MAWSON, C.: Containing anxiety in work with
damaged children.
str. 67-74
66 Pdamy Cohn
to separate out personal difficultiesh m pmfessiond ones, and to direct them,
where appropriate,to findthe aight kind of help. ato h times Hworked with the
staff as a ,pup, explohg their relationships and how these helped or hindered
the task. Always my function was to facilitate an awmrsess d $he emotional
issues on the wad the inevitable grief, pain, helplessness and sometimes
hopelessness. Greater awareness and understalnhg of these feelings, and
allowing for their sxpssion, 1 4 to better working practices and to a happier
ward.
Containing anxiety inwork with
damaged children
There are mental pains to be borne in working at any task, and these have to be
dealt with by us as individuals,each with a personal history of havingdevebpecl
ways of managing or evading situations of aaxiety, pain, fear and depression.
Collectively, in our institutions, we have also learned to do this, &stalling
defences against the painful realities of the work into our ways of arranging our
tasks, rules and procedures. It is incumbenton us try ZJI whatever way we can
to explore theseaspectsof ourworking practices, inorderthat ourwaysof coping
do not grossly interfere, subvertor even pervert our efforts.
To understand the worlds of work mupied by ourselves and others, we need
to be aware dthe particularh d s of gain and dificnlty encomtered in everyday
work situations. As Obhohrhas observed: 'Inl m h g at institutionalprocesses
it is obviously very helpful tohave someinklingdwhat the underlying anxieties
inherent in the work of the institution are. ...Given a knowledge of the nature
of the task and work of an institutionit is possible to have, inadvance,a helpful,
fairly specific understandig of what ;he urmddgrkg anxieties are likely to be,
eventhough one might not h o w the "institution spiilc" natureof Bhedefences'
(1987: 203).
Thus, when I was asked to consult to a cMd health team in a large teaching
hospital, H anticipated certain difficuPties. P h e w they were involved in the
assessment, long-term treatment and support of very young c M h n who had
been physically or mentally damaged from birth or soon after, and I expected
from the outset to encounter considerable mental pain both in myself and in
members of h e tern stemming &om the workers' close contact wiih these
damaged children. I anticipated,as was indeed the case, that the workers would
frequently feel depressed, despairing of king able to wake a worthwhile
differen= in the childpen's Eves. I also expectedthat they would sometimesfeel
intenselypersecutedby these feelings,even tothe extentof experiencing at some
bvel a measure of hostility towards h e children themselves. It was e e l y that
such intensely guilt-inducing feelings would oftera be deflected outwards md
68 Ghds Mawsm
away from fne wofl iPn dl probability findbg thek way into other parts of the
institution,where they wight wen haw adverseeffectsonworking mgements
and interprofessional~lations~ps.
In order to gin a real undehsmdlng ofthe tern's experience oftheir work H
knew I would need toh e m myselfinthe= experiencesovera iong perid, as
they shared them with me md with w e another irn ow regular meetings. The
following vignem, h m one of my hi meetkgs with the t.em illusm&s
sowething oftheseproblems:
Marie, a yomg physiotherapist inr the W d s h Child Hedth Team,
described lher visits to the home of a small child with a d e f o d hand. k h
time she went, she Snew her treatment would cause the child intense pah. It
was clearlysaddening forMarie tosee the child freeze and tumawayfrom her
as smn as she set foot in the f d y home. She ' k g mto adopt abrusque and
matter-of-factmanner with bothchild md mother,at timesking quite aware
thatshe was being cold and impmeable,butfor themost part consciousonly
of a heavy sense of persecution and dread whenever she visited. She felt
ashamed and defensivewhenever she discussed the cud and her aheBtment
with other members of the team, and came to feel that this one case was
casting a shadow over her enjoyment ofher work. To protect herself against
her guilt, she tAed to tell herselfthat she was only adopting an qpmpriately
professional distance, and that the occasional reproaches from the child's
mother were really evidence ofthe mother's Inappropriateneed for closeness
withMarie.
Whenthis was explored in one of the first meetingsthe teamh d with me,
there was a powerful rexLion against openkg up the issue of professional
distance, and great resistance to the idea that it can be used to defend us
against painful feelings in OW work. It was as though the whole group felt
attacked by me,andfor muchofthe meeting I felt as if1wen: a sadistic person
forcing an unwanted and painful treatment on them. They told me forcehlly
that they did not want me to make the pain of h e k work more acute, evenif
this was only a temporay effect.
