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Preparation of a Child for Major Surgery
Preparation of a Child for Major Surgery
A Case Report Foster W. Cline, M.D . and M ichael B. R oth enb erg, M .D.
There is an extensive literature abou t the psychological impact of surgeryon children. Many articles emphasize the fact that a child is a feeling and frightened person who needs explicit information about what will happen to him and who must develop a personal relationship with his physician. Perhaps even more than the adult, he needs the opportunity to work through fears and fantasies concerning surgery. Meyer (1967 ) and Bergmann and Anna Freud (1965) explicitly discuss children viewing surgery as pun ishmen t, or a "consequence of naughtiness." Gl aser et al. (1964) describe the strained mo ther-child interactions that build up in the families of chro n ically ill children, and note that lOaf 25 mothers whom th ey interviewed considered themselves "who ll y responsible for ha vin g produced a defectiv e child." Eissler (1955) has pointed out th at th e reaction to hospitalization and surgery in children is age specific. That is, younger children fear separation ; older children fear attack. At about age 5 to 9 (Nagy, 1948), death is regarded as a person , and is so feared. Only preadolescent children can begin to view death as adults do , with the accompanying fear of loss of control. At this point, th e literature on the effect of surger y in car d iac disease is extensive, and th e literature on the psychoso cial aspe cts of cardiac surgery is growing. Mar gol is (1967 ) and Abram (1965 ) stress the anxiety-provoking atmosphere of the intensive care unit, the isolation, the lack of privacy, and the impact of sensory depri vation. Familiarizing the child with aspects of the leu and anesthetic equipment (Jackson, Dr . Clin e is presently in pri vat e pract ice in Evergreen, Colorad o. This paper was begun while he was a Fellow with th e Division of Child Psychiatry at th e University of Washington . Dr. R oth enb erg is a Professor in Psychiat ry and Pedia trics, Un iversity of Washington School of M edicin e and is with the Division of Behavioral Sciences, Chi ldren's Orthopedic Ho spital and M edical Cent er, 4800 Sand Point W ay, N,E" Seattl e, Washin gton 98105, where repri nts may be requ ested from him .
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1951) and using hospital equipment as toys (Plank, 1963) aid in lessening the fear of the unknown and the anxiety of the unfamiliar. Other articles have explored the effects on patients of cardiac surgery per se. Meyer et al. (1961), Kaplan (1956), and Schneider (1954) explore this in detail. The most extensive bibliography today is given by Toker (1971); he reviews the significance of heart mythology and folklore as well as the literature on the psychiatric aspects of heart surgery. He presents the case of a 7-year-old Puerto Rican girl and her problems prior to and following surgery for a septal defect. The present paper details the experience of Bobby]., a 7-year-old middle-class, Caucasian boy, with open-heart surgery. Many problems were present which portended a poor prognosis. The illness was chronic, the parents lived in a "conflict-habituated" existence (Cuber and Harroff, 1965), and were unable to give their son emotional support in this period of crisis. The parents had religious differences, which were a source of conflict, and the father was a sailor away from home on sea duty for extended periods of time. This operation was the second attempt to repair a difficult septal defect by means of openheart surgery. A year previously, the first attempt at repair was followed by a stormy postoperative course with ensuing destructive parent-parent and parent-child interactions. The child was, in fact, used by his parents in living out their sadomasochistic marital relationship. For instance, the father maintained that Bobby's heart defect was God's punishment for his mother's premarital promiscuity. In recognition of these problems, special preoperative psychiatric evaluation was requested by the pediatric cardiologist and surgeon prior to making this second attempt at septal repair. In this paper we shall follow Bobby's treatment chronologically as it developed. Transcripts obtained from audio and video tape recordings made during interview and play sessions were subsequently used in supervision. During treatment, a number of transactional and technical problems unexpectedly developed. A discussion concerning these issues will follow the case presentation. CASE PRESENTAnON
Preliminary Correspondence We first heard of Bobby]. when his school queried the Department of Surgery about his activities. The report from the school noted: "The classroom teacher has observed Bobby shaking with apparent nervousness when asked to participate in class activities. Until recently he was quite cheerful in the classroom. His condition has improved since
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Mr. J. returned to a tour of sea duty. Mrs. J. also appears to be more relaxed at this time. She has indicated that a conflict exists between her and Mr. J. over the type and consistency of disciplinary methods used with Bobby. Mr. J. seems very protective, while Mrs. J. is attempting to encourage Bobby to become more independent in making decisions. Bobby has difficulty in doing the readiness skills the kindergarten children participate in as a step in preparation for first grade." The Department of Surgery answered, saying: "This youngster had a ventricular septal defect and pulmonic stenosis repaired with openheart surgery. We saw him several months ago and felt that his condition was quite satisfactory. It is our impression that he can engage in any activity he likes and does not need to be restricted. He should be treated as normally as possible." Several months later, following catheterization, a letter from the surgeon to his colleagues performing the catheterization expressed his concern and reflected the affective interpersonal appeal of this 7-yearold patient. The surgeon explained the technical difficulties inherent in the first operation and noted his concern about the completeness and the success of the operation. He stated: "Our concerns have proven correct. I'm sure you can imagine our dismay at having to reoperate on this lovely youngster, but it is clearly necessary and reality must be faced. We discussed this with Mrs. J. and she agreed to the surgical correction. It was emphasized to her that the defect is a difficult one and that it will be no less difficult at this time." At the time of psychiatric consultation, the pediatric surgeon expressed his concern over the family situation and explained that the mother had been prepared for psychiatric treatment. "On discussion of the problem with the mother, she feels that some sort of assistance would be very helpful. She indicates that the father is rarely home as a result of his occupation. They do not get along together and she is seriously considering divorce, although she plans to do nothing in that direction at least until after surgery is completed, and to make no particular indications of that to Bobby in the meantime, except what he can perceive on his own. She also states that the father was extremely anxious during the last operation and threatened various actions implying self-destruction, or possible destruction of others in the event of loss of this child. She states that when the father is home he exercises no authority whatsoever over the child but absorbs the child's complete command and complains afterward that he is completely exhausted from the experience. "Since we have rather healthy respect for the effect of the least depression on the survival of these youngsters, in addition to our concern
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for his long-range well-being, I would appreciate your suggestions on the best method of handling this boy and his family constellation." Intake
When seen for initial consultation, Mrs. J. was in the middle of a rather artificial and glib reading to her son, who was sitting in her lap. Bobby was looking furtively about. He was a curly-haired, brown-eyed, and very attractive little boy. The mother was first interviewed alone. She grew up the only daughter of a rejecting mother and alcoholic father. Many aspects of her childhood history appeared to bear on the type of relationship she subsequently developed with her present as well as with a former husband. For brevity's sake, only her marital history is noted here. Mrs. J. was first married at 15 to a man who was 25. She divorced him twice. In the process of this turmoil, she lost custody of her first child and was committed to a state hospital for 4 months. At 22 years of age, she was married again, to her present husband, who was then 33. As might have been anticipated with her past history, the present husband had been psychologically and physically abusive to her, saying that Bobby's illness was a result of her "sin." While not consciously accepting this, Mrs. ]. acted at times as if she believed it and wondered if she unconsciously accepted it. She pictured her husband as a very unstable person who constantly berated her with projections of his own feelings about himself. For example, he accused her of being unfaithful while he had numerous extramarital affairs of his own. She maintained that her husband held her responsible for all of Bobby's problems while he "exhausted" himself caring for Bobby. During the last operation, he was reported as pacing and crying during most of the surgery. He slept with his head on Bobby's bed during the first night in the hospital. Mrs. J. reported that her husband had threatened to kill her in the event Bobby died as a result of the contemplated second surgery. Mrs. J. responded to her husband's accusations by angry emotional outbursts in front of Bobby. Allegedly, her husband then further berated her for upsetting the boy. Mrs. ]. generally accepted her husband's accusations and stated that she was certainly to blame and guilty of all of his accusations. Mrs. J. described her life during the last 7 months while her husband had been at sea as "the happiest in my life." After his mother was seen, Bobby was interviewed. He had not been told of the impending operation, still 8 weeks away, although 2 weeks
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before this initial evaluation he had undergone his second card iac catheterization. The examiner felt it was a parent's prerogati ve, with the physi cian's support, to tell the son about his operat ion. In the interview, the doctor there for e approached this area ver y gingerly. Bobby was fairl y at ease with the examiner, first asking, "W hat in the world took you so long?" Con cerning scho ol, he said that he knew that the first grade was going to be "a real problem for m e," but would just as soon "get it over with ." Bobby had numerous, reali stic concern s about death. These were mani fested in many ways. When in the water , he constan tly th ou gh t th at he might su ffocate and drown . He stated that if an y other opera tio n was ne cessary he would accept it but would probably worry, and then commen ted : " I' m not sure how much I would worry. " If another operation were n ecessary, he said that he would rather his fath er be home, because the hospital was a lonely place and it was nice to have his father present. He said he would like to have his father at night and his mother during the day. I (F. W. C.) asked if at times his family life was more stressful when his father was home and he said "yes," tha t this was probably because his father spent so much time with him and made his mother feel lonely. The mother was again inter viewed and asked how she felt about her husb and's retu rn. She said th at it would be best not to tell her husband about the operation becau se he became so "u ptight" and that she did not want him to re turn until a week or so prior to the operation. In that time, she felt that he cou ld be supportive to Bobby, but there would not be enough time for th e parents to escalat e their feuding to an intolerably de structi ve level. It seemed a r eason able decision, and the authors supported it. They arranged for Bob by to be prepared for surgery in weekl y play th erapy sessions. No firm commitmen t was made as to how regularly the mother would be seen.
