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The traumatized child with CHD: understanding the traumatized child’s broadcast and how we respond

Updated: Aug 24

THE INNER, EMOTIONAL HEART OF THE CHILD WITH CHD

AUSTIN E. WILMOT, M.S.W., L.C.S.W.

Virtually every child with CHD has experienced trauma. Trauma occurs when the mind’s capacity to understand is overwhelmed by an overwhelming experience, including the internal experience of big feelings. For a child with CHD, trauma may be having to experience things beyond understanding as to their necessity (holds true for parents as well), or experience pain, confinement, or the presence of powerful people and absence of parental protection. A traumatized child broadcasts on virtually all channels their call for help–broadcasting on a variety of symptomatic channels with physical and/or emotional symptoms, including anxiety as a signal that there are feelings trying to come up and find expression. A traumatized child’s last hope is that their broadcast is heard, understood and responded to appropriately. Without this occurring, the child is at risk of another trauma—a

relational one—that of being left alone with their trauma. A child with CHD is virtually guaranteed to be traumatized one way or the other—whether that is via preverbal, somatic (bodily) experiences or those occurring later, post-verbally, in development (e.g., coming to know about and make meaning of their heart problem, surgeries or other procedures, restrictions on activity, etc.)—unless parents are available emotionally to understand and help with their child’s feelings. Dealing with their own trauma and the feelings that come with it related to the birth of a child with CHD, parents may be unavailable to buffer the trauma experienced by the child or the child’s siblings—unavailable to help with the things that make their child(ren) overwhelmed. It is imperative that parents and healthcare providers, alike, understand enough to be of help or know how to obtain help for a traumatized child with CHD. Many children, with and without CHD, diagnosed with ADHD or other labels representing other clusters of symptoms are, in actuality, dealing with underlying trauma which has been unaddressed—unaddressed by way of their broadcasts going unheard, their behaviors misunderstood or having been responded to inappropriately or not at all.

A few years ago, I wrote an article that invited parents to email me about their own awareness of trauma in their child with CHD. Here, I will demonstrate how one family was able to pick up on their child’s broadcast. Not all parents or families have the antenna to detect and take note of their child’s broadcasts, whether a child with CHD or not. It can be complicated, as well, by the presence of “static”—a child’s broadcast may be full of “static”, which may make it hard to understand, especially at the beginning. I invite you to consider how the inner, emotional world of your child with CHD might be broadcasting to you. What channels are broadcasting? What programs are playing waiting for you to tune in? Would just medicating your child with Lexapro or some other drug be helpful, or would it be a way of turning away from really addressing the underlying trauma, leaving your child alone with feelings? These and other issues will be considered.

The Case of Zander*

Zander (*named changed for anonymity) is a 9-year-old child with CHD whose mother emailed me after resonating with an article written about trauma in CHD families. The following is her story:

“For as long as we can remember, my son has wanted to be a chef when he grew up, or some iteration of a culinary expert: a baker, a confectioner, a restaurateur, and a beverage concocter are examples that come to mind from his speculations over the years. Most recently, he’s become fascinated with Chinese cuisine, and dreams of living in a China for a year or two to really learn about its flavors and ingredients.

From a young age, one might expect him to have been primarily concerned with raising awareness about CHD (congenital heart defects), as he has HLHS and has been through 3 open-heart surgeries himself. He takes daily medications, has to limit himself physically, and has regular cardiology tests and appointments. But, when asked about passionate causes and injustices, he would always say, “people not having enough food to eat around the world” was the biggest thing that stood out in his mind.

I tend to assume he got his love of fresh food from my Italian side of the family, as stereotypical as that sounds. I can’t say all of my Italian family members fit that stereotype, but my great-grandmother, who played a major role throughout my entire formative years, certainly did. As part of Boston’s old Italian grocer community, any ailment or deficiency she perceived me to have could be cured through eating, she claimed. She cranked out beautiful, delicious Italian cookies for Christmases that I remember the taste and texture and sight of to this day, and made lasagna for everyone at family events, asked or unasked for. Even as a senior in low-income housing, she farmed her own tomatoes and eggplant outside her apartment building, and took public transit across the city to shop at her preferred stores.

