Fonagy & Tronick

I want to make a statement to my professional colleagues – clinical psychologists and other mental health professionals – regarding the knowledge needed for professional competence.

In every clinical experience I’ve been in, the professional standard of practice expectation is that you know everything there is to know about the pathology, and then you read journals to stay current.

I consider that expected standard of practice.  So, when I was actively working in ADHD, I knew everything there was to know about ADHD and its treatment, and I was reading journals to stay current.

Same for when I moved into high-functioning autism as a differential diagnosis with ADHD.  As my work in pathology expanded into autism-spectrum pathology, so did the professional expectation for expanded knowledge.  I then had to learn everything there is to know about autism, and read the journals to remain current.

My shift in focus on ADHD into earlier childhood and the developing brain met with an increasing knowledge of autism-spectrum pathology, and I moved into early childhood mental health, a high-knowledge domain.  Psychology in the birth-to-five age range requires extensive knowledge of brain development – involving rapid and ever-shifting developmental phases across multiple systems.

You’ll see on my vitae a whole area of additional training I took when I entered early childhood mental health.  There’s an expectation when working with a pathology.  You’re expected to know everything there is to know about the pathology and its treatment, and then you read journals to stay current.

That’s what makes an old clinical psychologist kind of special.  I know everything there is to know about a lot of different pathologies.  Every pathology I’ve ever worked with, I knew everything about it at the time I was working with that type of pathology.

That’s called a professional standard of practice.  That was the expected standard of practice for all the physicians at the Children’s Hospitals I worked at.  I worked at two.  Don’t you want your child’s physician to know everything there is to know about your child’s pathology, and to be reading journals to stay current?

Of course you do.

I’m not a physician.  I’m a psychologist.  But I worked at Children’s Hospitals as a pediatric psychologist.  That was my world.  I was on medical staff at Children’s Hospital of Orange County as a pediatric psychologist, working with Jim Swanson and the UCI Child Development Center on a clinical research intervention for ADHD in preschool-age children.

Where I come from, the expectation of professional practice is to know everything there is to know about the pathology, and then read journals to stay current.  That is consistent with professional standard of practice expectations at a Children’s Hospital.

In assessing, diagnosing, and treating attachment-related pathology, Bowlby’s three volumes and the Handbook of Attachment are essential.  In assessing, diagnosing, and treating family pathology, Minuchin and Bowen are essential.  For conflict, Tronick and the Still Face research on the breach-and-repair sequence is essential.  If you are working with narcissistic or borderline personality pathology, then Kernberg, Millon, Beck, and Linehan are all essential.

Does that sound like a lot to know?  It’s not.  In the world I come from, the standard of professional practice is to know everything there is to know about the pathology, and then read journals to stay current.

Does that seem like an excessively hard standard?  To know – everything – there is to know?  It’s not. 

It’s considered standard of practice at a Children’s Hospital.  Don’t you want the treating physician for your child to know everything there is to know about the pathology, and be reading journals to stay current?  Of course you do.  That’s considered standard of practice for the treating physicians at a Children’s Hospital.  That’s professional standard of practice.

Whatever pathology you are working with, you are expected to know everything there is to know about the pathology, and be reading journals to stay current.  That means if you are working with an attachment pathology, you need to know everything there is to know about the attachment system.  Everything.  Families, family systems therapy.  Personality disorders, trauma, IPV, whatever the pathology is that you’re working with – everything there is to know and read journals to stay current.

You need to know the work of Peter Fonagy and Edward Tronick.  You need to, it’s not optional.

Peter Fonagy

Peter Fonagy’s work on borderline mothers and the intersubjective mentalization of the child’s psychological experience is required reading.  These articles by Fonagy regarding borderline personality pathology are required reading for all mental health professionals working with complex family conflict surrounding divorce.  Required means not optional.

Fonagy, P., Luyten, P., and Strathearn, L. (2011). Borderline personality disorder, mentalization, and the neurobiology of attachment. Infant Mental Health Journal, 32, 47-69.

Fonagy, P., Steele, M. & Steele, H. (1991). Intergenerational patterns of attachment: Maternal representations during pregnancy and subsequent infant-mother attachments. Child Development, 62, 891-905.

Fonagy P. & Target M. (2005). Bridging the transmission gap: An end to an important mystery in attachment research? Attachment and Human Development, 7, 333-343.

Fonagy, P., Target, M., Gergely, G., Allen, J.G., and Bateman, A. W. (2003). The developmental roots of Borderline Personality Disorder in early attachment relationships: A theory and some evidence. Psychoanalytic Inquiry, 23, 412-459.

If you are working with narcissistic and borderline personality pathology (which you are), then Kernberg, Millon, Beck, and Linehan are all essential – and Fonagy for borderline personality and attachment pathology.

Fonagy’s research describes the role-reversal relationship of the borderline parent’s interactions with the child, that feeds on and destroys the child’s inner psychological structure.

In borderline (and narcissistic) pathology, the parent psychologically feeds on the child’s self-structure development to meet the parent’s own need to support the parent’s own damaged self-structure.  That’s Fonagy, the role-reversal use of the child to meet the parent’s needs.

What ignorance sees as a “bonded” relationship to the parent is actually an extremely pathological and destructive role-reversal relationship, in which the child is being used to meet the parent’s emotional needs.  That’s Fonagy and the borderline parent.

