The quest to integrate pediatrics and mental health has engaged me for many years. The journey began in 1979, when I was a 17-year-old volunteer at New York Hospital Cornell Medical Center Westchester Division, and has led to my current position as a scholar with the Berkshire Psychoanalytic Institute and practicing pediatrician. After that spring/summer of 1979, when I had the opportunity to observe my beloved mentor Paulina Kernberg (who has recently died) teaching and working with children, I decided to be a child psychiatrist. However, I was turned on to the magic and wonder of child development when, while working as a research assistant with Kernberg between my first and second year of medical school, I took a course she taught on the subject to child psychiatry residents. My interest then turned to pediatrics. I saw the tremendous potential for helping children from the perspective of a professional who has a relationship with a family over time and can watch development unfold.
While I have been on my personal quest to integrate pediatrics and mental health, the field of pediatrics has been on a similar quest. The term “behavioral pediatrics” first appeared in the pediatric literature in the early 1970s, following the major advances in immunizations of the 1960s, which resulted in a significant decrease in morbidity and mortality from acute infectious diseases. Currently it is estimated that 30 percent of visits to the pediatrician involve some behavioral or psychosocial concern.
Following my residency in pediatrics, a fellowship in developmental and behavioral pediatrics, with its focus on research and multidisciplinary evaluation in the tertiary care setting, did not answer my original question of how to address mental health issues effectively in the primary care setting. A child psychiatrist I worked with gave me the idea of getting supervision for my behavioral cases in my primary care practice. My first experience with supervision, with Michael Jellinek, chief of child psychiatry at Massachusetts General Hospital, was deeply meaningful and helpful in my work at a community health center in Revere, Massachusetts.
Over the next 10 years, I practiced pediatrics in various settings. Then beginning in 2001, following a move to the Berkshires, three events occurred which helped the pieces of the puzzle of mental health and primary care fall into place. First, I began therapy with a senior staff member at Austen Riggs. With him I learned firsthand the value of the relationship itself. This had a profound effect on me personally, and I was also able to bring this experience to my clinical work. Then in 2003, when Otto Kernberg came to speak at Austen Riggs, I reconnected with Paulina. She praised my efforts to address the mental health needs of children in a preventive model, and agreed to do supervision with me. Our work together coincided with the third event, the acceptance of the first class at the newly formed Berkshire Psychoanalytic Institute. With Kernberg's encouragement, I had begun to do more behavioral pediatrics, and was eager to learn. I was accepted as a scholar with the institute and began to have regular supervision with a faculty member.
It was then that I began in earnest to develop my own ideas, based on the combination of my clinical experience and studies with the institute. When I learned of Winnicott's concept of “true self” and “false self,” I saw great relevance to my work. I sensed that when a child presents with a behavior symptom, something was preventing the parent from seeing the child's “true self,” and the symptom was a manifestation of the “false self.” The work of Paul and Anna Ornstein on parenting as a function of the adult self, helped me to understand why I was able to help some families and not others. When a caretaker experienced empathy from me in the clinical setting, he/she was free to access what was preventing him/her from empathizing with the child. When I tried to give advice, the standard approach of pediatricians to behavior problems, without understanding the caretaker's experience of this particular child at this stage of development, my words seemed to fall on deaf ears.
As I now read the current work on attachment, mentalization, and affect regulation, I see great potential for application of this work in the primary care setting. Expanding on the concept of empathy, it is my hypothesis that something in the caretaker's experience is preventing him/her from holding the child's mind in mind. The resulting affect dysregulation in the child manifests as the behavior symptom in the pediatricians office.
When I redefine my task as pediatrician from “managing behavior problems” to “facilitating empathy,” meaningful change often happens in one or two visits. I play and talk with the child while giving the caretaker an environment in which to tell his/her story, thus holding both the caretaker's and the child's experience simultaneously. In this way, I am able to help a caretaker access what is preventing him/her from holding the child's mind in mind. For example, a mother is unable to control her 2½-year-old daughter's aggressive behavior toward her 1-year-old brother. In the first visit, Mom realizes that her own anger at her own younger sibling has prevented her from setting effective limits with her daughter. Armed with this insight, she is able to come into her role as mother.
Claudia Meininger Gold, M.D., is a scholar with the Berkshire Psychoanalytic Institute. She practices pediatrics in Great Barrington, Massachusetts.
Not only does the conflict between mother and daughter soften, but the siblings are free to find pleasure in their relationship.
By working in this focal way, the rapidly progressing train of development can get back on track Often significant issues are uncovered in the caretaker and family which may need more in-depth therapy. However, there can be resistance to therapy and, once in therapy, change takes time. The pediatrician has the opportunity to use the powerful insights about human development offered by psychoanalytic theory in a preventive way in real time.