Trust and helplessness
Unlike a calf which can stand, walk, and nurse within two hours of being born, human infants arrive in a state of utter helplessness. There’s essentially nothing we can do for ourselves other than poop, cry, and sleep—and even with sleeping, we could use some help. Parents say that love is the essential bond with their newborn—because how else are they supposed to get through their kid’s first few months? For the newborn, however, the bond isn’t about love. Because she’s so helpless, the newborn’s bond is all about trust: when she cries because she’s hungry, does her parent figure this out and feed her? If parents regularly respond appropriately to their child’s needs, the infant forms a bond around trust. Throughout her childhood, this reliance on her parents presents endless opportunities for the bond of trust to grow or be damaged. This is especially true with respect to the parents’ caring for the child’s body and physical health. It’s not surprising that this dynamic between trust and helplessness is at the core of any medical intervention.
Let’s consider just how helpless a child feels when having a medical procedure. Not only does she not understand how her body works and what is medically wrong with it, she is not allowed to make decisions about her body. She gets dragged to appointments where doctors probe her with their hands, eyes, and questions, and sometimes with their machines and needles. If she doesn’t cooperate and allow all this to happen to her body, the adults, including her parent, will be frustrated and angry at her. Or worse, they’ll hold her and still stab her with the needle. While everyone is focused on her physical issues, she is having intense feelings which often get overlooked or ignored. Instead, she must listen to her parents who, in turn, are listening to the doctors. In the end, it’s her body which the doctors get to control. If she doesn’t like what’s happening, all she can do is protest; if she’s even listened to, she certainly won’t be obeyed.
When it comes to trust, hopefully any medical procedure is based on the parents’ trusting the doctor. While parents would like the child to share this trust, she’s unable to genuinely do so because she doesn’t have the intellectual ability to both understand what is medically happening and how she might evaluate the professional skills of the doctor who is often a relative stranger. If she says she trusts the doctor, it’s only because she trusts her parents and their opinion—because really, why should any little kid trust a doctor, especially one she doesn’t know well? Consider it this way: if the procedure is going to produce any pain or fear, it’s the doctor who is doing the hurting and scaring. The doctor is the bad one here. Even a seven-year-old will struggle holding within her mind the conflicting ideas of the doctor—someone who heals versus someone who hurts.
But there’s an added twist here. Not only will the young child distrust the hurtful doctor, she won’t know how to regard her parents who are taking sides with this bad doctor. After all, it’s the parents who are making the decisions, who are agreeing with the doctor’s plans. How can the parents still be good parents when they are joining with the enemy? This perspective is based on how children—especially under five—see the world in black and white. Even a seven-year-old may have trouble using her intellect to see the grey areas when her emotions are intense. In the child’s view, you are either on her side or the doctor’s. The parents are in a bind because if they support the doctor’s agenda, their child experiences this as a real breach of trust: the parent was supposed to keep her safe but is now feeding her to the lions. Of course this is not a rational perspective, but it leaves the child feeling alone and abandoned by those she trusts most.
Confusion and fear
Let’s look at an actual medical procedure not just to appreciate a child’s fear and confusion, but to also understand how the particulars of the procedure itself can have specific effects. How might a four-year-old child react to needing her tonsils removed?[1] I’ve chosen this procedure not only because tonsillectomies are one of the most common surgeries for children, but because they involve an extremely important part of a child’s body, and the child will therefore have additional, important responses.
Because this girl is young and can’t understand many things about how her body works, because a tonsillectomy is very invasive—she’s losing a part of her body!—because it involves her mouth, and because she will experience one to two weeks of recovery time as well as some pain, the procedure will likely feel somewhat traumatic.
How would she explain the tonsillectomy to herself as she interprets what she’s heard from parents and doctors? Here’s what might be going through this four-year-old’s mind prior to the surgery:
[1] Tonsils sit at the back of the throat and are part of the body’s immune system. They help fight infections and filter away bacteria and viruses.
