Structured Parent Interaction
PATRICIA O'DONNELL, A.C.S.W.
The role of the social worker in a juvenile amputee program as described by Wilma Gurney1 is, ". . . to evaluate families' readiness to accept the prosthetic program, to help with problems that may interfere with a successful use of a prosthesis, and to assist the parents in obtaining help in meeting other needs of the child or of themselves. Immediate intervention following birth of a congenitally deficient child or after traumatic injury helps to facilitate the family's adjustment and acceptance of the amputation. The parents' attitude and acceptance will be mirrored in the child's self-image and acceptance as he develops. The social worker uses the casework relationship to help the parents sort out their feelings and attitudes and make optimal use of their coping strengths at the time of the initial crisis and at other ensuing crisis periods. In addition, structured parent interaction has also facilitated parental adjustment and furthered treatment objectives. The opportunity to share feelings and problem situations with another parent often relieves the feeling the new parent may have of isolation and hopelessness. This technique has been used successfully in our clinic in parent group meetings, informal talks in the waiting area before clinic, preparing for surgical conversion, and crisis situations. The social worker involved with the parents structures the interaction according to the situation and the needs and strengths of those who are interacting.
Following are situations in which structured parent interaction may be used successfully. Short-term group sessions have been offered to parents to provide them with an opportunity to share their own thoughts, feelings, and experiences in raising a "handicapped" child, and then to help them learn to use these experiences in new and different situations and to formulate their own practical answers for problems that arise. The group meetings were held on Saturdays so that working parents could be included. The social worker initiated discussion by reviewing the group's general goals and then asking all members to introduce themselves and state what they would like to accomplish through the group. Topics included their initial feelings and adjustment when they learned of the limb deficiency, and the degree of support received from family, friends, their doctors, and other hospital personnel. Many parents were still angry and/or confused about others' reactions. The group explored their own feelings and the question of why others had been unable to be supportive. Role-playing and modeling were employed to help group members handle the particular problem situations presented. For example, a parent asked how to respond when another child on the playground loudly demands to know what happened to his 4-year-old's arm. He felt angry and uncomfortable in these situations. After several suggestions were offered, the parent was able to explore, with the support of the group, his feelings of guilt and embarrassment in the remaining sessions. The group's cohesiveness was evidenced in their nonjudgmental acceptance of each other's feelings in the real satisfaction of helping. Parents of older children have been particularly helpful to parents of younger children in helping them understand that they should discipline their amputee child as they would discipline any other child. At termination each parent reviewed his progress and what he felt he contributed to others. Some former members have continued contact during clinic visits.
Informal structured parent interaction has been used in our patient waiting area. This technique has been particularly successful with a group of four parents of preschool-age children with below-elbow amputations. One of the mothers has made an excellent adjustment and is exceptionally understanding of other parents' feelings. The social worker introduced her to a new parent who was having a difficult time. The social worker spoke with them briefly, initiating some questions and concerns the new parent had. They established an immediate rapport. The other parents were introduced as they became active with the clinic. Generally at least three of the four are scheduled simultaneously so they continue to meet and discuss their children's progress and success. They all have mentioned that they enjoy sharing the clinic waiting time, talking and learning instead ofjust sitting and trying to avoid looking at each other.
