The lasting presence of early hospital experiences

by Colm O’Connell

The experience of surgery is odd at any age: the loss of consciousness, the potential for overwhelming pain, the unfamiliar environment of hospital and professional medics, and perhaps the unusually fraught relationship dynamics with caregivers. Add to this mix the early stage of psychological development implied by childhood plus the highly adaptive nature of children in this phase, and what results is a crucible of experience, something that can crystallise the immediate responses into habits perhaps shaping a lifetime of future experience.

In this piece, I am using some of my own early hospitalisation experience and academic research to propose Early Childhood Experience of Surgery and Hospitalisation (ECESH) as a prototypical event that can result in character formation - a phenotype of experience, to borrow a term more commonly used in biology (to describe a category of thing malleable by its environment). The experience and subsequent meaning-making can result in long-term beliefs and behaviours, often beneath the level of conscious awareness. No doubt, the uncovering of the subtle impact of my own surgery in childhood played a part in my choosing to research the similar experience of others as part of my Masters dissertation. This impact (subtle and not so subtle) is often overlooked as a source of struggle or defence in therapy, as evidenced in the cases below.

Integrative psychology and psychotherapy are especially well matched to investigate the complexity of interactions and consequences in such experiences. And as a corollary, this class of karmic event also provides a useful case study encompassing the lived experience, environment, the unconscious, the arising of awareness and the elapse of time to affirm the value of integrative perspectives. This discussion does not extend to the possible effects of the birth experience itself, although that too has potential for exploration.

Many psychotherapy modalities might offer an apparently replete perspective on ECESH. For example, psychoanalysis might suggest an interpretation around the young psyche struggling to survive and choosing to split or repress any future association with that which was terrifying at a young age. Attachment theory might look at the important bond of safety between child and caregiver and how such a bond was stressed and perhaps misshaped as a consequence. Somatic approaches can feel into the physiological overwhelm and perhaps the need to re-regulate what once seemed unsurvivable. Whether these disparate perspectives can be reconciled, or whether such an endeavour is even a necessary ideal from a therapeutic perspective is somewhat of a philosophical question. There are of course newer modalities, for example Janina Fisher’s trauma model which seeks to make a useful blend of these somatic and psychodynamic perspectives (Fisher, 2017).

There are also new perspectives coming from interdisciplinary work that seek to blend the physical and social sciences into informative new models (such as neuroscience and mindfulness, to pick a popular example). Yet other approaches such as gestalt or integral psychology allow these disparate impressions to be held in mind and gracefully utilise the acceptance and humility of ignorance. Such integrative approaches are capable of holding these apparently independent perspectives together. Yet in allowing that integration, one chooses pragmatically to leave aside a neat theoretical synthesis of such perspectives. In practice, it is an example of what the poet John Keats called Negative Capability: to hold two paradoxical ideas in mind together without discomfort - a disposition well suited to integrative therapy (‘Negative Capability’, 2010).

Interviews around the hospital experience

In my research interviews (O’Connell, 2020) with three people who had an ECESH, each one was able to recognise the repetition of a pattern in their present day lives that was at least partially initiated back in their childhood hospital/surgery episode. For one subject her forgotten difficult postoperative separation as a toddler from her mother is speculated as originating in an attachment style lived out in a clinging relationship pattern in adult relationships. For another participant, the memory of his highly anxious mother and contrastingly reassuring calm medical team at the start of an excruciating appendicitis episode informed his adult relational style of helping others survive painful experiences. From my own experience, I wonder about the impact of the surgeon’s cutting and sewing which I experienced at the age of three months (possibly without anaesthetic, which was common as infants were thought not to experience pain) on my own attachment style and connection with caregivers.

There is substantial medical research into accidental awareness during surgery itself, which can be one aspect of ECESH. Research in this area displays an enormously wide range of accidental awareness, from more than 1 in 100 (Andrade et al., 2008) to 1 in 142,000 (Pandit et al., 2014). Pandit et al. (2014) in their study review of cohorts that did have post-operative recall of events reported a high prevalence (41% of participants) suffering consequences of moderate or severe long term psychological sequelae. Andrade et al. (2008) also suggest that the incidence of awareness in children can be eight times that of adults, measured by post-operative recall, while others have questioned if current methods are sufficient to catch or track these phenomena (Davidson, 2007; Russell, 2016). One can only wonder at the many unspoken meanings carried forward from such liminal experiences. 

The silent past

Psychoanalyst Paul Renn offers a relevant modern marriage of neurobiological, psychoanalytical and psychodynamic research in his perfectly titled work The Silent Past and The Invisible Present (2012). Renn’s book summarises an evolution in thinking on what Freud had called the dynamic unconscious and its content of repressed awareness (or the overlapping class of implicit memories) of what was once consciously known, to encompass preverbal experience and learning related to Bollas’ “unthought known” and Stern’s “unfathomable experience” (Renn, 2012:16). Renn also details the “neural Darwinism” of memory, in that meaning is being re-constructed and evolved anew with each recollection of an event (Renn, 2012: 18). The participants in my own research displayed something which I termed memory dissonance whereby memories of the ECESH were recalled yet actively discredited in an ongoing present-day process. In discussing the effects of early trauma on childhood development, Renn references research by Lyons-Ruth et al. (1999) on the intersubjective attachment systems where “subtle” aspects of the relationship seemed to be involved, rather than gross abuse, neglect or abandonment (21). This supports the proposition that experiences such as ECESH can be formative even below the level of what would be considered traumatic. I was interested to note in my own research study that the meaning-making of the three participants mainly referenced the relationship dynamics and consequences of the experience, rather than any transpersonal meaning with which my own experience seems somewhat imbued.

