For example, at the age of 22 months, Chris appeared to all who encountered him as a rather reckless, wild boy. He would carom from one piece of furniture and one person to another, sometimes glancing up at his mother with devilish glee before heading off on a new, cyclonelike path. Taking a certain delight in the child's rambunctious, explorative nature, the mother would tolerate a great deal of such activity, but as tensions would mount, she would after awhile "just blow.
In fact, Chris developed an interest in rock climbing and went on expeditions in which a group would scale precipitous cliffs. His father, a circumspect and thoughtful man, worried about these ventures. He did not stop Chris, but he insisted that there be adequate adult supervision, that Chris learn everything he could about mountain climbing, and that he use proper equipment at all times. Chris's parents did not simply put a stop to his behavior or demand that he control his impulses. Each parent in her or his way took pleasure in the child's motor skills, his explorations of the world around him, and his mastery of new challenges.
They clearly valued him and his efforts at self-development. But, recognizing the danger involved, they set clear limits, thereby conveying the message: we love you and deeply respect that you wish to express yourself and your aliveness and to learn about the world.
But we want to protect you, and we do not want you to be hurt or to damage anything else. So we will limit the risks that you will be allowed to take. We wish to get across to you that we love and value you enough to protect you, that you are a being worth protecting. There is clear evidence that Chris incorporated these messages, which became part of his self representation and ego functioning. He learned to master, first as a 2-year-old, and later in childhood and adolescence, the challenges he undertook.
Chris was a boy who from early on liked to "do it my way.
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Although he clearly was overcoming fears in relation to danger, his activities were not primarily defensive in their function. We can see in Chris's case, and that of many children like him, that the function of self-care is intimately related to the development of self-esteem. The capacity for self-care grows in the context of a loving parent's communication that he or she values the child and therefore considers the child worth taking care of.
The child incorporates this message and comes to value himself enough to protect himself from injury. A complex of functions—expressing pleasure in motor exploration, anticipating danger, setting limits upon oneself when danger is discerned, postponing or modifying the activity to make it safer and more secure—all these depend on valuing oneself enough to invest in self-caring. Small children and adolescents who, in contrast to Chris, take excessive risks and engage in dangerous rebellious behavior show an absence of self-care functioning.
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Such behavior may be indicative of pseudomastery. Exaggerated risk-taking is accompanied by denial of fear, which is not mastered. In such instances the self as subject undervalues the self as object and permits undue risks to be taken. True mastery is associated, as in Chris's case, with relatively little self-destructive risk.
A distinction should also be made between self-care, in the sense of taking care of, looking after, or protecting oneself, and self-comforting or nurturing. Many individuals are quite capable of soothing themselves, being "good" to themselves with food, alcohol, music, or even hypochondriacal behavior. Such individuals may readily stay home from work with minor illnesses or make frequent trips to the doctor. But self-comforting activity of this sort may not be associated with a genuine. Yet, even if a reasonably good capacity for self-care has been acquired, it is, like other ego capacities and functions, subject to erosion and regression, as the following case demonstrates.
Walter was a year-old black boy, who, by his own admission, was ordinarily conscientious and always tried to do what his parents wished. He had been admitted to the hospital after accidently burning his legs while starting a power lawnmower. He described in some detail how he usually would carefully wipe off any residual gasoline and then pull the starter rope to the motor. On this occasion he somehow had neglected to do this.
When he started the motor, it suddenly burst into flames. During his hospitalization the psychiatric liaison service was asked to see him because of his excitability and exaggerated sensitivity to pain. The two psychiatrists who saw him learned that there were two small children at home, a sister, aged 2, and a baby brother, a few months old. With a mixture of pride and irritation, Walter described how his parents looked to him as a big brother for assistance in taking care of his younger siblings. He also indicated that he had had his own room until he had been displaced from it by his baby brother.
In the course of the evaluation Walter revealed that his usual attentiveness and caution with the mower had not been present because of anger, irritation, and preoccupation with his changed status in the family. While in this case the boy's immaturity in combination with specific conflicts and stresses led to what one hopes was a temporary lapse in self-protection, there are other cases in which the capacity for self-care develops unevenly. A year-old single, professional woman in analysis functioned in a highly capable fashion, handling the stressful, at times physically threatening, requirements of her job with unusual intelligence and skill.
Working in a field close to that of her highly competent father, she could "look after" herself most effectively. Since age 4 she had suffered from moderately severe attacks of asthma, which continued in her adult life. Her view of her capacity to handle the illness was unrealistic, and as a result she sometimes used poor judgment. On several occasions during the analysis she.
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The asthma had been heralded in childhood by a severe attack which brought the patient to the point of coma before its nature was discovered in the hospital. The asthma became the arena in which an anxious struggle occurred between the patient and her mother. Constantly fearful for her daughter's safety, the mother held her in an intimate bond, anxiously protecting her and conveying the message that true autonomy was threatening to the mother's survival.
