I have found it very difficult to write this paper. The reason, I believe, is that in this discussion we are concerned neither with scientific nor with poetic truth.
Indeed, what I have to say must be affected by the history of my own development, it must be prejudiced according to my feelings about certain key matters, and it must be a sub-total statement in accordance with the limited scope of one man's experience.
Quite simply, I wish to state that the work we do which is at present called child psychiatry is a speciality on its own. If we retain the term ‘child psychiatry’, we must be quite clear that it is not a
part of general psychiatry.
I shall explore the relationship of our work to the work of neighbouring specialities, and I shall make a few positive suggestions.
The training of child psychiatrists depends on our views on the nature of the work we do, and I shall put in a plea for the retention of variety in the matter of portals of entry. In particular let no
overhead planning exclude the possibility of entry into child psychiatry through paediatrics. I shall assume that at the Child Guidance Training Centre and at the Tavistock Clinic and the Maudsley Child Psychiatry Department the same questions are being asked that I am asking in this paper. Recently there was a discussion on this subject at the Tavistock Clinic, and those who were present will agree that the ground was pretty well covered on that occasion.
What is Child Psychiatry?
The question that must be asked first is: what is child psychiatry? In child psychiatry the work is essentially practical. In respect of each case we meet a challenge. In terms of bringing about clinical improvement we may fail, and we often succeed. Real failure can only be stated in terms of a failure to meet the
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1 Contribution to Symposium first published in the Journal of Child Psychology and Psychiatry, 4, pp. 85-91.
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challenge of the case. For this reason the part of our work that is done privately and apart from team-work shows us more than team-work does that the need in each case is for someone to meet someone at a deep level. It is generally accepted that the case conference is of no value unless afterwards someone carries over into a personal relationship the new understanding that discussion has brought. New understanding does nothing by itself.
The basis of much of the work of the child psychiatrist is the psycho-therapeutic interview with the child. If he has not the skill for this, or is not a suitable person to make contact with the child in this way, he cannot even make a diagnosis, let alone know how to alter a fixed situation, or understand what the other members of his team are doing. A training scheme must take this into account. Likewise the child psychiatrist is engaged in working with the parents. Or it may be that he is in search of a plan that would enable the mother, or the father, or someone in loco parentis, to provide a suitable environment for a child during a phase of difficulty. The theory behind this is that suitable environmental provision facilitates the internal maturational process.
Often we find we are making a diagnosis of health, or normality, in face of the undoubted existence of symptoms in the child's developing relationship to the self, to the parents, to the family unit, and to the environment generally. Health is almost synonymous with maturity—maturity at age.
A Classification
It is not possible, I find, to make a comprehensive statement of our work, but instead I shall attempt a rough classification:
Cases Manifesting:
(a) Inherent difficulties in the emotional development of the individual. Environmental factors that are unhelpful or actually harmful. Symptomatology based on defence organizations relative to inherent difficulties interwoven with environmental failures. Illness based on the failure of defences
and the reorganization of new defences.
(b) Illness associated with or secondary to physical disease.
(c) Problems that take us to the borderline (paediatrics, neurology, adult psychiatry, obstetrics). (d) Illness involving society: The antisocial tendency. Co-operation with legal procedure. (e) Problems at the borderline of the educational specialist.
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A child psychiatrist must be medically qualified, and should have practised as a doctor, because he will need to take responsibility for life and death, and for the occasional suicide that must certainly come his way. What does he need in addition? The first answer is, of course, that he needs
opportunity for experience. (Here I was lucky, because as physician in my own right at The Queen's (now Queen Elizabeth) Hospital for Children for ten years, and at Paddington Green Children's Hospital from 1923 till now, I had a medical department of my own that I could exploit as I wished. Hector Cameron had just this. But it must be rare for anyone to have such an opportunity to come to child psychiatry slowly and naturally.) The moral here is that we must plan to allow those who wish to specialize our way to have the chance to develop at a natural pace. If, on the other hand, the child psychiatrist who is starting is immediately asked to do teaching, then he must teach what others have said and not what he himself has discovered, which is a pity.
The Backing for Child Psychiatry
But my main theme needs to be stated. I will approach it this way. The educational psychologist has the backing of education, and I am glad; it supports his learning process, it gives him status, and it looks after his finances. Now, who shall back those who are clinically involved? The universities are suspicious of the practical application of psychology in terms of human affairs, especially where individual human beings are being helped; also the universities are suspicious of psychology unless it keeps on the academic rails and eschews working with the dynamic unconscious.
