Les Bluets is an Avant-Garde Parisian maternity hospital, well-known since the 1950s when, founder Fernand Lamaze, eminent gynecologist and obstetrician, first introduced the idea of the mother’s active role in her pregnancy and labor, implemented training classes for “painless” labor and birth, while inviting the future father to stand by his wife during labor. At Les Bluets, the staff remains faithful to this innovative spirit and continues to face contemporary challenges (such as medically assisted procreation, the accompaniment of same-sex parents, single parents, couples of varying ethnic backgrounds, etc…) following Lamaze’s inventive path through creative research in various directions. Abandoned babies are one of these challenges the staff at the hospital have been asked to cope with.
We wish here, to present the approach that have been developd for them, as a unique combination of the psychoanalitical approach to caregiving and the Late Hungarian pedatrician Emmi Pïkler ‘s outstanding developmental approach.
Babies born “sous X.”: Who are they?
Babies born “sous X,” are children born to women who have decided, already in the course of pregnancy, to give birth “anonymously” and to leave their newborn child for adoption. What role can/should the maternity clinic play for these mothers and infants during the first few days?
At Les Bluets, the staff has a dual goal and ambition : on the one hand, to offer a “holding”, supportive framework for the mother who is entrusting her child to the care of the State aiming at adoption and, on the other hand, to provide specialized care for the infant during the time he/she spends at the hospital. Our therapeutic approach focuses on the babies’ daily emotional experiences at the hospital, rather than on the abandonment itself. Nonetheless, the abandonment issue remains at the heart of our preoccupations and constitutes a fundamental question for us, in our approach to the mother. Heightened attention and sollicitude are urgent needs for these babies in their first moments of life, In order to facilitate an experience of the world as “friendly enough”, like a buffer against the strom-like experiencee of abandonement.
French medical circles no longer use the term “abandoned” when speaking of these newborns. The term in common use today is “an infant having been entrusted to the State with the aim of adoption.”. This semantic change conveys a new look at these newborns, focused on planning their future life, rather than focusing on the abandonement, on bienf “let down”. Since 2003, a French organization, the CADCO (Coordination des actions pour le droit à la connaissance des origines – Organization defending a person’s right to have access to his or her origines), has been attempting to reconcile the interests of three distinct parties : the child and his right to know his/her personal history; the biological mother and her right to privacy; and the adoptive parents and their right to security. The French law, although it evolves more slowly than other European countries laws, recommends a psychological accompaniment for abandoned infants.
We will present here the main components of the psychological accompaniment we have developd, inspired from the combination of our psychoanalitical training, and teachings of the Hungarian Emmi Pïkler pediatrician’s unique developmental approach.
The basic concepts of the Pikler-Loczy Institute Approach
Pediatricians and psychologists at the Pikler Institute have elaborated a model of adult-baby relationship within a professional framework, which differs considerably from the mother-infant relationship. Myriam David, a child psychiatrist and the 2004 winner of the Serge Lebovici award of the WAIMH, and Geneviève Appell, psychologist, met the staff of the Hungarian institute and published their findings in Loczy : an Unusual Approach to Mothering, in the 1970ese.
E. Pikler, through her systematic observation of infants, has taught us a receptive attitude which enables us to recognize and respect the newborn child’s potential in any encounter with them. This receptive attitude also allows us to preserve that potential so that a newborn baby can actively participate, at his/her level, in creating his/her own well-being even during the very first days of her life, even in the absence of the mother.
This unusual type of mothering, in a stable environment, that is empathetic but does not impinge on the child’s innate capacities, the warm but “professional” treatment, enables the child to create fundamental bonds, In spite of growing in a residential nursery. It also incites the professionals to develop a better understanding and reorganization of their own ideas of what is essential for the psychological construction of a healthy and competent individual.
The experience of the Loczy residential nursery has been validated by a longitudinal, catamnesic study carried out by the World Health Organization that showed no signs of emotional deprivation among these babies, nor signs of trauma-repeating behaviors. The study showed that 150 children, who had entered the Institute before the age of one year, and spent more than a year there, had social skills comparable to those of other children of their age group and, in the long term, were able to create a stable family life of their own.
