable therapeutic intervention. These developments generate a vital question: how should the child psychiatric clinician adapt to that change and enrich its enhancement and refinement? Answers readily polarize into two prevailing suggestions. One asserts that comparison of the outcome of different treatments (with the exception of pharmacological therapy) reveals insufficient differences on which to base discriminative specific therapeutic prescriptions. Thus far, objective studies make it appear that whatever the convinced clinician does with enthusiasm proves to be equally effective (e.g., Frank, 1961). Therefore, clinicians should employ those treatments which they d o well and in which they have confidence. T h e second answer advocates that consideration be given to an alternative interpretation of these unrevealing comparative studies of therapeutic outcome. Instead of concluding like the dodo bird of Alice in Wonderland that “everyone has won and all must have prizes,” because there are similar factors inherent in all of the treatments (Luborsky et al., 1975, p. 995); the clinician should recognize the fact that there has been very little that is specific and discriminating in the prescription of different Lh.Harrisa is Professor of Psychiatly, Children’s Psychiatric Hospital, Uniziersity of Michigan Medacal Center (Ann Arbor, MI 48109), where rpplints may be requested. Compare Harrison and Carek (1966, pp. 231f.) with NIMH’s Research Task Force (1975, p. 31 1). 0002-71 38/78/1701-0165$00.81 @ 1978 American Academy of Child Psychiatry
Saul I. Harrison
treatments for different disturbances. T h e choice of treatment typically has been determined by clinician variables rather than by patient variables. This point of view urges child psychiatrists to be open and ready to consider a wide variety of treatments in the course of clinical assessments in order to maximize the possibility of matching the individual child and/or family and their disturbance with the most appropriate specific therapeutic intervention-regardless of whether the evaluating child psychiatrist is personally qualified to implement the recommended treatment. Reconridm’ng Eclecticism. In the history of medicine the availability of a multiplicity of treatments for a given condition tends to have a high correlation with limited effectiveness for all of them. I n addition, whenever a truly definitive child psychiatric treatment has appeared in the past, such as the dietary measures for phenylketonuria, it resulted in responsibility for administration of the treatment being assigned to pediatrics. At the same time, the development of more specific child psychiatric treatments increases the importance of the subtleties of diagnostic assessment. A tradition has grown u p of mutual exclusivity of different child psychiatric treatment modalities, leading to pseudopolarities between therapeutic approaches. Child psychiatric educational programs are all too frequently unidimensional. In a field burdened by ambiguity, the very process of learning tends to evoke discomfort and uncertainty. This in turn encourages student clinicians to attempt to cope with their distress by jumping aboard what Halleck and Woods (1962) designated a “bandwagon” therapy, a process that can readily turn into what Klagsbrun ( 1 967) labeled a “Garden of Eden” therapy. Such an allegiance, which is self-reinforcing and often enjoys institutional support, reduces the student clinician’s anxiety. Yet, this search for an illusory certainty risks compromising the clinician’s empathic sensitivity; as Adams ( 1974) noted, it can result in remarkably similar forms of egocentrism on the part of both the clinician and the young patient. Certain seminal concepts are inherent in almost every therapeutic transaction. I t is this phenomenon that makes it possible for truly different treatment modalities to be related. For instance, the concept of operant reinforcement is an integral part of behavioral learning theory; at the same time it is hard to conceive of any therapeutic transaction to which this concept would not be applicable. Similarly, such psychoanalytic and psychodynamic concepts as transference and countertransference merit consideration in pharmacological and behavioral therapeutic interactions. It is likely that the operant reinforcements employed by the clinician and how he or she elects to deal with the patient’s transference reactions are significant, if not central, in shaping the nature of every therapy-words and phrases which mean the same can sound quite different because of their derivation from different schools of thoughts (Witmer, 1946). Behaziioral and Psychodynamic Therapies. T h e surge of interest and activity in behavioral techniques was initially accompanied by an emphasis on the
Therapeutic Choice in Child Psychiatry