Beginn ing Th erapy The consu ltan t was surpr ised whe n Mrs. .J. phoned the following weekend, sounding extremely anx ious. She said th at her husband had suddenly returned from sea duty on emergency leave. " I told him about the surgery and about its being planned for 2 months. I knew he'd be very upset, but I didn't think he would come home so quick." Mrs. .J. then described ver y tens e marital conflicts in whi ch her husband played the role of dete ctive and prosecutor while she pla yed the role of cri m in al and victim. Mr. .J. accused her of seeing an other man, ri fled her purse and bureau drawers seeking information , and followed her when she left the hou se. She cr ied about hi s " par anoid" accusation s and vociferously denied h is suspicion s. However, during her son's post-
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operative recovery period, she was to undergo abortion for an out-ofwedlock pregnancy. Mrs. J.'s anxiety was apparent on the phone. It was diminished when the consultant suggested that she, her husband, and Bobby come in for the beginning of presurgical therapy. The authors met during a supervisory session and decided upon goals: 1. To form a therapeutic and warm relationship, if possible, with the father, as he would probably feel that he was an "outsider" and that there was an alliance against him. 2. Rather than deal with the content of marital feuding per se, it would be better to emphasize the importance of parental support for Bobby during this time of stress. In essence, the object of the work would be to try to help the parents interact around their son therapeutically rather than destructively. 3. To help the parents develop a way of telling Bobby about his operation, listening to his fears, and supporting him. The family was then seen, and after an hour interview, the consultant was satisfied concerning all of the goals. The father had expressed his dissatisfaction about his wife's seeing a psychiatrist, saying, "I don't know what is being said about me behind my back. You probably just heard one side." After a nonjudgmental exploration of his feelings, he appeared progressively relaxed and involved. Secondly, without attempting to go into detail about the marital dissatisfactions, we found that indeed there was a broad, habitual conflict between the parents. Mrs. J. verged on a decision for divorce. Her husband fought this, saying that he had given her no reason for divorce and that he wished the marriage to continue. The therapist emphasized the importance of working together now in order to help Bobby, and postponing the exploration of the larger marital issues until after Bobby's surgery. Both parents seemed agreeable and gave assurances that, for Bobby's sake, they could provide a united and supportive stand. Thirdly, it developed that Bobby had not been told of his impending surgery. Bobby had pointedly asked questions about his father's return from sea duty, what type of blood his father could give, what kind of blood he himself had, and how he would get blood should he need another operation; nonetheless, the parents had chosen to ignore these openings and this subject had been avoided. A careful discussion followed about how the parents might prepare Bobby for this operation. They agreed to discuss the operation with Bobby during the ensuing week. One week later, play therapy was to begin. The consultant then spent time with Bobby, specifically talking with him about his parents' feuding so that this also might be dealt with openly and in a supportive way. Seldom does a child express feel-
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ings of being caught in a chronic marital conflict as poignantly as in this transcript (audio taped session):
Therapist: Do you know what your folks and I were talking about down there? Bobby: No. What? T: What do you think we've been talking about? B: I don't know (despondent). . . . About first grade. T: We talked about that. . . . B: What else? T: We also talked about that sometimes your mom and dad have quite a few disagreements and quite a few fights, as a matter of fact. B: Yeah, that's right, they do. And every time I'm in one. T: You're in it? B: Yeah, I'm in it. T: How are you in it? B: Oh, I'm just in it. Every time . . . like this argument, you know, dad was callin' mom kind of dirty names I guess; I didn't hear very well. She was starting to cry. . .. And it isn't good. I was gonna. . . . My dad's home from overseas for over a month now. My folks are coming in 2 weeks, I think; I'm not sure and . . . yeah, they're coming in 2 weeks, I think, but I'm not sure . . . if it's gonna be 2 weeks. T: Well, listen, I want to know now how you are always in your mom and dad's fights? You mean when they fight you're right in the middle? B: Well, I'm not right in the middle sometimes, sometimes I . . . I'm in the fight (anxious laugh). T: You are? That must not be a very good position to be in, though. B: No, I get out of it. I don't like getting in those dirty bird fights. T: Well, what we were trying to do is to see if maybe your mom and dad can fight less. That's what we were talking about, having less fights. B: Yeah, that would be fine. T: (Laughs.) You'd . . . you'll go along with that, huh? B: Yeah. I don't like them arguing, then mom starts to cry about all of this . . . and then some of the time she cries . . . and then sometimes she just gets mad and starts arguing and then it's too noisy for me and so I go outside (laughs). T: Oh boy . . . you mean you don't like it. B: No, and I'd rather. . . . Every time my dad takes leave or is home, it seems like fights, fights, fights. T: What can you do to stop them, anything? B: No. I tried to stop them, but they won't stop, they just keep on, you know. And I don't understand it either. Just for a little thing . . . like we're seeing if we can buy a new car and it's up to daddy and daddy says it's up to mommy and then they don't know what's up
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to . . . . I want to get a new car, that's what I want to do. I want to get a new little Datsun, that's what I want to do; you know, these little cars. Well, are the fights do you think your dad's fault more or more your mom's fault or who starts them mostly, do you think? My dad, I think. Um. . . . I hope this doesn't hurt my dad's feelings, but he just starts most of them, but then, at the end, he says that's my fault, then blaah-like that-he does. He says then at the end that it's his fault, but then it's too late to change it, isn't it? I know it, and I don't. And I don't know what they were talkin' about, but, right after the day we picked my dad up from the airport-right after that day and night, rrruh' arguments; and I do not like that. I wish they were less arguing because arguments never gets you something out of it! I think you're right there.
