No parent is likely to deny these handicaps, knowing them better than anyone else. But since we parents, in clinical literature, have found few eulogists, it is up to us to put our handicaps into perspective. Since we are conscious of them, we can go a long way towards overcoming even the severest. And we, and others, should realize that they may be counterbalanced by special advantages that even the most gifted psychiatrist cannot match.
The first of these advantages is a considerable one: total familiarity with the case since birth. Every child psychiatrist who concerns himself with his small patient’s past is dependent on what its parents tell him, however he may decide to discount it. Even if he manages to call out of the child’s consciousness some fugitive memory which he can use to enhance his understanding, he must go to the details of the child’s history to make sense of what he has found, and his source for these will almost certainly be the child’s parents. The younger the child, the truer this must be, especially if its dysfunction affects speech and the therapist must work at mind-reading. The parents of a psychotic child are quarries of information which no psychiatrist has time to work to the full. If the child is obsessed with an object or a place, who but they know where he has been or what he has clung to? Who else knows their baby’s characteristic approach to food, to sleep, to play? Who else can say what threatened him and what delighted? Yet how much of what they know, which might prove relevant if the psychiatrist knew it, finds its way from their minds to his? Psychiatrists and parents both explore an unknown country, but parents at least hold a map that shows the major landmarks. They may not know all they need to, but they know more than anybody else. As long as the child develops rightly and they have no need of all they know, they may not even realize that they know it. If the time comes, however, it is there to be used.
The second advantage is another version of the first: as well as a fuller knowledge of the child’s past than any doctor can have, parents have a fuller knowledge of its present. They can observe the child in the complete variety of situations to which it is exposed, not merely in the artificial situation of the therapy hour. Children’s conflicts and anxieties become evident to skilled therapists through their displacements on to things; sibling rivalry becomes visible through the doll family with which every therapy room is equipped, training problems through the miniature toilet in the dollhouse. The parent can learn to use toys too, but he needs them more for stimulation than diagnosis since he can observe these things directly. He knows how his child responds to each of his brothers and sisters, to grandparents, teachers, passing visitors. He (or, more probably, she) knows what the child is like at breakfast and in the bath, how it reacts to strain, how it behaves at a party, in a supermarket, at the circus. It is she who quicker than the best psychiatrist will notice the deviation from customary behaviour that may suggest a new explanation or initiate a new stage. She will not, of course, do this because she is cleverer than he, but merely because she is there when he is not. I have written in the previous chapter of the time when Elly suddenly ran towards a crowd of school children, and of what we made of it, mother and analyst together. That moment could not have come at all in the analyst’s office, in the daily hour.
Parents are there. Because they are there they can act when the child is ready. In the first years of life, more often than not, one parent or another is on hand, in actual or potential contact with the child, twenty-four hours a day fifty-two weeks a year. Books on child therapy state that the experiences of bedding, feeding, and awaking are especially significant to a child: this is one of the reasons that many psychiatrists recommend residential treatment. Those out of reach of such treatment may reflect, however, that experienced parents do not need to be told when their child is most receptive. Their knowledge, transmitted through the generations, has been absorbed into the rhythm of family life, institutionalized in the family meal and the bedtime story. Even Elly smiled straight into my face when I got her up in the morning.
When you are in twenty-four-hour contact, every experience can be considered for potential usefulness. The fertile course of daily life offers you far more material than you could think of for yourself — a trip to the dairy (it was on one of these that Elly first climbed into the car under her own power), to the bakery where a lady’s kind hand provides a cookie and eventually Elly will begin to chirp ‘thank you’, a visit from a little girl who eats peanut butter so that Elly begins to eat it too. There are lessons in dustpans, sinks, pebbles, and bowls of cereal. And when you have known a child since birth you have as good a basis as anyone can for judging which of these experiences a child is ready to make use of and which he is not. Its withdrawal, or the edge in its voice, teaches you the difference between stimulation and pressure.
Growing out of this intimate knowledge is a curious advantage I have become conscious of only slowly. The parent knows his child, and he also knows his mate and his family. Individuals in a family differ markedly, and the parent is of course aware of that. But he is also aware of what is less obvious — of the ways in which they are alike, the patterns of behaviour that might seem strange to an outsider but are not so to parents, who see them in their normal children as well as in the deviate, and who also recognize them in themselves. My husband could recall that, like Elly, he had rocked his crib until it had to be nailed down. Elly’s relative passivity was not unfamiliar to us. We all shared her physical caution, though in us it stopped short of pathology. Looking at Elly, I could remember Sara, who even as a baby never put a foreign body in her mouth, and Becky, who cried when I pressed her to turn the faucet. Matt, apparently strong and well co-ordinated, was four before he learned to push the pedals of his tricycle hard enough to propel it forward. None of my children opened medicine bottles or explored unauthorized cupboards or jars, any more than I myself had as a child. All when excited waved their arms in a tense way unseen in other families. All were reluctant to apply pressure; long before Elly was born I had raged inwardly at three healthy children who cried ‘Mommy’ at a resisting door that my neighbour’s children would open with one energetic shove. We do not rush at life. The six of us have lived a total of a hundred and forty years (albeit most, concurrently, of course). The only bone that has been broken among us is one big toe, and there is no antiseptic in our medicine chest.
