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Admission of "mother/baby" couple to a department of general psychiatry

Par Rajablat M., Digonnet E., Louesdon J., Deslandes C., Dauphin G., Duplouich R., Le Priol B., Helmany N., Hittinger M., M.C. Lehene

Translated from French by Mrs Tina Hill.

The CATEB is a rest and care unit, situated in Paris, open day and night and offering short- time hospitalization (not more than 7 days).
This center was set-up to welcome adults suffering from psychiatric disorders and, thus, was not initially specialized in the care of mothers and their children.

Today, this center has merged with a second unit and functions rather differently. Presently, few care units offer the possibility to admit both young mothers and their babies within short notice. Consequently, the CATEB is fulfilling a long existing need. In most cases, medical units such as the CMP (medical and psychological out-patients departments), the CPOA (first aid psychiatric departments), SOS médecin (a 24 hour medical service), Mother and Child Protection units and local District units for child psychiatry or maternity hospitals, appeal to the CATEB as "a place of transit during the pathological trip represented by the depressive or psychotic episode which may emerge after the post-partum".

Though the young mothers that are welcomed with their babies are suffering from acute crisis, their psychological state does enable them to comprehend all the elements existing within the frame and the necessity of their hospitalization.

This means that we are rarely faced with emergency admittance, and seldom fear bursts of acting-out through the mother's self or projected aggression. Most often, admittance takes place within 24 to 72 hours after a first report.

Many an author has written about the short or long-term danger, for the child resulting from the presence of a psychotic mother, as well as about the devastating effects of a precocious separation. In his article: "Mother and child in post-partum psychosis", Racamier writes that "on the therapeutic level, it is necessary and very efficient to act upon the relationship between mother and child …it is not sufficient to only offer active support. One must carefully accommodate within its external and internal aspects, the relation of the mother to her child… and for this, the child needs to be present".

The hospitalization offered by the CATEB represents a transitional space/time unit allowing us to assess the quality of the mother/child relationship, after which they either return home, or are directed to a specific care unit concentrating on longer observation and treatment of mother/baby contact.

The case of Mrs Chahine will help us study the role of the nursing staff in the care of mother and baby.

She was sent to us alone, coming from the emergency ward of a big hospital in Paris. She had given birth a month and a half before to a little boy: Maximin. Her speech was very depressive, melancholy, sometimes even delirious. She explained that since the birth, she was "out of sync", was afraid of not knowing how to look after her child, fearing that she might be violent towards him. She was particularly frightened that she might throw him out the window and to avoid this, she lived with her shutters closed.

Her child was in the care of her husband's sister, as he had deserted their home for his job as she put it. Mrs Chahine was overwhelmed by her anxieties and her phobias of compulsion and felt isolated in facing her new responsibilities. Since the birth, she had stayed at home on her own, had not seen anybody and had not done anything.

Yet she could not stand being separated from her child. The day after her admittance we went to collect her son with her, so that they could be hospitalized together at the CATEB.

The first days were a time of observation and getting to know one another. Maximin was a beautiful big baby, quiet and smiling, interested in all that was going on around him. On the other hand, Mrs Chahine was very unstable. She came forward with a thousand projects for herself, for her child, she was restless and wouldn't stop talking. She was very happy to have her baby back, covered him with kisses, embraced him, shook him while telling us that she loved him and would be prepared to die for him. All at once, she verbalized her fears of being a bad mother and also rid herself of having to face such thoughts all day long.

As for every mother/baby hospitalization, the arrival of a baby in the unit was cause for great excitement, as much as for the practical organization of baby care (preparing the crib, the bottles, the nappies) as for the feelings side of carers and cared-for (awakening emotions in the mothers and fathers that we were or were not). Were we not, at a lesser degree, the reflection of the drastic change brought on by the arrival of any new born on this earth?

While we hesitated about a clear diagnosis, we were sure that she was indeed going through an identity crisis: hormonal disturbances, the questioning of her very existence, the search of a role, she was overwhelmed by massive mood switches, rapid changes in the representations she had of herself, fearful of her new responsibilities. And this constant obsession: "I am always afraid of throwing my son out of the window. I am attracted to windows. One day I won't be able to control myself, it will be too late. I am completely crazy, I am not like before".

She was excessively sensitive, exhausted, ready to burst, on the borderline of psychotic disintegration.

The combined hospitalization of mothers and child was first set-up to meet psychological disorders of the mother, be it a depressive episode or a psychotic decompensation and is often associated with psychotropic drug-treatment.

