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Maternal Function in Neonatal ICU: Psychoanalytic Considerations on the Experience of Mothers in Hospitals

Barreto Cristiane Palmeira de O., Nobre Thalita Lacerda*

PhD Clinical Psychology – Pontifical Catholic University of São Paulo (PUC/SP). Professor and supervisor at Catholic University of Santos – SP – Brazil and Paulista University – Santos – SP - Brazil

Abstract: This article is part of the dissertation entitled " Mothering and Maternal Function in Neonatal ICU: a psychoanalytic study" and has the purpose of elucidating the relationship between motherhood and maternal function in the hospital environment. Therefore, the meaning of the two concepts is presented, as well as a distance is proposed between the two where mothering competes the incumbency of the necessary caretaking for survival and maternal function, the exercise of a symbolic function - which refers the subject to the size of their psychic constitution in its relation to the language field. The research was to determine whether the difficulty in the exercise of motherhood, within a neonatal intensive care unit, could interfere with the conditions for sustaining maternal function, usually exercised by the mother. The research that led to this dissertation and the work was carried out in a private hospital of São Paulo city, with mothers of both male and female babies, preterm neonates at the Neonatal ICU, and subsequently after discharge. The theoretical foundation is sustained on the psychoanalytic theory of Freud and Lacan, and also on the four theoretical axes formulated in Clinical Indicators of Risks in Infant Development (IRDI). In conclusion, this study reveals the presence of suffering caused by the psychic impact of a preterm child and the admission in the Neonatal ICU, as well as the difficulty in mothering the baby, from the speech of mothers. However, despite the psychic rapture, in the analysis of the symbolic function – based on the four fundamental operations, deduced by me from IRDI - it was possible to note the conditions for the maternal function to be carried out.

Keywords: mothering, maternal function, Neonatal ICU, IRDI Research

Received August 05, 2014; Revised August 29 2014; Accepted October 27, 2014

Citation: Barreto Cristiane Palmeira de O., Nobre Thalita Lacerda, Maternal Function in Neonatal ICU: Psychoanalytic Considerations on the Experience of Mothers in Hospitals. American Journal of Applied Psychology, 2 (5A). 1-4. January 2014. doi:10.12691/ajap-2-5A-1

The article in question is part of the dissertation defended in 2011 at the Catholic University of São Paulo (PUC/SP) [1], whose research aimed to investigate the relationship between motherhood and maternal function in the hospital environment of a neonatal intensive care.

This goal was based on the idea that the reality of hospitalization in the intensive care unit, which causes difficulties to mothering, may have possible effects in exercising the maternal function.

It is then, from the outset, to clarify how these two concepts are addressed by me, since I do not present them as synonyms.

Mothering, according to Laplanche and Pontalis (1988), is explained "to define the care given to" infants "in a climate of active, sacrificial, attentive and constant tenderness." [2].

In Zimerman (2001), I encounter the term "function mothering" [3] with the concept that refers to the person responsible for providing essential primary care.

From my understanding, in Laplanche and Pontalis, the term appears integrating motherhood and maternal function (in terms of what Lacanian theory proposes on maternal function). Yet in Zimerman, it seems more objectively what motherhood is without integrating, at first, maternal function. It is with this latter understanding that the concept of motherhood is understood by me.

The concept of Maternal Function is based on the theory of Lacan: "The role of the mother is the mother's desire" (1970). [4] In this sense, what mom can put on exercise from her desire is a function that, as Lacan says in "Note on the child" (1969), sets in action "so far as their care bear the mark of one particularized interest, even if through their own faults." [5].

This particularized interest has to do with what Freud postulated about narcissism as the way in which the ego is, so that you will not let go of each other. This narcissism is a revival of the narcissism of the parents themselves and that is what he says:

The child will have more fun than his parents; he will not be subject to the requirements that they recognized as paramount in life. Illness, death, renunciation of enjoyment, restrictions on his own will not reach him; the laws of nature and society will be abrogated in his favor; he will once again be truly the center and core of creation - "His Majesty the Baby," as we once imagined the same. The child will realize the golden dreams that parents never performed - the boy will become a great man and a hero in his father's place and the girl will marry a prince as compensation for her mother. In the most sensitive point of the narcissistic system, the immortality of the ego, so overwhelmed by reality, security is achieved through the refuge in the child. Parental love, so moving and actually so childish, is nothing but the parents' narcissism born again, which, transformed into object-love, unmistakably reveals its former nature [6].