I, too, use food as a vehicle: I cook to relieve stress, as a creative outlet that gives far more tangible results than my writing, and to show people I love them--even if I’m not Food Network material. But it pales in comparison with my son’s seemingly natural-born love: he will weigh ingredients in his hand and smell each one for freshness. He will critique food presentation for its visual and aesthetic appeal. He’ll taste spices and seasonings before adding them to anything from popcorn to homemade soups. These aren’t things we taught him; they just...organically are.

But when I look back on my son’s early life, it’s amazing that he finds so much joy in food--or maybe it’s because of these early challenges and injustices. When he was a baby, recovering from his first open-heart surgery, he wasn’t allowed to eat by mouth. He had a NG feeding tube delivering his high-calorie formula through his nose. This high-calorie formula, along with his open-heart surgery, caused horrible acid reflux the first couple years of his life. Eating wasn’t fun, really--it usually resulted in tears, pain, and endless vomiting.

Food became stressful for us, as parents, too, because we had to measure each individual cubic centimeter (cc) he ingested for the first few months of his life, and report weekly back to the hospital with our numbers. If he wasn’t gaining weight, if he wasn’t eating enough, there was pressure: would he need to be put back into the hospital? Were we failing as parents?

At some point, the acid reflux backed off, although he has continued to have digestive issues here and there, at times, to this day. Somehow--almost miraculously--a love of food grew in him, but unfortunately, a whole new host of issues sprang up around eating.

During certain medical procedures at the hospital, food and drink would be withheld from him due to hospital protocols and anesthesia rules. My son never was able to understand these rules, and he would cry and cry for food and drink. When he would wake up from a procedure, he would often be desperately hungry, thirsty, or both, but told by the nurse he hadn’t been cleared to have anything yet by the doctors. It was--to be quite frank--absolutely miserable for my son, and for us parents.

He developed an irrational fear that food would be withheld from him by others: at home, at restaurants--and these fears would become so overwhelming to him that he would have meltdowns. At restaurants, he would anxiously wait in terror, fearing the food would never arrive, fearing the waitress would forget his order in the kitchen--all manner of things that we would try to reason out of him.

After his third open-heart surgery, he was required to be on a strict low-fat diet for a couple of months, and although we all got through it relatively just fine, it was one more experience of a loss of control over an issue my son and I both, by nature and by family history, consider a highly personal and meaningful part of our lives.

Then, came the coumadin--a powerful blood thinner that requires dietary monitoring. As a lifelong vegetarian, it was so challenging to try to limit leafy greens, fruits, juices--and for my son, who loved to both cook and eat these foods, it was perhaps the most challenging food-related blow we had been dealt with yet in such a young life, and we were unbelievably fortunate to be able to come off this medication for several years now and counting.

To this day, he still struggles with social situations involving food, such as eating at other people’s houses, holidays, special events, and restaurants. We’re still working on it--all of it….”

Hearing Zander’s broadcast

One of the first things noticed about the mother’s narrative is her capacity to hold her son in mind while suspending her own assumptions about the particulars of her son’s communications. She is able to hold distinct her ideas of whether her own family history and Italian heritage has something to do with his preoccupation with food, as well as her own love of food, from her son as a separate person—seeing him as a separate person with his own feelings about food coming from within himself, not from a projection of her own experiences. The mother, listening to the uncanny in her son’s desires and needs, grounds herself in a position of curiosity and openness.

Secondly, the mother demonstrates the capacity to wonder about the linkage between present circumstance and early experiences. The not uncommon minimization of or difficulty with the association of early infantile experiences with later presenting concerns or emotional problems is not evident in this mother’s writing. She reflects on her son’s NG tube in early life, the difficulties and medical impingements associated with eating and the profound anxieties he suffers in connection with his relationship with food. She does not just dismiss his fear that the waitress would forget his order in the kitchen, or tell him to just “get over” his worries about food at other people’s houses or holiday events. Although specifics about these anxieties are not included in her write-up, including how his anxiety manifests in social situations involving food, this mother is “tuned in” to a broadcast that is coming in loud and clear—a broadcast that speaks about something very much bothering and distressing her son.

