The Ideal Training Program in Child Psychiatry

Paul L. Adams, M.D.

A child psychiatry training group is, from one standpoint, a group of human service workers who are teaching a group of trainees how to perform proficiently in the delivery of human services, a delivery mainly occurring at a later date. Considerable formal and informal pedagogy occurs in this group of actors and interactors. How could they, as interrelated people, have a more ideal life style? As deepl y in volved as I am in the technical aspects of resident selection, training, and evaluation , those specialized matters will not be given priority in m y present descriptive essay. Instead of dwelling upon teaching methods and curricular content at the present, I shall try to consider some of the more-often-ignored aspects of child psychiatry training, namely, the character of the people who are involved in the enterprise, and how they might interact in even more salutary ways. BRICKS AND MORTAR

The physical location has a telling effect on the trammg experience. The spaciousness of the grounds and architectu re, the comfortableness of the intimate work space, the provision of privacy for the residents' reading, clinical work, dictation , and conferring, the nearness of telephone and library, and even the proximity of a staff lounge or coffee room will count heavily in setting the progr am's tone and flavor. Residents today listen with embarrassed semiamusement to their teachers' anecdotes about the latter's "good old da ys" of privation and want during their child psychiatry residency. The contemporary resident sees little of value in spartan scarcity and knows that it is onl y a questionable virtue which at-

Dr. Adams is Professor of Psychiatry and Vice Chairman for Graduate Education in the Department of Psychiatry and Behavioral Science at the University of Louisville. Some ofthe comments in this paper were presented in M ay 1974 to the T rans-Canada Workshop on Child Psychiatry Tra ining, held at Val-David, Quebec, under the auspices of the Laidlaw Foundat ion. Reprints may be requestedf rom the au thor at Box 1055, Lou isville, Ky. 40201 .

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tends the shoddy furnishings and fittings of many child psychiatry facilities. The contemporary child psychiatry resident, more a settler than a pioneer, looks disdainfully at child psychiatry's sometimes cramped quarters in renovated funeral parlors, tuberculosis hospitals, orphanages, and abandoned school buildings. I believe he is right. By the same token, the resident quickly perceives that the operating rooms of the surgeons, for example, are in excellent physical condition or that dental students do not work out of broom closets. By their housing you can discern where the specialties stand in the academic hierarchy. Well-equipped and functional working quarters enhance a training program and the trainee's morale. We merit disrespect when we cannot furnish some amenity in the physical habitat of the resident. LIMITED SERVICE

As

AN IDEAL

Child psychiatrists can be taught in clinics, nursery schools, social agencies, state hospitals, and many other facilities. However, their teaching is facilitated when the setting promotes values that are more academic than clinical. This is not to say that we ought to idolize the frills of pedantry and intellectual snobbery, but simply that we observe, over and over, that when an academic flavor is diminished, the education suffers. Ours is a specialty thoroughly committed to an ethic of human service and human welfare, but that ethic must be curbed in our training programs if we are to function most effectively as teachers. The situation of the training program in relation to the given community's whole institutional or associational spectrum has many influences on the training program. What, therefore, are the ideal service affiliations of the training program in child psychiatry? Where would we wish the training program to stand, relative to the human services network in its community? As I see it, the most felicitous setting in the human services mosaic would have as many as possible of the following features: 1. University and medical school affiliation. Child psychiatry is an academic, medical field. 2. Close and productive interaction with departments of psychology, social work, and other health-related professions' training enterprises. Education must be in the air, so that residents can learn from compeers and colleagues. 3. Close involvement with behavioral science training programs, especially their scholarly research components-anthropology, so-

