Métodos, técnicas, procedimientos e instrumentos de recolección para la

me, our conversation as well as the feed had been interrupted in the middle of the sentence. 1 felt a bit sad and confused as 1 left the unit.

Discussion

It seemed a fairly typical every day interaction on the Unit. It seemed to be a place where contact and

relationship were open to interference. Feelings, anybody's feelings were devalued and ignored, and continuity of treatment was not considered worth preserving.

The third nurse was advocating the belief that people are interchangeable; one pair of hands is as good as another. One baby is the same as another.

I thought that the Unit was in the grip of a part object culture. Whilst the first and second nurses where trying to resist this they were defeated. The first nurse allowed herself to be pushed out of her role as the feeding nurse. The dominating culture seemed to be that of a part object phenomena in the clutches of anti-meaning and anti-linking between a baby and a nurse or between a nurse and her own needs to feel she can feed and comfort after she caused pain.

Attacks on linking

Bion's work on thinking and thought disorders in his wonderful papers from the fifties are a development of Freud's work in "Formulation on the two principles of mental functioning" (S.E. 19) and "Neurosis and Psychosis" (1924) and Klein's work in "Notes on some schizoid mechanisms" (1946). In his paper "Differentiation of the psychotic from the non-psychotic personalities" (1957) Bion tells us about the attacks on thinking by the pyschotic part of the personality not only on thoughts but on the thought process itself "In fact , not only is primitive thought attacked because it links sense- impressions of reality with consciousness but , thanks to the psychotic's over-endowment with destructiveness , the

splitting processes are extended to the links within the thought processes themselves. As Freud's phrase regarding thought being turned to the relations between object- impressions implies, this primitive matrix of ideographs from which thought springs contains within itself links between one ideograph and another. All these are now attacked till finally two objects cannot be brought together in a way which leaves each object with its intrinsic qualities intact and yet able , by their conjunction to produce a new mental object"(p 50).

The psychotic process occurs according to Bion when there is a destruction of those parts of the mind that are capable of knowing and being aware of internal and external reality.

According to O 'Shaughnessy (1981) Bion places the emotional experience of trying to know the self and others in the centre of mental life and links the reality principal and the pleasure principal on par with the life and death instinct.

Summary

An interaction between a nurse and an ill baby is presented. The interaction is open to interruption of other staff. This interaction is looked at via countertransference response as well as through the facts of the interaction.

I am suggesting that the hating of knowing about pain, fear, and of being small is what we see working in this example. It overcomes and attacks an attempt at a meaningful contact. The arrival of the third nurse strips

the painful meaning of the contact between the first nurse and her little patient.

It also denies the nurse's contact with her own emotional reality, namely her need and wish to feed and thus make better the hurt she felt she had inflicted on her patient. The interaction between the first nurse and myself is exposed to the same fate as her interaction with her patient and her contact with her own needs.

3 .5 S eoon.d_______±n f or~ma 1_____v± s ± t: :_______Thie ± mp act: o f a clv±ng balpv on t h e t: e am .

Introduction

In this section I shall describe a visit dominated by a dying baby and its impact on the team and me. It seemed to have been a watershed visit. The death and the way it was handled or mishandled, the phantasies it provoked and the defences used are looked at. In retrospect I feel that this had a long term impact on me and propelled me into some of the actions that became a part of this project. The observation

I was told by a nurse that there was a dying baby on the Unit. Her name was Clair, she was dying from spina bifida complications. She has been on the unit for 3 weeks, a full term baby. It was not spelled out to me at the time but I understood later that she was fed only when she appeared to be hungry and no active medication was given.

I was aware of the feeling that something awful was taking place, or that the nurse was trying not to dwell too long on an awful situation. Years later I still think of this as one of the most difficult situations for anyone to bear.

I went into the little cubicle where Clair was. I was aware of my own fears and questions; what would I see? Would there be a very obviously damaged, perhaps revolting baby? The shock I felt when entering the cubical was that I vwas faced with a beautiful , full term blond baby. She was covered in a pink blanket, appeared to be asleep with her mouth moving as if looking for an object. Eyes closed, pink cheeks, a little snub nose and a head of fine blond hair.