It was clearly important for Marie to feel hat her colleagues from other
disciplines, partiiculdy those whose role did not involve physical contact with
the child, realized Marie's sense of hurt and rejection when faced with a cldd
who was afraidofher, whodid notperceive her asahealerorhelpexbutasa crud
and sadisticf i g m whocameintoherhome only tocauseherpain. hitidly it was
very painful forMarie totalk about experiences wMchcaused herso muchshine
md guilt. The wish bthe team was to treat it as Marie's problem, which added
to her stress and interfed with the whole team's leaning from her experience.
Once the team k a m e able to discuss these kinds ofexperiencesin a setting
where anxiety and guilt over feeling inadequate could be contained and
understood,it was possible for us to see the sad irony thatbecomingdefensively
had and impenetrab1ehad in fact madeit muchPIPOR likelythat the cMd would
perceive the physiotherapist as sadistic. To work wen with such children,and to
*kclear and supportive to their parents and families,pmfessionds c m o t
to defendthemselvesby erecfing these sorts ofbarriers.
Before such difficultfeelings can be openly explored h a p u p , p&cnlahly , '
whenthe members work together ona day-to-daybasis,it is necessary toprdvida ,
conditions of safety,respect and tolerance,so that anxieiy muad insecurityqin -be
contained a d e x b e d prductiveiy. It is essential &at a bounded space is
created within which participants can begin to tolerate bringing more or"their
feelings than they arc used to doing in other work activities, in anm atmosphere
which enmages opnness md self-exambation.Holding group meetings on
the same day and at the same time each week helps stxengthen this sense of
containment,as does endingthemeetingsontime.Itisnotpunctuality for itsown
sake that is important,butit is h o s t invariablydlstwbingforghoupmembers to
feel that their emotions dictate the 'shape' and structure ofthe meeting, as well
as its atmosphere and content.
Thebasic dispositionofthe consultantis irnpo&mt tm.The sense ofsecurity
in the group is greatly encouraged by the consultant'srestraint fromjudging and
blaming, and 'knowing' too much too m n , or seeming to believe in quick
solutions. It also helps K the membership of such a p u p is not constantIy
changing.The group often depend upon the consultant to stand up for the value
of struggling for understanding,rather than rushing into the solving of concrete
problems to get rid of uncomfortablefeelings. They o k n find it useful to have
such discussioms in the presence of a consultant who is not a part of the
organization,but this is not alwaysthe case.
Whetheror not there is an external consultant,it is necessaayfor members t~
l e mnotjust to listen tothe content ofwhat isbroughttothe discussion,but also
to anow the emotional @act of the c o m ~ c a t i o n sto work on and inside
themselves.Whenprimitive anxieties are shed up,there is a natural tendency
to try to rid ourselvesof the uncomfortableand unwanted thoughts and f e h g s ,
hating theminothersinsideor outsidethe group, asdeschikd in Chapter5. For
example, recall how in the illustration given earlier I was temporarily
experienced by the group as cruel, forcing on them m unwanted pahfi~l
experience by looking at the issues in detail. &'hen J was told that they were
unsure they wanted such a painful 'tpeatment' if it made the pah of their work
more acute it was airnost word for word what h e parents had said to W e .For
a while, I had in turn felt in relation to the staffmuch as she must have fejt with
her young patien$,saddened and guilty hat my work was being experienced as
cruelty. I had gone away fmm the meeaings feeling sorazewhat pecuted, and
had been tempted to defend myself by wi&&awing from their reproaches md
putting up someiking of a barrier, while telling myself hat this was merely
appropriate professional reserve.Ee was listeningto my own feelings in this way
that helped me to see how similar dl 111s was to Mde's predicament. It was
therefore possible not only to hear her feelings, but also to hecognize from
first-handexperiencehow suchfeelingsmdefended against,not onlyby herbut
also by the entire group in the institution.Understarmdinggained in this way can
sometimesbe put back to the group, or by the worker to the client, and, if timed
sensitively, tends to carry a great sense.of conviction.