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ciology, psychology, education, and behavioral biology. Human behavior is the content of the curriculum offered. 4. A clinical basis, whether a clinic, hospital, community mental health, or educational or more generic "human services" setting, that provides a diversity, or heterogeneity, of children with respect to their age, sex, class, race, religion, and human problems. New things about human differences and new empathies for a wide range of people are to be learned here. 5. A research basis, whether through affiliation with a research institute or through more independent accomplishment in clinical evaluation, or in basic biomedical study or biosocial investigation, for the training program is not merely a transmitter of but also a goad to inquiry and discovery. Without apology we must bring our training programs into the universities, where they belong, and acknowledge that the academic setting carries its own intrinsic set of constraints and obligations. For example, some of the un testable farther reaches of psychodynamic metapsychology seem odd and inappropriate in an academic setting. Academic values might not be any better, in the long run, than those of community welfare agencies, for example, but they are different and distinctively so. No training occurs without service, to be sure, hence our training always has a service setting to which it can refer and relate for its very identity. Still, the amount of service undertaken in our clinical base must be curtailed, or limited, lest clinical duties drown out learning. The limited-service setting is what is ideally called for. The ideal clinical load is hard to describe, for very good reasons. Learners are all different. Some residents can learn best from prolonged and frequent in-depth contacts with five or six patients. Some others can learn best from having a broader, and not necessarily superficial, experience with a caseload of twenty or more people who are seen one, two, and three times weekly. Hence, the ideal caseload is a range from five to twenty, in my experience, and it is customarily the second-year resident who seems to do better with fewer individual cases, since he gives more of his clinical time and energy to work with families and with agency consultations. The ideal training program, by an odd paradox, is never overly committed to giving direct services. Consequently, the training facility would not be the first, or the only, child psychiatry service in its particular city. As an extra clinical resource, trailblazing only by its academic endeavor, the training facility is more protected, more respected. As the one and only, it is eternally vulnerable to pressures that are not appropriate for an academic project. The fight

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of academicians against devoted human service workers-almost always female-who "man" the battle stations on behalf of children in the local communities across North America is a fight for small gains (bones or peanuts we say, according to whether our rhetoric is carnivorous or vegetarian). It is not pleasant, wise or right, as I see it, to fight that way. Let the academician prove his valor many times over within his academic jungle home, but he should be called on to fight for budgets only within the medical school, as I see it, and not in the United Way councils of his city. Citizenship, advocacy, and service are what child psychiatry training is intended for, what child psychiatry residency is all about. Nevertheless, academic priorities have to be placed first, all down the line, in child psychiatry training. That means that training directors must become more adept in maneuvering themselves out of clinical positions of management that necessitate fund raising, budget hearings, clamoring for a favored position in the impoverished services spectrum. For, when the battling is terminated, we discover that whatever the university child psychiatry clinic received, it was granted only at the expense of the Girl Scouts or a family service agency. To win a fight for such meager resources is a hollow victory. With a physician's commitment and a socialist's views about health care in North America, I am passionately concerned that human services be expanded and improved. But I observe that our academic departments and divisions suffer academically when they are diverted into large-scale delivery programs. For example, I can assert that good academic programs are hardly consistent with manning the sole clinical child psychiatry program in a given community. The training facility is left holding the bag. What we should strive for, I contend, is a small medical school base (outpatient and inpatient)-a "luxury" base, in a word, because it is not all that the city has to offer. For teaching child psychiatry we need a minimal service base. For building a society that cares about human growth and well-being, a multipronged service base, much larger than our habituated window dressings and much larger than we ordinarily conceptualize, is required. The human needs of human beings are not met cheaply. Services, research, and training are all costly endeavors, and we can anticipate that little will be appropriated for any of them until income, services, and power will have been redistributed into more numerous hands across North America. Social reconstruction is interwoven with child psychiatry training, but child psychiatry, I am convinced, is not enough to be a vanguard for needed change.

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AURA AND SPIRIT OF THE WORKSHOP

Given competent faculty members, promising residents , a commodious physical setup, and an academic-cum-service ethos, there exist the basic preconditions for a productive human experience-if the workshop is a happy, unalienated place. Unabashedly, we go about building workshops that do not fragment and alienate people. Arbeiten und lieben. The love that pervades our training workshop is, ideally, a "sector" love, conveying a great deal of genuine care about the personal and professional development of the child psychiatry resident. It is limited rather closely to the work sector, however, because his teacher does not operate as his therapist, not as a loving parent, and not as a real libidinal object, although our temptations to undo the ideal of limited, professional, and sector relatedness abound (in my experience) and are acknowledged (most of the time) and controlled (almost always) . Sometimes discretion breaks down and "scandalous" affairs do occur, particularly, as I have observed them , when the involved partners were sexually inhibited in adolescence, not enjoying a kind of agespecific promiscuity in that earlier epoch. Child psychiatry training groups even have fun together, to the occasional dismay of our colleagues in pediatrics and general psychiatry. Our puritan observers conclude that an ybod y working with that much enjoyment of work, pla y, and one another, cannot be decent and productive academicians. Not coopted by bureaucratic style , we have not totally interred our pleasure principle, subjugating it to what Herbert Marcuse labeled "the administered reality principle." The training workshop exists mainly for the trainees . They need to assume responsibility and to give an accounting for what they do. As their graded competence waxes, morale zooms and exuberance pervades their lives. This kind of high morale in important people is not necessarily related to the ideology of the trainers, or as some of my students have indelicately dubbed it, "the party line." Although a certain weltschmerz and gloom might logically accompany some of the more pessimistic psychodynamic theories, the noticeably different temperaments of academic child psychiatrists do not seem , to me , to vary as a function of their ideological commitment as much as of their congenital and early life events. To have some ideological outlook, some conceptual framework , seems to enhance morale, moreover . And the conceptual scheme can be loaded with metatheory or down-to-earth ; it can be existen-