Was she dying? I found it difficult to believe. There was nothing visible.. .How does a baby look when dying? I put this question to the nurse who was standing next to me. The nurse, a middle aged woman with an ashen face, somewhat stern and flat, told me about the change in the colour of the baby as it is dying. She went on to say in a matter of fact, vacant voice that the nurses were waiting for her to die. They hope she will not be there when they come on to their shift. The worst part is having to wash the body and put a paper nighty on her and put her in a box for the porter to take to the mortuary.

We were standing, the two of us looking at this baby, next to her a pink teddy and a card saying "Mummy and Daddy love you Clair". At this moment grief overcame me and tears came to my eyes I was thinking, such a small

baby came into this world for such a short time, suffering so much.

The Nursing Officer came into the cubicle and the nurse was complaining "Look, she is hungry she wants to eat" she said to the Nursing Officer in a somewhat accusing way. The Nursing Officer said "O.K. feed her when she w a k e s " .

I left the cubicle, I saw the blue sky outside, the babies who were getting better, thought about my kids at school,

felt very sad and lucky as I was leaving the Unit. Discussion

Unconscious Conflict enacted in the Unit

It seemed to me that the nurse was protesting that it was too much. She could not tolerate a baby being starved to death. It was too much and too difficult. The nurses want to preserve life, they are not trained to help babies to die. The nurse in the room with me might have been identified with the parents who desperately tried to deny the death by putting a pink teddy in the incubator and leaving a card saying "Mummy and Daddy love you Clair" as if they hoped the baby would be able to play with the toy? She, the nurse and the parents wanted a magic, omnipotent cure. Let us feed her and thus make her better, was the undertone of the nurse's message to the Nursing Officer. She will live! The Nursing Officer gave in, under the pressure of the accusation, and the suffering continued. The baby was not getting better, it took another ten days before Clair died.

There was a rebellious atmosphere outside the Unit. The Nursing Officer complained that instructions were not being obeyed. Staff appeared not to listen to her. Her authority she felt was questioned.

It seemed to me that the nurses felt they were told to kill the baby. They resented this and felt identified with the baby. They rebelled on her behalf as well as on their own behalf, were confused with her, and perhaps felt also identified with her parents too. It seemed that the Nursing Officer was perceived as the hated figure who was responsible for the tragedy. Unconsciously she was the bad murdering figure containing all the badness of the team. Social system as a defence against paranoid anxiety

In his 1955 paper Jaques describes a social structure as a defence mechanism against paranoid anxieties. He stresses the gain for the team if a member is able and willing to contain the projection and is then reintrojected by the other members of the team thus sharing the feelings that the attack was acceptable to the team and to that particular member of the team. I think that the Nursing Officer was unable to tolerate the level of projection that was necessary in the face of Clair's death.

Attack on meaning

A sense of stripping the baby of her dignity was vividly conveyed to me when the nurse was describing the washing of the dead body and "putting it in a paper nighty in a box". Here, I felt was the process of depriving the baby's life of its meaning, a kind of emotional death. It

was then in the process of turning from a baby into a "thing".

In the film "Shoa" by Claude Landsman there is an account of two prisoners from a concentration camp who were told to open up a mass grave dig up the bodies and burn them so as to wipe out any trace of what had occurred. One prisoner found buried there his own wife and children. He said that the guards did not allow him to say the words "bodies" when talking about what was in the grave. The prisoners were beaten up if the words "grave, or dead bodies" were uttered. 1 wondered if some "nazified" process was taking place when the nurse felt that she was asked to ""starve the baby to death" and she felt terribly guilty and extremely resentful as if she had been told to deny that a death of a baby was taking place and she felt as if she was murdering the baby and her life meaning.

It seems that guilt or other feelings made it impossible to bear the pain. The nurse in her flat description of what was to become of Clair's body was getting rid of her pain as well as her ability to think and feel. There was a sense of cruel devaluation in the account. Why a paper nighty? Why a box and not a coffin? It was not possible for me to think and clarify this for myself for a very long time. It felt as if 1 was being told about a deadening course of action.

The nurse conveyed the impression that this was an activity done by an outside agency to the baby. 1 wondered if the persecution was in part a statement of how the nurse felt about what she was involved in doing. 1 wondered if for a good nurse the task of looking after a baby in this way on the Unit has the meaning of stripping the baby's life of any meaning and therefore the nurse,

in identifying with the baby and her fate feels herself treated in the same way by her Nursing Officer, and thus a most vicious circle is created.