Case studies that triggered the implementation of “Les Bluets” Program
The two following case studies show the suffering and dilemmas which led us to imagine a new framework for care. The adults – caregivers and parents – involved in the care of these infants found themselves inevitably dragged into the turbulence of fantasies, projections, and acting-out behaviors. I will not dwell here on the painful stories of the mothers, which mobilized the affects of the staff so intensely, but will rather concentrate on the conditions in which the care of these mothers and babies was initially put in place.
Miss G. and Betsa
Miss G. is a an illegal immigrant in a precarious situation. Her pregnancy is the result of sexual abuse. During the prenatal appointments, she persistently repeats her decision to entrust her baby to the care of the state for being adopted.
Betsa’s delivery is uneventful, at term. The baby, healthy, is immediately presented to her mother, who takes her in her arms, and then is taken to the nursery. Everything goes according to the plan which the staff has agreed upon beforehand. At that time at the hospital, in 2002, the collective attitude was to follow the mother’s movements of approach towards and withdrawl from the baby.
The definition of my job, as the psychologist in the team, is to accompany this mother and her infant in this confusing situation…
When I go to the nursery, I find Betsa in her mother’s arms; Miss G. is giving the baby her bottle. The baby’s brow is creased, her mouth is tense, and her eyes are crossed. I am observing a baby who seems distressed, disoriented in her mother’s arms and the mother is obviously at lost and suffering. I notice the closeness of the bond established between mother and baby and I am afraid that if their stay together at the hospital is prolonged the inevitable separation will be all the more painful and destructive for both of them. I learn that the night nurse in charge of the infant has encouraged the mother to hold the child close to her breast, skin to skin. Miss G is coming more and more regularly to care for her baby in the nursery.
It seems to me that mother and baby are caught in a vicious circle that needs to be broken: someone must remind them of the reality of the situation, talk about the initial project of separation while remaining open to the possibility that the situation might evolve at all times. I suggest that mother and baby come and have a talk with me together. The mother accepts. After taking a silent moment to get in tune with the pair, I explain to Betsa the gravity of the moment, and ask her mother if she can say anything to her baby about it. Miss G. sheds silent tears and, in a moment of intense emotion, tells her baby she loves her. She hugs the baby very tightly to her chest but, nonetheless, maintains her decision. She is violently torn. I take the two of them in my arms and I address Betsa and, through her, her mother, recreating the distinct space of their separate futures. Little by little, after a moment of unbearble emotion, the mother gains sufficent calm to leave Betsa in her crib and to return to her own room.
A short time later, the nurse describes Betsa as much calmer, more relaxed. I see Betsa’s face transformed by a new glow and vitality. The nurse manages to express the fact that she does not want Betsa to be picked up and held like a doll by every person on the staff who passes through the nursery.
The mother continues coming and going; she is having trouble leaving her daughter in the nurses’ care, as if she thinks that if she takes care of her baby while they are both at the hospital then “they will at least have that.” In the present situation, if the mother and child become any closer it will only add to their mutual suffering and I find it necessary to remind the mother that her desire to care for her daughter goes against her fundamental decision to abandon the baby. I suggest that from then on, Betsa drinks her bottle in the nurses’ arms.
On the third day, in order not to drag out the painful process of separation any longer than necessary, we ask the staff of the residential nursery to come and get Betsa as soon as they can. They do and Betsa’s departure reassures her mother who leaves the hospital on the same day. In this case, mother and baby felt ever more painfully torn apart because they were experiencing a haze of uncertainty mixed with the more or less unconscious caregivers’ wish to reunite them.
Mrs. M. and Boriska
The staff at the hospital meets Mrs M. only one week before delivery and is told about her decision to give up her baby for adoption. The pregnancy happened accidentely at a particularly chaotic time in this woman’s life, while she is living in a precarious social environment. The baby, a girl, was born healthy and is named “Boriska.” At that time, at “Les Bluets”, we started the routine to write all the staff’s observation about baby’s daily activities, emotional states and behaviors, during their stay at the hospital. Boriska’s notebook described how she likes her formula, the temperature, the speed with which she drinks, what time she has her bottles, her prefered positions during feeding, how she burps, etc…. We are highly attentive to the way she conveys her pleasure and displeasure, any tension, her sleeping/waking rythms, her ability to be consoled and her explorations.