So that in a curious way Elly belonged in our family. She would have driven my energetic neighbour beside herself, just as the activity of my neighbour’s children would have been too much for me. Therapy begins in acceptance. We could accept Elly more easily, all of us, because we knew her in ourselves.
This deep knowledge of the child in context finds its climax in what is perhaps the most important of all the parents’ advantages: that they know the child’s language. The extreme difficulty of work with very young children, or those whose speech is defective or absent, is to a great degree one of language. Yet their difficulty in communication is a measure of how much they need help.
The parents — and their allies, their other children and their household helpers, who in some degree share in all these advantages — know this language. They have learned it the natural way, over months and years, gesture by gesture, sound by sound, word (at last) by word. Their understanding of it has deepened to intuition; their grasp of it is quicker and surer than any outsider’s can be. They hear the anxiety in the high squeal the outsider cannot distinguish from laughter; they understand that assent is conveyed by running across the room or jumping up and down. They will understand the new word in its fluctuating indistinctness because they first encounter it in the situation that brings it into being — and if it carries emotional or symbolic overtones they will know it if anyone does. It was not until her fifth year that Elly began to acquire words in any quantity, and what they gained in number they lost in distinctness. Who could expect a stranger to understand a child who says ‘buh’ for six different words from ‘baby’ to ‘fish’? That summer in Austria Elly would say ‘huh’ and cry with frustration if
we could not guess from context whether she meant us to draw a house, hand, hen, hat, or horse. (If we said ‘huh’ in imitation she was never satisfied; she heard the little differences she did not reproduce. ) Might her frustration have led, in the skilled hands of someone who could not rely on basic understanding of her language, to attempts to speak so she could be understood? We tried that then, saying gently that we couldn’t understand and waiting for her frustration to produce a more refined pronunciation. But she wasn’t ready; communication didn’t interest her enough to provide a motivation. Now, four years later, it is begining — only beginning — to.
Had Elly gone into professional therapy at five (and even that would have been years after the onset of the condition) it would have taken months for a psychiatrist to learn her language, and even then it would have been as a tourist, not a native in her world. Even if he had by some miraculous philological instinct realized that ‘Ih-ih huh’ meant ‘England house’, he would hardly have recognized it for a request to draw a remembered building and he would have had no clue to the frustration that would have occurred when he failed to respond. How many interpretations go astray from lack of the knowledge that any parent has? The English analyst, when she learned that Elly had once said ‘pee-pee’, assumed that it must be a toilet word. I deserved no particular credit for knowing that Elly had said it only when she saw our neighbour’s child Peter, or that ‘pee-pee’ was a word she had never heard and so could not have used. It was merely that I knew her language.
Skilled therapists do wonders without talk, working with objects and with direct play. But they must come to words at last; if the child is to move into a speaking world, they must acquire his language with him until he can speak the common tongue. When I took Elly, at five, to her present psychiatrist, he recognized how far he was from understanding her and how long it would take him to begin to do it. This was, in fact, an important reason why he left me on my own. In so severe a case the process was long, he said, and the advantage doubtful. And-as neither of us had to remind the other — psychiatry is a well- paid profession. Which brings me to another advantage of using parents as therapists. They work for nothing.
It would be more graceful, perhaps, not to press this point, particularly since we were fortunate enough so that for us it need not be decisive. But for many parents it is — for us it would have been if Elly had been born when we were younger. To overlook it would be unrealistic and unfair. Children with severe afflictions — call them psychoses, defects, or what you will — need intensive therapy if they need any — if not in a residential school, then daily. But the price of intensive contact continued over years is beyond the resources of all but the well-to-do, and even they cannot absorb it without strain. The family that cannot afford therapy, or enough of it, has one recourse. The parents are going to be on hand anyway. Every family can afford the services of its mother.
The last advantage possessed by parents, and by other amateurs with them, may well be a certain humility. This humility will grow out of their very consciousness that they are not professionals, and still more out of their sense, daily and hourly reinforced, of the mysteries and ambiguities of the condition which confronts them. Again and again they will have reached some explanation which has seemed plausible until the fact comes along which contradicts it. Living their lives among questions, not answers, they are natural empiricists in a field that — they may be pardoned for suspecting — is not yet ready to press beyond empiricism. They have learned to feel their way; they have learned it not only from their experience of abnormal children, but from normal children too. Years before Elly was born, in the course of one of those mother-to-mother chats by which parental expertise is spread, a friend told me a story. It contained a lesson, and since it has become as sure a part of my education as anything I have read in a book, I must tell it here.