I find Bion's work central to understanding the interaction between the nurse and me. There was clearly no object that could take the projections and offer them back in a modified way to the staff. If that was the case, "If the mother cannot tolerate these projections the infant is reduced to continued projective identification carries out with increasing force and frequency. The increased force seems to denude the projection of its penumbra of meaning. Reintrojection is effected with similar force and frequency". Infant or patient or nurse in that situation then "behaves as if it felt that an internal object has been built up that has the characteristics of a greedy vagina-like breast that strips of its goodness all that the infant receives or gives leaving only degenerate objects" (1962). He continues "The tasks that the breakdown in the mother's capacity for reverie have left unfinished are imposed on the rudimentary consciousness,.... The rudimentary consciousness cannot carry the burden placed on it. The establishment internally of a projective-identification- rejecting object means that instead of an understanding object- the infant has a wilfully misunderstanding object- with which it is identified. Further its psychic qualities are perceived by a precocious and fragile consciousness"(ibid).

Relation between Staff and the Nursing Officer in the Unit The Nursing Officer being full of the projection of the powerful hate and anxieties of her team was unreliable for the team to project into and to introject as a tolerating

thinking parental figure. Instead they were left without a thinking absorbing object, or according to Bion, an object that stripped their experience of its meaning, leaving it as meaningless, and themselves as empty of goodness or full with damaging and damaged internal objects which in turn they needed to rid themselves of, and then turn to attack their own thinking abilities.

A dying babv as an unconscious bad object

A baby that is dying on the Unit, or put more bluntly left on the Unit to die from among other things hunger is an awful burden for her parents and the staff to carry.

If that is the case there will be an unconscious wish to get rid of it i.e. destroy her and the memory of her, and thinking and remembering in general.

Segal states "Where such symbolic equations are formed in relation to bad objects, an attempt is made to deal with them as with the original object, that is by total annihilation and scotomata" (1957).

It seemed to me that this was such a disturbing task that a collapse took place in the team's ability to function. The mother figure was felt not to be able to take and absorb the fear of dying or murdering that was present in the team. In fact this member of staff left the Unit at the end of the month very shortly after Clair's death.

Summary

The event of a very ill baby dying on the Unit is looked at. The relationship between the staff and the Nursing

Officer shows the powerful projection of bad aggressive impulses into her. It left the nurses without an object that could tolerate the meaning of the event on the Unit. It seems that there was a struggle against a perception held by the staff that they were to strip the life and death of a baby of all meaning; that they are to act as if members of a Nazi organization. It seems that the dying baby became unconsciously confused with dying damaged attacked objects (Segal), and thus an almost catastrophic situation was set to develop where life was devalued to a very dangerously low point, and the ability to feel and think was attacked in an attempt, perhaps, to get relief from the horror that was unfolding.

3 . 6 Tine e s s e n c e o f t h e tz> r~ o Id 1_ em

Formulation

The work of the Unit with ill very frail or dying babies can stir up unconscious worries about internal attacked or dying objects. The reality of the task of the Unit is so close to unconscious phantasies and anxieties that symbolic equation is

rife resulting in a concrete way of thinking .

Also it is terribly difficult for the nursing staff to offer a container for the parents' projections if there is no container available for them. I show an example where this does not take place and the object instead of helping in metabolising the data is perceived as stripping the subject,

in this case the nurse of her goodness leaving her with only degenerate objects.

The dying baby obscured the reality of the recovering and growing infants. I felt I had to leave the Unit and remind myself of my living healthy children. The Unit in a crisis was

fe^t to be dominated by bleak hopelessness.

The observations were shared with Management. It seemed that while individual nurses were sensitive and caring human beings, the team was unable to provide a caring thinking and feeling environment for its patients and its own members. A culture of splitting and part object was dominating. A process of devaluing peoples' feelings and babies' lives had taken hold. There was no 'object' who was willing to take on the projections of bad aggressive impulses (Jaques), or able to introject and return them in a somewhat contained form (Bion). No place or opportunity to develop awareness was there, as the

"ego function" of the team was overwhelmed by the unconscious conviction of the strength and triumph of the death instinct. Some insight and concern was located outside in the Director of the service who sensed that this unit could become a dangerous place. The ego strength of the team needed supporting by providing a "good" experience that could be taken in and identified with. The culture needed reversing urgently. The how and what and when of this process of reversal was looked at in Chapter 2 and is developed further below.

S3C 4 . T i n e W Q X T k o f t i n e