The following week, the parents returned. In essence, they had not been able to fight less, although they had attempted to be supportive of Bobby. To the therapist's surprise, they maintained that there had been no opportune time to talk with Bobby about his surgery. It was apparent then that the parents needed the support of the therapist's physical presence to help them in dealing with Bobby on this issue. While Bobby waited upstairs, the method of telling him about his surgery was discussed. The therapist felt it would be helpful to the father, giving him an increased feeling of self-esteem, inclusion, and competency, if he could tell his son of the surgery. The following is from a transcript of this emotional conversation: Bobby Is Told of Plans for Surgery Therapist: Okay, do you want to tell Bobby why he's down here? Father: Yeah-as you know I told you up there we were gonna have some . . . some kind of bad news, but it wasn't too bad . . . it wasn't that bad . . . you know when you went through your catheterization? Bobby: Yeah . . . . F: You know the doctors had to study it and had to study it and they finally found that you had a . . . a little tiny hole in your heart still . . . and that . . . that they're gonna have to try to get in there to repair it so as you . . . uh . . . grow older then . . . uh . . . the little hole won't get larger. And this means that you'll be able to . . . to play and run and all like you always have without it hurting you. So . . . uh . . . sometime in October you're gonna
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have to go through open-heart surgery again. . . . (Bobby cries.) Okay-Oh, now-and it's going to be . . . to repair that little hole in there. We don't want that hole to get bigger. T: Say, Bobby, that isn't very good news is it, urn? . . . Bobby? Mother: Go ahead and cry, son, if you'd like and maybe that will make you feel better. T: How do you feel about it? Kind of scared or worried or just sad about it, urn? (Bobby continues crying.) I guess if I was told that kind of news, I'd feel pretty bad, too; but I guess even worse things do happen to people, but that doesn't make it any better for you, does it? Urn? Bobby, I think that we would have told you before, but the doctors had to study all the reports and make sure that they wanted to do it again, so it really wasn't for sure, although I guess you know that everyone was kind of thinking about it for a while. Did you kind of suspect that, urn? Did you kind of know that people were thinking about it, or did you not know? (Bobby continues crying.) F: Gee whiz, Bobby, things, you know, things gotta be fixed and you know how dad's always fixin' things around the house when they don't work right and that's all the doctors are doing, but it took them a while to study it out and to figure it out after your catheterization and . . . uh . . . so they feel that they should patch this little hole up so as you grow older that little hole won't grow any more-it'll be all fixed just like daddy fixes the car and fixes things around the house; fixes your toys and all. It's just one of those things that will happen like that, Bobby. T: Bobby, what makes you feel the worst about it? Can you tell me that? What do you feel worst about? (Silence.) When you were in the hospital last time were you on the ward where there were lots of other little kids and did you play in the playroom or were you downstairs most of the time? (Silence.) F: (Pats son.) Come on, big boy . . . huh? Hey, the doctor asked you a question. I . . . I . . . I don't want to answer it-I think that you know more about that than I do. Why don't you tell the doc? Urn? Tell the doctor . . . that you were in both places, but you don't really-can you tell him? Urn? Do you want me to tell him, huh? (Bobby nods.) Okay, I think Bobby was downstairs for a while and then was moved upstairs and then he stayed upstairs and met all the other kids that were up there with him-weren't you? Weren't you up there for a while too? I think you were upstairs for a long time. You were upstairs-longer than you were down. Don't you remember, huh? Sure you remember. You had your TV set out and you were watching TV. Bobby, am I right? T: I think it's better, see, to have this to go through this reaction now and get it kind of worked out. . M: I do too . . . I can see where . . . yeah. T: And I think what we have to do is just let Bobby know that if he
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wants to talk about it or if he wants to express his concerns about it, why, we're around and he can express them to us, that it's nothing that's too scary to talk about, see? That's right, Bobby, and you know that. It's just another operation, son. (Bobby cries.) That's about all. 1£ you wanna cry about it or if you wanna talk to daddy about it, come on, talk to dad about it, you won't be sc . . . you'll worry about it, naturally, but you'll get over that, Bobby? Oh boy, I'm glad tomorrow's not a school day, that way you won't have to worry about getting your clothes dirty. Want a handkerchief, huh? You don't want a little handkerchief? And I think one thing, too, that one thing we'll have to do is make sure that we let Bobby sort of approach us on this . . . so that we don't, you know, be too concerned and make him feel like he has to . . . . . . . to talk to us about it. Yes, that we're available, that's right. And if he wants to come to talk to dad or mommy about it, he's welcome to do it any time he wants. I'm sure, Bobby. I'll do this, too. Sure. . . .
Following this conversation, Bobby continued to cry on his father's lap, not speaking. The therapist recognized that he, as well as Bobby and the family, was very uncomfortable. It appeared unnecessary and fruitless to attempt to get Bobby to verbalize at this time, and with instructions simply to "hold Bobby and be with him," the mother, father, and son left. Play Therapy
The following week, Bobby began a series of weekly directive play therapy sessions, the goals being (1) to help him as much as realistically possible to work through his anxieties concerning surgery; (2) to develop a feeling of confidence that would follow from a more complete familiarization with and understanding of the surgical situation; (3) to provide a supportive person, the therapist, with whom Bobby could share his feelings and anxieties. He would know that the therapist would not use him or his feelings in some type of game as did the parents. He would also know that the therapist would not desert him during the operative or postoperative course. The play therapy was carried out over a 7-week period prior to surgery. As Bobby's anxiety and trust in the therapist increased during the course of therapy, an interesting sequence of anxieties related to surgery evolved and could be worked through. At the first play therapy session, a toy doctor's kit, clay, and various
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pieces of cloth were available on the play table for him to use. Bobby's anxiety was such that he could make no clay figures and did not approach the doctor's kit. He said that he had come for his session during school recess, which he enjoyed very much. He certainly did not like coming. He had misgivings about doctors in general, "although they're just trying to help you." The therapist discussed with Bobby how unhappy he must have been when he was told about the impending operation. He emphasized that "it sure is no fun" and wondered how Bobby had felt since, and how things had been going at home. This appeared to allow Bobby to open up. The child reported that his parents were continuing to fight; for his part, he appeared to have an attitude of resigned acceptance concerning the operation. Over the following 5 sessions, Bobby began to play with the doctor's kit spontaneously, and to work on his anxiety in "play surgery." Each session was videotaped, and 7 minutes of consecutive interaction have been transcribed from the 6th therapy session. During these 7 minutes, Bobby revealed his fantasies, blocked on talking about recatheterization, and talked of his fears of reoperation and death. He poignantly described a septal defect "too big" to repair and resignedly stated, "I guess the doll will just have to die." A transcription of this interaction is given below.
Bobby: Oh, boy . . . now we're going to get him back together; stitch him back up. Therapist: Okay, you want a needle for the stitching? B: No, I can have one of these (Bobby sees a safety pin). Oh, yeasurel But those are for body stitching. But right now I'm doing body-stomach stitching . heart stitching. T: What kind of stitching? B: Heart stitching. T: Heart stitching? Is that .. where's his heart? B: It's over there. T: His heart's over there? B: Yeah, for the mean. . . T: What are you doing right now? B: I'm stitching . . . so it won't fall out. T: You mean so his heart won't fall out? B: Uh huh. They all fall out and when he plays-he'll play. T: And the more he plays, the more they will fall out? B: Yeah, I'll put in twenty million of them. Some of them might stay, but he'll probably have to go through the catheterization. T: He'll have to go through a catheterization? B: If they don't stay. There. . . . T: Boy, those are a lot of stitches. Now, what are those stitches for? B: So his heart will stay together. T: Oh.
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It's hard to get off now. There now. Yep. Now we patch up the hole again. Okay. We need some more shot medicine. We do? Yes. I get that up there, way up high. What are you doing now, patching the hole up? Yeah. Very good. Boy, those holes are really getting filled up. What about this hole here? (The therapist is pointing to a hole in the chest that Bobby has avoided.) That connects to the knee bone right here. Uh hum. We'll have to stitch that up the rest of the way . . . and make a hole there . . . I think . . . it doesn't have to be done, well, I guess I did it. . . . There, good . . . . Now, good. Now, where. . . . Now, we don't need to do those anyway. We don't need to do it till . . . right over there. . . . Now, if that hole gets bigger, he's going to have to go through . . . another . . . another . . . another catheteriza. . . . If that hole gets bigger he's going to have to go through another catheterization? Yeah, because we can't plug that up anymore. You can't? Dh uh.
on.
Or he'll die. You mean, if you can't plug up the hole he's going to die? Yeah, and I'm not sure if we're gonna get to plug it up or not. Really! Well, I certainly hope that we get it plugged up. You know, most holes get plugged up after one or two times. Did you know that? Well, let me see. I guess he's going to have to go through another . . . darn . . . die. He's going to have to what? Die. He's going to die!? Oh, dear (Bobby laughs nervously), how did you decide that, doctor? Look. Look in there. I'll show you how big a hole there is in there and we can't patch it up either. Wow (Bobby laughs nervously). That big hole? You mean that's too big a hole to patch? Yeah. Are you sure of that?
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Let me see. We might be able to patch that. Well, we'll try. Okay. His body's too hard because of that dumb stuff I put on it (falls backward trying to cut). Wow, that is hard. It just knocks you backward trying to cut in there, doesn't it? We're going to have to let him die. Oh, no. Really? Yes. (Sighs.) I wonder if there isn't anything we can do besides that? (Laughs.) Yes, sure there is. What, what? . . . Hey, what are you doing now? Plugging a hole. You're plugging it. (Sounds of clay being hammered.) I think that hole is being plugged. It is. And there it is. No more hole over there. Oh, how does he feel about that? He feels pretty good probably. I bet he does! There you go.
