It's Okay Not to Be Okay

It was during my undergraduate training that I first learned about the complexity of crying. I was taught that crying can emerge from a myriad of emotions, that emotions are often a reflection of chemical changes in the brain, and that a human body is constantly attempting to maintain those chemicals in a state of equilibrium. It was like a lightbulb of understanding went off: that when one of those emotions’ skyrockets, our bodies need a release for that chemical, which is why human beings can cry when we are happy, sad, mad, scared and so on. As a student, I knew this information would be vital in my practice as a child life specialist to support patients and families during a variety of situations that can raise any number of emotions to new heights. However, it was not until I became an adult patient preparing for my first surgical experience that it truly hit home how the release that crying provides is necessary and sacred in one’s coping process.

It was a quick but defining moment in pre-op when the anesthesiologist placed the nerve block. I began to cry, and a well-meaning nurse told me “you’re okay, you don’t need to cry, you’re fine.” I’m sure the tears started as a response to the painful procedure, but I’m more certain that the tears continued as a result of fear due to knowing what surgery to remove a mass could mean for my future. Yet in that moment, it didn’t matter why I was crying, but that someone who was not in my shoes felt they could tell me I was okay. I was offended and annoyed by those words, and it made me consider that if I was experiencing this as an adult who is fully able to process emotions and thoughts, how do the countless children and teens feel when they hear those words in their own hospital experiences?

Crying is one of the ways we know when a child is in distress, as it is a natural and automatic response (Kuttner, 2010). Tears are the avenue for a person’s body to release the physiological tension that is produced by trauma or pain. From birth, babies spontaneously cry in response to distress, but as children grow, crying is increasingly inhibited or repressed. All cultures and societies have well-defined attitudes about whether crying is allowed, under what circumstances, and what crying means at those times. However, adults can cause harm when they disapprove of a child’s tears instead of supporting their efforts to gain control of their distress (Kuttner, 2010). If a child is told that it is not acceptable to cry, his or her ability to express distress in a natural and healing manner is impaired. Furthermore, children and adolescents are very sensitive to the judgement made about their pain or fear experiences, and if they do not feel heard or supported, they may become increasingly distressed in the moment, which can lead to deficits in their emotional intelligence, overall emotional well-being, and struggles with cooperation and compliance with their medical treatment plan.

Emotional Intelligence (EQ) includes one’s self-awareness, self-acceptance, impulse control, and empathy (Markham, 2012, pp. 92-93). Child life specialists are in a unique position to help nurture the EQ of children and adolescent patients. However, this opportunity can easily be missed if the child’s emotions are dismissed by telling them that they are “okay.” The most effective way to cultivate emotional intelligence is to learn to understand, accept, and work with one’s emotions. Health care professionals are in an optimal and unique position to help nurture the EQ of children and adolescent patients by actively listening when they work to explain what they are feeling, and helping them to communicate their emotions when they are unable. Any moment a child is telling us or showing us that they are not okay, which occurs often in medical settings, is an opportunity to help build their emotional intelligence. However, this opportunity is often disregarded through the act of dismissing a child’s attempt at communicating their distress.

There are a variety of reasons why health care professionals may tell an upset child, “you’re okay”— to comfort and reassure, to avoid a meltdown, to ease any personal feelings of guilt for performing painful procedures, or even their own personal belief that the child needs to toughen up. Witnessing a child in pain or the panic of a fight vs. flight response is distressing, no matter how many times you experience it. But by falling back on the statements of “you’re okay, you’re fine,” we are impeding the child’s ability to know and express themselves emotionally (Smith, 2016). In discounting a child’s experience and feelings, not only are we sending the message that their story is not worth telling, but we also lend an increase to feelings of confusion, anger, agitation, and distrust — a distrust of the professionals taking care of them and an actual distrust of their own feelings. Too much empathy and reassurance can trigger a child’s brain to sound a message of alarm about the pain, that it really must be very bad if an adult tells you they went through the same thing and reacted in a similar manner. Research has shown that when parents and professionals use language that promotes reassurance (it’s okay, you’re fine, you’re okay), are too empathetic (diving into stories about personal experience to make them feel better), or apologize to the child, this actually increases the child’s pain reports (Blount et al., 2009; Chambers et al., 2002). On the other end of the spectrum of reactions when witnessing a child in distress, health care professionals can feel not only the desire to help, but also fatigue, helplessness, irritation, or even hopelessness. While it’s natural to experience those feelings, we need to be mindful of our thoughts and actions. If you process or ward off the feelings just listed by avoiding or verbally minimizing a child’s distress, this may be self-protective but is ultimately a

blunted and negligent clinical response by an adult they are told they should trust.

So what can we do to help turn a painful or fearful situation into a more manageable one? When encountering an upset child, the first step is to affirm the child’s experience and acknowledge the child’s pain and/or fear, no matter your culture, belief system, or attitude toward the situation. Children in distress need their concerns to be consistently heard, believed, and addressed. It is absolutely crucial to their emotional well-being that no matter how nonsensical or frustrating the child’s feelings and display of emotions may seem to us, that we acknowledge the importance of the experience to the child by responding sincerely and promptly, remaining engaged in the process of their release of emotions until they are able to work through that challenging moment.

When we encourage and support children and adolescents in working through their distress, we are better able to engage and develop connections between the right and left hemispheres of the brain. We feel emotions in the right hemisphere, but to put language to those emotions, the left hemisphere must be engaged. Through a regular practice of identifying emotions, we are better able to find balance in the short term, and in the long term a more integrated brain, both of which are essential to one’s overall health and EQ. Research shows that the simple act of assigning a name to what we feel literally calms down the activity of the emotional circuitry in the right hemisphere (Siegel and Bryson, 2012, p. 29). As child life specialists, if we allow our patients to physically release their emotions through crying and then help them identify what they were feeling, we are better able to promote positive coping and the development of the child’s emotional intelligence.

After taking that first step of acknowledging the child’s pain and/or fear, some additional effective responses to use next for a child in pain or upset include the following:

• Responding promptly in an empathetic, professional,
  practical manner
• Explain in child-oriented language what is happening in
  his/her body
• Offer a positive touch or hand to hold
• Acknowledge the pain, discomfort, fear, etc.
• Tell the child calmly and slowly what positive steps are
  being taken to help them in that moment
• Provide hope or insight that the pain or fearful feeling
  will get better
• Instruct the child on using non-pharmacological coping
  strategies
• Keep yourself calm and watch your tone of voice.

If you feel that the child is becoming caught up in anxiety or pain, start by accepting and addressing their experience. A simple statement of, “I see that you’re still bothered by ____; could you tell me what feelings are happening in your body?” can go a long way in showing the child you trust what they are feeling and want to know more about it to better support them. But this is where it is vital to be mindful of using reassurance and sympathy.

When a child or teen is expressing that they are hurt, angry, frustrated, or scared by crying, they need someone to stop and listen. Every individual person is the authority on their emotional and physical experience, and they deserve to be compassionately witnessed and supported, free of judgement, during their challenging moment. Child life specialists are in a crucial position that invokes a responsibility to take the time to skillfully respond to children and adolescents who are upset, in turn helping them integrate their brain function, develop their emotional intelligence, and practice communication skills that will last through their lifetime. We are all in a position to support a child in distress, even if we do not necessarily understand what the big deal is. If it is a big deal to them, it must be a big deal to us.