(p. 277) Advising Parents
The title of this section is perhaps rather misleading. All my professional life I have avoided giving advice, and, if I succeed in my purpose here, the result will be not that other workers will know better how to advise parents, but rather that they will feel less inclined than they may do now to give advice at all.
However, I have no wish to carry this attitude to absurd lengths. If a doctor is asked: ‘What shall I do with my child whose illness has been diagnosed as rheumatic fever?’ he will advise the parents to put the child to bed and to keep him there until the doctor feels that the danger of heart disease is over. Or if a nurse finds nits in a child’s hair she gives instructions which may lead to a satisfactory disinfestation. In other words, in the case of physical illness, doctors and nurses sometimes know the answer because of their special training, and they fail if they do not act accordingly.
But many children who are not physically ill nevertheless come under our care; for instance in maternity cases the work is not curative, because mother and baby are usually healthy. Health is much more difficult to deal with than disease. It is interesting that doctors and nurses may feel bewildered when they are faced with problems that do not relate to physical disease or deformity; they have had no training in healthiness that is comparable to their training in ill health or definite disease.
(p. 278) My observations on the subject of giving advice fall into three categories:
1. The difference between treatment of disease and advice about life.
2. The need to contain the problem in oneself rather than to offer a solution.
3. The professional interview.
Treatment of Disease and Advice About Life
As doctors and nurses today become increasingly concerned with psychology, or the emotional or feeling side of life, they need to learn one thing, which is that they are not experts in psychology. In other words, they must adopt quite a different technique with parents as soon as they arrive at the border between the two territories, those of physical disease and of living processes. Let me give a crude example:
A paediatrician sees a child because of some condition of the glands in the child’s neck. He makes his diagnosis, and informs the mother, giving her the diagnosis and the outline of the proposed treatment. The mother and the child like this paediatrician because he is kind and sympathetic and because he handled the child well during the physical examination. The doctor, being up to date, gives the mother time to talk a little about herself and her home. The mother remarks that the boy is not really happy at school, and tends to get bullied; she is wondering whether to change the boy’s school. All is well up to this point, but now the doctor, accustomed to giving advice in his own field, says to the mother: ‘Yes, I think it would be good to change the school’.
At this point the doctor has stepped outside his domain, but he has carried with him his authoritarian attitude. The mother does not know it, but he advised a change of school only because he had recently changed the school of one of his own children who had been getting bullied, and so the idea was fresh in his mind. Another kind of personal experience would have made him advise against a change of school. In fact, the doctor was not in a position to give advice. While he was listening to the mother’s story he was performing a useful function, without knowing it, and then he behaved in an irresponsible way and advised, and quite unnecessarily too, since he had not been asked.
This sort of thing happens all the time, in medical and nursing practice, and it can be stopped if only doctors and nurses understand that they do not have to settle problems of living for their clients, men and women who are often more mature persons than the doctor or nurse who is advising.
The following example illustrates an alternative method:
Two young parents came to see a doctor about their second infant, aged eight months. The baby ‘would not wean’. There was no illness. In the course (p. 279) of an hour it emerged that the mother’s mother had sent her to the doctor. In fact the grandmother had had difficulty in weaning the infant’s mother. There was a depressed mood in the background, both in the grandmother and in the mother. As all this emerged the mother was surprised to find herself crying copious tears.
The resolution of this problem was brought about by the mother’s recognition that the problem lay in her relation to her own mother—after this she could get on with the practical problems of the weaning, which necessitated her being able to be unkind to her infant as well as to love her. Advice would not have helped much, because the problem was one of an emotional readjustment.
In contrast, this next incident concerns a girl whom I saw when she was ten years old:
The trouble was that she, an only child, had been giving her parents a bad time, though she was very fond of them. A careful history-taking showed that the difficulties started when the child was weaned at eight months. She had done very well, but never became able to enjoy food after leaving the breast. At three she was taken to a doctor, who unfortunately failed to see that the child was in need of personal help. She was already restless, unable to persevere in play, and all the time a nuisance. The doctor said: ‘Cheer up, mother, she’ll soon be four!’
In another instance, the parents had a consultation with a paediatrician at the time that they were experiencing a weaning difficulty:
This doctor examined and found nothing wrong, and quite rightly told the parents so. But he went further. He told the mother to complete the weaning immediately, which she did.
This advice was neither good nor bad, it was just simply out of place. It cut right across the mother’s unconscious conflict about weaning the child, the only one she was likely to have (she was thirty-eight). Of course she took the specialist’s advice; what else could she do?—but he ought never to have given it. He should have stuck to his limited job and should have handed over the understanding of the weaning difficulty to someone who could stretch out and around this much wider problem of living and of relationships.