In terms of character styles or traits and how they are engendered, Johnson (1994) has put forward a well-regarded psychoanalytic and somatic theory of styles, which may derive from the inevitable difficulty which arises when the environment does not meet the expectations of a child. He utilises a model of character development that goes through the following five stages: 1) self-confirmation; 2) negative environmental response; 3) organismic reaction; 4) self-negation; and 5) adjustment process. It is in the responses selected in stages 4 and 5 that a character style (or the lesser tendency of a character trait) is developed, according to this model. For ECESH, it can be imagined that stages 2 to 4 may be compressed into a very short intense timeline. These inner conflicts are dealt with in whatever way works for the child (splitting or repression for example).

Other depictions

There are quite a few examples of ECESH that arise in the psychotherapeutic literature (though none that assembles them together, as far as I can tell). Erskine’s (2015: 62-70) in his Relations Patterns, Therapeutic Presence contains a relevant case study in early hospitalisation. “Kay” is a 54-year-old woman suffering from a sense of loneliness and anger at feelings of being controlled by others. Erskine is her third therapist, and a significant unfolding in the therapy room happens by the opportune appearance of a spider climbing up and down a thread from the ceiling above. Initially thrilled, and then withdrawing, Kay remarks that a spider had been her only friend while she had lived in an iron lung for two years from two to four years of age. Kay had never thought to mention this to previous therapists or in a full year of work prior with Erskine, assuming it would be of no interest to anyone (as had been her relational experience in hospital). Erskine describes the ensuing work as a slow patient dyadic re-regulation of Kay’s present day experience, which unconsciously communicated her implicit (pre-verbal and never verbalised) memories of the hospitalisation experience and her unmet (nonmemory) relational needs. Erskine frames in-depth psychotherapy as a raising into consciousness of what was heretofore an unconscious relational need (or needs), even as the person persists in suffering the lack of that relational satisfaction which was previously unknown to themselves. 

Another example appears with therapist Annie Rogers, in her absorbing memoir-cum-case-study, A Shining Affliction (1997) which narrates her troubling experience of coming to terms with an invasive early childhood medical procedure which surfaces in a parallel process to her engagement with a child client in therapy.

In a wide-ranging case study and literature review, Riordan et al. (2017) discuss the successful treatment, via play therapy and Somatic Experiencing, of “Little Bill”, a 30-month-old toddler, who underwent two surgical procedures which resulted in restraint trauma and tonic immobility. Thereafter he showed signs of disorganised attachment towards his mother and shortly after was given a childhood PTSD diagnosis. The case study outlines a protocol that allowed the toddler to achieve dyadic completion, being the re-installing of a feeling of soothing and safety from his mother via iterated play scenarios that included physically running to the mother, an action that was traumatically truncated in the second surgical experience.

The normalcy of significant dysregulation

American psychiatrist Lenore Terr has written a number of illuminating studies on trauma and its (sometimes surprising) etiology in children and adolescents. To contrast with a previous group study on trauma arising from a very public mass kidnapping event, Terr performed a randomised interviewbased study of 25 children and adolescents not known to have any shared trauma, focusing around life expectations and connection to any significant discrete episode they recollected (Terr, 1983). The interviewees reported a range of experiences such as witnessing a brother and father having an accident, being hospitalised after a car accident, being hit by a ladder, fainting following a fright, or witnessing an earthquake. In 15 of the children these experiences occurred without it resulting in any serious difficulty, per Terr’s interview impressions.

But in ten cases Terr found that the severe fright or trauma was carried forward, resulting in a limited life view, even though none of these children would have had any previously acknowledged developmental or mental health issue. That is a significantly large proportion of 40% carrying a pathology or psychic trauma (per Terr’s impression) from such normal (although shocking) events. Terr (2013) suggests that this limitation is carried forward when a child spontaneously creates an interpretation in the moments after an event, which can install a bias to recognise “omens”, often mistakenly, for future experience. I suggest that ECESH can also be a source for such subtle hidden interpretations and biases.

The desire for self-regulation

What these instances have in common is the experience of overwhelm, where one or both of the child’s physiological and interpersonal systems are stretched beyond their usual bounds to such a degree that they don’t return back to stasis in the normal manner. They are beyond “the window of tolerance” (Siegel, 2015). There is a residue of adaptation, though perhaps not conscious, which alters the windows of perception going forward. There is evidence in the cases discussed here of that early adaptation and the later use of others (either in therapy or relationship or both) to repeat and repair the dysregulating overwhelm experience with a co-created repetition that has the opportunity (though not necessarily the guarantee) of co-regulation. It may in fact be what they seek out (perhaps unconsciously) in the therapeutic process.