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tial or essential; it can be biological , social, behavioral, psychoanalytic, or "systems." It can even be eclectic or, more accurately termed, pluralistic , and still be a workshop where people work hard and feel loved while learning. Skills for Leading

The child psychiatry resident sometimes derives a lifting of morale from the fact that his training program is aimed toward his assumption of leadership in the mental health field . That is, to come at the point from the opposite side, wherever the teachers require mostl y followership or prolonged subservience, there the training program falls short of the ideal. Many programs, immersed in a community service project, are so taken over by nonmedical workers (usually insuperable bargains from a services-delivery standpoint) that they show zealous determination to over power , to teach only yielding and following to the child psychiatry residents. This is sometimes justified by an antimedical ideological perspective, occasionally by a nonmedical perspective, and often by the empirical necessity of allocating the greater power to that profession, or combination of professions , often not psychiatric, which got there first and asserted control of the turf. In all events , the child psychiatry resident does not learn to move expeditiously to performing his best work in this rivalrous atmosphere, but expends energy counterproducti vely in placatory maneuvers and obligatory obeisance toward his elders on the "team ." These "lessons in humility" are not ennobling to the resident and do little to cultivate his rational esteem for his nonmedical colleagues. Above all, it does not give him an exemplary lesson in the ethic of humanitarian service, to which his nonmedical teachers often pa y verbal homage, for he discerns soon enough that the suffering consumers' welfare is not at the top of the value scale . By contrast, the child psychiatry resident who is taught to coordinate, to lead-to be interdependent, to share responsibilities, to be dependent, and to trust others to perform valued services for the children and families who are seeking help-is the resident who will grow as a person whose ver y bod y and mind will become instruments of healing service. Never mind that his nonmedical teachers may possess many of his skills, certainly more than he at the onset of his learning tim e. The work group members collectively share many capabilities, but all are engaged in teaching what they know to the child psychiatry resident. The ideal aim of the training program is to dispel the resident's ignorance, not to displa y the teacher's expertise. We can have sympath y for the resident

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who is in training in a program where his learning is impeded by rivalries within the team. TEACHING PERSONNEL

Teaching occurs through varied modalities. The curriculum of child psychiatry is taught by residents teaching themselves individually, by peer teaching, by faculty teaching, by research, and by mutual evaluations. The people who teach are many, but the best teachers are the residents who teach themselves. Self-teaching implies that the student knows what is good for him and can determine the content of his curriculum, within limits. Together with their teachers, the residents are equipped to set both educational goals and content. Students have known what they want to learn from the inception of the European university when students paid fees to faculty persons who would teach them what they wanted to learn. This fee for service arrangement worked rather well in its time, and for our time we can salvage from the scheme the notion that students aptly participate in their own learning programs. Two forms of transmission teaching are basic, one by the faculty and the second by fellow re sidents. Peer interaction is an important part of learning, for when they are taking on new roles, peers ably assist one another in achieving competent performance. The process occurs, and we might as well capitalize upon it. Teaching by the faculty is of our major interest in a subsequent section. Further, there is a mode of teaching through research. The child psychiatry resident learns the field by investigating the field. Our students are not onl y our followers, imitators, and disciples; they are also explorers. Child psychiatry residents who are fortunate move be yond transmission learning into exploring. The ideal training program would convey a zest for inquiry, would promote a contagion of scholarship, and would portray child psychiatry as an intellectual discipline. The more cerebral horsepower, the better. One small token of these values was instituted at the University of Florida, for each resident in child psychiatry was expected to complete a "research paper" during his fellowship. These papers were reviews of literature, case stud ies, controlled studies-all types were acceptable. Occasionally, this was like forcing new wine into old bottles, but at other times it uncovered some talents that were welcomed by the student and teacher alike. The required scientific paper is one way we could get across the point that ours is an academic discipline.