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A Note on the Postoperative Course During the postoperative course, Mr. and Mrs. J. continued to feud. One evening, about 10 days postoperatively, the mother had brought flowers for Bobby's room. That evening, smelling of alcohol, Mr. J. tore up these flowers and threw them in the wastebasket beside the bed. This frightened Bobby, and the nurses called the therapist. The therapist talked to Mr. J. on the telephone and told him never to come back to the hospital smelling of alcohol. The therapist was aware of his own feelings of anger and frustration that Mr. J. would display this type of destructive emotion to a pale little boy who had just undergone tracheostomy and was still on an internal cardiac pacemaker. At this time, Mrs. J. decided that she definitely wanted a separation, that the decision could not wait, that living with her husband was an impossible life. Mr. J. then told his son, "Well, it's all over, son. Mommy's leaving daddy. It looks like she doesn't love either of us anymore." In essence, Mr. J. presented the separation as a horrible catastrophe that had befallen both him and his son and continuously portrayed his wife as a mother without feelings. It was during this same period that Mrs. J. told the therapist that she 'was to have an abortion for an outof-wedlock pregnancy. During the 25 days of hospitalization, the therapist attempted to be
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an anchor of stability in Bobby's chaotic interpersonal world. In attempting to reassure Bobby, he told the boy that his mother did love him very much, that his father also loved him very much, and that if he went home to live with his mother, his father would be able to visit. "Both mom and dad love you very much, but do not want to live together. That puts you right in the middle again and that is pretty rough." Bobby's feelings toward being with his mother were discussed, and the boy maintained that he would rather live alone with his mother than in the middle of constant fighting. However, he felt terribly guilty about not living with his father, and Mr. J., covertly jabbing at his wife through Bobby, augmented the child's guilt feelings: "That's okay, son, I know you want to live with mommy more than daddy. Daddy will get over it, somehow." Twenty-four days postoperatively, Bobby had his demand pacemaker shut off and maintained his own persistent ideoventricular rhythm without symptomatic problems. Twenty-five days postoperatively he was discharged. One week later, he was brought by his mother to the emergency room complaining of chest and abdominal pains. Examination revealed that his chest was clear and normal to auscultation except for his murmur and ideopathic rhythm. There was only tenderness to deep abdominal palpation. Bobby was seen by both the cardiac surgical resident and the pediatric resident. Both concurred that he probably had gastroenteritis and should return to the clinic the following day. That night, on the way home, Bobby announced to his mother that he was tired of fighting it all and said, "I'm just worn out." He was found dead in his bed the following morning. Following the boy's death, Mr. J. threatened to kill his wife, but he did not attack her physically. Mr. J. insisted on a Catholic high mass, while his wife preferred a simple Protestant graveside funeral. The couple disagreed over who would receive Bobby's furniture and pictures, his clothes and toys. With Bobby's death, there was no more nidus for parental sadomasochistic interaction. Husband and wife never spoke to each other after the first month following Bobby's death. Divorce was final in one year.
DISCUSSION
Numerous management issues are raised by this case. Some of these were recognized during the work with the family; others are much clearer in retrospect. The first difficult management decision involved options in dealing with the parental conflict. Ideally, parental conflict should be resolved
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prior to elective surgery. This option was discussed early during the supervisory sessions. In retrospect, a decisive factor in the approach to the parents was the timing of the surgery. The date of surgery was accepted as a "given." The possibility of delaying surgery was not actively discussed. In fact, discussion took the form of: "Given that the operation will take place in 8 weeks, what is our best approach?" Without conscious realization at the time, the unquestioning acceptance of the surgical deadline narrowed our therapeutic choices. It has been our experience that this is a very common consultative error. Surgical deadlines are often considered as a given. Actually, it is imperative that professionals who are preparing persons for surgery do not hesitate to approach the surgeons directly about possible changes in date. Most surgeons are more than willing to readjust schedules for optimal patient benefit. The difficulty often rests with the consultants, who are hesitant to recommend changes or do not consider this option. In the present case, once the surgical deadline was accepted, the consultants found themselves very much in a "damned if you do, damned if you don't" position. The attempt to help this couple function smoothly by 8 weeks of work was immediately recognized as an exercise in futility. On the other hand, the child indicated strongly that he wanted his daddy present at the time of surgery. At this time he may have been maintaining the wishful fantasy of his parents rallying together and not fighting because they were concerned with his illness. It would be all the more understandable, since this hope, if not this fantasy, was present in the therapist's mind following the father's sudden unexpected early return from sea duty. At the time of the father's return, the therapist's and the supervisor's concerns took the form of: "Now that he's here, how can we best help this couple to pull together for Bobby until after the completion of the postoperative period?" Although the surgical deadline made it urgent to aid this couple in functioning together, one must add in retrospect that even if the surgery had been postponed 6 months, there is a strong likelihood that these parents could neither have given mutual support to the child nor achieved an amicable separation. It might have been possible to help the mother see that separation was both in her self-interest and in the interest of her son. However, Mr. J. would have continued to fight with his wife as long as he was at home. Another alternative might have been to postpone surgery until Mr. J. was again on active duty at sea. In spite of the child's strong desire for his daddy, perhaps it would have been an easier operation in his father's absence. Indeed, with the help and support of the therapist, Bobby might have adjusted to parental separation prior to his surgery.
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As the case actually developed, it is altogether possible that continued parental fighting during the critical postoperative period may have led to Bobby's "giving up" his futile hope for a more relaxed home atmosphere as well as life itself. During the week between his discharge from the hospital and his death, a week when he was not seen by his therapist, Bobby was subjected to the full impact of his parents' conflict without any of the support that his therapist and hospital personnel had been able to give him. It seems reasonable to speculate that, out of fear, Bobby would have held back the anger generated in him by his parents' narcissistic conflict and that severe depression rapidly would have supervened. With whatever fantasies of parental reconciliation he may have been able to sustain thus shattered, Bobby might well have lost the "will to live." Indeed, it was their concern about the connection between the depression and the loss of the "will to live," observed both by themselves and by others involved in performing cardiac surgery, that led the pediatric cardiologist and cardiac surgeon to make their initial request for psychiatric consultation. Another major issue in this case may be conceptualized in terms of the "FAGS Syndrome" (Vincent and Rothenberg, 1969). "FAGS" is an acronym for fear, anger, guilt, and sadness, the major emotional reactions experienced by children and their families in the face of serious illness and hospitalization. The children respond in this way as they are separated from their parents and subjected to painful ordeals such as blood drawing or surgery. Although trained to recognize and deal with these emotions in his patients and their families, the consultant found it more difficult to recognize these same emotions in himself. The consultant, father of three, had a boy nearly Bobby's age, with similar hair and eye color. The possible outcome of death following surgery was intellectually recognized but was never emotionally accepted. Denial was the main defense mechanism: "Of course 10 percent of the children have a fatal outcome and of course this is the second attempt on a very difficult case; however, Bobby will certainly not be part of that minority percentage." Thus it was that Bobby's fear of death and his ideas about life after death were never fully explored during the preoperative period. The therapist knew full well how to deal with a dying patient, but could not allow himself to deal with this child in this particular way. This is graphically demonstrated in the excerpt of the Videotaped conversation during play therapy. The clay patient died on the table. The defect in the heart was "too big to patch," and the patient would "have to die." This interaction was handled by the supportive reassurance that the physicians would not abandon the proce-
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dure on the table. The option supported by the therapist included only successful surgery, and the therapist thus lost this opportunity to explore the death and dying issue with Bobby.
REFERENCES ABRAM, H. S. (1965), Adaptation to open heart surgery. Amer. ]. Psychiat., 122:659-667. BERGMANN, T. & FREUD, A. (1965), Children in the Hospital. New York: International Universities Press. CUllER, J. F. & HARROFF, P. B. (1965), Sex and the Significant Ame1·icans. Baltimore: Penguin Books. EISSLER, K. R. (1955), The Psychiatrist and the Dying Patient. New York: International Universities Press. GLASER, H. H., HARRISON, G. S., & LYNN, D. B. (1964), Emotional implieations of congenital heart disease in children. Pediatrics, 33:367-379. JACKSON, K. (1951), Psychologic preparation as a method of reducing the emotional trauma of anesthesia in children. Anesthesiology, 12:293-300. KAPLAN, S. M. (1956), Psychological aspects of cardiac disease. Psychosom. Med., 18:221233. MARGOLIS, G. J. (1967), Postoperative psychosis on the intensive care unit. Compreh. Psychiat., 8:227-232. MEYER, B. C. (1967), Some considerations of the doctor-patient relationship in the practice of surgery. International Psychiatry Clinics, 4:17-35. Boston: Little, Brown. - - - BLACHER, R. S. & BROWN, F. (1961), A clinical study of psychiatric and psychological aspects of mitral surgery. Psychosom. Med., 23: 194-218. NAGY, M. (1948), The child's theories concerning death. ]. Genet. Psychol., 73:3-27. PLANK, E. N. (1963), Preparing children for surgery. Ohio State Med. I., 59:809-811. SCHNEIDER, D. E. (1954), The image of the heart and the synergic principle in psychoanalysis (psychosynergy). Psychoanal. Reu., 41:197-215. TOKER, E. (1971), Psychiatric aspects of cardiac surgery in a child. This journal, 10:156186. VINCENT, H. B., JR. & ROTHENBERG, M. B. (1969), Comprehensive care of an 8-year-old boy following traumatic amputation of the glans penis. Pediatrics, 44:271-273.