Understanding Zander’s broadcast—locating an alternate meaning to big feelings (1/3)

What does the constellation of symptoms and concerns about Zander mean about what is going on inside of him? Understanding Zander’s broadcast in the fullest possible way would require having Zander in psychotherapy over a period of time. Regular, consistent and dependable sessions with a well-trained child psychotherapist would set the frame for a safe space within which Zander could work out these feelings and anxieties by playing them out (like a picture book of sessions that is different ever so slightly from beginning to end) and finding words (to add to the book) with the help of his therapist. Children play with feelings (especially scary ones) to help make them smaller, decreasing the intensity of feelings that otherwise threaten to overwhelm them and/or limit their repertoire of responses to their own feelings. Children play to seek mastery of feelings, even feelings that concern traumatic events like surgery or the experiences of hospitalization. Children may also play to seek control—control, especially, of past experiences that were unwanted but necessary and beyond their control.

Although I state this limitation of not having Zander in a psychotherapy treatment situation, we are not without ample information for us to navigate towards an understanding of what Zander is likely struggling with. Beginning with the first sentence of the mother’s write-up, we can hypothesize that Zander’s wish to become a “culinary expert” is a way of broadcasting his underlying wish to gain mastery over his feelings around food—to become an “expert” on dealing with the incredibly big feelings he has when food enters the equation. As she states, a “host of issues sprang up around eating”—these are issues that the mother notes as largely behavioral in nature, a sign that there are feelings too big for his mind to process and therefore are finding residence for action and expression through the body. These big feelings likely fuel the profound, repetitious anxiety he experiences at restaurants and other places as regards his fear of deprivation—his fears of being deprived of sustenance. I quote the mother’s write-up here, for reference:

“He developed an irrational fear that food would be withheld from him by others: at home, at restaurants--and these fears would become so overwhelming to him that he would have meltdowns. At restaurants, he would anxiously wait in terror, fearing the food would never arrive, fearing the waitress would forget his order in the kitchen--all manner of things that we would try to reason out of him.”

Because of how large and overwhelming these feelings are for Zander, in combination with seeming disproportionate to the actual situation in reality, we are invited to consider the idea that these feelings belong not solely as a reaction to reality, but to another register of experience—the register of Zander’s fantasy life. Therefore, Zander’s fantasy life (his inner, emotional world) must contain alternate meanings for these big feelings—meanings that transcend explanations that only regard the immediacy of reality as relevant (e.g., “the restaurant situation is causing Zander’s distress” versus “overwhelming feelings inside of Zander causing Zander’s distress”). Above, the mother stated she “would try to reason out of him” his reaction. This reasoning does not help because it doesn’t explain how and why this similar situation occurred in the hospital by doctors and nurses that acted without awareness of the impact of their therapeutic efforts on the infant. With each hospitalization, others more powerful (doctors) controlled his food access. In the restaurants, they also (in his mind) have the control of food and might take it away! This is where Zander’s fantasy life comes into play.

In addition to the mother’s other accounts of big feelings surrounding strict diets, dietary monitoring and social situations involving food, a follow-up contact with the mother a few years later (Zander now age 11) resulted in the following new information:

“He is in middle school now…. Academically he does very well, and was on honor roll all last year, but behavior[-w]ise, [i]t's a real challenge at school at times as well as at home. …[L]ast year, he was placed in the adaptive PhyEd gym class instead of the regular gym class, and there was no room for them at the middle school gym, so they would often have to travel to the elementary or high school for gym. This class was also right before lunch, and often times they would get back so late that my son barely had any time to eat lunch. This became a major obsession and fixation with him, and resulted in some massive behavior issues and clashes with the adaptive gym teacher, which they unhelpfully tried to solve by threatening to send him to the principal's office for acting up over it at the end of gym class. [L]uckily, we were able to sit down and meet with his teachers over this issue so they were all aware of it, and they really did their best to get him to lunch on time after that!”