This kind of thing is not, unfortunately, rare; it is a matter of everyday medical practice. I give another example, at rather greater length:
I was rung up by a woman who said that she was involved with a children’s hospital, but wanted to talk about her baby in a different way. An appointment was made and she came with her baby, who was nearly seven months old. The young mother sat in the chair with her baby on her lap, and I was very easily able to establish the conditions which I need for observing a (p. 280) baby of this age. I mean that I was able to talk to the mother and yet to deal with the baby without her help or her interference. It quickly became apparent that she was a rather normal sort of person with a feeling for her baby which was easy. There was no jigging up and down of the baby on her knee and nothing false.
The birth of the baby had been straightforward. The baby was ‘born sleepy’; it was very difficult to get her to take; in fact she would not wake. The mother described how an attempt was made in the maternity ward to force the infant to take. She wanted to feed her baby by breast and felt that she could do so. She expressed the breast milk, which was given by bottle for a week. The sister was determined to make the child take, and tried incessantly pushing the teat of the bottle in and out of the child’s mouth, tickling the child’s toes, and jigging the child up and down. All these procedures had no effect and the pattern persisted, so that, even much later on, the mother found that whenever she did anything active in regard to the feeding of the infant this sent the child to sleep. At the end of one week an attempt was made at breast-feeding, but the mother was not allowed to use her intuitive understanding of the infant’s needs. It was extremely painful to her. She felt that no one really wanted it to succeed. She had to sit up and take no part while the sister did all she could to make the infant feed. The sister, ordinarily kind and skilled, grasped the child’s head and pushed it against the breast and so on. After a little of this, which only produced deeper sleep, breast-feeding was given up and there was a noticeable deterioration following this distorted attempt.
Rather suddenly, at two and a half weeks, there was an improvement. At a month the baby was 6 lb 6 oz (6 lb 9¾ oz at birth) and went home with the mother. The mother was told to feed the baby with a spoon.
The mother had on her own discovered that she could feed her baby perfectly well, although by this time the breast had ceased to function. She was feeding the baby for one and a half hours at a time, and then she switched over to being ready to give multiple small feeds. But by this time a children’s hospital had become concerned with the child because of certain physical abnormalities, and advice was given in the hospital outpatient department. This advice seemed to be based on the idea that the mother must be fed up, whereas in fact she was enjoying feeding her baby, and did not mind at all that it was a difficult art. She had to defy the doctors who gave her advice. (Her comment at this point was: ‘Definitely the next time I am not having my baby in hospital’.) Innumerable investigations were carried out at the hospital in spite of the mother’s protests, but naturally she felt that she must leave the physical side to the doctors. There was a shortening of the left forearm, and a cleft palate involving the soft tissues only.
On account of the physical abnormalities the mother felt it necessary to keep under the children’s hospital, but this meant that she had to stand (p. 281) being given advice about the feeding of the baby, advice which was usually based on a misunderstanding of her own attitude. She was told to give solids at three months to save herself the trouble of the long feeds or the frequent feeds. This was of no use, and she left over the matter of the introduction of solids. The baby at seven months had begun to want solids, as a result of sitting propped up while the parents ate. She was allowed an occasional titbit and so gradually had the idea that there was another kind of food. Meanwhile she had been fed on milk and chocolate pudding, and weighed 14 lb 4 oz.
Why did the mother come to see me? She found that she wanted support for her own idea of her infant. First, the infant was fully developed for her age, that is to say, not in any way backward, whereas there had been vague suggestions at the hospital that the child might be backward. Second, she was quite willing to accept the deformity of the forearm but not to accept having innumerable investigations, and especially she refused to have the child’s arm in a splint. It is evident that the mother felt about her infant’s needs in a more sensitive way than the doctors and nurses could hope to feel. For instance, she had been alarmed when the hospital asked to have the baby in for one night simply to have a blood test done. This she disallowed, and the hospital carried out the investigations in the outpatient department without the further complication of having the baby in the ward.
The problem therefore with this mother was that she recognized very clearly her dependence on the hospital on the physical side, and she was engaged in trying to deal with the fact that the physically-minded specialists had not come round to the idea that the baby was yet a human being. At one point when she protested against the splinting of the arm during the early weeks of the child’s life she was definitely told that this baby was not yet able to be affected by things happening to it, although she felt quite certain that the baby was in fact adversely affected by the complication of the splint; she could see, in fact, that the infant would be left-handed, and that the splint must hamper the left hand at a vitally important stage, in which reaching out and grasping are creating the world.
