The Problem of
Professional Anxiety
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 find 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 people 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 are 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 or 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 blinkered 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 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 the 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 and 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.
JOHN
Age 17 months In a Residential Nursery for Nine Days
Silver Medal, Venice Film Festival Silver Medal, British Medical Association 1971 B.L.A.T. Trophy for a Film of Outstanding Educational Merit 43 minutes VHS B
(Available in Canada from the CSPCC)
SYNOPSIS OF FILM
At 17 months John was a placid child and easy to manage. He and his parents had moved into the district a year earlier, and there were neither kin nor close friends to care for John while the mother was in hospital to have a second baby. Father would ordinarily have stayed home to look after John, but in that very week an insuperable circumstance prevented him. The family doctor recommended placement in a local residential nursery.
There in the toddlers' room John joins five other children between 15 months and 2 years of age. Four of these children have been in the nursery from the first few weeks of life, and because of the frequent changes of nurses have never known stable loving relationships; they are aggressive and unattached. The fifth child, Martin, had spent his first year in foster care and continues to see affection - the only child apart from John to do so.
During the first two days in the nursery John behaves for much of the time as he did at home, confident that people in the environment will respond to his needs as his parents had done. When this does not happen he is increasingly bewildered and confused, but he does not immediately break down. He makes more determined efforts to get attention from the nurses, but he cannot compete with the more assertive institutionalized children and his quiet advances are usually overlooked.
When John fails to find a nurse who will take the place of his mother he turns to teddy bears almost as big as himself. But clinging to these gives only fleeting comfort, and John gradually breaks down under the cumulative stresses of loss of his mother, the lack of mothering care from the nurses, strange foods and institutional routines, and attacks from the aggressive toddlers. He refuses food and drink, stops playing, cries a great deal, and gives up trying to get the nurses' attention.
His distress becomes so obvious that it can no longer go unanswered; the nurses pick him up and hold him more, but they are on shift duty and have also to attend to other children. Because of the work-assignment system, they cannot give sufficient individual attention to help John sustain the temporary loss of his mother.
When his father visits John revives briefly and gives a glimpse of the normality behind his distraught behaviour. But as the days go by he turns away from the father who does not answer to his wish to be taken from the nursery, clearly shown by John's gestures. Father is painfully aware of the deterioration in his son, and is distressed that he cannot take him home. John withdraws more and more from the busy life around him. For long periods of the day he lies with thumb in mouth, enveloped by a large teddy bear. He is overwhelmed by a situation with which he has tried to cope using all the resources of a normal healthy 17-month old child, and has withdrawn into apathy. Throughout his stay in the nursery the young nurses have been kind and friendly, but none has looked after him for any length of time. When on the 9th day his mother comes to take him home, John screams and struggles against her attempts to hold him.
A Note on Later Events For several weeks after returning home John showed extreme upset, often refusing his mother's comfort and the food she offered. He had severe temper tantrums. For some time any reminder of his stay in the nursery threw him back into the earlier distraught behaviour. Many months later he continued to be acutely anxious if he did not know where his mother was, and to have outbursts of unprovoked hostility against her.
John is a simple story of a type found in journals, short case notes which make little impact before the page is turned over. But, as with A Two-Year Old Goes to Hospital twenty-five years earlier, when told by the visual medium the story was powerful; it pierced defences and caused much disturbance in viewers. The reactions of a few colleagues convinced us we had a bomb on our hands...
In July 1969 a special edition of the Bulletin of the Home Office Inspectorate devoted all of its thirteen pages to John, accepting its message and considering the implications for policy (Home Office Children's Department Inspectorate, 1969). This marked a turning-point in the provisions for young healthy children in care in Britain. Moreover, the great number of reviews in professional journals in Britain and around the world were without exception keenly appreciative. A leading medical journal predicted, "This film is a landmark. What A-Two-Year-Old Goes to Hospital did for paediatrics, John will probably do for residential care" (Lancet, 1970).
Below is a selection of quotes from the great number of reviews:
A horrifying film which forces us to look at what despair is for a young child...What is so frightening is that the behaviour of the young nurses is kindly, but the system results in total failure to meet John's needs of a stable substitute mother (British Journal of Psychiatric Social Work).
Should be compulsory viewing for everyone engaged in child care. It forces the observer to identify with the plight of this little boy, and through him with that of all young children in care (British Journal of Medical Psychology).
No words could convey John's stress reactions as powerfully as the camera does. The impact of John's hour by hour increasing misery and deterioration becomes almost unbearable (Journal of Child Psychotherapy).
Superb photography, a disquieting film which upsets our complacency (Nursery Journal).
John is an individual who is defeated by a system which fails to recognize or meet his needs. The nursery can be seen as a microcosm of many other caring institutions, and perhaps of society itself and the many thousands who are damaged (Child Care).
Shows with disturbing clarity that institutional care is not geared to meet the emotional needs of small children. The camera dos not allow us to ward off John's mounting misery or to disregard his desperate need for comfort. It becomes quite harrowing to watch (Mental Health).
Again, as with the first hospital film, it was when John reached the rank and file that the impact brought varying reactions. Two principals of a national children's charity, whose name is tainted in the community because of its large-scale use of institutional care, react positively and invited us to conduct a weekend seminar for staff who would be brought in from the regions. But the plan was aborted by a prominent psychologist who acted as consultant to the charity; he advised strongly against the film and the seminar was abandoned.
The dangers of early separation had long been known intellectually. Every social worker and child-care officer had answered examination questions about separation. But it had not been known with appropriate affect. A story that could be told in twenty lines of textbook without causing comment, in its visual form struck deep and provoked emotional turmoil in most viewers. Although we had many grateful communications we also had others which verged on the abusive. Some said the film was 'obscene'. Some reacted as bereaved persons can do, searching in their pain for someone to blame - the parents, the nurses, the authorities, the Robertsons. We were accused many times of having sacrificed John to research, of having sat by without doing anything about his plight, about being heartless; some thought the nurses could have played more with John and were critical of the parents for having left him in a nursery, etc. All this was avoiding the essential communication about the vulnerability of the very young. The film touched upon childhood fears of loss and, in some, activated forgotten memories of events that had scarred their lives. The hostile reactions were classic examples of "shooting the messenger".
A university tutor wrote that she would not use the film again for teaching, because it had been too upsetting for her social work students; I replied that if she could not help her students to learn from this piece of reality in the classroom, how would they fare when they entered the field and were exposed to situations which could set up defences? A committee which recommended films for use with church groups blacklisted John as "unethical" - as if we had caused John's distress, instead of merely showing it.
Those who could use the experience of seeing John were helped by it, but some others seem to lock into their irrational responses. These ignored the fact that the four minutes shown of John's behaviour each day were focused on the stages of John's deterioration under fragmented care and gave no basis for making judgments on what, for instance, the Robertsons did or did not do. For some people reality was more than they could bear, whether for John or for forgotten parts of themselves. Even some consultants in psychiatry and psychoanalysis could not see through their defensive antipathy. "I could kill you", said a distinguished psychoanalyst...
Excerpted from Separation and the Very Young by James and Joyce Robertson, published by Free Association Books, London, 1989.
"This is an incredible book. It chronicles 50 years of the lives and work of the Robertsons whose work revolutionized the world's understanding of how small children feel when they are separated from their parents and familiar surroundings". ETB