In the communication between the child and the parents, it is very striking that protecting oneself is often achieved through protecting the other. Attempts to influence the other person's appraisal in order to reduce the other person's negative emotions not only involve compassion and empathy, but also serve to protect oneself against confrontation with the other person's emotions. This is called the law of double protection. It is essential for the child to believe that his or her parents are strong: if they can handle the situation, it constitutes the signal that the threat can be averted and boosts the confidence that the child will survive. All attempts by parents who conceal the true meaning of the situation from the child are attempts neither to burden nor to weaken the child. The parents' avoidance of discussing their worries and grief related to the illness prevents the child from thinking about it, but also protects the parents from being confronted with the child's emotions.
Not only do parents achieve self-protection through the other person, the child achieves it as well. Not asking questions which might worry the parents, hiding grief, and being brave are attempts of preventing the parents from becoming distressed, and themselves from becoming overwhelmed by the parents' emotions.
The phenomenon of double protection is observable as: (1) parental attribution of positive properties and dispositions to the child and the need of parents to create a positive image of the child; (2) avoidance of communication about the seriousness and the emotional experience of the illness and encouragement to act in a way of mutual pretense; (3) distortion of reality by (partial) denial, the use of symbolic language, and projection of feelings onto other persons. Some illustrations will clarify this.
Positive Attribution We have found support for the hypothesis that parents of children with cancer need to see their children as strong and that they adopt a positive perspective when looking at their children (Grootenhuis et al. 1997). Parents (n=321) and their children (n=205) in different conditions (cancer in remission and with a relapse, asthma, and healthy controls) completed questionnaires to investigate parents' attribution of positive characteristics to their children. It was found that parents of children with cancer attributed significantly more cheerful behavior to their children than parents of children with asthma and parents of healthy children. The findings obtained were equivalent for the mothers and the fathers. We believe that, in order to be able to count their child among the lucky ones who will survive the disease, parents create an image of vitality and zest for life. This positive attribution by parents of children with cancer may be a beneficial coping strategy as long as the emotional feelings of children are not underestimated. Caregivers should be aware of this coping strategy, especially if this coping strategy is out of balance or pathological. It can also be possible that children give their parents the impression they are doing fine to protect their parents from the more negative emotions resulting from the stressful situation.
An example of double protection in a family which was troublesome for the child is as follows. During a research project interviewers were given the impression by parents that their girl was cheerful and optimistic. The parents described their daughter as being unaware of the dangers and consequences of her disease. The impression of the researcher who interviewed the girl, however, contradicted this image. During the interview, the girl told the interviewer that she still worried a lot about her illness and about a possible recurrence. Furthermore, she told the interviewer that she often cried in her room, and she said: "My cuddly toy absorbs all my tears." She said that she did not want to bother her parents with this because they always said that there was no reason to be afraid. The girl had a high score on a depression questionnaire. This example illustrates that the emotional experiences of children with cancer may be ignored if their parents attribute too many positive characteristics to them because they need to see their child as strong. The need to see the child as strong may also become harmful if illness-related symptoms are ignored or underestimated. However, if there is considerable agreement between positive attribution and the emotional experiences of the children, and both the parents and the children are able to fight the experience of childhood cancer by adopting this coping strategy, there is no reason to interfere.