The patient failed to develop independent skills in self-care in relation to her health, relying on others to rescue her when asthmatic attacks reached crisis proportions. Sometimes she wistfully communicated to her analyst her longing for a "self-management company. As a consequence she was drawn to the religiously observing Roman Catholic family next door, who, in their elaborate system of rituals directed by an all-powerful God, seemed to have a way of providing protection from harm for small children. Specific fantasies, growing out of disturbances in narcissistic development, may interfere with self-protection and self-care.
Most important of these are wish-laden, grandiose ideas of protection that interfere with the capacity to guard oneself from danger. There may be the idea, for example, that no harm can befall one, that no matter what risks are taken, a powerful being will look after, protect, or come to the rescue. Often this fantasy is acted out dangerously in trying to rescue others.
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In these instances the "rescuee" represents the endangered self of the rescuer. The vulnerability and absence of self-care become manifest in the consequences which befall the rescuer, often at the hands of the rescuee, in the course of misguided though "well-meaning" rescue operations. The study of children who are accident prone, injure themselves, and become involved in dangerous activities offers an opportunity to understand some of the predispositions and vulnerabilities which result in impairments in self-care.
Such vulnerabilities in children also allow for comparisons with children,. But even more important, they provide an opportunity to consider the psychological structures and functions that ordinarily stand in opposition to or protect against danger and harm. Several reports Frankl, , ; Lewis et al. Although these reports shed light on important determinants that compel the dangerous activities and behavior of certain individuals, they consider only in passing, if at all, the factors that more usually protect against injury and accidents.
As in the case of the adult literature on accident proneness, these reports tend to place undue emphasis on drive theory and aggressive instincts, to the exclusion of other considerations e. Reviewing problems of self-preservation and accident proneness from a developmental perspective, Frankl presents many compelling accounts of accidents and injuries sustained by normal and disturbed children and adolescents.
She seems to appreciate that among healthy children the caring and protective functions of the parents or substitutes are gradually taken over by the child in the course of normal development. The failure to take over these functions leaves the children more susceptible to harm and is the result of deprivation of object love and a lack of cathexis of the child's body. However, in her subsequent discussion and formulations, she repeatedly attributes accidents in childhood and adolescence to conflicts relating to impulsivity, superego representations, and unfused or defused aggressive instincts turned on the self.
Her observations are graphic and clear, but suggest alternative mechanisms and interpretations. She presents, for example, the case of Eric, who was 14 years old when he put his eye out with a dart by pulling on a string that he had attached to the dart as a means of retrieving it p. Frankl interprets this unfortunate accident as the result of the boy's turning aggressive feelings against himself.
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She supports this interpretation with Eric's own admission that the self-injury was a form of attack on the. Most striking in Eric's case and Frankl's other cases is the absence of elements of caution, worry, anticipation, or other self-protective measures. In a study exploring the determining factors involved in accidental ingestion of poisons by children, Lewis et al. These children were compared with a control group, for whom it was assumed that the availability of poison and the child's ability to explore the environment were the same.
The most important factors in the accidental ingestion were developmental characteristics e. The latter in particular involved the way the mother organized the family environment, which in this study appeared to have been seriously disrupted within a year before the poisoning event in the majority of the cases.
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Two factors loomed large as disorganizing influences on the families of the children: 1 a recent birth or death of a sibling; and 2 a loss of adult support for the mother. In this study, spatial or physical elements in the environment invited an accidental ingestion by children who displayed high exploratory activity, superior motor skills, but poor impulse control. These factors combined with a "maternal depletion" that was present in all the cases in which the ingestions occurred.
The depletion state consisted of a relative exhaustion of the mother's psychic or emotional resources as a result of inadequate support or a sudden decrease in assistance from other adults upon whom she depended, most usually the husband or the mother's mother. Lewis et al. Their work has implications for understanding how lapses in the early mother-child relationship and maturational lapses contribute to later vulnerabilities in self-care.
The authors suggest that most children do not ingest poison because in the usual closeness of the mother-child relationship the child senses and anticipates the. In contrast, when the mother suffers from depletion states as a result of loss or stress, she is less attuned to the child and the positive bond of care and mutual attachment is disrupted. The authors stress that the timing for the establishment of such functions as motor skills, impulse delay, anticipation, and reality sense, all of which require some degree of inner guidance, varies from child to child.
We would add that the establishment of these and related functions early in life is crucial for assuring ego capacities for self-preservation and self-care later on. Studies of children from extremely disrupted environments, such as urban slums or poorly run orphanages, provide dramatic evidence of how experiences from such backgrounds can seriously warp, distort, and impair survival skills at an early age. Using a nursery school as a socializing and therapeutic setting, Malone et al. In particular, their findings about the children's motor activities and appearance vividly demonstrate what we have referred to as impairments and deficits in self-care.
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