For this consideration, the child will represent a narcissistic illusion for parents, which is fundamental to the constitution of the self of the child. On being put into action the maternal role, this illusion is present all the time, just look at mothers talking about their babies on their physical, motor, intellectual performances. One notes clearly the place of "His Majesty" occupied by the baby in the mother’s point of view.

Thus, I understand that the maternal function is beyond aimed at satisfying the needs and care, in this sense, is beyond motherhood. The exercise of the maternal function highlights the desire, the desire for a particular child.

For this desire and in the exercise of this function, a mother to her child can sustain the place of Other, a term used by Lacan to mark a "symbolic place - the signifier, the law, the language, the unconscious or even God - that determines the subject [...]." [7].

In this place of Other, a subjective existence will be anticipated in her baby in which is supposed, but that just might be set up to because it was supposed to be. With her look, her gesture and her words, in the exercise of this function, the mother will cover the baby's body whose flesh will disappear forever under this network she will weave.

Therefore, the distance of these two concepts proposed by me is supported by Jerusalinsky’s assertion (1984): "a mother who cares is not the same which desires." [8].

And therefore to propose the distinction between motherhood and maternal function proved so important in making the work of listening to mothers of newborn babies who required admission to the neonatal ICU. This is because, although mothering is usually found attached to the maternal role, this condition is not absolute.

The starter question to these conversations took place around the experience of these mothers in the neonatal ICU [9].

Listening to mothers who spoke to me about their days in the NICU with their babies and, noting the repetition of suffering on not being able to take care, touch, hold their babies, the question came to me: can the difficulty of motherhood in the NICU interfere with the exercise of the maternal function? Does the impact of the premature birth of the child and by shifting the position of knowing your baby may have effects in sustaining maternal role for a mother?

In order to listen to these effects in the exercise of the maternal function, I used the four theoretical axes of the maternal function proposed in IRDI Research (Clinical Risk Indicators for Early Childhood Development) [10] as a compass, namely: 1. Agent’s Assumption - characterized by the anticipation performed by the maternal agent who foresees a subject in the baby, 2. Establishment of Demand - understood as an addressed request, it means, the productions of the baby are taken by the mother as a directed order to her and that she should attend, 3. Alternation of Presence-Absence - that understands there is an alternation in maternal actions addressed to the baby, psychically. Paternal Function 4. - understands the place of third instance between mother and baby.

These axes, based on the theories of Freud and Lacan, were organized by GNP (National Research Group). [11] Such axes exceed the imaginary dimension of what being a good father or a good mother means and put into play the importance of sustaining basic operations so that it becomes an agent.

The approach taken to these axes was fundamental so I could see if the maternal role, built around these four areas could suffer interference before the opening, the slit that opens with a premature birth, his hospitalization in ICU and by the difficulty of mothering, revealing the lack in the mother.

The studies focused on prematurity and neonatal ICU currently interest the professionals from various areas of health because of the technological advances made in recent decades and the discoveries in medicine that allow the birth and survival of increasingly younger babies.

However, regarding the worthy proportions from these progress, questions about the organic conditions of these babies - regarding morbidity and quality of life can bring a lot of side effects to organic instrumental of the baby, and with regard to the field of mental health, the psychic conditions - with regard to the psychic constitution - have been deployed and studied.

To pursue studies on prematurity, I realize that numerous studies have been produced since the sixties regarding the relationship between parent-baby, among them, authors like Spitz [12], Bolwby [13], and some others, including with regard to premature babies, Brazelton [14], Klaus and Kenell [15], Dolto [16]. And it is interesting to note that, almost unanimously (of course each one according to his theoretical approach) all point in the direction that early intervention in the NICU is needed so that there is no crystallization of a "gap in language "as Szejer [17] says, around the child. The vast majority of authors that I refer understands that putting words in that suffering provides a symbolic connection by an interaction to the birth of this child that will have effects on the relationship between parents and their baby.