What shall we make of this additional information? In the first sentence, it is stated that Zander is doing well academically. That Zander has done academically well deserves its own comment (see Addendum #1 for more information). However, beyond the reference to his academic progression, the mother highlights further examples of the nature of his ongoing behavioral dysregulation. Such a pattern of behavior over such an extended period is confirmation (if we needed it) that there is something very meaningful playing out under the surface for Zander. What would have Zander so terribly worried, time and time again, that he would not be able to relieve his hunger pains? And, further, that someone would withhold food from him, or forget? To understand his broadcast for help, we must first look at the oral experience of “normal” infants.

Understanding Zander’s broadcast—discovering the developmental connection (2/3)

Our earliest experiences create templates and expectations for later life. If someone demanding you to suddenly stop ingestion by mouth for days/weeks/months (interrupting an inborn pattern of regulation, bodily integrity and security) is traumatic enough to generate protracted unease in one’s continuing sense of need-fulfillment and activity pattern, then we might be able to imagine how a similar interruption—that of a demand on an infant, wired to expect normal oral feeding, to be without nutrition by mouth—could lead also to a protracted impact (albeit a more serious, traumatic one) on an infant’s development of normal oral organization. As adults, we can think and process experience in ways an infant cannot, affording us an ability to understand and tolerate issues and work through feelings verbally—as adults, we could understand an alternate mode of taking in nutrition and process feelings about the change. Infants experience their environment through their bodies within their preverbal capacity—an infant would have only their sensory experience as input. How might Zander’s early patterns of experiences (notably his feeding patterns) shed light on his present patterns of behavior?

Children are born with a well-established food intake mechanism—namely to suck—breast or nipple of bottle. The baby does not know about tube feeding providing his nutritional needs. As a newborn, Zander’s “experience” was that he was starved, not fed, and as he grew, began to know that others control his food supply—he does not. “They might forget.” “They might not care.” “They might be angry with him.” He does not control the food supply, others control it.

In 1977, Dowling wrote an article concerning seven infants with esophageal atresia who received nutrition through a tube directly into the stomach from birth until surgical correction. While the paper pertains to the use of G-tubes (a tube through the abdominal wall), different than an NG-tube (a tube through the nose), it does speak to the relevance of oral organization in infant development and the effects of early abnormal feeding experiences. Dowling states, “[s]urvival of the newborn infant requires immediate competence in taking in life-sustaining components of the environment—oxygen, water, and nourishment—and in expelling body wastes—carbon dioxide, urine, and feces” (p. 244). Because of this innate press for survival, the sense of urgency underlying an infant’s biological drive to take in nourishment makes feeding behavior a crucial rhythm of existence. Quoted by Dowling, Spitz states that “[t]he repetitive and insistent frustrations of thirst and hunger … force the baby to become active, to seek and to incorporate food (instead of passively receiving food through the umbilical cord [when in the uterus]), and to activate and develop perception” (1965p. 147). Further, Dowling makes an important point, stating that “it appears that the ingestion of food is not only the model but, in fact, a biological foundation for successful incorporation, identification, and self-motivated learning” (p. 245). In all, the process of feeding for a baby forms an important basis for attachment, learning and other activities. You may see Addendum #2 for more information about the nuances of an infant’s feeding activity, as well as how Zander’s particular interest in “weigh[ing] ingredients in his hand and smell[ing] each one for freshness” may have its roots in his development having been shaped by necessary life-saving effects but experienced by the infant as trauma. Let us consider the ingredients of development surrounding the oral experience of infants below. What ingredients did Zander miss out on or were deficient?

Developmentally, four factors are involved in the oral experience of “normal” infants:

1. The support and subsequent elaboration of innate oral reflexes of rooting, sucking, and swallowing

2. The establishment of regular, cyclic patterns of [unpleasant] hunger and satiation

3. Provision of the extraordinarily complex sensory and motor experience of the ingestion of food (e.g., smell, texture, size, etc.)

