The Psychotherapeutic Role of the Pediatrician, by Milton J. E. Senn, MD, Pediatrics, 1948;2:147–152

The pediatric literature of this country has drawn increasingly on material from a variety of sources relating to the psychologic aspects of child care. The number of papers appearing in pediatric journals on the topics of child psychology, deviant behavior and mental illness, mental health, child development, psychiatric treatment, sociology, and even anthropology bears witness to this occurrence. For example, the pediatrician is urged to become acquainted with the facts of growth and development so that, as a “developmental pediatrician,” he may predict and interpret the behavior of children to their parents. Psychiatry, pediatrics, psychology, and education have all made contributions to the field of psychotherapy. Although each may credit specific techniques and methods from their respective professions, one wonders if the constituent principle held in common by these disciplines may not depend on a common factor that lies beyond the techniques and methods expounded. In searching for the essential ingredient in the therapeutic process, one discovers that what is important involves a process in the interpersonal relationships between the patient and the therapist. Successful psychotherapy requires from the therapist a highly personal and individual orientation and regard for the individual. In our culture, the physician is considered to be a person of wisdom, perhaps even of magical power. Considered trustworthy, he becomes the repository of secrets about problems that cannot be shared with anyone else. In addition, he is expected to supply guidance and advice capable of practical application. In describing the pediatrician9s view of the essential elements of his role as a therapist, first on the list are those qualities of character and personality that further the establishment of confidence, faith, or rapport. The question that may be asked is, “How does a physician instill confidence in a patient and maintain rapport?” The primary requisite in the development of a therapeutic physician-patient relationship lies in the ability of the physician, first, to be aware of the feelings that the patient brings and, second, to be able to accept them whatever their nature. Actually, in order to help the patient it is neither necessary nor desirable in every instance to offer anything more than the opportunity for the establishment of a relationship. In the beginning of treatment the physician is an observer, interested in his patient and particularly the feelings that he brings with him. The important thing is not whether these feelings are positive or negative but rather how the pediatrician is able to allow the patient to experience them in the time spent with him. Once the patient has had the experience of being accepted, he begins to develop trust in the physician. It may be said that the therapeutic situation has been established when the patient has succeeded in identifying the physician as a reliable and trustworthy person. The patient enters the relationship with an ambivalent attitude—on one hand trying to receive help, on the other guarding against its receipt. To many physicians it seems contradictory that anyone should have such strong mixed feelings when in need. It is not always easy for the pediatrician on the basis of time and in the framework of therapy to permit the patient to bring out his feelings. At times, the physician will feel at-ease, calm, and relaxed and, in those states, he finds it easy to accept the patient as he is; in contrast, on other occasions, even with the same patient, he may feel angry, hostile, frustrated, or tense and find the situation almost impossible to bear without bursting out with a word of censure or of criticism. The pediatrician must be able to keep himself sensitive and responsive to the needs of his patients, accepting them in their human qualities without becoming engulfed in their distress. In order to achieve such objectivity, every physician should have an understanding of the behavior of people under stress and an awareness of his own personality so that he recognizes the reasons for his different responses to the diverse emotions of patients. To be truly effective, pediatric training must provide ample opportunity for the establishment of intimate teacher and pupil relationships. With these at the core of training, not only will pediatricians learn the fundamentals of child care, but they will be able to incorporate quite naturally psychologic insight with medical understanding and make pediatrics the comprehensive discipline it should be.