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Sent Before My Time: A Child Psychotherapist’s view of Life on a Neonatal Intensive Care Unit by Margaret Cohen published by Karnac Books and reviewed by Kelly Noel-Smith.

This book is part of the Tavistock Clinic series.  The series looks to bring the results of clinical, theoretical and research work to a wider audience.  Margaret Cohen, author of Sent Before My Time, trained as a child psychotherapist at the Tavistock and now works in the neonatal intensive care unit of a large London hospital.  Her book brings to light the profound trauma of premature birth for the baby, the parents and the hospital staff.  She is aware of the painfully emotional impact of her book but shows why the pain is both necessary and worthwhile:

The babies’ experience is so hard for us to imagine, and it is so much easier for us not to imagine it, because it is often painful, but if we dismantle our ability to think, this affects the way we think about each other and our patients. Our ethical frameworks often turn out to be inadequate, and we have painfully to rethink our values(Cohen, p. xxii)

Cohen’s elaborate description of the locked unit, with hand-drawn diagrams and photographs of the babies and their attachments, reveals a harsh, clattering, overlit environment.  There are three nurseries within the unit.  The babies, if they make progress, move from the intensive care nursery (the ‘hot’ nursery) through the intermediate, high dependency nursery to the ‘cool’ nursery.  In the hot nursery, babies lie in Perspex incubators surrounded by infusion pumps, ultraviolet lights, monitors and ventilators.  They are attached by tubes and monitor-leads to the machines which feed them, breathe for them and monitor their hearts and breathing.  In the intermediate nursery, the care is less intensive although the babies’ heads are often surrounded by Perspex head-boxes to conserve their oxygen supply and they are fed nasogastrically.   In the cool nursery, the babies:

…may be “in air” – that is, breathing naturally – or they may be “in a trickle of oxygen”.  It seems that many preterm babies find it very hard to give up this trickle of oxygen and to breathe unaided, and this is often an obstacle to their going home. (p. 6)

The babies clinging on to their trickle of oxygen brought to my mind experiments carried out on monkeys in the late 1950’s to study the effects of maternal deprivation (Harlow and Zimmerman, 1959).   Baby Rhesus monkeys were separated from their mothers and provided with two surrogate structures: a wire ‘mother’; and a soft cloth-covered ‘mother’.  Half the infants were provided with milk from the wire mother, the other half from the cloth mother.  Regardless of which one fed them, all of the baby monkeys clung to the cloth mother for comfort: they used it as a safe base from which to explore a new cage and would pathetically seek comfort from it when frightened by a mechanical toy.  The babies in the neonatal intensive care unit seem to need their trickle of oxygen in a similar way to the monkeys needing their cloth mother: in their very unsettled and maternally deprived world, there may be something comforting and constant, even soft, about the oxygen trickle which makes it difficult for these premature babies to relinquish it and breathe for themselves.

The high levels of oxygen pre-term babies require to breathe causes retinal damage which can lead to blindness.  Sight, insight, and loss of both, are themes which Cohen explores and develops throughout her book.  She wonders whether babies, in destroying their vision by growing cysts on their eyes, have had to sever their links with the outside world which has grown too painful to bear.  She articulates the experience of the laser treatment to remove the cysts in terms of a searing counter-attack by the outside world from which the baby is already trying to withdraw.  Cohen’s observations reveal that staff and parents, too, sometimes cannot bear to see what is going on and we learn of doctors who cover babies before trying to get a line into a limb, so that they cannot see the distress that they are causing, and of parents who avoid visiting. 

Cohen’s observations of ‘Daniel’ and ‘Lucy’, premature twins born thirteen weeks early, illustrate how easily insight can be lost.  Cohen observes Daniel’s mother talking to someone next to his incubator.   She ignores Daniel who is screaming and writhing as a doctor tries and fails to take blood from his right hand.  Eventually, Daniel’s mother turns to him but then decides to change his nappy before giving him a cuddle.  A nurse arrives to give Daniel eye drops in advance of a test he is to have later that day for blindness.  The nurse prises Daniel’s eyes open whilst Daniel continues to scream, all the time looking at his mother who is still not holding her crying child.  The nurse asks Daniel’s mother to help but she says can only after she has changed Daniel’s nappy and washed her hands.  Whilst the mother is away, washing her hands, the nurse, at Cohen’s request, puts in the eye drops quickly.  Cohen’s analysis follows the observation:

It did seem in this observation as if there was a terrible attack on seeing and on insight.  Daniel’s mother seemed to find it unbearable to see him in such a bad state, so she undermined her insight into his state of mind.  As I watched the drama unfold, I felt full of a dreadful urgency and had a searing headache for the rest of the day. Daniel had stared into his mother’s eyes, feeling perhaps that he was making little impact with his screaming, and perhaps he then felt attacked by these drops forced into his eyes.  Over all this hung the dreadful, but unacknowledged, prospect of the eye test that afternoon, to see whether Daniel had any retinal damage, an iatrogenic hazard of prematurity. (p. 42)

Developing the themes of sight and insight, Cohen differentiates between the rational and necessarily practical perspective of the medical practitioner and the psychotherapist’s perspective which includes awareness of the ‘non-rational, the imaginative, fantasy, and the insane’.   Sometimes the two perspectives collide, leading to an institutional denigration of Cohen’s work: some doctors believe that babies’ movements are involuntary, pseudo-movements generated by an immature nervous system and so Cohen’s observation of the babies is deluded; some nurses idealise or become angry about the choice of baby being observed.  Cohen discusses the strain put on her own internal world by these external and her own internal accusations of delusion:

And it is not just out there – inside I feel that perhaps I am deluded, or that I need some learned authoritative guide, internal or external, to interpret for me what is going on.  I find myself in the middle of the philosophical debate about consciousness.  Is there consciousness behind these movements, am I searching for a world of meaning which is not there, am I putting questions that are pseudo-questions?  I cling to my intuition that these babies have their own consciousness and legitimate experience and to my psychoanalytic belief that we as adults carry our infantile experience inside us and that the terrors accompanying this are what hinder us from entering more imaginatively into the babies’ experience.  I think the apprehension of these babies sometimes unheld 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 support. (p. 20)

Cohen’s internal world seems to stand up to these strains, presumably because the philosophical and psychoanalytic support for which she is casting around comes from within, from her psychoanalytically-informed belief system.  This book is not a textbook on Kleinian psychoanalysis but it is clear that Cohen, who trained at the Tavistock, operates within the Kleinian tradition.  Klein’s model is explained by Cohen in terms of integrity and respect for others.  Cohen’s stance is that we often deny the independent humanity of those we depend on – first, our mother – because to do so makes us aware of our vulnerability to abandonment.  Our recognition of others’ independence obliges us to undertake the difficult task of recalling from them our projections of fear and impotence and to seek containment from our own resources.   Undertaking this difficult task leads to respect for others’ separateness and allows their pain, suffering and other emotions to have an impact on us.  In this context, Cohen helpfully records her own feelings of pain resulting from the observations.  She wonders whether her habit of taking notes during her observations is a means of distancing herself from the raw and painful quality of the observed baby’s experience.  Indeed, she introduces her observations of Daniel and Lucy by acknowledging that part of the reason behind her choice to observe these babies was their relatively hopeful prospects: she felt overwhelmed by the pain of some of the other babies and their mothers she had observed.  Cohen’s honesty about her own feelings fits comfortably with, and lends strength to, her compassionate accounts of what she observes. 
Cohen’s observations are of a very different quality from the more usual sort which tend to be of a mother and a baby, with the observer negotiating a particular type of access to the observed baby through the baby’s parents.  Winnicott wrote: ‘There is no such thing as a baby – meaning that that if you set out to describe a baby, you will find you are describing a baby and someone.  A baby cannot exist alone but is essentially part of a relationship.” (Winnicott, p. 88)   Usually, the ‘someone’ is the mother, the essential counterpart of the nursing dyad.   In the unit, the absence of the mother, who, for the most part, is unable to hold or feed her very premature baby but can instead only visit, is experienced as a vacuum.  The following extract forcefully illustrates the absence of a baby’s mother.   It shows Lucy, Daniel’s twin sister, interrupted in an attempt to make sense of her world:

I went to watch Lucy.  She seemed to be concentrating very hard on bringing her hand to her mouth.  She brought her thumb to her forehead and then away, and then back, all the time mouthing.  Her eyes, too, were searching.  Lucy went on doing this with great attention.  She brought her hand to her open mouth and smiled.  I was very absorbed in her work.  Then a doctor came to take blood.  She apologised to Lucy as she did so.  When it was over, Lucy put her hand up against her nose; her eyes were closed and she was very still.  Later her eyes opened, but they were no longer focused.  She looked red and bloated.  Her hand came near her face, her eyes opened and her hands moved rather shakily.  She was less sure of her movements.  She had been assaulted and arrested in her purposeful activity. (p. 32)

 Lucy’s mother is not there to hold Lucy, to negotiate the doctor’s assault or to help Lucy process the pain: there is a powerfully present sense of the absence of a mother as container, protector and giver of meaning.  Cohen articulates this experience in terms of it activating our worst nightmares in which we are exposed to extreme pain and frustration in the absence of a powerful and benign mother who can mediate these experiences for us.  

When the twins eventually leave hospital, the mother breast-feeds Daniel but not Lucy.  Cohen visits the family at home and learns that Lucy sleeps with her paternal grandmother, who has come to stay and who bottle-feeds Lucy.  Daniel sleeps in his parents’ bed so that his mother can more easily feed him.   It would be easy to feel resentment towards the mother for seemingly favouring Daniel over Lucy but Cohen’s gentle handling of the descriptions of the family dynamics creates the space to consider the impact on the mother of what has taken place. 

Cohen reflects that babies stir up feelings in all of us: about babies we have had; babies we have not had; babies that have died; the type of babying we had; and the type of babying we would have liked to have had.  What is common to most of us is that we would not want to be these babies and these mothers.  Cohen shows that deeper feelings underlie the parents’ often effusive thanks for the staff’s work on the unit which sometimes explode through into abusive attacks on the staff.   The work on the unit is essentially about integrity and respect, to try ‘in such a traumatic environment to treat babies as human beings, mothers as proper mothers, and families as the true environment of the baby; to help staff to treat each other with respect, and the families who are in great pain, to treat the staff with respect. (p54) 

Cohen includes an informed and enlightening chapter which uses Renaissance artists’ depictions of the Virgin Mary to explore the impact of pregnancy and motherhood on women and the close interrelationship of birth and death, nurturance and murderousness.  In this chapter, Cohen reflects on issues that affect all mothers:

One of the most difficult and painful tasks for a mother is to recognise her own murderous feelings towards this creature, who is also often the most precious thing in the world to her.  In our culture we are very bad at helping mothers with all of this.  Advertising continually bombards us with idealised and sentimentalised pictures of motherhood – images that give no idea of the enormous mental work that is involved in mothering. (p99)

A reassuring and beautiful representation of the type of support needed by new mothers is provided, Cohen suggests, by Leonardo da Vinci’s cartoon, The Virgin and Child, with Saint Anne and Saint John the Baptist (National Gallery, London).  This depicts Mary holding Christ on her lap with the infant St John at her knee.  Mary is sitting on her mother’s own lap and St Anne is smiling gently at her daughter.  Cohen suggests St Anne represents the good mothering that new mothers need: ‘support, love, flexibility and the ability to subordinate one’s ego to the needs of one’s daughter’.  It is of note that Freud also uses this cartoon to illustrate his discussion of Leonardo’s narcissism:  Freud suggests that Leonardo’s brushwork merges his step-mother (represented by Mary) into his real mother (represented by St Anne), from whom he was taken away aged five.  Freud suggests that Leonardo identified with this composite mother-figure to love boys in the way that his real mother loved him as a child (Freud, 1910).   Despite their different interpretations of the painting, both Freud and Cohen see, I think, St Anne as representative of the primary source of good mothering suggesting that, to be a good enough mother means drawing on an experience of having been mothered well enough oneself.

