IT IS COMMON KNOWLEDGE that experiences in the
first years of life have a profound influence upon later mental health. In
particular, it is known that to ensure good social and emotional
development the young child needs a stable relationship with a responsive
mother figure (Bowlby, 1951). This is an experience that most young children
find within the security of their families.
An implication of this knowledge is that if a young
child has for any reason to lose the care of his mother, it
is
essential that his experience of responsive mothering be maintained. But at
the present time, if a young child goes into hospital without his mother, he
will be handled by a succession of nurses, and if he goes into residential
care he will rarely there a stable mother substitute.
Why does this happen? Why is
it that
although the importance of meeting the emotional needs of young children is
well established by research, and is taught in many trainings, this
requirement of mental health is not well attended to in our child-care
practice? Why is it
that
although we know it to be imperative that young children have stable
relationships, we still fragment their care among many people when they come
into hospital or other residential settings?
If the relevant professions had a serious concern to
meet the mothering needs of young children in their care, practical
difficulties arising from staff shortages and the short working week might be
found to be hard to overcome. But scanning the journals of the paediatric,
nursing and other caretaking professions reveals that, although there is an
endeavour to provide play and education, there is
little or no reference to the much greater need for mothering-type care.
Systems of care that disastrously fragment
relationships can operate in institutions busy with ‘child-oriented’
activities, and are more likely to result from planning for work efficiency
than from staff shortage. It is well known, for instance, that even in large
teaching hospitals where there is no staff shortage, nursing is commonly
organized on a ‘job-assignment’ basis in disregard of the emotional needs
of the young patients, even though in the same hospitals the nurses are likely
to be taught the importance of stable relationships.
The major obstacle to suitable care is neither
practical difficulty nor lack of knowledge. It is that, whatever level of
intellectual understanding may obtain throughout the professions, the
appropriate sense of urgency and alarm is missing, or is dampened down. There
is a tendency for even the best-educated and the best-motivated of people
working with young children to become to some extent habituated to the states
of distress and deviant behaviour that are commonly found in young children in
hospitals and other residential settings.
Thus the medical or nursing student, who in the
beginning may be seriously affected by the distress of the young patients
separated from home, will in time develop a ‘second skin’ against being
upset by these painful sights and sounds. Later encounters with similar
distress make less and less impact than did the first, and to some extent
sensitivity is blunted.
Similarly, at more senior levels those who arc all the
time associated with situations of stress for young children — the executive
officer with absorbing administrative responsibilities, the child-care officer
with a heavy case load — may become distanced from the problem and lose the
sense of urgency which goes with full awareness.
Intellectually there may be good understanding of the
typical distress responses in newly separated toddlers and of the personality
impoverishment that results from lengthy experience of discontinuous
relationships common in residential care and in long-stay hospitals; but
because concern is blunted the reality situation has a certain psychological
distance even for those working within it.
Paediatricians, child-care officers, policy-makers and
administrators may understand very well that the behaviour of bright and
disarming, deprived young children is unsatisfactory development, yet take
comfort from the bland behaviour just because it is superficially reassuring
and fits into the need for peace of mind.
The worker’s defence against pain may cause him
unwittingly to avert from the newly admitted child whose extreme distress is
painful to see, accepting with resignation that this is inevitable and that in
time this child, too, will merge with the others who are bright and
unattached. Young children tend to be seen en masse or only fleetingly
as people, with little awareness of their individuality and less of their
extended individual experience. Although this may be imposed by the nature of
the job, the fleeting contact or the view en masse can only be a way of
defending against the hurt of coming close to the plight of the individual in
distress.
It has to be acknowledged that this defence against
hurt is not confined to the professions. It is used by all human beings as a
way of dealing with persistent threats to comfort, becoming deaf or bunkered
as the situation requires. But when it becomes insidiously
effective in the caretaking professions, a consequence is not only reduced
stress for the worker but the sense that the problem itself seems less
pressing.
Even the literature comes to have less meaning than in
student days when it was first learned that early separation from the
mother into hospitals and residential institutions commonly results in
overwhelming distress — in protest and despair. These phrases, so evocative
when first encountered during training, come in time to be barriers against
the empathic pain they once aroused. Familiarity gives a palatable gloss to
case material.
A degree of fatalism enters in. The problems may seem
too immense, and the detriments inevitable and unavoidable. Without putting
the reservation into words, or even into clear thought, the consoling notion
may be harboured that young children in long-stay wards or residential
institutions are in some way different from our own more fortunate children —
not
to be compared to them. So, with these elements of defensiveness and
rationalization, many within the services acquiesce more or less in child-care
practices that are an affront to their understanding and training and that
endanger the well-being of the young child.
In this situation it is not only that the
children are cared for in ways which are detrimental to their good social and
emotional development. Their caretakers, mostly young girls with little
intellectual understanding of the problem but with affection for children, are
also denied the conditions of work that would fully utilize their potential to
be good substitute mothers. They in turn tend to become defended against
disappointing relationships with the children and frustrated in the expression
of their mothering concerns. Their natural empathy becomes
blunted and they grow less perceptive of the needs of
the young children whose care they share with others. Their ability to help
and support the younger children is thereby diminished.
Thus, in the everyday handling of young children in
hospital and other institutions the rank and file develop defensive attitudes
to distress and deterioration similar to those in the higher levels of the
professions, pressed upon them by work situations that deny them adequate
involvement with the children.
Although there is everywhere goodwill and good
intention towards young children in care, with great resources of knowledge
and understanding of their needs, and although statements of principle issue
from the Ministry of Health and the Home Office, the field situation stagnates
because the common defence against pain allows the acuteness of the problem to
be dulled as by a tranquillizer.
Without a sufficient degree of anxiety in the
professions there can be little improvement, no matter how much knowledge is
available. The problem is how to bring pain and anxiety back into the
experience of professional workers, but in such a way that these are put to
constructive use instead of being defensively sealed off by the constant
pressure in all of us to escape hurt.
Our way of focusing attention on the problem was to
turn to narrative film. The advantages of a narrative film record are twofold:
first, presentation on film gives the nearest approximation to actuality and
the visual medium is much more effective than the spoken or printed word in
piercing resistance in the field of child-care. Secondly, by focusing on one
child it is possible to show the sequence of events from first day to
last, noting shifts and changes in significant areas of behaviour, and to
condense the related factors within a relatively short presentation. This
allows the child’s experience and behaviour to be perceived in a
longitudinal way that is not possible for staff caught up in multiple duties
and diversions or for the occasional visitor open to impressions from the
entire child group.
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