My friend and her husband, travelling with their children, had arrived in Germany. They had come to visit an elderly relative, the husband’s great-aunt, never seen before and barely known through infrequent correspondence. His parents had left Germany sixty years before; these young Americans were nervous about the visit, aware that the free-wheeling spontaneity of modern academic children might not pass muster among German ladies of an earlier generation. So when they arrived they were relieved at the old aunt’s suggestion that they sit inside while the children played in the garden. After a few minutes the mother went out to check and found to her consternation her four-year-old son standing beside a broken sundial. A mother both permissive and understanding, she gently explained that everybody knew that accidents happened and that little boys made mistakes and that it was very much better to own up to a thing than to pretend you hadn’t done it. Hand in hand they went inside and the little boy told his aunt how sorry he was he had broken her sundial. The old lady looked at her young relatives with amused puzzlement and told them that the sundial had been broken for years.
Elly’s comprehension is still too primitive to tempt me to offer her any interpretation of her behaviour; the ‘why’ and ‘because’ of human motivation are words and realities she does not yet understand. But even if she did, I would think carefully and long before I told her why she did a thing, remembering this story and knowing how easy it is for an admired adult to convince a child of his own interpretation. Not all therapists are as cautious as the English analyst who warned me against ‘constructs’. In the case histories I have read I have come across interpretations both brilliant and ingenious, and the more ingenious they are the more they frighten me. An interpretation must be pretty obvious if it is to be safely offered. I have read of a little girl, no older than Elly and talking no better, whose psychiatrist guessed from obscure words and actions that she feared she had injured her mother. And so she may have. No one ever found out, for she did not get well. But it is well to be humble in the face of facts; for a therapist to verbalize that a child, for example, feels guilt may liberate it from an oppression it cannot face, but it may also suggest a responsibility that was never felt and create guilt where none existed. A parent, seeing so much more of a child than does a professional therapist, will be chary of interpretations, both because he has not been trained to make them and because he feels his immersion in a complex reality which at any time may prove them simplistic, or harmful, or wrong. One can know too much as well as too little.
Yet I am far from denying that parents know too little. I do not mean to make ignorance a virtue; it is one only under the rather special circumstances that obtain when specialists know — as Mark Twain remarked of the human race in general — ‘so many things that ain’t so’. Yet although many of them may know — about castration-anxieties, masturbation, rejecting parents, and the like — many things which in particular cases are not so, they also know an immense amount that is, and that a parent will have to learn. One of the most famous of child psychiatrists, whose therapy for disturbed children depends on a complete separation from their parents, has written that Love Is Not Enough, and he is right. One must know how to love as well. Far from denigrating the knowledge of psychotherapists, I only ask that they let parents share it.
I learned what I had to from Elly, slowly and painfully, she and I together. But I would have learned faster, and with fewer gaps, if I had been in contact from the beginning with skilled and sympathetic professionals (the plural is deliberate). People whose profession is working with children — I do not limit my statement to psychiatrists — possess a great arsenal of the techniques of siege-warfare. Lacking access to it, I had to develop my own, with difficulty and duplication. I had nothing to guide me but common sense and a till then unverbalized knowledge of three normal childhoods, to which I could add the imperative that an eminent mathematician has given as a two-word definition of the scientific method: ‘Try everything.’ When I came to read case histories, it comforted me to find that was what the professionals were doing. They might indeed have theories to guide them, but they led to no agreed-on therapeutic
regimen. Qualified, trained people dealing with children like Elly were trying everything, drugs and shock treatment, massage, all kinds of play therapy — even love. [15] But they were in contact with each other and with professional literature, while we were alone. No one person, trained or untrained, will think of everything, or even everything in the limited range of possibilities relevant to one particular case. It was for this reason that I profited from those case histories, lacerating as I found them, and that I was glad of the chance to observe the Institute people and the English analyst operate with Elly. Four hours at the Institute, four with the analyst — that was my training until Elly was four and a half. Then fifteen hours or so at the Blankshire Nursery School — if only they had come earlier! Later, Elly’s present psychiatrist suggested I visit Dr Carl Fenichel’s League School for Seriously Disturbed Children, where I was welcomed and acquired in a day suggestions for months of work. These experiences were the most valuable help I could have had, but only the last was planned and recommended. The others occurred almost by accident and there were not nearly enough of them. Professionals conscious of the problem could have helped me to have many more. Far from underrating professional knowledge, all I wanted was for the professionals to let me watch them work. But this desire was so unorthodox that it took years for me to reach a point where I could articulate it. I was, at the time I needed to, quite unable to make it known, and I am afraid I can guess what would have happened to such a request at the place where I was told that case histories were bad for me. Yet with all the expertise about, it is strange that in the mid-twentieth century a mother should be left to her own devices and such assistance as she can get from Saturday Evening Post articles[16] and biographies of Annie Sullivan.
Parents need help, but not in the current American under-standing of the phrase. They may need it from the same people, but they need a different kind. I appeal for a breakdown of the separation between parents and the psychiatric profession. At present it is common practice for a child to receive psycho-therapy for months, sometimes years, without its mother or father having any direct conversation with the child’s psychiatrist. Especially is this true in large clinics, where the social worker exists as a kind of mediator (or buffer) between psychiatrist and parent. It is thought best that the parent, even of a small child, know nothing of what goes on in those privileged sessions, and the only way she may hear what the expert actually thinks of her child’s case is if he is kind enough to speak to her if she passes him in the hall. Yet there is so much that she must learn that he could teach her.
The Siege Page 19