Cohen suggests that the staff in the unit need this type of ‘motherly’ support and usually do not receive enough of it.  Her observations show that, when they can reflect on their own feelings brought about by interaction with the babies and their parents, the staff are better able to process the feelings stirred up by, for example, babies whose disability is such that questions arise as to how ethical is prolongation of their life.  At weekly psychosocial meetings, held to discuss these and other highly-charged ethical issues, Cohen notes with pride how the staff struggle to recognise each other’s viewpoints, to contain feelings of persecution and to maintain respect for one another.  At one meeting, we see junior doctors talk honestly about how they sometimes feel persecuted by the babies they find difficult to treat, feel hatred for them and fear of their hatred.  The following extract from one of Cohen’s observations illustrates this hatred in what Cohen describes as a ‘harrowing’ struggle for respect.  ‘Jane’, a Senior House Officer (‘SHO’), has failed four times to insert a long line into ‘John’, a very small premature baby.  A radio is playing.  Cohen has described John’s face as twisted in agony and his mouth open in a terrible noiseless scream:
As I looked at them, I did not know which one I felt more sorry for – they both seemed so desperate.  Again John was writhing as she held his arm and screamed when the needle went in.  Another SHO came in and said, “Oh Jane, can’t you get it in?”  She said that she could not, went on trying, and then gave up.  She looked at the baby and said, “You horrible little thing”.  I said that I thought that she must be feeling angry by now – she said that it was awful, that it made you hate the baby.  Anthony, the other SHO, came over, and she said that she could put the baby through a mincer.  He said that he would hold the light for her, and she tried again – this time John was screaming continuously.  The two of them pored over him – Jane was whistling softly to the music. I began to feel quite sick.  I wondered why people care so much about torture and yet allow this to go on.  Jane failed again – and got up.  Anthony took her place.  He said something quite kindly about the little fellow and then added he was misbehaving.  Anthony set to: at one point he moved in rhythm with the music.  He relentlessly continued while John writhed and screamed.  Eventually he got it in.  He looked up triumphantly and jigged around in his seat to the music.  He said that he should always play this music when he was trying to get in a long line. (pp 61, 62)

Cohen never ignores the reality of the impact of politics on the unit.  She acknowledges the hierarchy within medicine which makes it difficult for junior doctors to challenge the status quo and ask for support to help deal with their experience of work with seriously ill babies.  She discusses these internal politics in context.  She also explores the wider political and social issues which have led to years of under-funding for the unit which often contains the babies of refugees, prostitutes, drug addicts and prisoners.  I learned painfully that babies born to addicts go through many weeks of agonizing withdrawal; that women prisoners can be shackled to their (sometimes male) warders in labour; that most prisons only allow mothers to stay with their babies for a limited time.  I read sadly of an initially secure baby sinking into depression as his imprisoned mother began to withdraw from him in preparation for their imposed separation once the baby reached 18 months.  Cohen provides thoughtful and well-written accounts and reflections on these harrowing issues.

One criticism.  The book assumes (and deserves) a wide readership.  Cohen provides a glossary of terms for the non-medical reader (most of the terms are easy ones anyway, for example: ‘brain scan’; ‘epidural’; and ‘reflux’).  Readers without a psychoanalytic background might benefit from a glossary of psychoanalytic terms to help them make sense of, for example, Cohen’s use of the language of psychoanalysis, of projection, containment, disintegration and the death instinct.  But this is a small criticism.

Cohen’s sensitive accounts are painful to read and thinking about the experience of premature babies and those who care from them is difficult.  Cohen’s book shows why this painful type of thinking is necessary and how the presence of a child psychotherapist in the Unit who maintains her insight can help the babies, the staff and the babies’ parents.  The babies, the nurses tell her, like to be observed by Cohen.  The staff, if more aware of their own feelings of abandonment and disintegration, brought about by being part of the babies’ raw and painful experience, are then better able to mediate for the babies whose mothers are unable to take on this role whilst the babies are in intensive care.  And the parents, seeing the determination of the observer to continue her observations, to hold their babies in her mind and with her eyes, grow in confidence: they become empowered to develop their own parental interpretative function, to become their babies’ protectors and mediators, both in hospital and, in some cases, on eventually going home.

Cohen, M. (2003) Sent Before My Time: A Child Psychotherapist’s view of Life on a Neonatal Intensive Care Unit, H. Karnac (Books) Ltd: London

Freud, S. (1910) Leonardo da Vinci and a Memory of his Childhood,  vol. 11. The Penguin Freud Library, Penguin Books: Harmondsworth

Harlow and Zimmerman (1959) discussed at p.651 of Richard Gross’ Psychology: The Science of Mind and Behaviour, (1999) 2nd edition, Hodder and Stoughton: London



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