This technique was also used with three parents who appeared in a clinic film together. At the social worker's request the parents of a 17-year-old boy and of a 14-year-old girl talked about their experiences, both positive and negative, with the parents of a 1-year-old boy. All three children were congenital below-elbow amputees. The social worker guided the discussion and provided information and support as needed. All parents later felt it had been a worthwhile exchange and offered to speak with other parents if the social worker requested them to do sIt is always a difficult decision for a parent to agree to surgical conversion of a limb for better function. In our clinic we have six preschool children with proximal femoral focal deficiency. All but one of the children are girls. Four of the children have had their feet ablated between the ages of 2 and 3. In helping these parents to make the decision for the surgery we have arranged for them to meet with another parent whose child has had the same procedure. After a meeting between the parents and the doctor, the social worker encourages both parents to speak with each other informally, not only about the specifics of the procedure, but also about how they felt making the decision, about the child's adjustment, and about present feelings. This approach was particularly helpful with Mrs. N., the mother of a 21 2 year old, L. Her marriage was unstable at the time of L.'s birth. Within a year the parents separated and felt that it was a good decision. The father continued to visit L., but when the mother attempted to discuss the proposed surgery for L., the father absolutedly refused to offer his opinion or give any support. As a result, Mrs. N. was distressed and unable to make a decision. The clinic team members continued to point out the advantages of the surgery but were aware of her feelings and refrained from "oversell" and playing on the mother's guilt. The social worker introduced her to another mother who had a similar situation to face when her daughter had the surgery. Her husband died before her child was born, and she also faced a lonely decision. Mrs. L. was empathetic and sup portive of Mrs. N. The social worker and the two mothers met together several times to help Mrs. N. explore her feelings and make a comfortable decision. Throughout the hospitalization, recuperation, and training with the new prosthesis, Mrs. L. remained in contact with the social worker; and Mrs. N. was appreciative of the support and guidance, feeling that she had learned to appreciate her own strengths and to become more sure of herself.
The final example of structured parent interaction took place during a crisis period. C. was born in February 1976 with severe anomalies of both legs and her left arm. The social worker visited Mr. and Mrs. R. at the hospital the day after C. was born. The maternity staff was sensitive to the parents' feelings and asked for the support of the social worker in helping Mrs. R. in particular. Mrs. R., a 38-year-old mother of three nonhandicapped children, was extremely distressed by the birth of the child and had told the staff she did not want to take the baby home for at least six months. She intellectualized, saying they could not afford to care for a handicapped child, nor did she feel she could handle the baby expertly. During the social worker's visit with the parents, the father continually voiced his and the siblings' acceptance and eagerness to take the baby home. However, he was understanding of his wife's feelings and fears. As the interview continued it was increasingly obvious that Mrs. R. was ambivalent but really wanted the baby. She could not make a commitment but wanted to be encouraged to take C. home. The social worker suggested that she might want to talk to another parent who had experienced similar feelings and fears. She was visibly excited about this possibility and felt it would be helpful.
After the interview the social worker spoke with the nurse practitioner. She arranged to have the baby moved into the mother's room and to be available to help Mrs. R. handle and care for C. The social worker then called one of our parents who had experienced a difficult time at the birth of her child but who had adjusted well with family and casework support. She agreed to call Mrs. R. at the hospital and speak with her. She reported later that she and Mrs. R. had a long and open conversation and felt that Mrs. R. really wanted the baby. She had ar- ranged to visit Mrs. R. at the hospital. The social worker reviewed with her what she might say and how to handle questions. During the visit she showed Mrs. R. pictures of her own child and was very honest about the joys and problems she had experienced. The nurse practitioner reported that Mrs. R. was enthusiastic and loving in her care of C., and the subject of placement was not seriously considered again. After Mrs. R. returned home with C., the social worker continued casework services, and the other parent visited several times with her child. At termination of intensive casework service with Mrs. R., she felt the support of all involved had helped her adjust more rapidly. She was now more aware of her own strengths and realized she could have eventually made the adjustment on her own. However, she felt the support she received hastened her adjustment, allowing her to devote more attention to her family's needs, not to just C.'s situation. Structured parent interaction cannot relieve all situations, nor can it be used independently of the casework relationship. It is an added tool to help parents adjust to their child's handicap and ensure their continuing growth and development as parents. The social worker must consider the psychosocial diagnosis of each family involved and must use parent interaction discriminatingly. Parents who have severe emotional disabilities prior to the birth of a limb-deficient child are inappropriate for this type of intervention and should be referred for psychiatric consultation. Structured parent interaction also aids the medical team by alleviating the social and/or emotional blocks to treatment objectives.
1. Gurney, Wilma, The psychosocial problems, in Berton Blakeslee, ed., The Limb Deficient Child. University of California Press, 1963, 93.