Boriska has to stay at the hospital for 15 days while she waits for an opening at one of the state-run residential nurseries. The observations in Boriska’s notebook are very illustrative of the many pitfalls that caregivers come across while accompanying babies waiting to be adopted and their mothers, waiting for the separation.
During the first week, whenever Mrs M. makes a brief visit to the nursery, which she does often, but irregularly and for short bouts of time, the caregivers (midwives and nurses) suggest that she feed her baby, wait for her, and so does the baby. The team in fact persists in believing in the possibility of creating a bonding process between this mother and her infant, in spite of knowing she has given her for adoption.
Meanwhile, Boriska is described as ever more anxious and irritable, crying a lot and shaking, like a « small bundle of nerves.” At the end of the first week, Boriska’s attitude towards food is described as very “bizarre.” The mother’s behavior Is described as very ambivalent towards the baby, and problematic towards the staff. The father, on the other hand, takes care of his daughter, and his visits are becoming more and more regular; the mother’s attitude toward the father is very unstable : some days she allows him to approach the baby, other times, she refuses.
During the second week, some quieter moments are observed, but also of times when Boriska swallows her milk like a “drug addict “. Little by little, we note that a dysfunctional routine has set in, despite our efforts, due to Mrs M.’s erratic comings and goings as well as those of the staff. Most often, when Mrs M. comes for one of her lightening-speed visits, she leaves Boriska crying and in a painful state of excitation. The “holes” in the continum of the baby’s care routine are reflected In the baby’s behavior.
Further on, strong countertransferential can be detected through reading the notes left by caregivers. For example: “I brought you some clothes and stuffed animals…I carried you with me all day long wrapped in a carrying scarf.” One of the midwives has developd a symbiotic relationship with Boriska. The number of people caring for the baby mulitplies: osteopath, pediatrican, trainee nurses and nurses aids, etc. Incapable of envisioning a coherent future for this child, the staff, filled with pity, cares for her in a succession of acts and gestures aimed at comforting her and at dissipating their own feelings of confusion and disarray. Boriska remains tense and stiff while she drinks her milk, and wants to be held incessantly. Several of the midwives indeed carry her constantly, wrapped tightly to their bossom as they go about their daily activities. Alone in her crib, Boriska is agitated and screams; she becomes ever more disorganized and difficult to console.
Finally, after fifteen days, an opening at the state-run nursery becomes available for Boriska. One of the nurse-aids comes to meet the baby at Les Bluets before her final departure for the nursery. When she does leave, the caregivers at the hospital are filled with a sense of emptiness and loss.
This case illustrates the well-too common situation where, in spite of their good will, the team, torn by their strong countertransferential feelings, could not provide the baby a coherent, reliable, and stable setting, based on attention and respect for her own needs and pace. Consequently, Boriska was not able to peceive herself as an active partner in the daily caregiving interactions, nor to develop a sense of self.
Discussion
The two case studies above, triggered our thinking about the uniqueness of the abandonment situation, because of the intensity of the reactions they had evoked, in the baby, the mother, and the team altogether. It made us realize how the absence of a solid professional framework within which the staff can care for these patients, leaves them to face, alone, their projections and impulses. This, in itself, leads to disorganization at the three levels (the baby, the parent, and the team), with possible detrimental long term effects on the baby’s own development and the mother’s future functioning.
As a result, we have progressively put in place a new framework for care which helps contain the emotions of both parents and caregivers and which allows us to welcome and protect the new baby in better conditions.
The first step was to wonder about the representations the abandoned baby evokes in us. The idea of an infant who has been abandoned by his mother is generally unbearable, especially in a maternity hospital, where the sacredness of birth is ever present. It engenders pity, whichh Is, In Itself, detrimental to the infant’s primary narcissism. The notion of an “infant engaged in the process of being adopted” has made the reality more acceptable for us. Still, it implies a period of waiting: waiting to leave the hospital, waiting for a foster family, waiting for adoptive parents. In this transitory period, the present is overshadowed by the future adoption. Yet close attention to the “here and now” is vitally important to a newborn infant in his first interactions with the world. At Les Bluets, our representation of a baby “hanging loose,” “in transit” has minimized the impact of the time the infant spent with us at the hospital. In retrospect, this short but important transitional time has been blurred with the staff’s perception of a baby suspended in limbo, waiting in the void.
