March 2013
Richard S. Ward MD

Life Member LogoBill Langford was my training director in child psychiatry. Dr. Langford was one of the founders of child psychiatry in this country, an early president of the Academy (now the AACAP), and a founder and chairman of the Committee on Certification in Child Psychiatry (ABPN). He was the Director of Children's Psychiatric Services at the Babies Hospital in NY (Columbia Presbyterian where I went to medical school). He had started those services in 1935, and he was to stay in that position until his retirement in 1972. I was a trainee in his clinic for the two years - 7/1/48-6/31/50.

Although I was too junior to have much sense of it, I believe that Bill Langford was widely respected and even beloved, among his colleagues, both locally at Columbia, and nationally in child psychiatry. (See a memo by John F. Lambert in the Journal of the AACP, Vol.16, Issue 2, page 347, Spring 1977).

From my lowly vantage point as a medical student and then as an intern at the Babies Hospital Dr. Langford appeared as a fixture in the hierarchy there. I don't remember that he did any teaching of me at those early levels, yet he was a presence. At times, during my internship, I read some of his psychiatric consultations on patients I was involved with. I remember that his suggestions were very practical and free of psychiatric jargon.

In the spring of 1946, as the war was winding down in Europe, the Army changed its war-time deferments for residency training, and began a dance with me over when, if ever, I would be called to active duty. (I suffer from unilateral deafness, a right ear lost to mumps encephalitis, age 15 - not a good candidate for Army duty). Yet a letter suddenly informed me that I would be called on July 1st. My internship ended March 31, and my 2nd year residency at Cincinnati Children's was now canceled; I had 3 months open, with no position, and no money.

It was Dr. Langford who came to my rescue. He found, or created, a 3 month fellowship for me at the Emma Pendleton Bradley Home in Riverside RI, one of the first child in-patient psychiatric hospitals. That was an exposure to child psychiatry that was eye opening to me, and as it happened, ultimately shaped my choice of career.

Of course the Army was not done; July 1st was then canceled, and I was again scrambling for positions and stipends. Luckily I landed in Bellevue Hospital Children's Medicine (N.Y.U. - Dr. L. Emmet Holt Jr.) That was for 2 years, the 2nd one a wonderful year as the chief resident. That's where I really learned most of the medicine that I know. But, pediatric training done, I still remembered child psychiatry. So I came back to Babies Hospital and Bill Langford to learn more about it.

In 1948 the newly active NIMH advertised training fellowships in psychiatry and child psychiatry, and either I, or Dr. Langford, or both of us together, succeeded in getting one. Then, when the Republican Congress of 1948 canceled the funding for this program, Dr. Langford worked his connections with the Rockefeller Foundation to provide me a substitute fellowship. Not adequately learning from experience, we went through the same charade again the 2nd year - new NIMH fellowship, money canceled by Congress, back hat in hand to the Rockefeller Foundation again.

Bill Langford was an exceeding warm and generous man. He was always very good to me. I had ample reason to feel grateful to him for his unfailing support of me, although I suspect that that was really more a function of the kind of person he was, than of any strong belief on his part that I had any special aptitude for a career in child psychiatry. It was not his way to be dogmatic or critical. During the two years that I was a fellow there I do not remember any evaluative comment from him about me, or my work, positive or negative. Granted, one thing I do remember. He was enthusiastic about the possibility that I would get board certification in both Pediatrics and Psychiatry (and much later, of course, Child Psychiatry). That suggests some confidence in me. Unless, of course, his thought was just that I would need an awful lot of training. The Triple Board path did not exist back then; I did it the long way.

At the Babies Hospital I began as a total novice, and it was a precipitous fall from the prestige and recognition of a chief residency at Bellevue (with Dr. Holt's hands-on support), to stumbling around in a new field. It didn't help that Dr. Langford's seniority was such that his allotted vacation each year was the full summer at his country place; I started July 1st; he didn't come back until after Labor Day (My back-up for occasional supervision was a charming lady, Dr. Exie Welsh). But even when he was back, Bill Langford was a very non-directive director of a program. He always seemed relaxed and unhurried, qualities that I had begun to associate with child psychiatrists since my short time at the Bradley Home. I never saw him angry, or heard from him a sharp word.