In describingdifficultwork situations,membersdthe gmup will not ody be
communicatingidomtion, but will also be conveyingstatesdmind which are
often very distanbing and painful. From infancy we evolve the expatation that
we can gain some relief from these pressures by seeking a 'container' for the
painful feehgs and the part of ourselves that experiences them. Partly, we
uncomciously try to rid ourselves of them, but there is also the hope zhat the
recipientof the projected distresswight be able to bear what we cannot, and,by
articulatingthoughtsthat we have foundunthinkable, contributeto developingin
us a capacity to think and to hold om to anxiety o m 1 e s . (These comp1ex
processes, termed projective identification,were&scnssd in detailin Chapter9.
See also Bion 1967;HClein 1959.)
In many work situations, the chief anxiety which needs to be contained is the
experienceof inadequacy.Thefollowingexample6s&awn frommy consultation
to the staff of h e Tom SawyerAdolescentUnit,who were complaining about a
difficult group of adolescents:
M e r severalweeks of feelinginmasinglyuselessasa consultant,iradqwte
and quite irrelevant to the needs of tlhis hard-pressed p u p , I was told
haughtily by one member ehae hey wodd be better off without me. mey
would do better to organize a d o n meeting or an encounter group. I felt
ridiculed, devalued and somewhat provoked. bother member of h e team
c o q l a i n d that I invkably tmk every o p p o d ~ y$0 divert them from their
real task.A third, speakingin falsely concernedtones and with kaitted brows,
asked why people Eke me were so intent on causing mfision by always
lmkinp more deeply into things. They were, after dl,just honest workers
whose only wish was to be left done t~ get on with a &&cult job, with little
or no support. Yet another wondeed why I bothered with &ern, and whethex
H was some kind of mam&st.
Just when I bad .Qen abut as much as 1couid wi&ot Yodng my temper,
another staff member, who up to &at pht had re
despairing shebad been feeling in her work EEiately, andhow devalued. Shefelt
her efforts h d '=en under attack by some of the adoiesceat clients and their
fadies. hother then added that it seemed their work was *uenntly
anndernnaianed by the aalminism~qsestaff who were supp~sedto be s u p e n g
them. It emerged that the whole team had beena criticized reca~dyby
management for their handing of a difficult and sensitive situation in &e
unit.
It was at this pint that I was able tomake sense of my own feehgs md &e way
I had been made @ feel by the group. Icould then put into wo& thetern's deeg
sense that they and their work were under attack. In turn, they had needed $
make me feel unwanted, ineffectual and under a t a c t p d y to get pid of &eir J
own feehgs, but also to show me what it felt like for them; tBis m y have a n
the only way they were able $0 iet et how. It extendedto their tryingto get me
to give up on them. or else to retaliate. h s t as they sometimes slpoke of going
home wonderingwhetherthey shouldresign, or whetheror not to appearatwork
the next h y , they had spent a month testing whether I would have the tenacity
(or was it masochism?) to keep corning back to them. Another previously dent
member confirmed ;his, saying she had seccrtly hoped that I would be able to
keep going and not 'pack it in'. She also had wondered whetherI had anyone to
whom 1could turnwhen the going got tough.
m s led to a change of emotionalc h t e in the meetings. It became possible
to reflect on what had been taking place in the room and to make useful links to
the current problems both in the team and in the wider institution. For exaqle,
it was possible to consider the predicament of some of the team's patients a d
f a d e s who, in extreme distress, often seemed to use the same projective
mechanisms for alleviating their anxieties as the team had been doing with me.
The feelings of the staff mirrored ?hose of the parents, who had repeatedly been
made to feel useless and impotent. W e n such feelings of inadequacy am
unbearable the temptation to 'pack it in' can be too strong to resist and this is
precisely what had happened with many of the children there. n e i i presence on
a psychiatricward felt to them (and also to their p m t s ) as evidencethat thejob
of parenting them had &come overwhelming and had bezn 'packed in'. The
childrenhad made the staff feel much asthey had made their parentsfeel, and in
turn the staff had made me bear the impact of the= violent and demoralizing
feelings. Furthemre, the question of whether I had my own sources of suppox%
could then be linked with ?he team's desperate need to h d support and
understandingin the face of such projections b m their patients, so they would
neither have to become masochisticnor have to 'pack it in' and resign.
