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Dr. Gauthier is one of the bright lights in the field of child and adolescent psychiatry, both in Canada and on the international stage. In this interview, we will trace his career over the decades, during which time his professional development was closely intertwined with the development of child and adolescent psychiatry. Dean of the Université de Montreal (2 terms), head of the psychiatry department at the Université de Montréal, founding member and president of the Canadian Academy of Child and Adolescent Psychiatry (CACAP), and president of the World Association for Infant Mental Health (WAIMH), Dr. Gauthier is one of the true pioneers of child and adolescent psychiatry. Recently, he completed a book titled “L’avenir de la psychiatrie de l’enfant,” published by Editions ERES (Toulouse, France).
Let me begin by saying that young and “not so young” psychiatrists are unaware of the pioneers in child and adolescent psychiatry in their own country. I hope this interview raises awareness of how privileged we are to have professionals of your calibre—the giants of our profession—who have paved the way for others to follow.
My decision to move from Quebec to Philadelphia was one of the most important decisions in my life. It allowed me to work in a hospital environment that fully embraced psychoanalysis. There I discovered a dynamic form of psychiatry – one that would be the primary influence on my career and theories.
At that time, I had already read the first major works by John Bowlby, but it was only much later that I familiarized myself with the ideas underlying attachment theory. It is important to remember that John Bowlby was, himself, a psychoanalyst. Bowlby introduced the key concept that observing the behaviour and development of the child, and the mother-child relationship, was essential and must guide the development of theory—and not the other way around. For me, these observations of the mother-child relationship, which led to microanalysis, (Stern, Tronick, Fivaz, etc.) come together to form a dynamic approach, and have enriched psychoanalysis and attachment theory. Bowlby was reproached by analysts for being interested in behaviour alone; it was not understood that his concept of internal working models includes the fantasy world of the young child and is fully compatible with psychoanalysis. As well, attachment theory has modernized psychoanalysis, with its emphasis on the importance of early interactions. In other words, Bowlby called into question certain hypotheses within psychoanalysis by placing the emphasis on the social world of the child.
Yes, it was an enormous task to change the practices and behaviour of the pediatric staff who cared for hospitalized children. It took a full ten years to change the practices and mentality in the hospital, so that families encountered an environment that was consistent with attachment theory. In my opinion, the most significant impact of this work was the success in raising awareness among non-psychiatrist colleagues of the importance of preserving a secure attachment for children during hospitalization. Children (and their families) in such situations are already vulnerable, due to their illness; to make matters worse, they then find themselves separated from their families and placed in an unfamiliar environment. By simply making the staff more aware of why these children were in such distress, I believe we took a major step forward. It is also vital to acknowledge that certain children, who have chronic illnesses and are regularly hospitalized, bond with medical teams, with all the emotions this provokes within the medical teams, and to acknowledge the grief experienced by staff who become attached to very sick children on the brink of death.
Working with the director on the film titled “Les Départs Nécessaires” (or “Sudden Departures” since the film has been translated into English) has been an unforgettable experience. The film was very well received and widely distributed, and has provided me with a new perspective on how a story, told through the medium of film, can touch people on a different level.
The fact that I initiated this project demonstrated the importance I already placed on social factors in early child development. This research allowed me to trace the link between the fantasy (imaginary) life of the child and his environment, and family and community life. The drawings by children from underprivileged backgrounds are more disordered and the themes of their drawing are more likely to be disorganized and more aggressive than those of children from advantaged backgrounds. It is not my intent to deny genetic influences, but this research clearly has demonstrated how a social factor (poverty) can influence child development.
My research on asthma was another turning point in the evolution of my ideas and career. This research permitted me to observe interactions between mothers and children (between 14 and 30 months of age), and then follow them for 5 years, through hospital and home visits. The starting hypothesis was that the chronic nature and severity of the asthma was a reflection of the overprotectiveness and ambivalence of the mother. This was the period when mothers were blamed for all the world’s problems (refrigerator mothers caused autism). But we observed the opposite. Most of these children had normal interactions with their mothers, who were, in the vast majority, very adequate. Because our research was prospective, we realized that, if the children were still having difficulties after five years, it was caused by stress related to the illness. We, therefore, called into question the retrospective approach, which tends to attribute an initial cause from observations made much later. It was primarily through this research on very young children that I discovered the movement (primarily American at the time) toward infant psychiatry, with which I became gradually involved.
One must remember that, at the start of the 1980s, biological psychiatry had not yet been established. Heads of psychiatric departments were often psychoanalysts—like Fred Lowy and Gerry Sawer-Foner—who were profoundly influenced by psychoanalytic theory. There was no difference, or at least I perceived none, between adult and child psychiatry. My colleagues in adult psychiatry spoke the same language I did; that is to say that there was a common developmental theory underlying dynamic psychiatry. Today, all that has changed. Although we need to accept biological factors, we currently lack a developmental theory that can be applied to people of all ages.