differences between behavioral and psychodynamic approaches. Eysenck ( 1960) emphasized the distinction between psychotherapy and the developing treatment strategies which employed behavior explicitly. A comparable segregationist attitude was as evident on the psychodynamic side where the boundaries were demarcated by an active depreciation of treatments which focused on symptoms. I t was assumed, inaccurately as it happened, but nevertheless asserted dogmatically, that such treatments could lead only to symptom substitution. This exaggerated segregation entailed a tendency to neglect earlier integrationist efforts (Mowrer, 1950; Dollard and Miller, 1950). Often enough there was a valid basis for the segregation; nevertheless too little attention was paid to the presence of psychological influences in even the most mechanistic behavioral techniques. T h e inevitable presence of behavioral influences in the “purest” psychological therapies was similarly ignored. For instance, Feather (quoted in Aronson, 1972) suggested that some of the effectiveness of systematic desensitization in behavior therapy may be a consequence of enhancing the patient’s discrimination between fantasy and reality. Contrariwise, the effectiveness of interpretation in the psychodynamic therapies may in part be derived from its desensitizing effect. Marks (1971) noted that even the term “behavior therapy,” which seems so amenable to description and classification when compared to many of the other psychotherapies, has lost much of its meaning. Today it denotes a number of different techniques, many of which Marks asserts have little in common beyond “common lip-service to debatable, theoretical antecedents” (p. 69). In his view, there are more differences than similarities between desensitization, aversion, operant conditioning, modeling, covert sensitization, feedback control, and negative practice. Further, he observes that flooding or implosion is considered to be a behavior therapy, although it was originally conceived by Stampfl in psychodynamic terms; on the other hand, paradoxical intention, an allied technique, is thought of as a form of existential psychotherapy. Probably the most vivid examples of integration of psychodynamic and behavioral approaches, even though they are rarely explicitly conceptualized as such, are to be found in the milieu therapy of child psychiatric residential and day treatment facilities. Noshpitz (197 1) noted what he referred to as a “ping-pong effect” in residential treatment. Behavioral change is initiated in the residential setting, while its repercussions are explored concurrently in individual psychotherapeutic sessions, so that the action in one arena and the information stemming from it augment and illuminate what transpires in the other arena. Blom (1972) summarized it succinctly by mting that change is “capable of being accomplished both from the inside out and the outside in” (p. 676). Family Therupy. Over the course of its brief two decades of productively creative activity, significant aspects of family therapy have become increasingly segregationist. As family therapy strove for a special identity that is more than just another modality to be added to a roster of therapeutic options, some of its advocates asserted that family therapy is a distinctly
Saul I . Harrison
unique perspective on the human condition and that conceptually it is not interchangeable with other therapies. This segregationist trend can generate unfortunate by-products; for example, some child-oriented clinicians do not benefit from the fruitful productivity of the family therapy field. At the same time there are encouraging indications. Discussing the advantages of flexibly combining therapeutic work with individuals, family subsystems, and total families, Malone (1974) asserts that the “central concept involved is the inseparability of internal and external” (p. 439). Pharmacotherapy and Psychotherapy. It is self-evident that prescribing medication should not preclude attention to intrapsychic and interpersonal factors; nor should the employment of psychotherapy necessarily preclude the use of medication or environmental intervention. Nevertheless, there has been a marked tendency for proponents of each treatment modality to view the other with suspicious concern and righteous indignation. This has frequently resulted in each ritualistically giving empty lip service to the other while behaving as if the other did not exist. T h e accumulation of knowledge has exposed increasing numbers of physicians to the theory and practice of both psychotherapy and pharmacotherapy. With this, the competition between the two has been diminishing and increasingly they are being judiciously employed together. Yet, as vividly noted in a GAP report (1975) devoted to these interrelationships, some physicians remain unable to translate psychological conflict into cellular malfunction, or biochemical dysfunction into behavioral difficulties. As a result they often behave like “split-brain preparations”-comfortable with either frame of reference only when considered individually. Mandell ( 1976) labeled the selective forgetting of psychodynamics while prescribing psychotropic medication as the “peek-a-boo” use of drugs. One hopes that this will diminish in the future as a consequence of a growing number of promising integrative contributions (e.g., Gittelman-Klein and Klein, 1973). Therapeutic [email protected]
&. Therapeutic intervention requires a capacity for effective problem-solving in complex situations. T h e problem is usually multidimensional, of mixed etiology, with the unique idiosyncratic features of the individual and/or family always present. As a biopsychosocial synthesis, a person suffering disturbance in one aspect of the integrated human system often experiences it as being reflected in other parts of the system. Thus, the system manifesting the most disturbance is not necessarily the one where the basic problem resides. Similarly, the fact that a therapy directed to a particular system is effective does not necessarily constitute evidence that the primary difficulty is located there. Consequently, clinicians are inevitably faced with the interesting challenge of systemic interrelationships which demand multifaceted therapeutic modes. This is illustrated concretely in the GAP report (1973) devoted to child psychiatric treatment planning in which 5 cases of school refusal are outlined. In each instance, diagnostic assessment led directly to a rational selection of 5 different therapeutic methods, each designed to change a