A Case Report Foster W. Cline, M.D . and M ichael B. R oth enb erg, M .D.
There is an extensive literature abou t the psychological impact of surgeryon children. Many articles emphasize the fact that a child is a feeling and frightened person who needs explicit information about what will happen to him and who must develop a personal relationship with his physician. Perhaps even more than the adult, he needs the opportunity to work through fears and fantasies concerning surgery. Meyer (1967 ) and Bergmann and Anna Freud (1965) explicitly discuss children viewing surgery as pun ishmen t, or a "consequence of naughtiness." Gl aser et al. (1964) describe the strained mo ther-child interactions that build up in the families of chro n ically ill children, and note that lOaf 25 mothers whom th ey interviewed considered themselves "who ll y responsible for ha vin g produced a defectiv e child." Eissler (1955) has pointed out th at th e reaction to hospitalization and surgery in children is age specific. That is, younger children fear separation ; older children fear attack. At about age 5 to 9 (Nagy, 1948), death is regarded as a person , and is so feared. Only preadolescent children can begin to view death as adults do , with the accompanying fear of loss of control. At this point, th e literature on the effect of surger y in car d iac disease is extensive, and th e literature on the psychoso cial aspe cts of cardiac surgery is growing. Mar gol is (1967 ) and Abram (1965 ) stress the anxiety-provoking atmosphere of the intensive care unit, the isolation, the lack of privacy, and the impact of sensory depri vation. Familiarizing the child with aspects of the leu and anesthetic equipment (Jackson, Dr . Clin e is presently in pri vat e pract ice in Evergreen, Colorad o. This paper was begun while he was a Fellow with th e Division of Child Psychiatry at th e University of Washington . Dr. R oth enb erg is a Professor in Psychiat ry and Pedia trics, Un iversity of Washington School of M edicin e and is with the Division of Behavioral Sciences, Chi ldren's Orthopedic Ho spital and M edical Cent er, 4800 Sand Point W ay, N,E" Seattl e, Washin gton 98105, where repri nts may be requ ested from him .
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1951) and using hospital equipment as toys (Plank, 1963) aid in lessening the fear of the unknown and the anxiety of the unfamiliar. Other articles have explored the effects on patients of cardiac surgery per se. Meyer et al. (1961), Kaplan (1956), and Schneider (1954) explore this in detail. The most extensive bibliography today is given by Toker (1971); he reviews the significance of heart mythology and folklore as well as the literature on the psychiatric aspects of heart surgery. He presents the case of a 7-year-old Puerto Rican girl and her problems prior to and following surgery for a septal defect. The present paper details the experience of Bobby]., a 7-year-old middle-class, Caucasian boy, with open-heart surgery. Many problems were present which portended a poor prognosis. The illness was chronic, the parents lived in a "conflict-habituated" existence (Cuber and Harroff, 1965), and were unable to give their son emotional support in this period of crisis. The parents had religious differences, which were a source of conflict, and the father was a sailor away from home on sea duty for extended periods of time. This operation was the second attempt to repair a difficult septal defect by means of openheart surgery. A year previously, the first attempt at repair was followed by a stormy postoperative course with ensuing destructive parent-parent and parent-child interactions. The child was, in fact, used by his parents in living out their sadomasochistic marital relationship. For instance, the father maintained that Bobby's heart defect was God's punishment for his mother's premarital promiscuity. In recognition of these problems, special preoperative psychiatric evaluation was requested by the pediatric cardiologist and surgeon prior to making this second attempt at septal repair. In this paper we shall follow Bobby's treatment chronologically as it developed. Transcripts obtained from audio and video tape recordings made during interview and play sessions were subsequently used in supervision. During treatment, a number of transactional and technical problems unexpectedly developed. A discussion concerning these issues will follow the case presentation. CASE PRESENTAnON
Preliminary Correspondence We first heard of Bobby]. when his school queried the Department of Surgery about his activities. The report from the school noted: "The classroom teacher has observed Bobby shaking with apparent nervousness when asked to participate in class activities. Until recently he was quite cheerful in the classroom. His condition has improved since
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Mr. J. returned to a tour of sea duty. Mrs. J. also appears to be more relaxed at this time. She has indicated that a conflict exists between her and Mr. J. over the type and consistency of disciplinary methods used with Bobby. Mr. J. seems very protective, while Mrs. J. is attempting to encourage Bobby to become more independent in making decisions. Bobby has difficulty in doing the readiness skills the kindergarten children participate in as a step in preparation for first grade." The Department of Surgery answered, saying: "This youngster had a ventricular septal defect and pulmonic stenosis repaired with openheart surgery. We saw him several months ago and felt that his condition was quite satisfactory. It is our impression that he can engage in any activity he likes and does not need to be restricted. He should be treated as normally as possible." Several months later, following catheterization, a letter from the surgeon to his colleagues performing the catheterization expressed his concern and reflected the affective interpersonal appeal of this 7-yearold patient. The surgeon explained the technical difficulties inherent in the first operation and noted his concern about the completeness and the success of the operation. He stated: "Our concerns have proven correct. I'm sure you can imagine our dismay at having to reoperate on this lovely youngster, but it is clearly necessary and reality must be faced. We discussed this with Mrs. J. and she agreed to the surgical correction. It was emphasized to her that the defect is a difficult one and that it will be no less difficult at this time." At the time of psychiatric consultation, the pediatric surgeon expressed his concern over the family situation and explained that the mother had been prepared for psychiatric treatment. "On discussion of the problem with the mother, she feels that some sort of assistance would be very helpful. She indicates that the father is rarely home as a result of his occupation. They do not get along together and she is seriously considering divorce, although she plans to do nothing in that direction at least until after surgery is completed, and to make no particular indications of that to Bobby in the meantime, except what he can perceive on his own. She also states that the father was extremely anxious during the last operation and threatened various actions implying self-destruction, or possible destruction of others in the event of loss of this child. She states that when the father is home he exercises no authority whatsoever over the child but absorbs the child's complete command and complains afterward that he is completely exhausted from the experience. "Since we have rather healthy respect for the effect of the least depression on the survival of these youngsters, in addition to our concern
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for his long-range well-being, I would appreciate your suggestions on the best method of handling this boy and his family constellation." Intake
When seen for initial consultation, Mrs. J. was in the middle of a rather artificial and glib reading to her son, who was sitting in her lap. Bobby was looking furtively about. He was a curly-haired, brown-eyed, and very attractive little boy. The mother was first interviewed alone. She grew up the only daughter of a rejecting mother and alcoholic father. Many aspects of her childhood history appeared to bear on the type of relationship she subsequently developed with her present as well as with a former husband. For brevity's sake, only her marital history is noted here. Mrs. J. was first married at 15 to a man who was 25. She divorced him twice. In the process of this turmoil, she lost custody of her first child and was committed to a state hospital for 4 months. At 22 years of age, she was married again, to her present husband, who was then 33. As might have been anticipated with her past history, the present husband had been psychologically and physically abusive to her, saying that Bobby's illness was a result of her "sin." While not consciously accepting this, Mrs. ]. acted at times as if she believed it and wondered if she unconsciously accepted it. She pictured her husband as a very unstable person who constantly berated her with projections of his own feelings about himself. For example, he accused her of being unfaithful while he had numerous extramarital affairs of his own. She maintained that her husband held her responsible for all of Bobby's problems while he "exhausted" himself caring for Bobby. During the last operation, he was reported as pacing and crying during most of the surgery. He slept with his head on Bobby's bed during the first night in the hospital. Mrs. J. reported that her husband had threatened to kill her in the event Bobby died as a result of the contemplated second surgery. Mrs. J. responded to her husband's accusations by angry emotional outbursts in front of Bobby. Allegedly, her husband then further berated her for upsetting the boy. Mrs. ]. generally accepted her husband's accusations and stated that she was certainly to blame and guilty of all of his accusations. Mrs. J. described her life during the last 7 months while her husband had been at sea as "the happiest in my life." After his mother was seen, Bobby was interviewed. He had not been told of the impending operation, still 8 weeks away, although 2 weeks
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before this initial evaluation he had undergone his second card iac catheterization. The examiner felt it was a parent's prerogati ve, with the physi cian's support, to tell the son about his operat ion. In the interview, the doctor there for e approached this area ver y gingerly. Bobby was fairl y at ease with the examiner, first asking, "W hat in the world took you so long?" Con cerning scho ol, he said that he knew that the first grade was going to be "a real problem for m e," but would just as soon "get it over with ." Bobby had numerous, reali stic concern s about death. These were mani fested in many ways. When in the water , he constan tly th ou gh t th at he might su ffocate and drown . He stated that if an y other opera tio n was ne cessary he would accept it but would probably worry, and then commen ted : " I' m not sure how much I would worry. " If another operation were n ecessary, he said that he would rather his fath er be home, because the hospital was a lonely place and it was nice to have his father present. He said he would like to have his father at night and his mother during the day. I (F. W. C.) asked if at times his family life was more stressful when his father was home and he said "yes," tha t this was probably because his father spent so much time with him and made his mother feel lonely. The mother was again inter viewed and asked how she felt about her husb and's retu rn. She said th at it would be best not to tell her husband about the operation becau se he became so "u ptight" and that she did not want him to re turn until a week or so prior to the operation. In that time, she felt that he cou ld be supportive to Bobby, but there would not be enough time for th e parents to escalat e their feuding to an intolerably de structi ve level. It seemed a r eason able decision, and the authors supported it. They arranged for Bob by to be prepared for surgery in weekl y play th erapy sessions. No firm commitmen t was made as to how regularly the mother would be seen.