The goup came to feel that it had not so much been me who had been
diverting them from their task, but that they had unconsciouslybeen preventing
me kom doing my work with &em. Their sense of having acted with some
collective nastiness towards me made them feel guilty, but there was also the
reality of what we had weathered and thus discovered together. 'This was of far
greater value than any amount of abstract discussion or lectures - the latter
having been suggested by them when free discussion had felt so bad and
worthless. They had been able to experience someone who had obvio~~lyk e n
buffeted by their attacks, but who had been able to contain feelings without
bitting back or abandoning them This demonstration of using reflection to
manage feelings arad reach m d e n m h g carried mt convictio~aw& heipd
them to move forward.At the next meeting it was possi'kde for them to connect
the2 fear that Hwould give up on &em wit$ their patients' artKieliesthat the SF&
would stopcaringforthemif hey weretoo negative andwrp,warding.Theywere
also able to acknowledge their own fear that they would become too W1 of h&
and angerto continuetheir work, and &at they really were at risk of abmdo&ng
their already traumatized clients. This had been minored i~ my impulses to
explodeor leave them, which H had w a g e d to contain before acting on &en.
Another common anxiety met by hospital workers is related to their
inadequacy in the face of deatk this is espsckdly p a when it is a child or
baby that has died. There i grief a b u t the death itself. but dso the feeling of
havingfailledto savea life. Thefollowingexample is takenfrommyconsultation
to the Wdsingham Child Health Team:
As we were m g i n g the chairs into a circle a booming voice codd be h a d
just outside the door - which was still open because there were five more
minutes before our starting-the - saying 'b this a dance? The voice
belonged toIDrRoyce, a seniorconsultantpaiediathicimwhodidnot attendthe
meetings, despite having been invited m y times. mere was no apparent
reaction, as though nobody had bead this comment. However, when the
meeting began, it seemed to me unusual$ sluggish and
team memberslookingat one another for aninstant and then breaking off eye
contact. There were then a few remarks complaining about the lack of
participation by medical colleagues, and why they didn't value the meetings.
As Ilistened, 1wondered what negaiive feelings a b u t ourwork were being
attributed to the 'absent profession'. I recalled s i d a r remarks in the past
about doctors' non-attendance: an often-shred attitude on the ward was that
those who did not attend the meetings were commendablybusy, while those
who did had too much time on their h d s . H also remembered hat this had
been a week in which the condition of several chilckn on the ward had
worsened, and a! baby had died. There h d been quite a subdued atmosphere
beforeeveryonehad ;arrangedtheir chairs, and nobody h d madecoffeetoday,
which was unusual. H found myself thinking again about E)r Royce's jokey
putdown. A s6ance is an attempt to contact the dead, and it suggests an
unwillingness to face bss. Bearing dl this h mind H decided to take up Dr
Royce's remark, saying I had been surprised that not only h d n o m
commentedon it, but there appeared to have h e n a concerted effoht to act
though it had not been said. Z wondered K they felt that their pab and loss
could easily be denigrated.
Alison, a physiotherapist who tended to permit herself closer emotional
contact with the children than most ofthe others, then spokeof the difficulties
in expressingfeelingsof griefin the hospita1. Joan, an occupationaltherapist,
spokeof her relief when a seniorpaediahcian had wept atthechild's W i d e .
Alison remarkedthatnwses werelabelled 'emotionally over-hvolvd' ifthey
Wor2 with d m chlBdreo 33
grieved, and others chimed in with comp%Bintsabut the 'stiff aspper lip'
cultme. There were a number of issueshere, but what H chose to address was
the way in which the p u ppreferredat thatmomentt~ thinkof &is repressive
culture as belonging to the nurses, rather than as s o ~ e t h h gin themselves.
Only when the members could face their owpl 's= upper Pips', a d thek
conscious and unconscious equivalentsof H>r Royce's mockery, would they
be able to carry through the necessary work of m o d $ for the baby, md for ,
the many experiences of failure and limitation represented by that bsei L
This was a moving and productivediscussio~,but in spite of the obviousr shared
relief, E was left feeling doubtful about whether the lessons learned would be
generalized and applied elsewhere.Perhapsit was only in,that particular s e a g
that professional defences codd be lowered and such painful experiences
explored.
