Franz Resch: “We should blend in with their everyday life.”
Franz Resch is professor of child and adolescent psychiatry at the Heidelberg University, head of the university clinic for child and adolescent psychiatry, expert in early onset psychosis and founder of the AtR!sk outpatient clinic for adolescents exhibiting risk-taking and self-harm behaviour. He is a keynote speaker at the 2019 ESCAP Congress in his birthplace Vienna.
The position of psychotherapy in child and adolescent psychiatry is a returning discussion on the European playing field. Insights differ between countries and educational backgrounds; when it comes to professional mental health care for adolescents, some advocates argue for burying the differences and concentrating at real relationships with young, almost adult patients. One of them is professor Franz Resch. Famous in Germany and Austria for his outspoken viewpoints in favour of psychotherapy. He pleads for a key role for psychotherapeutic skills in the psychiatric practice.
“Psychotherapy must be a standard part of the training of every psychiatrist. In Germany, we have convinced our politicians to put this into practice, but it is desirable that other countries would follow this example”, Resch says.
The whole person
“To me, it is very important that psychotherapy takes a core position for a psychiatrist. The look on psychopathology of a psychotherapist is quite different from someone who might only be looking at brain functions. The nosological orientation is only one way of looking at patients with mental disorders. It is important to also take a look at the functionality of the symptoms. We should not only try to understand where the symptoms came from, or what footprints these symptoms have within the brain. For applying drugs for example, it may be important to recognise pathogenic mechanisms of the brain – but that is not all. This may explain how symptoms can arise, but on the other hand these symptoms may continue to be there because they have a functional sense: they make sense in the lives of young people. The functional look on symptomatology and trying to understand the relevance of these phenomena is a more hermeneutic view, which is important to child psychiatrists because it changes their portrayal on mankind – the Menschenbild, as we say. We may know a lot about a child, for example, that it does not speak in the company of others – like in selective mutism – and we know how that works in the brain, and we understand the anxiety that those children have, then we still have to take the functionalities into account: how the parents and the siblings are trying to deal with this person and many other circumstantial aspects. We have to consider that for some reason, for the children in this example, staying mutistic may well be better than speaking. We should look at the whole person. Many of these symptoms are multicausal, and they are multifunctional. If we do not look at the individual causality and functionality of the person, we miss an important part of our view on the symptoms.”
– Would you say that psychotherapy is an essential skill for child and adolescent psychiatrists?
“Yes it is. It would be a great pity if we divide groups of skills, and consider psychotherapy as another profession, while we appoint psychiatry only for the neurological and pharmacological aspects.”
– Some say psychotherapy is not a profession, it is a skill.
“That is an intelligent observation and I agree with it completely. A ‘human’ psychiatrist would never strive for technical improvement like making better brains or increasing intelligence. The skill of psychotherapy may help us to prevent such stupidity.”
– Still, many European child and adolescent psychiatrist are not trained in these psychotherapeutic skills.
“Let us not give them up immediately. There are many ways of adapting and changing one’s views. These colleagues could perhaps change their way of thinking, without having to thoroughly learn all sorts of treatment methods. They could adopt the systemic view on patients, for example. Or they could take part in emotion therapy courses, or learn about psychodynamics and gather knowledge in developmental psychology. These are very important parts of the psychiatrist’s profession. These aspects are now trained on top of the training that we all had, but I think these should always be part of the standard training. Ideally, a full psychotherapeutic training should be part of the education of a psychiatrist.”
– Psychotherapeutic training also involves experiencing psychotherapy yourself. Should this be a standard part of the training for child and adolescent psychiatrists as well?
"Yes. In Germany it is obligatory. We need Selbsterfahrung as we call it – self-awareness. Many hours of it. Possibly by getting the chance to look upon yourself within a group, and by interacting with a supervisor. A therapist needs this, for example, for determining the problems that they themselves put into the relationship with the patient. Not everything in that relationship has to be from the patient – it may have come from you as well, and you need to be aware of this. You have to know what is your part of this by experience – if not, you may end up in very problematic relations with clients and the situation may get uncontrollable.”
– How should psychotherapy for young people adapt to ‘modern times’?
“The most important thing is that you adopt new ways of interacting with the patient. Short sessions, social media, applications for smart phones. For children and adolescents, a therapist would also need more building blocks from developmental psychology.”
– What kind of therapies would you say are relevant for adolescents in this era?
“In my opinion it is not the ‘school’ that matters. It does not matter if you are more psychodynamically oriented, or if you are working with mentalization-based treatment, or if you are more behaviourally oriented, or if you practice dialectic-behavioural therapy for young people. It is most important that a therapist adopts new ways of interacting with the patient. The traditional psychoanalytic routine of seeing a patient four times a week is outdated. This is nothing for young people today. We should blend in with their everyday life, because that is exactly what we are helping them with. The old fashion does not fit in with their lives at school, with their friends and in their families. As therapists, we should not disturb a patient’s social life with our interventions. Instead, we should help them to get on with their everyday lives.”
“Therefore, we are developing short intervention programmes, with repeated intervals for instance. Experiencing with these new treatments and measuring its affects, is bringing us new insights. The old animosity between the behaviourists and followers of a psychodynamic approach has stopped. Both have an important view and both views have produced very useful instruments to connect to patients. Together we should now concentrate on developing new intervention methods, including – for example – the use of social media to reach these young people. The core of psychotherapy will always be the adaptation to the relationship with the patient. It is our job to find out what is best individual way to get related to a young patient."
– How does psychotherapy relate to education at schools?
“This collaboration is of great importance. The school is the working place of the children. Not going to school is a form of unemployment. Not going to school is stealing their future. For inpatient care and day care, we have an official school integrated in our clinic in Heidelberg, as every main hospital has in Germany has. Additionally, we have facilities for ten outward patients, especially to tackle the problem of school refusal. These patients go to our school facility every day and attend therapy, weekly or whenever it is needed. Normally these patients can return to their own schools after an eight-week programme.”
“For outpatient care, we have regular contact with the teachers, or we exchange written reports on the progress of the children.”
Schools and prisons
– Would you agree that in many cases, schools are an underestimated source of information for psychotherapists?
“In some cases, that could well be true. In cases where school problems are part of the syndrome, we keep close contact with the teachers. We are quite open to such relations, although this is not a routine. But if it is necessary or desired by the children, we are very willing to maintain contacts with the teachers.”
– Are you able to offer your services to children who are locked into forensic institutions, or even in prison?
“This is a problem. For those who are in jail, we have to leave all care to their internal mental health services. And I must admit: this is a poor service. For these patients, the psychotherapeutic possibilities in Germany are bad – similarly to other European countries, I expect.”
“Unless there is a special court order, we only work with voluntary patients that do not have any real problems with the law. Only in ambivalent cases, such as anorexia nervosa, we meet patients that are forced to some kind of therapy.”
– Would it be desirable to maintain a closer collaboration with youth help services, schools, and prison?
“Psychotherapy is so important for the development of children and adolescents, that we should have a more integrated and collaborative view on young people’s problems. This is not only about child psychiatrists: the social workers, the psychological therapists, the nurses – very important! –, the educators, teachers, the musical therapists, the occupational therapists. All these supporters around the patients need to work from a common view and collaborate to support the children.”
Read more: the Franz Resch interview, on the new morbidity in adolescents.
This story: courtesy of the Dutch Association for Child and Adolescent Psychotherapy (VKJP).