Therapeutic Choice in Child Psychiatry
different aspect of the individual child’s existence. Are there any child psychiatric syndromes that would not be most appropriately discussed in a comparable pluralistic fashion? A clinician must have dexterity to undertake different treatments with different patients. This requirement escalates when the appropriate strategy either is a simultaneous combination of therapeutic modalities with the same patient and/or family or entails the employment of different treatment approaches at different phases of the process. I t would be unrealistic to expect a similar level of adroitness to be within the repetoire of all child psychiatrists. What is incumbent on each of us, however, is cognizance of our capabilities and limitations of knowledge, technical skills, and agility in the clinical use of self. Clinician’s Use of Se$ Despite all the advances in psychopharmacology and in the therapeutic utilization of behavioral, social, milieu, and other external agents and instruments, the child psychiatrist’s personality remains a most potent and important diagnostic and therapeutic instrument. Many psychiatric treatments are enhanced by a quality of spontaneity on the part of the therapist. Indeed, except in the biological and some behavioral therapies, the therapist has limited opportunity to calculate the dosage of each therapeutic intervention. Once an assessment of the situation is made and the therapeutic approach is determined, experienced therapists generally behave relatively spontaneously. These quasi“spontaneous” therapeutic interventions are then subjected to post hoc scrutiny and critical review. Consequently, child psychiatric work encompasses individualistic styles requiring the clinician to achieve a considerable degree of self-understanding, self-realization, and self-actualization. These capacities in turn encourage the refinement of clinical sensitivity, empathy, and intuition. Such traits are central to participant observation, evocative listening, and intervention that characterize almost all child psychiatric diagnostic assessments and so many of the therapeutic interventions. This use of self, as child psychiatrists know, calls for a change in the detached approach model that characterizes most medical practice. During residency, many have observed that to accomplish this change may require substantial alteration in previously adequate coping styles. This is one area for which educational programs typically offer too little help. In addition, the use of different therapeutic modalities requires additional selective differentiation in use of self (Harrison, 1977). Qualities Required f o r Therapeutic Dfferentiation. As distinguished from the technician or even the cultist, the hallmarks of the professional are trustworthiness, sense of responsibility, and grasp of realms of theory, their knowledge base, and their related technical modes. These include those treatment methods which the child psychiatrist, as a psychosocially oriented human biologist with a special skill in diagnostic assessment and multidimensional formulation of the problem, may not personally have the skills to administer. I n consequence, the child psychiatrist may require the services of other mental health professionals or technicians for thera-
Saul I. Harmon
peutic intervention. This is analogous to the general physicians’ faniiliarity with insulin for diabetic coma and craniotomy for intracranial pathology even though they are not personally capable of administering these forms of treatment. T h e ability to consider selectively the broad range of possible treatments and the readiness to do so are prerequisites for a comprehensive diagnostic assessment. However, these do not have to be extended as far as the actual administration of the therapy. Indeed, in the treatment of patients, it is often advantageous to tune out selectively those techniques judged to be inappropriate for a particular patient or family. Not only are many techniques contraindicated in a specific situation, but the endeavor to keep the related ideas in mind would risk creating confusion. Therefore, the initial diagnostic assessment and the ongoing reassessments during the course of therapy require the broadest gauged professional competence, but the actual administration of the treatment does not. A limited focus may in fact enhance the quality of the treatment. It is evident that with the passage of time, other professionals and paraprofessionals are becoming more expert in specific delimited therapeutic skills. This tends to threaten those child psychiatrists who only yesteryear were the most expert at everything and draped themselves in an aura of clinical omnipotence. I t has required adaptation to accept the fact that nurses and child care workers may be far more expert in life-space interviewing, and that a paraprofessional inner-city resident is more gifted at talking down the drug-overdosed, acutely psychotic adolescent from the same neighborhood. Demarcations