As dean, you are confronted with a great many challenges that have nothing to do with psychiatry. I would like to think, however, that my training in psychoanalysis and child and adolescent psychiatry enhanced my ability to listen to others. I had made it a priority to develop the Department of Family Medicine and to make it a formally-recognized specialty in our institution; until then, it had been just a program. This was a complex challenge. It was difficult to convince everyone, especially those in already-established specialties, to think of family medicine as a specialty in its own right. I certainly saw a role for the general practitioner as someone who should have knowledge in several areas and be qualified to understand family dynamics and child development as a whole. There is a psychiatry-related component to this role, in keeping with the biopsychosocial approach.
Yes, these two interesting periods in my life (the two sabbaticals), were sandwiched between my time as dean, which lent a rather ping-pong-like aspect to my career at the time! I found the atmosphere in Montpellier to be very open. Although they were already receptive to problems related to prematurity, they had not yet explored the areas of pregnancy and childbirth. I went there to conduct a project that would study the effects of high-risk pregnancy on the mother-child relationship. This is how I came to work with child and adolescent psychiatrist Francoise Molénat— the preeminent authority in France in all perinatal-related matters.
Absolutely! My sabbaticals were productive periods in my professional and personal evolution, and I believe that universities must continue to offer the option of sabbaticals.
During my second sabbatical, I delved deeper into the idea of attachment and continued to ask myself why psychoanalysts still resist this as a concept, since the mother-child relationship is such an important element of attachment theory. This question inspired me to write these two articles. The second one is especially important, since it was published in the journal “Psychiatrie de l’enfant” by Serge Lebocivi, a highly-renowned psychoanalyst in France and the journal’s editor-in-chief. This article was a turning point for me, since it was an attempt to integrate current knowledge of psychoanalysis with attachment theory.
Currently, there is a strong trend in Canada and the United States to abandon psychoanalysis and dynamic psychiatry. I believe this brings with it a grave danger of throwing the baby out with the bathwater. In recent years, longitudinal studies with high-quality methodologies are confirming certain hypotheses that were developed by psychoanalysis. The work of Alan Sroufe in Minnesota, Mary Main at Berkeley, Howard and Miriam Steele in London, the Grossmanns in Germany, all demonstrate the impact of the mother-infant relationship on development across multiple generations. It is exciting to note all the possibilities for renewal and integration of biological and psychodynamic factors. The work of Michael Meaney here in Montréal (thought it is difficult to generalize from rat to human) provides a fascinating example, allowing us to see how mother-infant interactions can have a profound impact at the epigenetic level.
Yes, I sensed that many people had a special interest in young children and infants, but no professional organization existed to bring these people together. WAIMH, which is now an international organization, has only been in existence since 1980. As I hope I have already conveyed to you, I was passionately interested in this area, and wished to play an active part in promoting its vital role. I felt the same way about CACAP. At first, we had few members. While scientific studies are valid, it is equally important to raise awareness in society at large and these associations are an effective way to do this.
My concerns about children and teenagers in foster homes (I am referring here to cases where they are repeatedly moved and, as a result, suffer harmful consequences) arise directly from attachment theory. With repeated placement, they lose the opportunity to form quality links with others. If we look back to the original work by Bowlby, involving delinquent teens, we note that the majority of these teens had lost their mothers during their early childhood.
Nearly 15 years ago at Sainte-Justine, I developed a clinic with two pediatricians to provide preventative treatments for attachment disorders. I think this is an important area and one that requires collaboration between staff in social services and in child and adolescent psychiatry. It seems to me that we are currently working in two solitudes. Community services personnel very often find themselves trying to manage these youths when placement became necessary. Psychiatrists and other mental health staff are resistant to working in this area because it involves dealing with the legal system and that takes a great deal of time and patience. As a result, these two groups tend to work in silos, without collaboration, and the most vulnerable children lose as a result.
This book is my response to what I perceive to be a powerful trend towards domination in our field by psychopharmacology and genetics to the exclusion of psychodynamic factors. While I am certainly not against these new discoveries, it seems to me that this trend is accompanied by a strong tendency to set aside all we have learned over the past 40 years.
The thesis of my book is that we must integrate all new knowledge—both the work that comes from genetics and psychopharmacology, and seminal work of a longitudinal nature that stems from attachment theory and the area of early intervention. All factors—biological, psychological and environmental—have a developmental impact on the affected person and those around him. I use my own journey, which began in the early years of psychoanalysis, as a way to demonstrate the need to integrate all spheres of knowledge in the best interest of the child and his family.
To Dr. Aidan Stokes, for suggesting Dr. Gauthier’s name