Beginn ing Th erapy The consu ltan t was surpr ised whe n Mrs. .J. phoned the following weekend, sounding extremely anx ious. She said th at her husband had suddenly returned from sea duty on emergency leave. " I told him about the surgery and about its being planned for 2 months. I knew he'd be very upset, but I didn't think he would come home so quick." Mrs. .J. then described ver y tens e marital conflicts in whi ch her husband played the role of dete ctive and prosecutor while she pla yed the role of cri m in al and victim. Mr. .J. accused her of seeing an other man, ri fled her purse and bureau drawers seeking information , and followed her when she left the hou se. She cr ied about hi s " par anoid" accusation s and vociferously denied h is suspicion s. However, during her son's post-
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operative recovery period, she was to undergo abortion for an out-ofwedlock pregnancy. Mrs. J.'s anxiety was apparent on the phone. It was diminished when the consultant suggested that she, her husband, and Bobby come in for the beginning of presurgical therapy. The authors met during a supervisory session and decided upon goals: 1. To form a therapeutic and warm relationship, if possible, with the father, as he would probably feel that he was an "outsider" and that there was an alliance against him. 2. Rather than deal with the content of marital feuding per se, it would be better to emphasize the importance of parental support for Bobby during this time of stress. In essence, the object of the work would be to try to help the parents interact around their son therapeutically rather than destructively. 3. To help the parents develop a way of telling Bobby about his operation, listening to his fears, and supporting him. The family was then seen, and after an hour interview, the consultant was satisfied concerning all of the goals. The father had expressed his dissatisfaction about his wife's seeing a psychiatrist, saying, "I don't know what is being said about me behind my back. You probably just heard one side." After a nonjudgmental exploration of his feelings, he appeared progressively relaxed and involved. Secondly, without attempting to go into detail about the marital dissatisfactions, we found that indeed there was a broad, habitual conflict between the parents. Mrs. J. verged on a decision for divorce. Her husband fought this, saying that he had given her no reason for divorce and that he wished the marriage to continue. The therapist emphasized the importance of working together now in order to help Bobby, and postponing the exploration of the larger marital issues until after Bobby's surgery. Both parents seemed agreeable and gave assurances that, for Bobby's sake, they could provide a united and supportive stand. Thirdly, it developed that Bobby had not been told of his impending surgery. Bobby had pointedly asked questions about his father's return from sea duty, what type of blood his father could give, what kind of blood he himself had, and how he would get blood should he need another operation; nonetheless, the parents had chosen to ignore these openings and this subject had been avoided. A careful discussion followed about how the parents might prepare Bobby for this operation. They agreed to discuss the operation with Bobby during the ensuing week. One week later, play therapy was to begin. The consultant then spent time with Bobby, specifically talking with him about his parents' feuding so that this also might be dealt with openly and in a supportive way. Seldom does a child express feel-
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ings of being caught in a chronic marital conflict as poignantly as in this transcript (audio taped session):
Therapist: Do you know what your folks and I were talking about down there? Bobby: No. What? T: What do you think we've been talking about? B: I don't know (despondent). . . . About first grade. T: We talked about that. . . . B: What else? T: We also talked about that sometimes your mom and dad have quite a few disagreements and quite a few fights, as a matter of fact. B: Yeah, that's right, they do. And every time I'm in one. T: You're in it? B: Yeah, I'm in it. T: How are you in it? B: Oh, I'm just in it. Every time . . . like this argument, you know, dad was callin' mom kind of dirty names I guess; I didn't hear very well. She was starting to cry. . .. And it isn't good. I was gonna. . . . My dad's home from overseas for over a month now. My folks are coming in 2 weeks, I think; I'm not sure and . . . yeah, they're coming in 2 weeks, I think, but I'm not sure . . . if it's gonna be 2 weeks. T: Well, listen, I want to know now how you are always in your mom and dad's fights? You mean when they fight you're right in the middle? B: Well, I'm not right in the middle sometimes, sometimes I . . . I'm in the fight (anxious laugh). T: You are? That must not be a very good position to be in, though. B: No, I get out of it. I don't like getting in those dirty bird fights. T: Well, what we were trying to do is to see if maybe your mom and dad can fight less. That's what we were talking about, having less fights. B: Yeah, that would be fine. T: (Laughs.) You'd . . . you'll go along with that, huh? B: Yeah. I don't like them arguing, then mom starts to cry about all of this . . . and then some of the time she cries . . . and then sometimes she just gets mad and starts arguing and then it's too noisy for me and so I go outside (laughs). T: Oh boy . . . you mean you don't like it. B: No, and I'd rather. . . . Every time my dad takes leave or is home, it seems like fights, fights, fights. T: What can you do to stop them, anything? B: No. I tried to stop them, but they won't stop, they just keep on, you know. And I don't understand it either. Just for a little thing . . . like we're seeing if we can buy a new car and it's up to daddy and daddy says it's up to mommy and then they don't know what's up
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to . . . . I want to get a new car, that's what I want to do. I want to get a new little Datsun, that's what I want to do; you know, these little cars. Well, are the fights do you think your dad's fault more or more your mom's fault or who starts them mostly, do you think? My dad, I think. Um. . . . I hope this doesn't hurt my dad's feelings, but he just starts most of them, but then, at the end, he says that's my fault, then blaah-like that-he does. He says then at the end that it's his fault, but then it's too late to change it, isn't it? I know it, and I don't. And I don't know what they were talkin' about, but, right after the day we picked my dad up from the airport-right after that day and night, rrruh' arguments; and I do not like that. I wish they were less arguing because arguments never gets you something out of it! I think you're right there.