This raises a question about the potential for growth and developmentin groups,
and how it can be supported. When painfin1 work situations, such as those
described here and in other chapters, are worked though again and again, it
becomes possible for some degree of individual change to take place.
Institutional practices can be scrutinized and sometimes changed, though this is
rarely without difficulty and resistance. The 'change in emotional climate9
mentioned above refers to shifts in ibe group from a highly defensive and
mistrustful attitude towards one of regret verging on depression, as they
recognized how eff~lastoprotectthemselveshad led to treatingo&ersbadly.The
experiencesIhave describedin thischapterstand out for me, not only because of
the cPiscomfo~,but also because they are such vivid examplesof the shift h m a
paranoid-schizoid position to one in which there was a preponderance of
depressive anxiety (seeChapter I). h the formerposition, thefearis of attackar~d
annihilation, blame and punishment. Primitive defences against paranoid
anxiety, if carried toa, far and with too much emotional violence, lead to the
severance of contact with reality.For example, st& may deny the reality of the
degree of damage, and of the limitations of what they can offer, as happened
when the Walsinghm team often felt under pressure to engender false hopes
about the degree of improvement which could be expected in severeiy
handicapped children.
The shift in emotional climate does not, however, result in freedom from
anxiety.Instead, our fears of what others are doingto US a ereplacedby a fear of
whai we have done to others. This is the basis of genuine concern,but guilt and
facing one's insuff~ciencyare painful to bear. Iftheseanxietiesare not contained
- and we therefore cannot be% them - there is likely to be a return to more
primitive defences, to the detriment of om work and mental health, as was the
case in the example of the staff grieving over the baby's death, where denid and
Chapter 8
Tit! death us do pad
Caring and uncanng in work with the elderly
VegaZagief RobeHs
moc!&g took the place of sadness ma loss until the feelings could be worked
through in the groupdissussions.
I have triedto demonstratehow importantit isforstaff involvedin painful and
stressful work to be given space to thi& about the anxieties stirred up by the
work and the effects of these anxieties on them. The cost of not having this is
considerable, both to clients and to workers. As well as offering much needed
support, consultation cm offer the opportunity for insight and change in the
,pup and wider institution,gthe pains and difficultiescan be tolerated.
Caringforelderly peoplebrings with itparticularstresses,insofarasageingis the
fate of all who live long enough. It inevitably stirs up anxieties about our own
future physical and mental decay, and Boss of independence. It also stirs up
memories and fears h u t our relationships with older generations, especially
parents, but also grandparents,teachers and others, towards whom we have felt
and shown a mixhare d caring and uncaring. 'Ibis chapter discusses how these
anxieties were dealt with in one geriatric hospital. However, the processes
describedexist to some extent in all caring work.
Shady Glen wasa specializedhospitalfor severelyimpairedelderlyp p b who,
without being particularly ill, required intensive, long-term nursing care. It had
two wings: the smaller North Wing had three rehabilitation wards for those
patients who were thought likely to be able b leave the hospital eventually;
South W i g had four 'continuing-care' wards for those who were not expected
ever to be able to Eve outsidethe hospitalagain.
The four war& of South Wing were particularly bleak and depressing. The
bedswere arrangedina circlem m d the edgeofeachwad, pointingtowardsthe
centre, from where the nurse in charge COUMkeep a watchful eye on everyone.
Squeezedbetween each bed and the next one stood a s d w a d r o b and chest
of drawers; there was link space for personal possessions, and vimdy no
privacy. A few patients couldmove aboutwith w&rs, but theothersspentmost
of their time in bed or sittingimmobilein chairs. Mostwere totally dependenton
the nursing stafffor all their physicd needs, and were fed, toile& andbathed on
a fixed schedule.
The nurses maintained a high standard d physical care. There were few
bedsores or accidents, %itticillness, and the patients were clean and well
nourished. However, the w a g e r s of ShadyGlen were concernedabut the poor
quality of We for the patients in South Wing, and asked the senior nurses of the
South Wing wards to form a working party to explore what could be done to
improve the situation. It quickly b e m e apparent that patients' quality of life