of expertise are accepted by child psychiatrists in other countries. Concern about it is primarily an American phenomenon and is often accompanied by a tendency on the part of significant segments of American psychiatry to think of psychiatry in other nations as inferior. There is evidence of a diminution in this superior attitude; this may be associated with modification in the previously overwhelming influence of the psychodynamic point of view. Other medical specialists also have adapted to sharing health care delivery with others who have greater expertise in well-defined, limited areas. Consider the ophthalmologist vis-a-vis the optician and increasingly i n relation to the optometrist. Another example is the orthopedist vis-a-vis the physical therapist and brace maker. Yet, the ophthalmologist, orthopedist, and others have retained exclusive expertise in what is universally perceived as the most significant aspect of the activity. In child psychiatric work, however, diagnostic assessment, treatment planning, prescription, coordination, and ongoing reassessment have not always been considered the most esteemed aspects of the field. None of my emphasis on a multidimensional pluralistic integration is intended to deny that there are clinical situations in which a unitary approach is best. A careful clinical assessment may suggest that for a given case an exclusive, rigidly adhered-to, therapeutic strategy is indicated for that particular youngster and/or family. T h e thrust of my intention, however, is to assert that by and large children d o not get better because child
Therapeutic Choice in Child Psyliidry
psychiatrists display an unvarying devotion to a particular technique with all patients, a devotion to which the various mental health fields seem to be exquisitely vulnerable. This is specially true when a growing niomentum of interest is building u p around an exciting new therapeutic strategy. Some clinicians react to new developments by shutting their eyes to the new approaches and clinging tenaciously to what they have always done, while others may be readily persuaded to join the enthusiastic proponents of the new method who write and speak to the point of overzealousness about the merits of exclusive use of that particular treatment. That seems to have been the case with psychoanalysis in the 1940s and l93Os, whereas in the 1960s and 1970s similar claims are made for behavior therapy and family therapy. Child psychiatry has much to learn about how to prescribe treatment. T h e goal is specificity and therapeutic differentiation, and the method by which to achieve it is based on a careful meticulous diagnostic assessment. There is so much more to be learned about when nonspecific factors help; when the therapist's interest or charisma is all that is required; and when it is essential that children have the benefit of specific psychological, behavioral, physiological, and environmental interventions. Perhaps the most important need is to learn when there is nothing additional needed to enhance the child's developmental potential. This knowledge can be accumulated only by methodologically sound, rigorously executed investigations that will document publicly the value of differentiated application of specific therapeutic interventions.
REFERENCES ADAMS,P. L. (1974), A Prnner of Child Psychotherapy. Boston: Little. Brown. ARONSON. G. ( I 9 7 3 , Learning theory and psychoanalytic theoi-v. . "1. Amrr. Psychoanal. Assn., 20:622-637. A osvchoanalvtic viewmint of behavior modification in clinical and eduBLOM.G. E. (1972). , rational settings. This Journal, 1 1 :675-6!$3. DOLLARD, J. 8c MILLER, N. (1950). Persomlzq and Psychotherapy. New York: hlcGrawHill. EYsmch, H. J. (1960), Behavior Therapy a d the Neuroses. London: Pergamon Press. FK-ANK, J. (1961),Persuasion and Healing. Baltimore: Johns Hopkins University Press. GITTUMAN-KLEIIV, R. 8c KI.EIN,D. F. (1973), School phobia. J . N m . Ment. Dzs., 156: 199-215. GKOLTP FOR T H E ADVANCEMENT OF PSYCHIATRY (1973).From Diagnosis to Treatment. New York: GAP Report 87, 8:.320-661. -(1975), Pharmacotherapy and Psychotherapy. GAP Report 93, 9261-431. HALLECK. S. 8c WOODS,S. (19623, Emotional problems of psychiatric residents. Psvchiatry, 2.3:339-346. S. I. (1977), Expanding the role of supervision in child psychiatric education HARRISON, (unpublished manuscript). -8c C h R E h . D. J. (I966),A Gude to Psychotherapy. Boston: Little, Brown. K L A C S R R U N . s. (1%7), I n search of an identity. Arch. Gen. Psychiat., 163286-289. LURORSKY, LESTER,SINGER, B . , 8c LuBoRS~Y,LISE(1975). Comparative studies of psychotherapies. Arch. Gen. Psychid., 32:995-1008. MALONE, C. A . ( 1 Y74), Observations o n the role of family therapy in child psychiatry training. This Journal, 13:437-458. .
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MANDELL, A. J. (1976). Dr. Hunter S. Thompson and a new psychiatry. Psych&. Dig., 37: 12-17, MARKS,1. (1971), The future of the psychotherapies.Brit.J. Psychiat., 118:69-73. MOWRER,0. H. ( I Y j O ) , Learning Theory in Personality Dynamics. New York: Ronald Press. NOSHPITZ, J. D. (197l), The psychotherapist in residential treatment. In: Healing Through Living, ed. J . F. Mayer & A. Blum. Springfield: Thomas, pp. 138-173. RESEARCHTASK FORCEOF T H E NATIONAL INSTITUTE 0) MENTALHEALTH (1975). Research Zn the Service ofMental Health. Rockville: NIMH. WITMER, H. L. (1946), Psychiatric Interviews wtth Children. New York: Commonwealth Fund.