In retrospect I am struck by how little I knew about Bill Langford outside of our relationship in the program, - what was his background training in psychiatry, what he had in the way of a wife and family, what was the significance of an apparent wandering eye (mild strabismus?) which seemed to come out when he relaxed back in his chair, whether that had been something that exempted him from active participation in the war? He talked many times about the Army's "90 Day Wonders" (drafted internists and surgeons whom the Army converted into psychiatrists in a Wisconsin based program 1942-3) and I had the impression that he had participated in some way (consultant?) in that program. I didn't feel empowered to enquire much into those kinds of things. I was the only full time trainee, so there was no fellow resident to talk to. That was true until close to the end of my time, when an advanced trainee in the analytic program, Gove Hambidge, came to get some part time exposure to child psychiatry with Dr. Langford. Gove was supported by the US Public Health Service and close to the end of his training. After the war he went on to a psychiatric career in Minnesota, but not child psychiatry, I believe.

The clinic that Bill Langford ran in the Babies Hospital was loosely modeled on the Commonwealth Fund supported child guidance clinics of the time. We had the three disciplines: Dr. Langford as the psychiatrist, a rather imperious and dogmatic woman as the chief social worker (there was also an assistant one, with whom I got along better), and at least one staff psychologist. I had ample supervisory time with all three.

The founders of child psychiatry were all somewhat mavericks and Bill Langford was no exception. His clinical work was very rooted in hospital pediatrics. The Babies Hospital was a tertiary care hospital with emphasis on Cystic Fibrosis, Nephrosis, Celiac Disease, H. Influenza Meningitis and so forth, so his focus was on special syndromes (often genetic), and the psychological aspects of conditions such as anorexia nervosa, ulcerative colitis, or childhood asthma. He was not much of a theoretician in child psychiatry. A popular concept of the time was Erik Erickson's reformulation of Freud's 5 psychosexual stages into 8 psychosocial stages. Bill Langford was aware of all this, but I never heard him use it to explain anything about a case. He was more enthusiastic about Leo Kanner's first description of infantile autism, yet I remember that he had some reservations about Kanner's concept of the "refrigerator mother". His approach to parents was mostly collegial; he rarely devoted energy to conceptualizing their emotional problems.

Bill Langford's psychiatric thinking always struck me as rather concrete. He had an amazing memory for the details of cases he had seen, and could tell endless anecdotes about them. That was his way of thinking about them, rich in narrative and concrete observations, very sparing in interpretations of what might be causing what. He did lots of careful follow-ups on his former patients when they returned to the hospital for any reason, so his view of them included a trajectory from early in their psychiatric difficulties through to a continuing curiosity about what happened to them much later. This gave him, I think, a somewhat unique perspective. His office was piled high with charts, in which he was always behind in his observations, notes, and follow-ups.

His way of supervising me was also unique. When I reported to him about a case that I was seeing in the clinic, looking for his approval or criticisms of my efforts as a beginning psychotherapist, his response was generally oblique. He would tell me what he had done with a case of his own that seemed to him to have some parallel with my case. This gentle way of teaching by example was probably over my head at this stage of my development. I was overly intellectual and lacking in basic confidence in my skills in emotional communication, especially with children. Gove Hambidge, further along in psychiatry and more self-confident, clearly enjoyed this kind of supervision. My frustration with the approach was much like the old story about the chess novice, eager to learn faster about chess, who hires a chess master to teach him the "basic principles". The novice discovers that the master doesn't know any "basic principles". He doesn't think about chess that way. The master prefers to teach by starting a game and making little comments as they go along. The frustrated novice is left with his struggles to find his own rules and principles.

By my 2nd year of fellowship, I realized that I definitely was going to need more psychiatric training. I felt the need to understand adult patients as well as children, and for this I went on to apply for a general psychiatric residency at Columbia, mixed with enrollment in the newly developed Psychoanalytic Clinic (Drs. Rado, Kardiner, etc.). As a part of all this I had already found a training analyst; it was Dr. Abram Kardiner.

I guess that people react in different ways to beginning a personal psychoanalysis, and I have no survey to tell me if my reaction was idiosyncratic or not. But for me, the facet of the experience that dominated all the others was simply that, for the first time in my life, I had somebody of importance who was committed to sit and listen to me for 45 minutes, three times a week. Obviously this satisfied some hunger in me to be listened to, the depth of which I had been relatively unaware of before. I treasured every minute of those sessions.