The following week, the parents returned. In essence, they had not been able to fight less, although they had attempted to be supportive of Bobby. To the therapist's surprise, they maintained that there had been no opportune time to talk with Bobby about his surgery. It was apparent then that the parents needed the support of the therapist's physical presence to help them in dealing with Bobby on this issue. While Bobby waited upstairs, the method of telling him about his surgery was discussed. The therapist felt it would be helpful to the father, giving him an increased feeling of self-esteem, inclusion, and competency, if he could tell his son of the surgery. The following is from a transcript of this emotional conversation: Bobby Is Told of Plans for Surgery Therapist: Okay, do you want to tell Bobby why he's down here? Father: Yeah-as you know I told you up there we were gonna have some . . . some kind of bad news, but it wasn't too bad . . . it wasn't that bad . . . you know when you went through your catheterization? Bobby: Yeah . . . . F: You know the doctors had to study it and had to study it and they finally found that you had a . . . a little tiny hole in your heart still . . . and that . . . that they're gonna have to try to get in there to repair it so as you . . . uh . . . grow older then . . . uh . . . the little hole won't get larger. And this means that you'll be able to . . . to play and run and all like you always have without it hurting you. So . . . uh . . . sometime in October you're gonna
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have to go through open-heart surgery again. . . . (Bobby cries.) Okay-Oh, now-and it's going to be . . . to repair that little hole in there. We don't want that hole to get bigger. T: Say, Bobby, that isn't very good news is it, urn? . . . Bobby? Mother: Go ahead and cry, son, if you'd like and maybe that will make you feel better. T: How do you feel about it? Kind of scared or worried or just sad about it, urn? (Bobby continues crying.) I guess if I was told that kind of news, I'd feel pretty bad, too; but I guess even worse things do happen to people, but that doesn't make it any better for you, does it? Urn? Bobby, I think that we would have told you before, but the doctors had to study all the reports and make sure that they wanted to do it again, so it really wasn't for sure, although I guess you know that everyone was kind of thinking about it for a while. Did you kind of suspect that, urn? Did you kind of know that people were thinking about it, or did you not know? (Bobby continues crying.) F: Gee whiz, Bobby, things, you know, things gotta be fixed and you know how dad's always fixin' things around the house when they don't work right and that's all the doctors are doing, but it took them a while to study it out and to figure it out after your catheterization and . . . uh . . . so they feel that they should patch this little hole up so as you grow older that little hole won't grow any more-it'll be all fixed just like daddy fixes the car and fixes things around the house; fixes your toys and all. It's just one of those things that will happen like that, Bobby. T: Bobby, what makes you feel the worst about it? Can you tell me that? What do you feel worst about? (Silence.) When you were in the hospital last time were you on the ward where there were lots of other little kids and did you play in the playroom or were you downstairs most of the time? (Silence.) F: (Pats son.) Come on, big boy . . . huh? Hey, the doctor asked you a question. I . . . I . . . I don't want to answer it-I think that you know more about that than I do. Why don't you tell the doc? Urn? Tell the doctor . . . that you were in both places, but you don't really-can you tell him? Urn? Do you want me to tell him, huh? (Bobby nods.) Okay, I think Bobby was downstairs for a while and then was moved upstairs and then he stayed upstairs and met all the other kids that were up there with him-weren't you? Weren't you up there for a while too? I think you were upstairs for a long time. You were upstairs-longer than you were down. Don't you remember, huh? Sure you remember. You had your TV set out and you were watching TV. Bobby, am I right? T: I think it's better, see, to have this to go through this reaction now and get it kind of worked out. . M: I do too . . . I can see where . . . yeah. T: And I think what we have to do is just let Bobby know that if he
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wants to talk about it or if he wants to express his concerns about it, why, we're around and he can express them to us, that it's nothing that's too scary to talk about, see? That's right, Bobby, and you know that. It's just another operation, son. (Bobby cries.) That's about all. 1£ you wanna cry about it or if you wanna talk to daddy about it, come on, talk to dad about it, you won't be sc . . . you'll worry about it, naturally, but you'll get over that, Bobby? Oh boy, I'm glad tomorrow's not a school day, that way you won't have to worry about getting your clothes dirty. Want a handkerchief, huh? You don't want a little handkerchief? And I think one thing, too, that one thing we'll have to do is make sure that we let Bobby sort of approach us on this . . . so that we don't, you know, be too concerned and make him feel like he has to . . . . . . . to talk to us about it. Yes, that we're available, that's right. And if he wants to come to talk to dad or mommy about it, he's welcome to do it any time he wants. I'm sure, Bobby. I'll do this, too. Sure. . . .
Following this conversation, Bobby continued to cry on his father's lap, not speaking. The therapist recognized that he, as well as Bobby and the family, was very uncomfortable. It appeared unnecessary and fruitless to attempt to get Bobby to verbalize at this time, and with instructions simply to "hold Bobby and be with him," the mother, father, and son left. Play Therapy
The following week, Bobby began a series of weekly directive play therapy sessions, the goals being (1) to help him as much as realistically possible to work through his anxieties concerning surgery; (2) to develop a feeling of confidence that would follow from a more complete familiarization with and understanding of the surgical situation; (3) to provide a supportive person, the therapist, with whom Bobby could share his feelings and anxieties. He would know that the therapist would not use him or his feelings in some type of game as did the parents. He would also know that the therapist would not desert him during the operative or postoperative course. The play therapy was carried out over a 7-week period prior to surgery. As Bobby's anxiety and trust in the therapist increased during the course of therapy, an interesting sequence of anxieties related to surgery evolved and could be worked through. At the first play therapy session, a toy doctor's kit, clay, and various
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pieces of cloth were available on the play table for him to use. Bobby's anxiety was such that he could make no clay figures and did not approach the doctor's kit. He said that he had come for his session during school recess, which he enjoyed very much. He certainly did not like coming. He had misgivings about doctors in general, "although they're just trying to help you." The therapist discussed with Bobby how unhappy he must have been when he was told about the impending operation. He emphasized that "it sure is no fun" and wondered how Bobby had felt since, and how things had been going at home. This appeared to allow Bobby to open up. The child reported that his parents were continuing to fight; for his part, he appeared to have an attitude of resigned acceptance concerning the operation. Over the following 5 sessions, Bobby began to play with the doctor's kit spontaneously, and to work on his anxiety in "play surgery." Each session was videotaped, and 7 minutes of consecutive interaction have been transcribed from the 6th therapy session. During these 7 minutes, Bobby revealed his fantasies, blocked on talking about recatheterization, and talked of his fears of reoperation and death. He poignantly described a septal defect "too big" to repair and resignedly stated, "I guess the doll will just have to die." A transcription of this interaction is given below.
Bobby: Oh, boy . . . now we're going to get him back together; stitch him back up. Therapist: Okay, you want a needle for the stitching? B: No, I can have one of these (Bobby sees a safety pin). Oh, yeasurel But those are for body stitching. But right now I'm doing body-stomach stitching . heart stitching. T: What kind of stitching? B: Heart stitching. T: Heart stitching? Is that .. where's his heart? B: It's over there. T: His heart's over there? B: Yeah, for the mean. . . T: What are you doing right now? B: I'm stitching . . . so it won't fall out. T: You mean so his heart won't fall out? B: Uh huh. They all fall out and when he plays-he'll play. T: And the more he plays, the more they will fall out? B: Yeah, I'll put in twenty million of them. Some of them might stay, but he'll probably have to go through the catheterization. T: He'll have to go through a catheterization? B: If they don't stay. There. . . . T: Boy, those are a lot of stitches. Now, what are those stitches for? B: So his heart will stay together. T: Oh.
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B: T: B: T: B:
T: B:
T: B:
T: B: T: B: T: B: T: B:
T:
B: T: B: T: B: T: B: T:
B: T: B: T: B: T: B: T:
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It's hard to get off now. There now. Yep. Now we patch up the hole again. Okay. We need some more shot medicine. We do? Yes. I get that up there, way up high. What are you doing now, patching the hole up? Yeah. Very good. Boy, those holes are really getting filled up. What about this hole here? (The therapist is pointing to a hole in the chest that Bobby has avoided.) That connects to the knee bone right here. Uh hum. We'll have to stitch that up the rest of the way . . . and make a hole there . . . I think . . . it doesn't have to be done, well, I guess I did it. . . . There, good . . . . Now, good. Now, where. . . . Now, we don't need to do those anyway. We don't need to do it till . . . right over there. . . . Now, if that hole gets bigger, he's going to have to go through . . . another . . . another . . . another catheteriza. . . . If that hole gets bigger he's going to have to go through another catheterization? Yeah, because we can't plug that up anymore. You can't? Dh uh.
on.
Or he'll die. You mean, if you can't plug up the hole he's going to die? Yeah, and I'm not sure if we're gonna get to plug it up or not. Really! Well, I certainly hope that we get it plugged up. You know, most holes get plugged up after one or two times. Did you know that? Well, let me see. I guess he's going to have to go through another . . . darn . . . die. He's going to have to what? Die. He's going to die!? Oh, dear (Bobby laughs nervously), how did you decide that, doctor? Look. Look in there. I'll show you how big a hole there is in there and we can't patch it up either. Wow (Bobby laughs nervously). That big hole? You mean that's too big a hole to patch? Yeah. Are you sure of that?