The social workers of various kinds are struggling to establish themselves as professional workers. What about the child psychiatrists? Who shall give them backing (except that which they
automatically get by being medically qualified)?
We need only consider two types of backing, paediatrics and psychiatry, and we can say that in each case we have been so badly let down that we now cannot consider anything but autonomy. The fact that our chairman is a paediatrician can rightly be taken to indicate that there exist enlightened paediatricians now who are not only friendly but who are actively supportive. Also at Paddington Green and then (since we became absorbed) at St Mary's, I have been treated generously, and with great friendliness. But I cannot allow my own good fortune to blind me to the general position. Paediatrics has failed as a parental figure for child psychiatry, and so has psychiatry.
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I will first refer to adult psychiatry and then to paediatrics, and then attempt to formulate something positive.
Psychiatry
How far can general psychiatry be trusted with the task of representing child psychiatry at planning level? I suggest that the general psychiatrist is not usually aware of what a child psychiatrist does and is. If this be so, how can he represent child psychiatry? There are of course vast areas of overlap
between general psychiatry and child psychiatry. Who could say whether mental defect is
psychiatric, neurological or paediatric? No need to decide. Also adolescence gradually merges into adulthood, and so child psychiatry overlaps with adult psychiatry when patients get stuck at the time when their teenage doldrums normally resolve. Also, parents and parent figures are frequently to be recognized as ill in a psychiatric sense; and adult type psychiatric syndromes do periodically appear in the child psychiatry clinic. There will always be a proportion of those entering child psychiatry who graduate first in adult psychiatry, and I have no wish to see this altered. In any case we need the adult psychiatrist to look after us when we ourselves go ungracefully into a decline. But I do wish to express the opinion that, for us, adult psychiatry is concerned with alien problems. If your son wishes to enter child psychiatry, if you advise him first to become a psychiatrist you are advising him to waste a great deal of time which he could be better spending in paediatrics.
Is it not true that adult psychiatry grew out of a concern for people who had diseased brains or who were thought to have a physical or inherited disorder? Is it not true that adult psychiatry has clung on to the biochemistry and the neurophysiology of mental disorder, at the expense, in this country, of a study of the contribution that could be made through co-operation with dynamic psychology? This is understandable in view of the fact that the adult psychiatrist has to cope with the enormous burden of the degenerated insane and with the almost insoluble problem of their nursing needs. But these same considerations make it necessary for child psychiatry to separate itself off from adult psychiatry, especially in respect of training.
Areas of Concern
Adult psychiatry is concerned with two sets of problems:
(a) Disorder of the mind secondary to inherited tendencies, to brain tissue deficiency, to brain tissue disease, to general
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degenerative diseases, such as arteriosclerosis, which incidentally affect the brain. (b) Disorders of the mind which are late evidence of early emotional distress.
In this second category may come the majority of adult psychiatric cases, and here the adult psychiatrist always comes too late to the field. In all these latter cases, the time at which the illness started was in the patient's infancy or early childhood. The paediatrician was the doctor who was naturally involved at the time of maximum stress, but fortunately for his peace of mind the
paediatrician did not know. If he did, then he may have called for help from the child psychiatrist, and a proportion of the adult psychiatrist's cases are therapeutic failures of the combined paediatric and child psychiatric departments. Our successes manage to avoid coming to the department of adult psychiatry.
Child psychiatry is concerned with:
(a) The development of the personality and the character of the individual in health, and in various family and social patterns.
(b) The disorders of emotional development at their beginning, and in the early stages, when the defences are in process of hardening into syndromes, and as these interweave with the
environmental provision and reaction.
The vast majority of our cases can be dealt with satisfactorily (as clinical problems) and every improvement we initiate is expanded into a larger improvement because our patients are immature and growth-process can be set free. We scarcely meet with disorders due to degeneration of tissues, and this distinguishes us from the adult psychiatrist. Moreover, we can usually rely on the parents to
provide the patient's nursing home or mental hospital by their adaptation to the ill child's needs at home.
