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Premature twins on a neonatal intensive care unit

Margaret Cohen


At the heart of the life of the neonatal intensive care unit are the babies, but it is often hard to view them as babies—that is, as small human beings. A junior doctor once informed me that the babies made no impact on him—he just did his job; but later he said that he was having bad nightmares about them and asked if he was "going nuts". So at the heart of our working life there are the babies—and we often do not want to see them. Doctors may cover the baby while they take a limb to try to insert a line. Nurses are more in touch but even they are sometimes more involved with the machinery than with the baby. The very small babies have their eyes closed; gradually they begin to open them; what is this world like that they have come into? There is always the terrible fear that a very premature baby may end up blind because of the high levels of oxygen used to help them breathe. So sight and seeing are problematic issues.

It is against this background that I have decided from time to time to observe a particular baby regularly during his stay in the NICU.

Because I too have my reservations about letting the impact of these babies hit me, I often find reasons not to do this and it is very easy for me to fill my time with other things. It is easier to talk to mothers, fathers or staff, however traumatic this may be, than to sit and watch the babies. There is the difficulty of looking at the babies who may be in pain, or be uncomfortable, or who may have deformities of one kind or another. There is the further difficulty of entering a particular baby's world, of how to make sense of these movements and of this experience. Doctors sometimes argue that the movements are involuntary, springing from an immature central nervous system. Is it crazy to be watching them? Certainly the reaction to one's doing so is that one may well be for the birds. "Maggie, what are you doing? Oh, you're bird-watching again." And it is not just out there: inside I feel that perhaps I am mad, or that I need some learned guide, internal or external, to interpret for me what is going on. I find myself in the middle of a philosophical debate about consciousness. Is there consciousness beyond these movements? Am I searching for a world of meaning that is not there? Am I putting questions that are pseudo-questions? I cling to philosophical work that supports my intuition that these babies have their own consciousness and legitimate experience. I cling to my psychoanalytic belief that we as adults have our infantile experience inside us and that the terror accompanying this is what hinders us from entering more imaginatively into the babies' experience. I think the apprehension of these babies, un-held sometimes for weeks and often in pain, is so excruciating that the goodness and strength of our own internal world is put under great stress—hence my casting around for philosophical and psychoanalytic parents. This could be one explanation for the high level of irritability often found on the unit. The pull into paranoid-schizoid states is very strong.

Along with the denigration of what I am doing there is, of course, the accompanying idealization and anger at the choice of baby. "Why are you so interested in that baby?" And I begin to worry whether the baby will suffer because I have chosen it, or that others will be neglected.

The method of observing which I have chosen is adapted from my Tavistock training. When I watch the very small babies lying alone in their incubators, I take notes as I watch, not feeling myself capable of remembering the almost unceasing movements, which the babies display. Once the babies are being held by their mothers or fathers, I observe and write up my observations afterwards. I also inevitably have a mixed role: I cannot be only an observer. I am the unit child psychotherapist—sometimes I intervene or give my view. Nevertheless, I see my job primarily as some kind of container for experience on the unit. I have wondered whether my decision to take notes as I watch is in order to distance myself, to give me something to do in the face of the raw unprotected experience of the baby, and I think there may be something in that thought.

This chapter describes a slightly modified type of infant observation method used in the neonatal intensive care unit and the link between observation of the infant, discussion with parents, and staff, and exploration in a very subtle way of the development of emotional communication in the infant. Importantly it illustrates how the role of highly detailed infant observation can have sometimes in assisting parents especially mothers in focusing on difficult and unknown aspects of their relationship to the baby and their infant's development.

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