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Research is a luxury for the child psychiatry teacher, seldom guaranteed as a right to the busy clinician, and at times seemingly made almost impossible to materialize. As teachers we are busy giving didactic and supervisory instruction. Also, we are busily doing the direct clinical work that we need to do for our own gratifications as well as to keep us credible to our students. So there is precious little time for research. Still, we must be scholars, and it gets done. We must become more astute in negotiation for research time as a right. I think it makes more sense for the training faculty to demand , and get, research time through their teachers' union bargaining efforts than for them to grumble as individuals against the doctrine, "Publish or Perish ." Ideally, every faculty member can be an exemplar of scholarly work and not alone of clinical expertness or teaching skills.

Ways Faculty Members Teach The faculty member teaches by what he does well as a child psychiatry teaching team member. Social workers, psychologists, and others are adept teachers in our field. The background discipline does not matter as long as there is an earnest desire to teach child psychiatry, as a humane life of service, and as a scholarly field with biosocial and biomedical roots and branchings. Effective pedagogy is not terribly mysterious, and if well planned and conceived, it can occur with some grace. Ideally, our pedagogy pays careful attention to teaching objectives, curriculum, teaching techniques, evaluation, and follow-up . In the discussion that follows, I shall give only abbreviated consideration to the technical side of all these, in keeping with my promise to emphasize the ideal life style. Nevertheless, technical and material things have untold "spir itual" significance. Our goals should be made explicit for each teaching sequence or unit. That requires that we know fairly precisely what it is we want to teach, and when we know that, it helps our students. Generalized, vague goals will not pass for serious education in this day and age. The educational goals, therefore, that make most sense to me, are highly practical and set in behavioral terms: to make a home visit to at least one poor, one working-class, and one middle-class family, and even to a rich famil y if one is available; to help a famil y with anticipatory grieving for a child with a fatal illness such as leukemia; to aid a you ng woman living in a commune, whether married or not, to keep the baby she delivers by natural childbirth , etc. An effective curriculum is well planned, as far as its content is

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concerned, to be used in helping the learner to achieve his behavioral goals. An "Experience List" that I have worked with in the past includes: consultation to child welfare or school or other generic human service; examination and write-up on three newborn babies; examination and write-up of interaction between chimpanzee mother and neonate; ten pediatric consultations, either inpatient or outpatient; one comprehensive pediatrics conference; three joint interviews of a child with a faculty member; three joint interviews of parents with faculty member; three families evaluated and treated as a family group; writing a child's family history covering four generations; treatment of a blind child; treatment of a nonverbal child; a study of ten dreams reported by a child in treatment; intelligence testing of a child under 3 years; intelligence testing of a child aged 3 to 8 years, and so on. It is only in such specifiable and measurable tasks that a planned curriculum that makes any sense can be brought to life. I do not argue for the soundness of the specific examples offered, but I do contend that the idea is a sound one for giving some shape to the list of skills expected to be learned by a child psychiatry trainee during his time of specialty training. Effective teaching techniques span individualized tutorial work (which I like to do only if a resident prepares an advance agenda for our session of work together), small group or seminar work, and large group/lecture/panel work. All of these approaches utilize audiovisual aids, and the best ones in my experience are those made up by the trainees themselves, although some professionally prepared, prefabricated aids are richly instructive. Two reminders come to my attention, however: the first is that the printing press is a marvelous invention which, I predict, even medical educators will acknowledge soon. A book or journal, read by an inquiring and skeptical person, provides an excellent visual mode of instruction. The second reminder, also given facetiously, is that we should recall that the eye as well as the ear can bring enlightenment to a trainee. Not everything has to be said. Some of it can be written or otherwise displayed visually. A videotape may be worth a thousand words, even if they are attended with a third ear. The medieval faithful saw impregnation and delivery of the Virgin occurring through her ear, and all too often we (who teach child psychiatry) similarly overvalue the ear to the exclusion or diminution of other important sensory modalities. Syllabuses and reading lists are helpful. Some textbooks assist the student of child psychiatry. If we choose to, we may fruitfully borrow from the technology of the legal profession, and adopt