4. Sensitive participation in the feeding experience by a devoted caretaker (usually mother)

In order to understand the developmental connection to Zander’s present distress in an organized fashion, let’s consider what we know about Zander’s early experiences in relation to these factors involved in the oral experience of infants:



Using this information, we can see how the establishment of a need-fulfilling relationship (versus a need-withholding relationship—e.g., Zander’s experience of the restaurant waitress), as well as pleasure (versus pain) within the context of the feeding situation and feeding relationship with mother, would present itself as a challenge given Zander’s experiences. Dowling states that “the stability and “reality” of association of pain reduction with incorporative activity is learned by oral feeding in a state of need, and, once learned, is fiercely retained” (p. 251). Given Zander’s fierce drive to be fed (versus giving up or lacking desire for food), we could hypothesize that he has, in fact, secured a link between the cyclic pattern of hunger-pain and satiation-relief. He certainly makes a scene if he is held up from going to lunch! Quoting Dowling, his “extension of questing, consuming feeding behavior, driven by the pressure of hunger-need” does appear with other activities and pursuits such as is apparent, in my view, with his successful questing for academic food (p. 252). We may also consider how his fascination “…with Chinese cuisine, and dreams of living in China for a year or two to really learn about its flavors and ingredients” may represent not just his love of food, but also communicate something of his fantasy life—that such a quest revolving around food has the quality of being far away from home and a long time of separation from home (versus being able to fulfill his hunger for food-study closer to home)—a repetition of the kind of questing he likely experienced as an infant in terms of waiting for food and perhaps the cyclic pattern of hunger-pain and satiation-relief taking place without the immediate somatic (bodily) association with a nearby, symbolic, symbiotic home of mother (i.e., mother=food via oral feeding experience). Said another way, Zander may have a host of fantasies about what life in China would be like for him. It would be helpful to know this information as it could uncover the extent to which Zander’s desire to go to China is also an expression of his need to get away from home which he might associate with a place of withholding and limits placed on him—a fantasy that China is a land far away where you can live free, never be deprived of food, have as many ingredients as you want and exist free of need-withholding relationships or limits.

Understanding Zander’s broadcast—putting the puzzle pieces together (3/3)

Having been so terribly and traumatically frustrated in his early infantile experience of attempting oral incorporation and gratification (by way of complete severance of oral activity from nutritional intake), Zander is likely in a state of trauma and engaged in repetition compulsion. Repetition compulsion is action wherein a person is unconsciously driven or seeking to recreate an original trauma in their present life out of an attempt to master it this time around (see Addendum #3 for more information). Consciously this is not understood, nor the intention—it is precisely because the person does not have the words or another outlet for the feelings underlying the action that the compulsion arises. Here, Zander is recreating his experience of early deprivation—bringing into his outer life (reality) his inner, (fantasy) life production which plays within him—a production in which he stars as a character destined to be deprived of promised, expected nourishment by a withholding other. This is Zander’s earliest template of how the oral organization of life proceeds—an organization that “has been recognized as the foundation of an infant’s pleasurable interaction with his own body and with the world in which he lives” (p. 215). In Zander’s case, we see how his experience of the world in which he lives (and the people in it), has been damaged through earlier trauma. While there are likely a diverse array of other roles and circumstances he finds himself starring in within his fantasy life, there is most often a constellation of fantasies that become crystallized around a core, inner emotional dilemma to be solved. For Zander, he has to see how his current thinking and feeling about food is the outcome of earlier experience—while life-saving, like a skin scar, it was caused when he did not eat in the usual infant way (by sucking) and so feels starved as an infant (no sucking = no food). He has not knowledge of his tube feeding. He did not use his mouth.

An important puzzle piece for us to place regards Zander’s view of the world, which, as we just learned, can relate to one’s template of oral organization. When Zander was “asked about passionate causes and injustices, he would always say, “people not having enough food to eat around the world” was the biggest thing that stood out in his mind.” This is Zander’s way of externalizing his own experience outward, projecting it away from himself as it represents something very painful for him. Even with the best of intentions and efforts of healthcare providers and parents, it is the truth most in alignment with his broadcasts—that of Zander telling us that he was the one that did not get enough food to eat and was deprived of it. For an infant, this generates profound anxieties and terrors that threaten a sense of safety and security. Zander went from the symbiotic safety of mother’s womb to the dangers of what he experienced as a world that does not have enough to give and will deprive you, forget about you and tease you with what it has to offer. In the mind of an infant, we could imagine how Zander’s first and most important relationship—that of with mother—“failed” him not only nutritionally but also as regards emotional attunement (e.g., early mirroring and mentalization of emotional states in the context of a “good enough mother”). You may see Addendum #4 for further understanding about the meaning of a “good enough mother”, a term coined by Winnicott, a notable English pediatrician and psychoanalyst. We now look towards responding to Zander’s broadcast from our position of awareness and understanding.