The sole presence of the baby is not therapeutic. We observed Mrs Chahine looking after her baby. With the exception of a few mistakes due to lack of habit, she did know how to take care of it. However, she was sometimes quite clumsy and feared that she might hit the baby against the wall or let him fall (it never happened). As the days went on, we either "did instead of her", "did with her" or "let her do". It was necessary to "do instead of her" when she was submerged by her anxieties and when this affected her behaviour (her clumsy gestures for example).

During these moments, the aggressivity initially directed at the child was received by the nurse and could therefore be verbalized. "To do with" enabled the confused young mother to learn the gestures that - whatever one may say - are not natural and must be taught. The nurses who where mothers told her about their mummy-worries. This "chatting" enabled us to transmit to her all that women must tell each other about children.

For Mrs Chahine, some steps had been neglected, she had given birth alone, without the presence of her family, whereas normally, in the tradition of the Maghreb, women rest seven days after the birth and do not look after the child. "During this period, the mother is brought food to reconstitute her lost strength". The women of the family and particularly the other mothers care for the child, revealing the secrets to be shared by all mothers. Our young patient had missed out on these rites of initiation.

Sometimes the youngest of us tried desperately to teach her some techniques: the sterilizing of milk bottles for example. A young nurse tried to teach her to use the pincers to remove a bottle from boiling water, or how to test the temperature of the milk on the back of her hand.

Mrs Chahine sent pincers and aseptic measures flying and brought the bottle to her mouth to test the warmth of the liquid on her own tongue. Common sense and memory of her mother's gestures won over our techniques. One doesn't put anything, in any way in the mouth of one's child! We would laugh with her. She was no longer then the "bad mother" deprived of "maternal instinct". She was discovering the goodness she could give to her baby. Mrs Chahine said she found no pleasure in bathing Maximin, though she realized more and more that the delighted smiles, the babbling that he addressed to her were evidence that she was able to give love, that he accepted it and gave it back.

We followed her patiently, enhanced and gave meaning to each of her gestures. We tried to re-link mother and child. We tried to arouse in her and in her child the pleasure in giving and receiving. We touched Maximin with her, without her, and then let her touch him alone. We spoke alternatively to the baby, to both of them; we encouraged the mother to speak to her child. We were never short of compliments for her son, the sweetest and brightest baby we had ever seen, and we had seen many. Little by little, she took over from our care, our advice, her baby, and eventually we let her care for him on her own. She progressively organized her own way of looking after the baby, took more and more initiative, pleasure and assurance in it.

The young woman had become calmer. She let herself be approached and began to confide in us: she had been a rebellious and pugnacious young woman. She was living in the provinces with all her family when she met her future husband. Of Algerian origin, her parents opposed her marriage to an "African". She took no need of her father's prohibition, got married and followed her husband to Paris. She told us how she had fought to find a job and a small flat. They were both rootless, so she had put all her energy into building an island of happiness, against all odds. Presently, Mrs Chahine had become bitter, her beginnings in an adult life had been too brutal; she had deluded herself.

"I love my husband, I dreamt of something beautiful, I believed him when he told me that he would never leave me, that we would be happy together…" Her husband worked a lot. No doubt, the arrival of the baby had also been difficult for him. If his wife had no choice and had to take care of the baby, he could flee to his friends in order to avoid her complaints and he paid little attention to her state.

Moreover, Mrs Chahine could expect only little help from her family. She had hidden her pregnancy from her parents and sisters. All mothers, they didn't understand what was happening to her. She had no quite come out of adolescence and none of the women of the clan could help her, at that moment, to become a mother.

"The maternal situation revives the experiences belonging to the oral phase. The mother of the child is at the same time the child of her own mother. Her infantile experiences of satisfaction and frustration, of love and devouring aggressivity have made up the complementary images of loving, loved and good mother, and of the loved, loving, and good child - and the contrasting images of the with holding mother, attacked or threatening, and of the destructive, bad, and threatened child. These images are appealed to, pushed away, re- appropriated and altered like stones by the sea, at the mercy of instinctual waves, and are projected on the representation that the mother has of herself, of the mother she is and of the child she has."

She couldn't stand her child crying. "It's too sad, I'm afraid of crying with him". She was worried if he slept too much, fearing that he might be dead. She was terrified if he appeared to have the slightest cold or fever. We had to help her spot the signs of well-being in her child.