In our experience, working in the “here and now” may lessen the impact of this void. A coherent care routine set up in concert by all concerned, a respect for and the preservation of the baby’s personal resources can give meaning to every second of his life. Adopting a therapeutic attitude in which one pays close attention to the details of the present moment is essential; it transforms the way we preceive the baby and the quality of the environment we create for him. As we reviewed above, this is one of the premises of the Emmi Pickler approach, which has been taught at the Loczy Institute.
I have been able to communicate to my colleagues my deep belief that if the environment offered to her is “good enough” then the newborn infant will have the capacity to exist without her mother and my conviction has spread within the hospital. We have been able to contain critical situations in which acting out on the part of the mother or the staff was immanent, and we have managed to second guess destructive impulses due to a generalized feeling of guilt triggered by abandoned infants. The staff has managed to understand that an act will take the place of a feeling that can not be thought through or understood. The importance of having a time and a place for sharing emotions and thoughts is now fully recognized by everyone, as is the importance of observing the baby and being attentive to Its needs. Strong psychological support for the staff is obviously recessary in that challenging task.
The main features of the therapeutic model at “Les Bluets”
Accompanying the mother
Along the years of giving support to mothers who are in the process of giving up their babies for adoption, we have realized that the process is much easier and the outcome more favorable, when started in pregnancy. We accompany the pregnant woman, paying constant attention to her feelings of ambivalence, guilt, anxiety and to the psychological transformations she goes through, as an individual as well as a mother. We try to work out plans for her own future, as well as for her baby’s best interest. Our aim is to differentiate the fetus from its mother, making him exist as an individual in the mother’s eyes. It is a complex process, but as far as we can judge from our experiencee, it eicitates in most mothers feelings of empathy towards their fetus, together with an understanding that her “relationship” with her/him, is the very first chapter of her child’s future interpersonal relationships.
We aim at giving the mother an active role in this process, and therefore we provide her with detailed information about the postpartum arrangements: how long, where and how (such as knowing she and the baby will be in different wards, their meetings will be in the presence of a mediator, and that psychological work will follow these encounters.
When delivery comes, a referent caregiver is designated for the mother and the planning for the baby as well as for the mother, goes along what has been decided during the pregnancy. During her hospital stay, the mother’s maternal capacities are usually mobilized. We invite her to write for the child elements of her life that she considers important for him/her to know, in any case she/he decides to seek information about her/his origins.
In some cases, we seek for professionals in the community to provide the mother with support after her return home and during the two months during which the French law allows her to reverse her initial decision.
Welcoming and caring for the baby
Our foremost preoccupation is to get to know the newborn’s own characteristics, and to keep a daily continuous, nurturing, and attentive interaction with him/her. This, we believe, allows the baby to feel as a worthy and welcomed subject. One of the conditions for continuity of care at the hospital, like in any residential nursery, is the transmission of information from one shift to another. We teach the nurses to make detailed reports of their observations. Thus, the major inconvenient of having multiple caregivers is buffered by the sense of continuity and familiarity conveyed to the baby. Also, every baby has one designated main caregiver, and the number of intervenants are kept to the minimum.
The major task of the main caregiver is to respond contigently to the baby’s emotional states and behaviors, an interactive experiencee different from the one with the biological mother, but also different from the expected one with the adoptive parent. Indeed, the place of the baby’s future adoptive parents is preserved by keeping the relationship with the baby professional in a warm, contingent, and nurturing context.
The daily caregiving tasks (such as feeding, bathing, carrying, and putting to sleep) are privileged times for an intimate exchange with the baby, watching her/his affects emotions, spontaneous movements, search for and loss of the link to the mother. It is believed that in this privileged and respectful space, the baby may develop a vital and competent sense of self.
When time comes to leave, the baby is given a diary, with all the pictures and the notes that have been collected about him/her. This concrete testimony of the beginnings of his/her life is aimed at guaranteing continuity, and will accompagny the baby to the residential nursery and sooner or later, to her/his adoptive home.