Responding to Zander’s broadcast

Children struggle with what their parents struggle. Responding to a child in a state of trauma requires more understanding than meets the eye. If parents cannot see the trauma their child has experienced, understand it and respond to it appropriately, then the child will be left alone with it and with their overwhelming feelings. Parents are not immune to trauma themselves. Parents come with their own personalities, upbringings, histories, blind-spots and capacities. While we lack information about Zander’s parents, such background would be a normal part of an initial information-gathering stage of a child psychotherapy. This would include a full developmental history of the child, as well as histories of both parents. That Zander continues to have the anxieties and behavioral dysregulation that he does, indicates that his parents are not reaching him in some way as regards his emotional world. For Zander, the puzzle of what is going on inside of him remains unsolved and no pill will change that. Attempts to “reason out of him” this “irrational fear”, as the mother wrote, while a valiant effort, were only destined to fail. This is so because the response to “irrational” fear is not to reason it out, but to understand the rationale in the fear that is operating under the surface—the real fear that Zander carries from his early experiences. Successfully responding to Zander’s broadcast will lead to a resolution of symptoms and post-traumatic growth. A positive tendril of health, and, in my view, some evidence of post-traumatic growth, is represented through Zander’s joy and pleasure with food. However, this is not to be understood as evidence of resolution of trauma.

It is imperative that we also consider the situation that Zander is still growing and developing. Zander’s unresolved trauma, while seen on surface as his current behavioral dysregulation and anxieties within the developmental stage of his 11-year-old self, will continue to shape his ongoing developmental trajectory in virtually all areas of his life unless it is addressed. As one enters adolescence and adulthood, the possibilities open for frustrations and overwhelming feelings to be dealt with in more seriously troubling and damaging ways. The recruitment of addictions (e.g., alcohol, drugs, food, sex, spending, gambling, etc.), unhealthy relationship patterns and other manners of distraction from emotional pain or attempts at self-soothing that ultimately fail to touch the underlying trauma are not uncommon. How could Zander’s overwhelming feelings and anxieties manifest within a teenage boy’s or adult body? What about the ongoing challenges and dynamics surrounding his CHD as he ages? There is a lot to navigate and lots of feelings to talk about.

Conclusions

Trauma is a fact of life. Children with CHD require the specialized care of a pediatric cardiologist—a specialist for caring for a child’s physical heart. It is my view that children with CHD require specialized attention to their inner, emotional heart. Whether that is an emotionally attuned and responsive parent or through the teaming up with a well-trained child psychotherapist, a child with CHD must be helped with their heart worries that weigh heavily on their heart. It is my view that many children are stuck in a “heart worrier” state, on top of being instructed to be “heart warriors” before they have been helped to address their heart worries and think about their congenital heart disease and identity. These children grow up (and, often, into adults) with unresolved and unsolved feelings about their CHD, bodies and sense of self. A traumatized child’s last hope is that their broadcast is heard, understood and responded to appropriately. I hope this paper stimulates hope through understanding more about the inner, emotional heart of children with CHD.

Addendum #1

Learning is an oral process and has its basic roots in the oral organization of life—an organization that, for Zander, failed in a number of areas during his early experiences. These failures, which we will take a closer look at, are important for us to understand in order to understand Zander’s distress. His academic success is a good sign as it indicates he is (1) interested in eating up/taking in knowledge (versus refusing/denying needs or resisting food/knowledge), and is (2) digesting/processing knowledge well (versus having difficulty with chewing on/thinking about thoughts/ideas).