Here is a picture of the baby (nearly seven months) at the consultation:
As I came into the room the baby fixed me with her eyes. As soon as she felt I was in communication with her she smiled and clearly felt as if she were communicating with a person. I took an unsharpened pencil and held it in front of her. Still looking at me, and smiling and watching me, she took the pencil with her right hand and without hesitation put it to her mouth where she enjoyed it. In a few moments she used her left hand to help, and then she held it in her left hand instead of in the right hand while mouthing it. Saliva (p. 282) was flowing. All this continued in one way and another until, after five minutes, in the usual way she dropped the pencil by mistake. I returned the pencil and the game re-started. After another few minutes the pencil dropped again, less obviously by mistake. She was now not entirely concerned with putting it in her mouth and at one stage put it between her legs. She was dressed, since I had not thought it necessary to undress her. The third time she dropped the pencil deliberately and watched it go. The fourth time she put it down near her mother’s breast and dropped it between the mother and the arm of the chair.
By this time we were near the end of the consultation, which lasted half an hour. When the pencil play had come to an end the baby had had enough and began to whimper, and there were necessarily an awkward few minutes at the end with the baby feeling that it would be natural to go but the mother not quite ready to do so. There was no difficulty, and the mother and baby went out of the room fully contented with each other.
While all this was going on I was talking to the mother and only once did I have to ask her not to translate what we were talking about in terms of moving the baby; for instance, when I asked about the wrist she naturally went to turn up the sleeve.
The consultation achieved no great purpose except in so far as the mother got support where she needed it. She needed support in regard to her very real understanding of her own infant, which had to be defended on account of the inability of the physical doctors to recognize the boundary of their speciality.
A more general criticism is expressed by a nurse who wrote:
I have worked for long periods at a famous private maternity home. I have seen babies herded together, cots touching, shut up in a stifling airless room all night, no attention being paid to their cries. I have seen mothers, their babies just brought to them for their feeds, all trussed up with nappies round their necks, and their arms pinned down, the baby’s mouth held to the mother’s breast by the nurse, trying to make it feed, sometimes for an hour, until the mother is exhausted and in tears. Many mothers had never seen their own babies’ toes. Mothers with their own ‘special’ nurses fared equally badly. I have seen many cases of definite cruelty to the baby by the nurse. In most cases any doctor’s orders are ignored.
The fact is that in health we are constantly engaged in keeping time with natural processes; hurry or delay is interference. Moreover, if we can adjust ourselves to these natural processes we can leave most of the complex mechanisms to nature, while we sit back and watch and learn.
(p. 283) The Problem Contained Within Oneself
I have already introduced this theme in my illustrations. It can be stated in this way. Those who have been trained in physical medicine have their own special skills. The question is, should they or should they not go outside their special skill and enter the field of psychology, that is to say, of life and living? My answer is this. Yes, if they can gather into themselves and contain the personal, family, or social problems that they meet, and so allow a solution to arrive of its own accord. This will mean suffering. It is a matter of enduring the worry or even the agony of a case history, of conflict within the individual, of inhibitions and frustrations, of family discord, of economic hardship, and it is not necessary to be a psychology student to be useful. One hands back what one has temporarily held, and then one has done the best that can be done to help. If, on the other hand, it is in a person’s temperament to act, to advise, to interfere, to bring about the sort of changes he or she feels would be good, then the answer is: no, this person should not step outside his or her speciality, which concerns physical disease.
I have a friend who does marriage counselling. She has not had much training except as a teacher, but she has a temperament which allows her to accept, during the counselling hour, the problem as it is given her. She does not need to probe to see if the facts are correct and whether the problem is being presented in a one-sided way; she simply takes over whatever comes, and suffers it all. And then the client goes away home somehow feeling different, and often even finding a solution to a problem that had seemed hopeless. Her work is better than that of many who have been given special training. She practically never gives advice, because she does not know what advice to give, and she is not that kind of a person.
In other words, those who find themselves stepping outside the area of their special skill can perform a valuable function if they can immediately stop giving advice.
The Professional Interview
Psychology if practised at all must be done within a framework. An interview must be arranged in a proper setting, and a time limit must be set. Within this framework we can be reliable, much more reliable than we are in our daily lives. Being reliable in all respects is the chief quality we need. This means not only that we respect the client’s person and his or her right to time and concern. We have our own sense of values, and so we are able to leave the client’s sense of right and wrong as we find it. Moral judgement, if expressed, destroys the professional relationship absolutely and irrevocably. The time limit of the professional interview is for our own (p. 284) use; the prospect of the end of the session deals in advance with our own resentment, which would otherwise creep in and spoil the operation of our genuine concern.
Those who practise psychology in this way, accepting limits, and suffering for limited periods of time the agonies of the case, need not know much. But they will learn; they will be taught by their clients. It is my belief that the more they learn in this way the richer they will become, and the less they will feel inclined to give advice.