Edward Tronick

The Still Face research of Dr. Tronick at Harvard is remarkable and essential knowledge regarding the parent-child relationship and the nature of conflict.  Google still face Tronick YouTube, and Dr. Tronick will explain the research and the breach-and-repair sequence.

Tronick: Still Face

You see what Ed Tronick at Harvard says about the breach-and-repair sequence, he calls it “the good, the bad, and the ugly” – you heard that, right?   The worst possible thing we can do – the ugly – is to leave an un-repaired breach in the parent-child relationship.  That’s the WORST thing possible, to leave the child in an un-repaired breach with a parent – the “ugly” of Dr. Tronick’s characterization.

Dr. Tronick’s work isn’t about infants – it is… and it’s more.  It’s about the structural development of brain systems governing social interaction, and for navigating social conflict, the breach-and-repair sequence.  This is how we’re constructed to work. 

Conflict is normal, excessive conflict is unhealthy.  The key to conflict is the breach-and-repair sequence.  We always want to repair, we never leave an un-repaired breach in the parent-child bond.  How do we repair?

That’s why you need to know Tronick and the Still Face knowledge.  He will explain how we repair.  Daniel Stern also does a remarkable job of explaining the sequences of repair as well.  Stern and Tronick will open up doors of understanding regarding protest behavior and the breach-and-repair sequence.

Not only should you know Bowlby and all of the attachment literature, you should know Minuchin and Bowen (hopefully more) from family systems therapy, Kernberg, Millon, Beck, and Linehan from personality disorders, van der Kolk regarding complex trauma (and hopefully Perry and Briere regarding trauma), and Fonagy and Tronick (hopefully Stern) from neuro-development and intersubjectivity.

Does that seem like a lot?  It’s not.  Standard of practice is to know everything there is to know about the pathology, and then read journals to stay current.  That has been the standard and expectation everywhere I have ever worked.  That was the expectation working at Keith Nuechterlein’s project on schizophrenia at UCLA.  It was just expected that everyone knew everything there was to know about schizophrenia and we were reading journals to stay current.

Now no one can know everything… except maybe Keith on schizophrenia.  Seriously, he knew everything.  If you’re in conversation with Keith and you don’t know something, he’s nice and all about it, but you feel like, dang, so then you have to go learn everything so you don’t feel completely ignorant in conversation… The expectation is that you know everything there is to know about the pathology, and then read journals to remain current.

That was the expectation working with Jim Swanson and the UCI Child Development Center.  Jim Swanson is another one of those knows everything there is to know about ADHD grand-kahuna type people.  That’s why I went from Children’s Hospital of Los Angeles (CHLA) to Children’s Hospital of Orange County (Choc), it was specifically to work on a project with Jim Swanson on ADHD in preschool-age children.  His work in the field is substantial.  I remember he put me onto an adaptive genetics line of the ADHD research that is intriguing.  His psychometric innovation from the SNAP to the SWAN has also been of immense value in the creation of the Parent-Child Relationship Rating Scale, anchored to a normal curve, bow to Dr. Swanson and the SWAN.

Again, Jim never made you feel stupid for not knowing something, but dang, he knew everything and you were kind of wasting his time if he had to explain things so… the expectation was that you know everything there is to know about the pathology, and then read journals to stay current.

That was the expectation working on the spina bifida clinic at CHLA, and on oncology research at CHLA.  That was the expectation for standard of care at Choc – to know everything there is to know about the pathology, and then read journals to stay current.

Ignorance is lazy.  Go be lazy somewhere else.  If you are going to work with a pathology, know what you’re doing.

A child rejecting a parent is an attachment pathology.  The attachment system is the brain system governing all aspects of love and bonding throughout the lifespan.  A child rejecting a parent is a problem in love and bonding, a problem in the attachment system.  It is standard of practice for you to know everything there is to know about the attachment system and attachment pathology, and to be reading journals to remain current.

A child rejecting a parent surrounding divorce is a family pathology.  It is standard of practice for you to know everything there is to know about family systems therapy, and then be reading journals to stay current.

If this seems like a lot to expect, it’s not.  You’re just lazy.  Lazy is not tolerated at a Children’s Hospital.  That’s not acceptable standard of practice for children and families.  When children’s health and well-being is on the line, the standard of practice is to know everything there is to know about the pathology, and then to be reading journals to remain current.

What possible argument can there be in favor of ignorance and laziness in professional practice with children and families?  What possible argument can there be in favor of ignorance and laziness in professional practice with the courts, when lives hang in the balance?

The professional standard of practice expectation is for the highest standards of practice, which means that you are expected to know everything there is to know about the pathology, and then be reading journals to remain current – that’s attachment, family systems therapy, personality disorders, complex trauma, and the neuro-development of the brain in the parent-child relationship.

That especially includes Fonagy and Tronick.

Knowledge and the application of knowledge is a professional expectation and standard of practice (Standard 2.04 of the APA ethics code).

Everywhere I have ever worked, the expectation and standard of practice is to know everything there is to know about the pathology, and then read journals to stay current.  That’s the standard of Children’s Hospitals, and I agree with that standard when working with children’s mental health and well-being.  

That’s the standard I apply, I’ll leave it to others to explain why their ignorance and laziness is warranted.  The standard of practice in my world is to know everything there is to know about the pathology, and then read journals to stay current.

Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857