From the conception of a baby starts their subjective experiences from one other/Other, premature birth and ICU are facts that cannot pass without effect for those taking up a function that can be suspended or impeded.

In Freud's work since "On Aphasia" (1891) [18], where I believe that Freud began his first elaborations on the apparatus of language, as in the "Project for a Scientific Psychology" (1895) [19], are already revealed key concepts for understanding psychic constitution like the idea of the specific action and the assistance of others, the concept of the experience of satisfaction, desire and the Thing (Das Ding). Later, as continuity, Freud could assert in "Three Essays on the Theory of Sexuality" (1905) that:

The relationship of a child with whoever is responsible for his/her care gives him/her an endless source of sexual excitement and satisfaction of his/her erogenous zones. This is especially genuine, since the person who takes care of him, who is, in general, his own mother, looks at him with feelings that arise from her own sex life [...] treats him as a substitute of a complete sexual object [20].

I understand that the germs of what Lacan later appoints as maternal function are present in this conception, because these care are already imbued with the desire for this child, able become erogenous this body, and that is why Freud says that the mother with her care becomes his "first seducer". But because she is his first seducer [21] that the mother sets in motion a body that becomes instinctual, narcissistic, ego constituent of the child.

This constitution of the self /ego is theorized by Lacan especially in his text "Mirror Stage" (1966), which postulates a psychic operation in which the self is recognized by another. Previous to their own physiological domain either from the point of view of the acquisition of motor control, whether from the point of view of establishing the language, the self gets a status that integrates him with an image given by another. The importance of the theory of the mirror stage occurs primarily by the prospect that there is truly a stadium and not a mirror. This theory is taken from the unconscious point of view and not by a psychological insight linked to perception and consciousness.

Thus, the mirror stage is a psychic operation, by which the human being is constituted via identifiable with his similar. This organization brought about by the recognition of a body unit provides to the subject an instance of self.

By the apprehension of this experience, the subject has the ability to hold its first identifications, entering another field that is the symbolic field. It is noteworthy that, in the experience of the mirror stage, observing the reflection in the mirror, the child turns to the person who sustains him searching for a sign of recognition of the other, which grants its image.

The importance of explaining all the above lies specifically in the fact that the mother, since that she might appropriate the maternal role, which calls the primordial another place for the child, gives the place of the supporting image for the child at the same time opens up space, a rest, a gap that arises precisely in order of ratification, allowing the subject access desiring position. Who am I to you? That's the question we seek to address the subject from the ideal self.

What may suffer a shock in this process is precisely the place of this baby to the mother. When a baby is admitted to a Neonatal ICU and goes to medical care, a narcissistic disinvestment and hindering of the project envisioned for this child may occur. Before birth, a child is already inserted in a symbolic field to which it will come or not to appropriate, but when quickly, this project suffers a shock, the functions for which a subject comes to be his psyche can also suffer impact.

Piera Aulagnier is a psychoanalyst which helped myself to think about the relationship between the baby and his mother in the neonatal ICU, based on his conceptualization of the role of spokesperson and designing an originating process capable of representing the first experiences after birth, you can reflect how a baby hospitalized in ICU can come to subject the desire of the Other. This subjection is postulated by Lacan (1958) to discuss the theory of the Oedipus because, according to him, "the child outlines how subjected [...] because, at first, he experiences and feels as deeply subjected to the whim of that he depends on [...] [22].

As the concept of Aulagnier (1975) [23], it is possible in the understanding that a baby exposed to the same experiences of suffering can also autoproduce experiences of pleasure by sensory pathway through the voice of his mother and his father, the touch and warmth of skin-to-skin constituents to his psyche. The child psyche will be inaugurated by the work of prosthesis that the maternal psyche has on the psyche of the child.

However, from the point of view of the mother, the fact that they cannot have an exchange between her body and her baby determines an experience of pain for her. It is attentive to the maternal pain and the fact that the baby born prematurely needs, with the goal of safeguarding their physical health, a team specialized in minimal handling of the neonate, which I raise the possibility that the mother may feel deprived of her position of being a mom to his son and consequently there may be interference in the exercise of the maternal role.