Supporting the caregivers
The medical staff in charge of these mothers and babies has a complex task to achieve. Each person’s role must be well defined; a principal caregiver for both mother and child must be designated. Setting aside specific times in the daily hospital routine for sharing information about these patients as well as allowing for more exceptional, unexpected moments is especially necessary in these situations. Regular institutional meetings and mini-encounters with the psychologist are also required. Each caregiver works out for herself/himself the appropriate professional attitude to adopt towards the baby. This attitude must be different from the one of a fantasied substitue mother’s. Thus, the caregivers’ demeanor will protect the baby from developping multiple – and illusory – emotional attachments which are destined to a more or less brutal ending. Basically, the suitable attitude is one of professional restraint and reserve concerning one’s personal projections while centering one’s attention on what the baby is expressing in the here and now. We give the caregivers support for their individual psychological reactions, especially those revealing resistance and defensiveness linked to their personal history.
Today, after much collective questioning and thanks to a fundamental change in the way the care providers perceive babies, we have begun to be able to act jointly, so that this extremely complex and difficult passage for the mother, the newborn baby, and the staff, becomes a constructing event, with sometimes, unexpected featues, as the next vignette illustrates.
Illustrative vignette
Mrs S. is at her sixth month of pregnancy, after having conceived out of wedlock. She is married and has two children. She doe not intend to dismantle her household, and manages to conceal her pregnancy from her family until the eighth month. Thanks to our weekly sessions, she finally decides to reveal the pregnancy to her husband. Together, the couple decides to give the baby up for adoption. During the therapeutic sessions, Mrs S. can sense my concern for her, but also for the baby as a distinct individual. We explore the option of involving the child’s biological father, but she does not want to have him informed. While giving her the support she needs for the decision she has made, I mention to her several times the lawful reversibility of her decision during the two-month period after birth.
Nonetheless, my main objective is to help her at maintaining the position she has elaborated during our prenatal sessions, and at avoiding confusion at the time of birth and during the hospital stay. I offer to help her stepwise, along the way she has chosen; I assure her that she will not be left alone during the significant moments of her stay and that she will be surrounded by a staff of supportive staff. Thanks to the well-defined setting put in place for her, she feels relieved, though very sad. This sadness, expressed during our sessions, reflects an inner strength at elaborating her decision.
When time comes, things happen the way she had asked for during the sessions. For instance, in the delivery room, her wish not to see her baby immediately is respected. The newborn infant is separated from her mother and installed in the nursery, one floor higher the mother’s. Then, the mother understands the rule of being accompanied during all her visits to the baby (twice by myself, and then by other caregivers). The baby is described in the daily notebook as an easy-temperament baby, who eats and sleeps well, and is easy to console.
The mother’s farewell to the baby is extremely emotional, but my presence helped her to contain herself. The baby’s relaxed face and calm state suggest that mother has managed to avoid projecting her massive inner conflict onto her. While the baby is taken back to the nursery, I stay with the mother until her husband comes and takes her home. The next day, a place in a good residential nursery in the Parisian metropolitan area becomes available for the baby. Members of an Association for Mothers giving up babies for Adoption made regular home visits during the the two-month period and provided Mrs S. intensive support throughout that difficult time.
The final separation required a great deal of courage and determination from the mother. From the staff, too, and many team meetings helped us to internalize the idea that the baby would indeed have a valid existence, in spite of the context of her conception. As a result, the staff acted with the mother and the baby insightfully, instead of being driven by their own impulses and emotional turmoil due to the mother’s ambivalent decision. The psychologist’s role was a very active one, quite different from the traditional position psychologists have. Indeed, reading Gerda’s notebook made it clear that this baby, as opposed to the other two babies described above, had not experienceed “being in limbo”, nor had been exposed to uncertainty, confusion, or conflicted behaviors. Gerda was the first baby to benefit from this change of therapeutic approach at the hospital.
Two months after the baby’s departure for the state nursery, I learned via the association that Mrs S. had told the baby’s biological father about the child’s existence. He decided to take her and bring her up with his own family’s help. Mrs S. visits them every fifteen days. The support this mother received from our institution allowed her to build, first for herself and then for her baby, the representation of herself identifying with a baby which she had not damaged. The child was protected against impulsive actions on the part of the adults caring for her; she was protected from unelaborated ambivalence and from massive, collective projections. The intensive, institutional support put in place around Mrs S. and her baby allowed this mother to imagine and build another future for her child.