Psychiatry and the Theory of Personality Development
While I am exploring this area I want to say that I personally am not impressed when I look at the contribution made by adult psychiatry to the understanding of the developmental processes that lead to the growth of the personality and to the establishment of character. It is said that the practice of psychiatry has greatly advanced in the last thirty years, but on the debit side a few things could be said also. Here I definitely let myself go in expression of some personal opinions. With the passing of the word asylum it has become almost impossible for an ill patient
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to find asylum, unless perhaps in a religious house. Also, treatment by fits has produced clinical improvement in very many cases, but has it added anything at all to the understanding of the way illness develops or treatment produces change? Perhaps by giving fits the psychiatrist helps the patient to commit suicide without dying? And in a course of convulsion therapy, the hatred of the treatment that the patient develops, that is to say, hatred without murder, may produce valuable integration in a disintegrated personality. But if these theories have truth in them they do not come from psychiatry. Lastly, in my series of personal complaints, treatment by leucotomy really shocked me, and gave me a suspicion of adult psychiatry from which I shall not hope to recover. In
leucotomy, which has now mercifully gone out, I can only see the patient's insane delusion being met by a delusion on the part of the doctor.
Perhaps but few share these, my personal prejudices. There is a reluctance on the part of dog to eat dog and on the part of medical men and women to criticize colleagues. There are moments,
however, when we must criticize and expect to be criticized, and we can do this within a framework of respect for one another as persons.
I am glad I never did work in a mental hospital where I would have had to do these bad things. I could not have done them, and I should have reverted to physical paediatrics, where I could have enjoyed myself immensely. But I would then have missed much that I value in the practice of child psychiatry.
Paediatrics
I now come to the subject of paediatrics. As is well known, my bias is towards paediatrics as the natural training ground for child psychiatry. Paediatrics gives the student and the doctor the very best opportunity for really getting to know the child patients and the parents. If paediatricians wish, they can be child psychiatrists without even knowing it. The paediatrician has to be fully equipped to deal with physical emergencies and this puts him in a very strong position in the management of doctor-parent relationships; in the guise of infant-feeding, the paediatrician can, if he is so minded, work in with the mother in her very delicate task of introducing the world to the baby, and therefore of laying down for the child the mental health which is the negative of the mental hospital disorders. It was as a practising paediatrician that I found the therapeutic value of history-taking, and
discovered the fact that this provides the best
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opportunity for therapeutics, provided that the history-taking is not done for the purpose of
by-product.
I have continued throughout my career to believe in paediatrics as the proper root of child psychiatry, and the main thing that I wish to say in this paper is that in any planning that is to be made, the way must be left open for the doctor who wishes to come to child psychiatry through paediatrics. I mean the practice of paediatrics, over a decade. If he is to be compelled to go through the adult psychiatry training, if he is to take the D.P.M.,1 then he must inevitably cease to be a practising paediatrician in the true sense of the term. There is so much to be learned and
experienced in the practice of paediatrics that it is not possible to embrace another speciality such as psychiatry, which has so much in it that in no way concerns infants or children.
I hold this view very strongly in spite of the fact that paediatrics has failed to play the part that it was destined to play in relation to child psychiatry. Twenty-five years have been wasted now since those who are responsible for paediatrics in this country were introduced to the idea that child psychiatry is one half of paediatrics. Official paediatrics has avoided the issue quite deliberately, and there is now nothing to be gained by waiting longer for child psychiatry to become a twin with physical paediatrics. This could have been done, but it has not been done.
Child Psychiatry in its Own Right
But it is open to child psychiatry to give preference to paediatricians, and to ask for paediatric training and experience. The only solution is for child psychiatry to become a thing in its own right and to devise its own training. I would like to ask, has the Professor of Paediatrics ever met the Professor of Psychiatry to discuss this question of there being one day a Professor of Child Psychiatry?
But, and here is a very big but, sometimes paediatricians tend to think they can simply switch over to child psychiatry, as by changing the name from ‘paediatrics’ to ‘child health’. This of course is not possible. If they come over to child psychiatry they must be prepared to re-orientate and to drop much of the power that they wield as physical paediatricians.
————————————— 1 Diploma of Psychological Medicine.
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Place of Psycho-Analysis
This leads on to the matter of the relationship between child psychiatry and psycho-analysis and I will be brief because I believe this is not intended to become a main issue at this meeting. But I cannot avoid the issue. Committed as I am to the idea that paediatrics is the best of the various possible preparations for child psychiatry, I have to go quickly on to an assertion that the really necessary preparation for child psychiatry (whether of paediatrician or psychiatrist) is in the psycho-analytic training. It is an important thing for me that what I have to say about this is now generally recognized, whereas a few years ago it was quite revolutionary. It is now in my
experience an asset when a candidate applies for a child psychiatry post if he is an analyst or if he has been accepted as a student at the Institute of Psycho-Analysis. (For the purposes of this discussion I must here include the Jungian training, in spite of the important differences which we can find between the two disciplines if we are looking for differences.) Many child psychiatrists in charge of clinics today have completed one of these trainings. This does not mean of course that the