Addendum #2

To understand more fully the goings-on of feeding and their derivative importance on the idea of a child’s “lost toy” to be found, consider Dowling’s narrative here:

“Head, hands, arms, and trunk are brought into active participation as the infant anticipates the feeding, strains to the breast, holds and fondles the breast, the bottle, his mother and himself. This activity is initiated by the recurrent pressure of hunger need, terminates in the satisfaction of a full stomach, and re-creates again and again the sensory and motor synthesis of nutritional incorporation. Just as the activity of the mouth, fortified through feeding, is extended to other objects, both animate and inanimate, in exploration and for pleasurable and aggressive purposes, so too are large muscle and postural skills extended from hungry incorporative movements toward bottle and breast to other, nonnutritional, activities. The lost toy is regained by the searching and exploratory grasping of the eye and hand. This forceful exploration and grasping originate and are practiced in the searching, exploring, and taking in of feeding—propelled by the need for relief of hunger. The pleasure-providing mother—and later the interesting toy—is grasped hungrily, held, fondled, and finally pushed away when the infant has had his fill. Taking-in and pushing-away activities and attitudes may have their genesis in the feeding situation; the study of children [in Dowling’s authored article] dramatize the important diminution of function which follows an absence of this experience” (p. 252).

What we might consider, based on Dowling’s assessment above, is a certain quality to Zander’s behavior that the mother noted in her write-up. I reference it here:

“…it pales in comparison with my son’s seemingly natural-born love: he will weigh ingredients in his hand and smell each one for freshness. He will critique food presentation for its visual and aesthetic appeal. He’ll taste spices and seasonings before adding them to anything from popcorn to homemade soups. These aren’t things we taught him; they just...organically are.”

Upon reflection, it is my view that Zander’s passionate interest in the ingredients in his hand is very much like Dowling’s description of the derivative exploration and grasping occurring with the interesting toy. Zander, in holding and taking in the “interesting-toy”-object-ingredients so exquisitely, acts out the very searching, exploring and taking in of feeding through which he concomitantly broadcasts his intense hunger and drive for finding satiation-pleasure. This speaks to the way in which the development of his oral organization and associated activity patterns has been shaped by his trauma.

Addendum #3

Generally speaking, the problem with a repetition compulsion is that one may go through life continuing to recreate the same problems or mistakes without ever “working it out” (e.g., always picking a narcissistic partner hoping that this time around they will be able to change them). One aim of psychotherapy is for one’s repetitive, fixated patterns to, over time, become a feature of the work within the relationship with the therapist so that the actions occurring in one’s life can be talked about, contained, understood, and through psychic work, changed—helping to free the person up to live life with more possibility for choices than before. For Zander, this might look like helping him overcome the big feelings that drive his behavior so that he can be freed of his fixated terrors.

Addendum #4

Winnicott (1948) describes “the ordinary good mother”: “She exists… She is there to be sensed in all possible ways. She loves in a physical way, provides contact; a body temperature, movement, and quiet according to the baby’s needs. She provides opportunity for the baby to make the transition between the quiet and the excited state… She provides suitable food at suitable times. At first she lets the infant dominate, being willing (as the child is so nearly a part of herself) to hold herself in readiness to respond. Gradually she introduces the external shared world, carefully grading this according to the child’s needs which vary from day to day and hour to hour. She protects the baby from coincidences and shocks, … trying to keep the physical and emotional situation simple enough for the infant to be able to understand, and yet rich enough according to the infant’s growing capacity. She provides continuity [and concern and empathic contact]. By believing in the infant as a human being in its own right, she does not hurry his development and so enables him to catch hold of time, to get the feeling of an internal personal going along” (p. 160f.). Thus, “the ordinary good mother” (Winnicott, 1948) brings a readiness to perceive and respond to the infant’s needs and provides a physical and emotional climate which promotes the infant’s capacity to thrive without too much anxiety or frustration.

Bibliography

Dowling, S. (1977). Seven Infants with Esophageal Atresia—A Developmental Study. Psychoanal. St. Child, 32:215-256

Spitz, R. A. 1965 The First Year of Life New York: Int. Univ. Press.

Winnicott, D. W. 1948 Paediatrics and Psychiatry In: Collected Papers New York: Basic Books, 1958 pp. 157-173

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