Theoretical formulation of our therapeutic model at “Les Bluets”
For babies born “sous X”, i.e abandoned babies at birth, the essential question for the maternity staff is what kind of environment and relationship with mother and baby, will facilitate an overall creative and positive experience for the baby during its first days of existence. The unique challenge, for us as psychologists, is to create such an experience in a regular maternity ward at the hospital.
Winnicott’s work revealed that for a newborn infant, from the moment of birth, the experience of feeling himself impact on his environment is fundamental to the development of his psyche. M. Klein showed the fundamental necessity of primary splitting in the ability to separate good from bad for a good object to be introjected and thus preserved.
Following the Piklerian concept of psychological care expressed through concrete bodily care provided by primary caregivers (holding, feeding, changing,etc), the baby is able to try his hand at a type of relationship in which he can “discover and create” and even influence his environment. He will thus experience, from the moment he was born, a founding illusion in his sense of existence.
The application of these concepts to the unique situation of a pregnant woman coming in a maternity ward for delivering a baby she intends to give up for adoption, is not for granted at all. It requires from the staff to be willing to reflect upon their daily behaviors, to integrate psychological concepts, and to put aside their judgmental attitudes towards the abandoning mother, as well as their compassion towards the abandoned baby.
This therapeutic model is based on the combination of a psychoanalytical reading of the mother’s and staff’s inner movements, together with the elaboration of a « here and now » setting for the baby with its own characteristics. Containing projections, centering work on the provided bodily care (a process that make daily caregiving becoming a narcissistic object to the caregiver), preserves for the baby a space for illusion. This, we believe, has the potential to enhance his capacity to believe in himself and in his surrounding world.
Conclusion
It is hard to imagine how a “given up” newborn can grow out of this fundamental negative experiencee into a healthy individual. Assuming the first days of life are crucial in putting the baby on the right developmental path, we have developd a model aimed at facilitating the newborn’s self organization and openness to significant interpersonal exchanges, while focusing on the staff’s, mother’s and baby’s behaviors during the few days at the maternity ward, that ultimately aim at the definitive mother-newborn separation
Following the clinical cases described above, and others alike, we have progressed from an improvised welcome to an organized one, as we have tried to describe along this paper. Though it seems impossible to anihilate the pain of abandonment, it does seem possible to avoid its traumatic effects.
We have detailed here the specific model put in place to keep mother and staff from being overwhelmed with distress and guilt, feelings inevitably linked to the act of abandonment. We have described the attention we pay to the organization of the daily care which allows the newborn infant to feel welcomed and protected. The attentive bodily care given to the infant becomes therapeutic: it provides her/him with a vital and necessary welcoming. The babies are not waiting in a void. While at the hospital, they experience their caregivers’ sollicitude and lively attention to their “here and now”. In other words, the baby is thus encouraged to introject a good and protective object, and leaves the hospital opened to future.
The necessary splitting between care for the mother and for the baby, protects both parties from destructive affects. We focus our attention on creating and protecting the baby’s life space from the time of birth on, in order to guarantee the continuity of her/his personal body care history. Each moment spent at the hospital is part of the baby’s personal history, and is recorded in a diary.
Moreover, preserving the baby has an organizing effect on the mother. It repairs within her the abandoning part of her self. Something of her parental capacity, initially unthinkable, reemerges and, sometimes, even results in a revision of the decision to give up the child. This revision is not the goal of our accompaniment – each woman has a right to her own life story – yet we allow it to be a by-product of the work we do with the mothers.
To conclude, we have grown into being able to convey greater respect and support for mothers who do not want their babies, and we have transformed pity for the baby into consideration for its personal resources. The next step for us is to study our model in a systematic research design. We believe it has some unique contribution to our arsenal of intervention for very high risk population of women and babies, such as those presented here, but we definitely need to have it become evidence-based.
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Vamos, J., Eguillon, C. (2007). Avenir ou devenir des maternités ordinaires, in Spirale, n°41.
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Videos:
Martino, B. (2000). Loczy, a place to grow, Association Pikler Loczy, France.
Vamos, J., Csatàri, I. (2001). The baby’s time (1): bathing and caring. Association Pikler Loczy France, Association Pikler Loczy Hungary.
Authors
Vamos, Julianna, Ph.D,
France