The research points to such experiences and consequent limiting adaptations often being held in the body, beyond conscious recall, expressed in somatic symptoms (such as chronic pain or skin conditions) or dreams. It is most notable that these events rarely surfaced with the individual’s first therapist, often overlooked by both parties, only to surface somewhat serendipitously in later work. While some of these cases include other sources of ongoing trauma, the evidence for psychic impairment from a single shock related to overwhelming physical pain is considerable (Riordan et al., 2017; Rogers, 1995).

In my own research interviews, it was possible to pick up the desire for repetition of some relational dynamic around the ECESH in the therapeutic relationships of the participants. The previous dysregulating relational circumstances (the overwhelm of physical pain around surgery, or caregivers unable to provide comfort post-surgery) was occasionally able to be held, examined and reframed in therapy such that the underlying subconscious need was met and psychic energy freed up, decades after the initial psychic insult.

Final discharge

On leaving hospital one is discharged and is considered as no longer requiring ongoing care - yet I contend that not everything may be appropriately discharged at that point, and that ECESH can be a source of significant psychic struggle which may persist into adulthood through somatic symptoms, have an influence on attachment style and on personal narrative and identity. It appears often overlooked as a source of struggle or defence by client and therapist.

The process of dealing with a discrete overwhelming episode such as ECESH serves as a “simplified” model of the unconscious and awareness writ large. It contains the elements of (neurological) development and growing capability, challenge to the autonomic nervous system, self-regulation and co-regulation (via others), somatic memory, and the slow evolution of meaning that is possible with increased awareness.

It seems evident that it is simply not possible to have the capacity to process such challenges at a young age, and that the opportunity for integration arises with maturity, (therapeutic) assistance and perhaps no small amount of good fortune. There may be much to be learnt by inquiring into the dynamics of early childhood surgeries and hospitalisations and the adaptations that persist, perhaps unhelpfully in the present day.

Colm O’Connell is an IAHIP certified associate psychotherapist working in private practice in Dublin. For more information see meadow.ie

References

Andrade, J., Deeprose, C., & Barker, I. (2008). Awareness and memory function during paediatric anaesthesia. BJA: British Journal of Anaesthesia, 100(3), 389–396.https://doi.org/10.1093/bja/aem378

Davidson, A. J. (2007). Awareness, dreaming and unconscious memory formation during anaesthesia in children. Best Practice & Research. Clinical Anaesthesiology, 21(3), 415–429.

Erskine, R. G. (2015). Relational patterns, therapeutic presence concepts and practice of integrative psychotherapy. Karnac Books Ltd.

Fisher, J. (2017). Healing the fragmented selves of trauma survivors. Routledge.

Johnson, S. M. (1994). Character styles (1st edition). Norton.

Negative Capability: Poetically Living a Life Full of Uncertainty. (2010, October 23). In Dictionary.Com. http://www.dictionary.com/e/negative-capability-keats/

O’Connell, C. (2020). The Wizard Of Odd: A Psychotherapeutic Reading Of What Experiences Of Childhood Surgery Reveal About ‘The Man Behind The Curtain’ https://esource.dbs.ie/handle/10788/4091

Pandit, J. J., Andrade, J., Bogod, D. G., Hitchman, J. M., Jonker, W. R., Lucas, N., Mackay, J. H., Nimmo, A. F., O’Connor, K., O’Sullivan, E. P., Paul, R. G., Palmer, J. H., Plaat, F., Radcliffe, J. J., Sury, M. R., Torevell, H. E., Wang, M., Hainsworth, J., Cook, T. M., Royal College of Anaesthetists, … Association of Anaesthetists of Great Britain and Ireland (2014). 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. British journal

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Renn, P. (2012). The Silent Past and the Invisible Present (1st edition). Routledge.

Riordan, J., Blakeslee, A., & Levine, P. A. (2017). Toddler Trauma: Somatic Experiencing, Attachment and the Neurophysiology of Dyadic Completion. International Journal of Neuropsychotherapy, 5.

Rogers, A. G. (1995). A shining affliction: A story of harm and healing in psychotherapy. Penguin.

Russell, I. F. (2016). Unreported paediatric awareness during surgery. Anaesthesia, 71(5), 590–591. https://doi.org/10.1111/anae.13470

Siegel, D. J. (2015). The developing mind: How relationships and the brain interact to shape who we are (2nd edition). The Guilford Press.

Terr, Lenore C. (1983). Life Attitudes, Dreams, and Psychic Trauma in a Group of “Normal” Children. Journal of the American Academy of Child Psychiatry, 22(3), 221–230.https://doi.org/10.1016/ S0002-7138(09)60369-1

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America, 22(1), 51–66.https://doi.org/10.1016/j.chc.2012.08.003

(C) IAHIP 2021 - INSIDE OUT 94 - SUMMER 2021