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B: T: B: T:
Let me see. We might be able to patch that. Well, we'll try. Okay. His body's too hard because of that dumb stuff I put on it (falls backward trying to cut). Wow, that is hard. It just knocks you backward trying to cut in there, doesn't it? We're going to have to let him die. Oh, no. Really? Yes. (Sighs.) I wonder if there isn't anything we can do besides that? (Laughs.) Yes, sure there is. What, what? . . . Hey, what are you doing now? Plugging a hole. You're plugging it. (Sounds of clay being hammered.) I think that hole is being plugged. It is. And there it is. No more hole over there. Oh, how does he feel about that? He feels pretty good probably. I bet he does! There you go.
B: T: B: T: B: T: B: T: B: T: B: T: B: T: B:
A Note on the Postoperative Course During the postoperative course, Mr. and Mrs. J. continued to feud. One evening, about 10 days postoperatively, the mother had brought flowers for Bobby's room. That evening, smelling of alcohol, Mr. J. tore up these flowers and threw them in the wastebasket beside the bed. This frightened Bobby, and the nurses called the therapist. The therapist talked to Mr. J. on the telephone and told him never to come back to the hospital smelling of alcohol. The therapist was aware of his own feelings of anger and frustration that Mr. J. would display this type of destructive emotion to a pale little boy who had just undergone tracheostomy and was still on an internal cardiac pacemaker. At this time, Mrs. J. decided that she definitely wanted a separation, that the decision could not wait, that living with her husband was an impossible life. Mr. J. then told his son, "Well, it's all over, son. Mommy's leaving daddy. It looks like she doesn't love either of us anymore." In essence, Mr. J. presented the separation as a horrible catastrophe that had befallen both him and his son and continuously portrayed his wife as a mother without feelings. It was during this same period that Mrs. J. told the therapist that she 'was to have an abortion for an outof-wedlock pregnancy. During the 25 days of hospitalization, the therapist attempted to be
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an anchor of stability in Bobby's chaotic interpersonal world. In attempting to reassure Bobby, he told the boy that his mother did love him very much, that his father also loved him very much, and that if he went home to live with his mother, his father would be able to visit. "Both mom and dad love you very much, but do not want to live together. That puts you right in the middle again and that is pretty rough." Bobby's feelings toward being with his mother were discussed, and the boy maintained that he would rather live alone with his mother than in the middle of constant fighting. However, he felt terribly guilty about not living with his father, and Mr. J., covertly jabbing at his wife through Bobby, augmented the child's guilt feelings: "That's okay, son, I know you want to live with mommy more than daddy. Daddy will get over it, somehow." Twenty-four days postoperatively, Bobby had his demand pacemaker shut off and maintained his own persistent ideoventricular rhythm without symptomatic problems. Twenty-five days postoperatively he was discharged. One week later, he was brought by his mother to the emergency room complaining of chest and abdominal pains. Examination revealed that his chest was clear and normal to auscultation except for his murmur and ideopathic rhythm. There was only tenderness to deep abdominal palpation. Bobby was seen by both the cardiac surgical resident and the pediatric resident. Both concurred that he probably had gastroenteritis and should return to the clinic the following day. That night, on the way home, Bobby announced to his mother that he was tired of fighting it all and said, "I'm just worn out." He was found dead in his bed the following morning. Following the boy's death, Mr. J. threatened to kill his wife, but he did not attack her physically. Mr. J. insisted on a Catholic high mass, while his wife preferred a simple Protestant graveside funeral. The couple disagreed over who would receive Bobby's furniture and pictures, his clothes and toys. With Bobby's death, there was no more nidus for parental sadomasochistic interaction. Husband and wife never spoke to each other after the first month following Bobby's death. Divorce was final in one year.
DISCUSSION
Numerous management issues are raised by this case. Some of these were recognized during the work with the family; others are much clearer in retrospect. The first difficult management decision involved options in dealing with the parental conflict. Ideally, parental conflict should be resolved
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prior to elective surgery. This option was discussed early during the supervisory sessions. In retrospect, a decisive factor in the approach to the parents was the timing of the surgery. The date of surgery was accepted as a "given." The possibility of delaying surgery was not actively discussed. In fact, discussion took the form of: "Given that the operation will take place in 8 weeks, what is our best approach?" Without conscious realization at the time, the unquestioning acceptance of the surgical deadline narrowed our therapeutic choices. It has been our experience that this is a very common consultative error. Surgical deadlines are often considered as a given. Actually, it is imperative that professionals who are preparing persons for surgery do not hesitate to approach the surgeons directly about possible changes in date. Most surgeons are more than willing to readjust schedules for optimal patient benefit. The difficulty often rests with the consultants, who are hesitant to recommend changes or do not consider this option. In the present case, once the surgical deadline was accepted, the consultants found themselves very much in a "damned if you do, damned if you don't" position. The attempt to help this couple function smoothly by 8 weeks of work was immediately recognized as an exercise in futility. On the other hand, the child indicated strongly that he wanted his daddy present at the time of surgery. At this time he may have been maintaining the wishful fantasy of his parents rallying together and not fighting because they were concerned with his illness. It would be all the more understandable, since this hope, if not this fantasy, was present in the therapist's mind following the father's sudden unexpected early return from sea duty. At the time of the father's return, the therapist's and the supervisor's concerns took the form of: "Now that he's here, how can we best help this couple to pull together for Bobby until after the completion of the postoperative period?" Although the surgical deadline made it urgent to aid this couple in functioning together, one must add in retrospect that even if the surgery had been postponed 6 months, there is a strong likelihood that these parents could neither have given mutual support to the child nor achieved an amicable separation. It might have been possible to help the mother see that separation was both in her self-interest and in the interest of her son. However, Mr. J. would have continued to fight with his wife as long as he was at home. Another alternative might have been to postpone surgery until Mr. J. was again on active duty at sea. In spite of the child's strong desire for his daddy, perhaps it would have been an easier operation in his father's absence. Indeed, with the help and support of the therapist, Bobby might have adjusted to parental separation prior to his surgery.
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As the case actually developed, it is altogether possible that continued parental fighting during the critical postoperative period may have led to Bobby's "giving up" his futile hope for a more relaxed home atmosphere as well as life itself. During the week between his discharge from the hospital and his death, a week when he was not seen by his therapist, Bobby was subjected to the full impact of his parents' conflict without any of the support that his therapist and hospital personnel had been able to give him. It seems reasonable to speculate that, out of fear, Bobby would have held back the anger generated in him by his parents' narcissistic conflict and that severe depression rapidly would have supervened. With whatever fantasies of parental reconciliation he may have been able to sustain thus shattered, Bobby might well have lost the "will to live." Indeed, it was their concern about the connection between the depression and the loss of the "will to live," observed both by themselves and by others involved in performing cardiac surgery, that led the pediatric cardiologist and cardiac surgeon to make their initial request for psychiatric consultation. Another major issue in this case may be conceptualized in terms of the "FAGS Syndrome" (Vincent and Rothenberg, 1969). "FAGS" is an acronym for fear, anger, guilt, and sadness, the major emotional reactions experienced by children and their families in the face of serious illness and hospitalization. The children respond in this way as they are separated from their parents and subjected to painful ordeals such as blood drawing or surgery. Although trained to recognize and deal with these emotions in his patients and their families, the consultant found it more difficult to recognize these same emotions in himself. The consultant, father of three, had a boy nearly Bobby's age, with similar hair and eye color. The possible outcome of death following surgery was intellectually recognized but was never emotionally accepted. Denial was the main defense mechanism: "Of course 10 percent of the children have a fatal outcome and of course this is the second attempt on a very difficult case; however, Bobby will certainly not be part of that minority percentage." Thus it was that Bobby's fear of death and his ideas about life after death were never fully explored during the preoperative period. The therapist knew full well how to deal with a dying patient, but could not allow himself to deal with this child in this particular way. This is graphically demonstrated in the excerpt of the Videotaped conversation during play therapy. The clay patient died on the table. The defect in the heart was "too big to patch," and the patient would "have to die." This interaction was handled by the supportive reassurance that the physicians would not abandon the proce-
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dure on the table. The option supported by the therapist included only successful surgery, and the therapist thus lost this opportunity to explore the death and dying issue with Bobby.
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