That is to teach her how to avoid waking him at all times, but instead to watch him sleep, to listen to the rhythm of his breathing, to put her hand on his chest to feel it raising. We taught her the signs and the means to prevent a cold, otistis, teething, and diarrhoea…

We always encouraged her thousand questions. Eventually, we let her speak about her compulsive phobia of throwing her baby out the window. She then told us that, at the age of ten, she had seen a little girl fall from a window. Before the birth of Maximin, she, herself had feared going through a window, and at the birth of her son, she had transfered her fear onto him.

Later she continued to be overwhelmed by this "vision" and long after her stay at the CATEB, she would suddenly turn up to tell us how, not finding her child in her apartment (her sister had taken him for a walk while she was asleep) she thought she might have throw him out the window.

At this stage of her stay, she felt reassured about her abilities to take care of her child. The need remained for us to help her find some distance to her child and convince her to accept some care for herself. She wasn't convinced about this. However, though we had worried a lot, could we only allow ourselves to speak in terms of psychopathology? The question remains open.

Of course, a short hospitalization would not be enough to resolve the enigma. We could only begin to care for the daily needs and lay the foundations for a longer follow-up if she felt the need for it. We thus started to talk about her departure and possibility of help at home: a nursery nurse as long as she felt like it her, visits to the Mother and Child Protection unit for the baby and to out-patients department for herself.

Nurse is a term we use to define and speak about our nursing staff -women and men-. Is our function so undifferentiated? Obviously not. The technical gestures, the competences are identical, but the relationships are different.

We haven't spoken much of fathers here. In many cases, he was at best, a discreet man, at worse, an absent man, understating the difficulties of his wife.

In the case of Mrs Chahine, as we observed it, the father was at the center of all conflicts. She didn't forgive her husband for the break-up with her family that their marriage had caused. He was presented as having deserted the family in order to spend excessive time in his job.

The nurse appeared then as the ideal father for her son: "If only my husband knew how to look after Maximin as you do". Full of patience, he knew how to handle the aggressivity of the mother, relieving her of her child by providing care for him. Attentive to his well-being, he also appeared to be full of attention for the mother: "Your wife is so lucky to have you". In order to save himself from the mother's gratitude, the male nurse hid behind his function, his technical competence in order to avoid a transference, which the short stay of the patient would not allow to be fully carried through.

The nurse, as a third party, tried to give back to the father of the baby a specific role by talking about him, by underlining his existence: he is the real father, out of a carnal relationship with him came this child. Mrs Chahine benefitted fully from the first half of her hospitalization.

The second half was marked by the conflict, which ensued with her husband. (The father was present!) Though we had often asked to meet him, he remained suspicious as to our methods, surprised about our worry for his wife who was only according to him a little tired. It was obvious that our references were not his.

Let us not forget that in his tradition, the presence of women after the birth was on a par with an abstemious and remote husband. And had we not, as carers, replaced all the mothers? The best evidence of this was provided by the fact that after her hospitalization, Mrs Chahine mended the relations that she had cut off earlier with her sisters and her mother.

She went to stay with her older sister took over the baby and provided her with some advice. Some things may have come back into order. For the time being, she was caught between her loyalty to her husband and her loyalty to us, between her wish to be a child (to be cherished, cared for, helped) and her wish to be a mother (to cherish, to care, to help). She chose to go back to her husband.

We kept lively contact with her. She was not "left on her own". It was agreed that she would come and visit us regularly for a nursing follow-up -medically prescrived- with Maximin. As soon as came in to care with his mother, Maximin was given an "impossible mission", to care for his mother: "I must get better for him".

When she left, she stopped her treatment. When new morbid ideas against her son began to overwhelm her, we had to report to the Children's Magistrate. It is thus with facing a new risk of separation of the mother and the child that we advised Mrs Chahine on the necessity of personal therapy.

This work is the result of the reflections of nurses having worked at the CATEB. Many meetings led us to bring up this subject. It is deliberately built around the case of Mrs Chahine and therefore, does not show all the aspects of a mother/baby hospitalization. In many cases, the availability of the center, its prompt response, an emergency consultation constitute the beginning of a form of care that tends "to lower the pressure", to put the situation into perspective.

We are then only one part of the line of possible care and the work of the following interveners can be carried on in a more serene way.

We have only spoken very little of the mediating role of the nurse between the mother and her baby, between the mother and her husband. The nurse is also a third party present in the relation between the mother and the psychiatrist, somebody "permanent" in the line of care, enabling the mother to verbalise her emotions in a quieter way, during the meetings that punctuated her stay.

There remains a lot to be said on the role of the nurse in the "mother/baby" hospitalization in a general psychiatric department, but also about the interaction between all the other members of the team.