To illustrate, I present a small cutout of listening to a mother with whom I talked in the NICU. This mother highlights that she would like to be a "normal mother". And when I asked her what that means, the mother becomes emotional and answers to be a normal mother relates to the action of taking her baby in her arms, something which it is not permitted by the complexity of the picture of her son at the time.

Clearly this is a sign attached to the ideals of motherhood, but when that possibility actually occurs, it is remarkable how the speech with and about the baby is established.

So I speculate that motherhood can be a facilitator to support maternal function, although they are not synonymous, largely often are connected to the same agent of flesh and blood, but this is not an unconditional relationship. The Other in the maternal function is to perform mothering, but the other in the motherhood may not be the Other in the maternal function.

I am also mindful that a mother who, on the day of discharge of her baby, carrying the child in her arms and leaving the NICU in an interesting ritual where all the mothers come out of the rooms and applaud the parents and the baby who is leaving by a large door open only on this occasion, when she leaves, she says: "Now he is mine." Interesting to the ears of a psychoanalyst, revealing the effects of the absence of motherhood statement, i.e., in the care of Science, the baby didn’t belong to the mother.

Another mother with her child admitted in NICU for monitoring of clinical outcome, without appliances, presented a picture of colitis. As we talked she is thrilled and says, "I have not caught him in my lap. .. I can only touch him through those two holes. .." [referring to the holes in the incubator].

Those speeches rang me too significant for the moment a mother sees her child as a result of medicine.

However, the speech of mothers, despite the premature birth and neonatal ICU that showed greater or lesser distance and interfered with the exercise of mothering the way that mothers would like to use it, I noticed that this experience does not seem to have produced effects of disinvestment in the baby and have not caused so far as my observations were made, obstacles in the conditions to sustain the function of another. Obviously, the exercise of this function will undergo other vicissitudes that come with life and nothing of generalizing can be postulated.

I cannot say how much of this work of psychoanalytic listening of that suffering may have had effect for these mothers, but I assume (the receptivity of mothers, especially in the post-discharge) that speaking about this suffering could be, at least, the establishment of a symbolic narrative that situates the subject in its history and, in this sense, is not imprisoning, static, unchanging, but, instead, full of surprises, moves, changes, such as the hospital discharge of their children.

As stated in the final considerations, the difficulty of mothering that caught my attention for the suffering caused in mothers reveals that there is no determinism between this difficulty and the exercise of the maternal role. The difficulty of mothering in the ICU presents in the beginning, an obstacle, a barrier to the Other that cannot deliver herself to a boundless joy with her newborn.

As contributions, I think that this work points to the importance of psychoanalytic listening in the hospital and specifically within a Neonatal ICU, both which can contribute to parental distress to be put into words in order to create symbolization of the missing meeting, as to the stoppage before the impact of events in the ICU take place to the time to understand and the time to complete.

This psychic abandonment of parents can be heard, but I believe that interventions cannot be technical or in a sense that addresses them as a guide showing what should or should not be done. From what I heard from the mothers, the more a professional puts in to listen to them, the more they can unfold a narrative about this birth and their baby's position. Thus the speeches appear, sometimes with crying, sometimes with smiles and others loaning the words from the baby. I realized that, in many moments, it was in the absence of my words but in the presence of a differentiated listening that a function was performed, the function of helping to sustain the psychic elaboration of that event in those lives.