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casebooks that are a source of clinically rich, reality-bound observation and speculation conducive to effective learning. Further, short courses are excellent. I have seen fine ones dealing with family therapy (though restraining and confining their devotees to ten sessions is difficult), dreams of children, poverty, sexism, childism, and the cult of childhood. Some of the best short courses are those given not by the core teaching team in social work, psychology, and psychiatry, but by auxiliary faculty such as child neurologists, sociologists, and anthropologists. Optional workshops for those with special lags or special depth are fruitful. So are relatively stable "interest groups" or "research groups" as these are called at the Hampstead Child Therapy Clinic in London. The Adolescent Research Group, the Clinical Concepts Research Group, the Developmental Profile Research Group, and many others brought together voluntarily for weekly sessions a few staff and students whose special interests related to the topic of the group's title. Teaching Evaluation

The manner of systematic and periodic evaluation that seems ideal to me (amazingly, I also practice it) is mutual and shared. At least every six months, student and teacher meet for a special session in which the student evaluates the teacher for "fund of knowledge, ability to communicate knowledge, willingness to learn further, availability and punctuality, interest in resident's professional welfare and growth, competence as a functional model for child psychiatry practice, sensitivity as a clinician and supervisor, fairness in dealing with resident group, respect for differences, respect for resident as a person, being interesting as a teacher, being interested in own daily profession, well-organized presentation of ideas, keeping student informed of teaching objectives, approach to child psychiatry as a scholarly field, and overall rating compared to other faculty." In the same session, the resident is evaluated for "knowledge concerning theory, practice, use of self; quantity of work; intellectual curiosity, enthusiasm; responsibility and accountability in patient care; scholarly promise for research and writing; sensitivity and empathy; interest in the patient's humanity and respect for his individuality; maturing judgment and its application; ability to handle patients' frustration and anxiety; working relations with patients, peers, faculty/staff; handling of personal problems without professional impairment; and overall rating compared to resident peers." In each instance, a rating is made on a 5-point scale (with an X for "Don't Know"), and a space is provided for the rated one to

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make a written rejoinder or rebuttal. These evaluations are open and above board between rater and rated-in itself a meritworthy device in a profession in which paranoid distrust of one's associates waxes in synchron y with secrecy, alienation , and loneliness. Life is peer review, it seems. Evaluation is unending for a child psychiatrist; so to make it useful we structure it, take it seriously, and share it. Sometimes the outcome is both educational and joyous. Other forms of evaluation have a variable utility, but ideally in child psychiatry training we should be exploring every possible way to evaluate our programs in their every facet-what they do to us, to our students, to patients; what they do cognitively and emotionally; how good they are, and good for what. Formal topical examinations could be fun, but child psychiatry residents often fear them and despise them. Self-assessment examinations, as promulgated by the A.P.A. and at the 1974 Child Psychiatry Boards for the examiners, are more tolerable , ap par en tly. The Board examinations themselves are becoming better as techniques for adjudging clinical competence. In these and all other forms of standardized evaluations, we need to be ascertaining what we really do in our training programs, how effectively we do what we are set up to do, and to what degree we are successful teachers of a worthwhile and plausible cr aft. We, the teachers, set the pace in selfexamination, self-disclosure, and in making our being evaluated and "reviewed" a part of the role, child psychiatrist. We are interactive. We live in a fishbowl of public awareness, accountability, and recurrent scrutiny for competence. Peer review is part of our way of life, and if we make it serviceable and humane, it can only improve the care we give to patients. Hence, an ything we do to keep abreast helps us and our students. We mean to be teachers who keep alert intellectually, who stud y and publish , alwa ys learning from colleagues and students in our work groups. Follow-up of the academic consumer , that is, of our graduates, is an important task that must be done, ideally. We continue to learn with them, and about them, after they leave our academic work places. We should urge each of our graduates to keep his credentials current, since they reflect upon both his vitality and our program, and we should proffer our continuing education and supervision, for hire, if necessary. RESIDENTS IDEAL AND REAL

Residency selection is a procedure that can be done with dull gravity, with pompous self-seriousness, or with some lightness and in-