Something’s wrong inside my mouth, and people are going in there and taking out the bad thing. The bad thing will get thrown out. I don’t know how it got there. Maybe something bad got in my mouth. Or maybe I did something to make it bad. They have to make me fall asleep to get it out. I’ll go to the hospital. They’ll put me in a room by myself and put a needle in my arm. They’ll make me sleep so I can’t wake up. That’s when they take out the bad thing. Then they make me wake up. I’ll go home. My mouth will hurt because they hurt something inside. It won’t work right because I won’t be able to eat anything except ice cream, which is my reward. But then my mouth will start to work and I can eat pizza. Then I’ll be fixed, but not really because I’ll have to see the doctors again. They’ll look in my mouth some more. I don’t want them to find more bad things and take them out because it will hurt. I don’t want anyone to think I have bad things.
In this example, the girl understands a few things: something will be removed from her mouth, she will go to the hospital, she will come home, her mouth will hurt, she will eat ice cream then pizza, and she will have to see doctors again. Even though her parents have talked with her, she’s missing a few, key facts, which is normal considering her age. She doesn’t know what tonsils are or what they do or even where they are in her mouth. She doesn’t know why hers are being taken out. She doesn’t know what will happen in her mouth after the surgery or why she will continue seeing doctors. She doesn’t even understand why she gets ice cream except that it’s a reward, not that she needs to eat soft foods following the surgery.
If medical procedures can be confusing to adults, imagine what they’re like for a child—especially when the procedure carries the added, emotional weight of involving the kid’s own body. The more confused a child is, the more likely she will be scared. Out of fear and a need to understand, this girl invents reasons for her surgery. Given her age and limited knowledge, she imagines some possibilities. The first, that “something bad got in my mouth,” may sound a bit ridiculous to adults, but this kind of thinking is normal for four-year-olds. She’s also naturally self-centered at this age, so it’s not surprising that she thinks herself responsible for bringing on the badness, that she “did something to make it bad.” These misperceptions are setting her up for some unhealthy narratives, which we’ll explore below.
We can’t overlook the specific body part that is involved because the child’s experience—and additional misunderstandings—will be influenced by her relationship to that part of her body. In this case, we’re talking about her mouth.[1] I chose to explore this type of procedure because kids have a particularly intense relationship with their mouth. For kids, this little opening at the front of their face is pretty incredible. With a mouth, you get to eat, drink, taste, speak, yell, sing, burp, bite, suck, kiss, lick, spit, cough, throw up, blow bubbles, make endless sounds, and more! There’s also room in it to put plenty of things (other than food), not to mention the stuff that’s already in there like teeth and a tongue, and lips on the outside as an added bonus. A mouth is endless entertainment, though it can cause plenty of trouble, too, especially with grown-ups who are quite focused on mouths and what goes in them and comes out (i.e. words and noises). You get the idea: mouths are super special. Which means that for this four-year-old who, developmentally, is learning how to re-negotiate her world not through physical means but through language, her mouth is critically important. She definitely doesn’t want part of her mouth to be broken, much less to have something bad in there which must come out and which might somehow reappear after the surgery.
There’s one more thing to consider, which is also a particular response to this particular procedure: the ectomy part of tonsillectomy, or the removal part. To adults, this doesn’t seem like such a big deal. We know that we can function well enough without our tonsils, and anyone who’s had them removed doesn’t exactly miss them. But to a small child, it doesn’t matter what you are removing. For the tonsil-less child, while she can intellectually hear that she doesn’t need her tonsils, she’ll emotionally feel something altogether different: doctors are severing a piece of her from herself. Logic takes a backseat to this intense emotional reaction, and she will need help mourning her loss.
[1] As adults, we know that tonsils and mouths are separate and distinct, but this detail can get lost for little kids. Because the surgery is in her mouth, this girl will falsely assume that it’s her mouth—and more importantly, all the functions of her mouth—which will be effected.
Related Posts
Medical Trauma, part 4: Narratives (putting the pieces together)
Putting the pieces together to see how medical trauma creates narratives in children.
Medical Trauma, Part 2: What Kind of Procedures Are We Talking About?
All the factors that make a procedure traumatic, from the child’s age and body parts involved, to the invasiveness and recovery from the procedure.