If the parents of children with cancer attribute positive characteristics to their children, this may have consequences on who clinician or researchers will choose to obtain valid information about the child's health and psychopathology. Caregiv-ers must realize that if they ask parents of children with cancer to report about their children, the parents' perception might be obscured by the use of this coping strategy. Avoiding Communication Open information about the diagnosis and prognosis is found to be associated with a positive influence on the child's emotional reactions, as we have described before. Although most of the children with cancer are aware of the seriousness of their disease, it is found that the communication about the disease between the child and parents is mainly about the necessity to continue treatment and to undergo painful medical procedures and not about the emotional impact of the situation. Once, a 9-year old boy stated: "During her visits in hospital my mother always cried. Then I had to cry too. Once I said: 'If you don't cry anymore, I wont cry anymore.' From that moment on she never did cry again. She always smiled when she visited me." This statement illustrates the child's attempt not only to block the expression of sadness of his mother, but also the child's implicit proposal of mutual pretense: "Let us act as if we are not sad, let us behave as if there is no reason for crying." The conflict between the need to express feelings of distress and the need to protect oneself against these emotions can be solved by a (partial) distortion of reality. Parents who show their grief in front of their child frequently do not give an explanation or they deny that their child's illness is the cause. Illustrative is a mother who says: "When it happened once, he said: 'Mommy, are you crying?' 'No dear, I have a cold,' I said." Communication about the emotional experience can also take place in a symbolic language. An example of this type of communication is provided by a mother in a discussion group for parents. This mother talks about her 11-year-old son, who talked in his sleep while dreaming. In the morning when she asks which of her children had such a troubled sleep, he initially remains silent. She encourages him: "Was that you? Come on, you can tell your mother everything. Dreams are just lies anyway." Then her son tells her that he had dreamed about a physician who told him that he should be dead for 1 year. In the communication between this mother and her son, the expression of fear of death is embedded in the reassurance that dreams are lies and in the magical conception of a temporary death.
Another example of double protection is found in the phenomenon of projection of feeling onto other persons. It is frequently found that children with cancer can worry about the well-being of their parents. In self-report questionnaires and interviews children agree remarkably often with statements referring to something bad that can happen with the family or their parents. With the expression of feelings of anxiety about their parents, the child probably shows feelings of anxiety about his own vulnerability in a self-protective way, whereas parents onto which anxieties are projected, are protected against worrying for their child.
Above we described the phenomenon of double protection in pediatric oncology by children and parents, sometimes observable by attributing positive characteristics to one another. In relation to this, we speculate that staff members may also need to see children with cancer and their parents as strong, and presumably achieve self-protection via attributing positive characteristics to children and/or their parents. Staff members have to confront children and parents with bad news, with burdensome treatment regimens, and painful medical interventions. Because of the intensity and length of care involved, a strong emotional relationship usually develops between the patient and staff. During the course of treatment, staff members may be confronted with situations in which they are uncertain about the benefits and risks of their work. It is conceivable that if they create an image of children and parents who are able to manage the situation, it enables them to continue their work and to endure the continuing confrontation with the emotional turmoil of the family. With more years of experience in oncology this need to see children and parents as strong may even become increasingly necessary as a coping strategy.
In a study conducted in our department, a to tal of 76 staff members, 84 children with cancer, and their 163 parents participated (Grootenhuis et al. 1996). We compared staff members' ratings with the parents' ratings on the need for support and with the children's ratings on experienced pain. We found that both gender and number of years working in oncology care were positively associated with increased self-protective reactions in staff members. Male staff members rated medical procedures and the pain children experience in general as less painful than did female staff members. Their judgments about experienced pain in general and the lumbar puncture procedure in particular tended to be lower than the children's ratings. Female staff members attributed more positive characteristics to children with cancer and their parents than did male staff members. Staff members with more years of experience in oncology tended to rate all three medical procedures as less painful than those with fewer years of experience, and they also attributed more positive characteristics to the children. Although some limitations of the study should be taken into account (small numbers, general ratings), we believe that these data provide some support for the hypothesis that staff members' perception is influenced by so-called 'double protection'.
There is no doubt that pediatric oncology staff members need a certain professional distance to cope with the stress of their work. However, care should meet the needs of the children with cancer and their parents. The staff's tendency to attribute positive qualities to children and parents should not interfere with decisions about administration of pain medication or the referral to other additional support services. For this reason, it would not only be desirable to pay attention to the coping strategies of both children with cancer and their parents during medical education programs, but also to focus on self-protective behavior in staff members themselves.
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