References

[1]   | BARRETO, C.P.O. Mothering and Maternal Role in NICU: A Psychoanalytic Study. 2011 203F. Dissertation in Clinical Psychology - Center for Psychoanalysis - Pontifical Catholic University of São Paulo, São Paulo, 2011.
[2]   | LAPLANCHE, J.; PONTALIS, JB The Language of Psycho-analysis. 10 Ed. Trad. Pedro Tamen. São Paulo: Martins Fontes, 1988, 356.
[3]   | ZIMERMAN, D.E. Vocabulário Contemporâneo de Psicanálise. (Vocabulary of Contemporary Psychoanalysis) Porto Alegre: Artmed Ed., 2001. 263
[4]   | LACAN, J. (1969-1970). The seminar. Book 17: The Other Side of Psychoanalysis. Brazilian version of Ari Roitman. Rio de Janeiro: Jorge Zahar Editor, 1992, 105.
[5]   | LACAN, J. (1969). Note on the child. In: Other writings. Translation. Vera Ribeiro. Rio de Janeiro: Jorge Zahar Editor, 2003, 369.
[6]   | FREUD, S. (1914). On narcissism: an introduction. In: FREUD, S. Brazilian the Complete Psychological Works of Sigmund Freud Standard Edition. Translation. under the general direction of Jayme Solomon. Rio de Janeiro: Imago, 1974, 108, v. XIV.
[7]   | ROUDINESCO, E.; PLON, M. Dictionary of Psychoanalysis. Trad. Vera and Lucy Ribeiro Magalhães. Rio de Janeiro: Jorge Zahar Editor, 1998, 558-560.
[8]   | JERUSALINSKY, A. N. Autism Psychoanalysis. Porto Alegre, Medical Arts, 1984, 12.

[9]  
It is noteworthy that, after discharge, I visited two more times the mothers and their babies and conducted interviews with the intention of observing the mother-infant relationship and the conditions for the exercise of the maternal function could or could not be performed, taking into account that the established (or not) exchanges are revealing in those conditions.

[10]  
Research funded by the Ministry of Health, the National Council for Scientific and Technological Development (CNPq), by the Foundation for Research Support of the State of São Paulo (FAPESP) and conducted by IPUSP, with the researchers responsible: Maria Cristina Machado Kupfer, Sandra Josefina Grisi, Mario Eduardo Costa and Leandro Pereira of Lajonquière. In: Kupfer, M.C.M.; PINTO; F.S.C.M. (Eds.). Place of Life, twenty years later: exercise therapy education. São Paulo: Listening / FAPESP, 2010, 14.

[11]   | Group of psychoanalysts coordinated by Prof. Dr. psychoanalysts. Kupfer Maria Cristina Machado, Institute of Psychology, University of São Paulo. In: LERNER, R, Kupfer, M.C.M. (Eds.). Psychoanalysis with children: clinical and research settings. São Paulo: Listening, 2008, 9.
[12]   | SPITZ, A. R. (1965). The first year of life. Trad. Erothildes Millan Barros da Rocha. 2.ed. São Paulo: Martins Fontes, 1998.
[13]   | BOWLBY, J. (1969). Attachment and loss: Attachment. Trad. Alvaro Cabral. 3 ed. São Paulo: Martins Fontes, 2002 v.1.
[14]   | BRAZELTON, T. B. On Becoming a Family: The Growth of Attachment. Translation Dayse Batista. Porto Alegre: Medical Arts, 1988.
[15]   | KLAUS, M.S.; KENELL JH Parent / Infant Bonding. Translation. Daise Baptist. Porto Alegre: Medical Arts, 1992.
[16]   | DOLTO, F. (1994). Everything is language. Trad. Luciano Machado. São Paulo: Martins Fontes, 1999.
[17]   | SZEJER, M. Words to be born: a psychoanalytic listening in motherhood. Translation Claudia Berliner. São Paulo: Casa do Psicólogo, 1999, 59.
[18]   | FREUD, S. (1891). The interpretation of aphasia: a critical study. Translation. António Pinto Ribeiro. Marsilio Editora, 1977.
[19]   | FREUD, S. (1895). Op. cit., 421-422.
[20]   | Idem. (1905). Ibidem, 229-230.
[21]   | The sexual term appears here with the sense that Freud attributes to sexuality, i.e. sexual drive or libido. Therefore, sexuality is taken in a broad sense, not limited to procreative purpose and neither the genital.
[22]   | LACAN, J. (1957-1958). The Seminar. Book V: The formations of the unconscious. Trad. Vera Ribeiro. Rio de Janeiro: Jorge Zahar Ed, 1999,195.
[23]   | AULAGNIER, P. (1975). The violence of interpretation: from pictogram to statement. Trad. Maria Clara Pellegrino. Rio de Janeiro: Imago, 1979, 33.