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tentional risk-taking. Like all the rest of the steps involved in training of child psychiatrists, their selection should be taken seriously, seriously evaluated, tested, and reexamined many times. But selection is a ground for murkiness and wooliness, by and large, and in view of that I will not be too shy to report here only some of my personal anecdotal and impressionistic findings-or intimations, to be fairer about my remarks. The ancient alchemists were ou r predecessors (if not directly our inspirational fonts) in speaking the language of mystery and absurd paradox. Alchemists knew assuredly how to guarantee a successful outcome, as they asserted, working all the while with lead, "To get gold you must begin with gold." We can expect to wind up with winners only if we select winners at the outset. A record of effort, of disciplined hard work, and of demonstrated success , in both biomedical and biosocial sciences, is a good credential for the aspiring child psychiatrist. Of course, a moderately endowed stu dent of child psychiatry can, under the influence of a grand guru, undergo profound changes, theoretically, but everyone sensible knows that hopeful promise, alone, languishes unless there is a record of some prior fulfillment, some gold. Applicants for child ps ychiatry residency positions are old enough to have completed some of their requisite blooming and ripening. It is incorrect to think that we start residents from scratch, for in truth we only add finishing touches to some alread y competent stuff. We delude ourselves if we think we transmute base into precious metal. The "well-qualified" applicant is one who made high scores or grades in undergraduate, medical, and general psychiatric studies. That person is a good risk, but can be boring, dull, and unimaginative. Earnest industriousness is not enough . Diligence and competition for grades are not alwa ys the marks of a gifted person. Further, you ng ph ysicians-like their older role models-are alarmingly easil y faked out, so eager are they to conform to the expectations of respectability. Sometimes they present themselves as more pedestrian than they are. Hence, it is good to include a note of warning in the application blank, as we did in one place I worked, "Persons with humanistic and unusual backgrounds are given preference." That bit of encouragement led some ver y straight-looking candidates to divulge some magnificent, but often concealed, things from past and present. What is meant to be unearthed in the applicant is the soul of a poet. If it is there, it helps in the training of the child psychiatrist. Alas, when the poetic touch lies dormant, we have to go on without it in undertaking some worthwhile educational activities.

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As compensation, we find that many who are not truly educable are, in the terminology of mental retardation experts, at least trainable. A willingness to learn , to grow, to be vital is a sign of trainability. In former year s, I had the idea that a special mystique , or certain endowments directly from the gods to the doctors, were required if one were to be fit in the field of child psychiatry. I no longer believe that,just as I no longer believe the testimon y of people who proclaim competence with adults but not children, for I think the generic gift is what matters-to be a good psychiatrist. Undeniably, the child psychiatrist has a finer repertoire of skills for working in the world of children, but a general psychiatrist should have most of the same basic skills. One more consideration of the ideal in resident selection should be made: the manpower pool from which child psychiatry applicants are drawn should be expanded and diversified. Already, considerable inbreeding from fathers to sons is in evidence here and there. What I would advocate as a way to enrich both the profession and the society would be for child psychiatry programs to defy the rigidifying tendencies of certifying agencies, even if those tendencies seem to be those agencies' notion of what competence entails. Witness their quick reimposition of a required internship. We assuredly need more wornan power in child psychiatry, and we should find ways to help women come in, have their birth control or their babies , and receive proper maternity leaves without penalty. Moreover, by variances (as the zoning boards say it) we could allow them to bring their babies to work , interspersing work with care of the infant without our making a federal case of the pregnancy and child rearing. If we cannot make our workshops places where normal baby care occurs, naturally, we should not expect it to happen in man y other places. Child psychiatry would be a richer field if there were more cultural and ethnic diversity in our trainee group. Black people particularly are the victims of our racism in both its attitudinal and institutional forms. Institutional racism in child psychiatry expresses itself with a clear conscience, because we can find blacks not "qualified," as far as grades are concerned, and pass over them. Or they do not apply. Or they lack the zeal we require. When institutional racism is at work, blacks 'Just happen" not to be present, and "nobody is to blame." Considerable cultural diversity would be much easier to obtain in our resident applicants, furthermore, and this applies to our having more blacks also, if relative affluence , even richness, were not the basis of a kind of negative means test