So a problem soon emerged in my supervisory sessions with Dr. Langford. Those sessions came at the end of the working day, and often just before I left to go to an analytic appointment. With Dr. Langford the closing of the session was never easy. I am reminded of one test we used back then in studying ADHD (we called it Minimal Brain Dysfunction). It was part of the search for minor signs of difficulties in perceptual motor development, less emphasized today in the criteria for ADHD. This test involved setting up a stage, and inviting a child to choose puppets to act out the parts of a story on that stage. What we looked for in MBD kids was a difficulty in closing, where to stop in adding new characters. Some of the kids just couldn't decide where to stop. As long as there were unused puppets, they would keep adding them to the cast, while the justification for each addition would make less and less sense, until there was no justification at all. I am not sure exactly what this test revealed about brain function, but it definitely showed a problem in closure.

Dr. Langford, in supervision, was a little bit like that. His anecdotes would start by being relevant to the case we were discussing, but after a while those connections would dwindle until they just seemed to be anecdotes that he was reminded of by some chance association. The end of our hour might be long passed, but as he finished one story, before I had a chance to move, he was already started on another one. I was reluctant to say " Dr. Langford, I really must go". I didn't want to be disrespectful or appear uninterested. I didn't want to discuss where it was that I was going (analysis). I didn't know how he felt about my having taken the step to start an analysis while I still was a fellow in his clinic. So I developed a strategy. After one pause in his talking I would stand and listen to the next story standing up. Then, at intervals I would move toward the door. Then I would be standing in the doorway. Finally when he drew a breath I would disappear from the doorway, break for the stairway, down to Broadway and the subway downtown.

Fast forward some 17 years. I was at Emory University in Atlanta, having initiated there both a child psychiatry training program, and the beginnings of a psychoanalytic institute (the analytic program was an offshoot of the Columbia Psychoanalytic Clinic where I still retained a faculty position). With our chairman, Bernie Holland, as the driving force, we had gotten the State of Georgia to build the Georgia Mental Health Institute, a joint state and university enterprise for psychiatric training and research (modeled after the Psychiatric Institute in NYC, or the Langley Porter Clinic in San Francisco). The child and the adolescent buildings were not yet completed, so at the time in question, I still held responsibility for the child psychiatric clinic on the Emory campus (later we recruited Jerry Wiener to lead the child program at the GMHI. The Emory department of psychiatry was riding high. This was still some time before political difficulties with the state government under Carter, as well as the force of deinstitutionalization, tragically began to doom all of the GMHI to impotence and failure (sparing only the bright spot of the research labs).

Sometime in about 1966 or 1967, I got a phone call from New York. It was Bill Langford. He told me the news that the NIMH was about to fund a first-ever national conference of child psychiatry training directors. And it was to be held in Atlanta, at our new facilities in the GMHI. But there was a catch. He was anxious to be the first to tell me about this because of the awkward fact that the NIMH had set a strict limit of 25 child program directors for the conference, and according to their records nationally I was listed as number 26. He didn't want me to hear about it before he had had a chance to explain it to me. Although Emory was to be the site of the conference I was not personally going to be invited to it.

I don't remember being bothered by this particular awkwardness; I looked forward to seeing him. When the weekend of the conference rolled around, I picked him up at the airport and took him to his hotel. I enjoyed seeing him. He had planned his arrival for the afternoon before the meeting started, so there would be time for us to talk. I told him the history of the child psychiatry program at Emory and showed him the new buildings at the GMHI. He in turn filled me in with follow-ups on patients I had seen 17 years before during my fellowship with him. He remembered them well; I remembered them scarcely at all. The difference between us was striking, and I couldn't help wondering if, I had followed his example more, I might have turned out a better child psychiatrist.

That evening I had arranged for him to be entertained at dinner with our child psychiatry faculty and residents. Swanson Millians (of sainted memory) had volunteered to host the occasion at his house. I drove Bill Langford out to Swaney's house, where after dinner we sat around and talked, mostly our guest doing the talking. The faculty and residents were entranced. Bill Langford was in fine form.

As the evening wore on. I began to be concerned about the time. I knew that Dr. Langford had to get up early the following morning for the conference, and I felt responsible to get him back to his hotel room for some rest before the work weekend started. The audience showed no flagging of attention. If I looked for any sign that Bill Langford was feeling any need to stop, there was none. The stories and anecdotes rolled on.

It was then that a little voice at the back of my head spoke up. "Have you no capacity whatever to learn from experience?" it said. "You, of all people, should know that this man is almost totally unable to find a closing point for himself." So, I abruptly rose to my feet, and said "Dr. Langford, I think that it is time that we need to be getting you back to your hotel.' He made no protest. He got up, got his coat, and obediently followed me out to the car.