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THE PROBLEMS OF
(This was originally given as an unpublished lecture in 1970.)
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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