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governing admissions to medical school. To make medical education available to the erstwhile poor has been done in a few countries of the world, and the level of medical care has improved, not declined, when class has not determined selection. One remaining manpower source, pediatrics, needs to be mentioned. Pediatricians had some legitimate claim on child psychiatry. However, in 1959 it was the American Board of Psychiatry and Neurology which became the "parent board" (quite a symbolic term, all by itself) for the new child psychiatry certification procedure. Child psychiatry retained some liaison with the American Board of Pediatrics by virtue of having a single representative from the Board of Pediatrics sit on the Committee on Certification in Child Psychiatry. In my mind, the tie with pediatrics should become closer now that former territorial fights have been concluded fairly appropriately. This means that an ideal training program should make efforts to draw from the pool of accomplished pediatricians, especially those who regard themselves as "behavioral pediatricians," a group who will be trained not according to the calendar but by design and according to competence and skills. In other words, training programs should be able to admit pediatricians, and provide them with a well-planned and rational program of basic psychiatry and child psychiatry in less than four years. To state it bluntly, what we do now is to require aging, not skills. One place where we might start in changing our habits would be with the pediatrician, a person who has already done his aging in another, but closely related, specialty. Therapy for Residents

For most students, child psychiatry is a specialty occupying one's middle years, not one's absolute beginnings. Many prerequisite years have been demanded by all the forces of certification and legitimation; thus, the resident is rarely below 28 years of age when commencing training in this specialty. It is histrionic to describe the residents as greenhorns in need of learning the most basic lessons in medicine, psychiatry, and behavioral science. Much has already occurred to lay down the basic competences required. By the time he gets to child psychiatry, he has done a lot of coping merely to survive. But this does not mean that therapy is seldom called for, or that only an occasional resident will need psychotherapy. Far from that, a policy of recommending that every resident enter treatment at once would make more sense. The work to be done by a child psychiatrist is fraught with many hazards, so the typical resi-

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dent needs to have entered into a treatment relationship prior to completing his child psychiatry residency, if not done prior to commencing the residency in child psychiatry. Treatment emphasizes and illuminates the intrapsychic and the interpersonal , and puts the young psychiatrist into a frame of mind that augments his empathy and self-control. Empathy, because he gets an experience in being a patient and learning how ubiquitously human are transference distortions, resistances to change, and proclivities to adoption of neurotic ways. Self-control, because the child psychiatrist relies upon himself as the major instrument of his work of helping, because to help most efficiently he needs to be freed up sufficiently to use the uncluttered self as a healing instrument in aid of others. If he is not informed about himself, he cannot make himself fully available to do the curative service that the world needs. This self-study has nothing to do with a neurotic quest for omnipotence; indeed , it enhances one's simple humanity , in my experience. Ideally, every child psychiatrist would have a hundred hours or so of personality study while in the patient role, or a more prolonged personal psychoanalysis. Whether group therapy and sensitivity training could replace this individualized work remains uncertain. Therapy, obviously, in and of itself is not enough; hence, the pediatrician-to name one example---eould not substitute a personal analysis for training in general and child psychiatry. The specialty training is largely cognitive, but some work of liberation, through therapy, makes for a pleasant accompaniment to the cognitive growth. CONCLUDING REMARKS

The ideal training program, as a result of much good thought and planning, takes cognizance of the ways the people involved interact and live with one another and with the clientele served by all. I purposely played down the services aspect of the academic program in child psychiatry, in the hope of highlighting certain aspects of morale and quality of life . Our situation in academic child psychiatry is one of being committed to serve children and their families, and to changing the world in pursuit of the goal of service. We prepare our students to be the agents and instruments of change, of both intrapsychic and institutional changes. We who live for serving have learned to serve vicariously through our students, to delay our gratifications, and to

The Ideal Training Program in Child Psychiatry

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let our trainees-once they are graduated-work at the front lines of human service. Academic child psychiatry faces many difficulties. There are monetary shortages. There is second class treatment in many of our academic departments. There are hassling and battering by our students. There are cuffing by pediatricians, besieging by deans and committees in the medical school jungle, and undermining by our own colleagues in our workshop-notably, psychologists and social workers. Still, it is a life with good quality and flavor . We could do better, but it would be hard to know of any other field that offers more promise.

The ideal training program in child psychiatry.

The Ideal Training Program in Child Psychiatry Paul L. Adams, M.D. A child psychiatry training group is, from one standpoint, a group of human servi...
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