Journal of PrimaryPrevention,6(4), Summer, 1986
Premature Birth: A Crisis Intervention A p p r o a c h CIPORAH S. TADMOR and JOSEPH M. BRANDES ABSTRACT: The study of mothers of premature babies allows for the formulation of the specific psychological tasks that make for adaptive or maladaptive coping patterns. In line with a novel theoretical model of crisis denoted as the Perceived Personal Control Model (PPC), a preventive intervention program was implemented by medical caregivers trained in the underlying principles of the PPC model. That model as well as Social Action to facilitate the accomplishment of the adaptive psychological tasks of the target population are discussed.
Premature birth is defined as a potentially hazardous circumstance characterized by a sudden, unanticipated onset likely to involve a loss or a threat of loss of a child. The psychological definition of premature birth advanced here departs from the medical formulation which defines premature delivery as a pregnancy terminated before the completion of 36 weeks of gestation. The difference between the psychological and medical definitions of prematurity is significant in the sense that from a psychological point of view, premature delivery is viewed as a potentially stressful event only when there is a threat of loss of the infant (Caplan, Mason, & Kaplan, 1965). In line with this definition the scope of the preventive intervention formulated in this paper focuses on the mothers of medium to large premature babies (1,000-2,500 grams). These prematures, in contrast to the very small premature babies (500-1,000 grams), have a good chance of survival. Focus on this target population, namely mothers of medium to large premature babies and their families, is dictated by the following concerns: Increased mortality and morbidity risks in premature infants conThe authors are with the Department of Obstetrics at the Rambam Medical Center and the Samuel Neaman Institute for Advanced Studies in Science and Technology at the Technion Israel Institute of Technology, in Halfa, Israel. Reprint requests may be addressed to the author at the Center. The authors wish to express their appreciation to Professor Gerald Caplan, Chairman, of Department of Adolescent and Child Psychiatry, Hadassah University Hospital, Jerusalem, for his guidance in preparing this manuscript. The authors wish to thank Professors I. Timor and the medical and nursing stafffrom the Department of Obstetrics "A" in Rambam Medical Center, as well as Professor M. Zeltzer, Dr. J. Katzir, and P. Sugov (neonatologists) and the ICN nursing staff who are actively involved in the implementation of preventive intervention. 244
© 1986 HumanSciencesPress
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sist of realistic hazards capable of triggering an emotional crisis in the mother and her family. Emotional crisis is defined by Caplan (1964) as a temporary period of emotional disequilibrium in an individual facing a difficult and important task which he or she is not equipped to deal with. Furthermore, crisis is viewed as a crossroads in the individual's life span, entailing the potential for personality growth or emotional impairment (Caplan, 1964, 1974). Premature delivery is precipitated by a series of unanticipated, rapidly evolving events for which the expectant mother is not likely to be prepared, such as hospitalization, confinement to bed, medication aimed at suppressing premature contractions, a series of unfamiliar tests, and most likely a caesarean birth. Clinical evidence appears to support the notion that disturbance in mother-child relationships can be traced back to such periods of crisis as prematurity. The child is likely to be perceived as a constant reminder of the mother's failure to deliver at full term (Prugh, 1953, Caplan; 1960). The disordered relationship with the child can be seen as an attempt to deal with premature birth (Caplan, 1974). Premature delivery in itself may be the result of stress. There is some evidence to suggest that mothers of premature babies are at high risk even before the birth of the premature baby (Wortis, 1960). The relationship between stressful life events and premature delivery is advanced at least by one study (Hertzel, Bruer, & Poidevin, 1961). Recent findings have shown a link between early disruption of mother-child relationship and later child maltreatment. The data suggest that low birth weight infants requiring special care in intensive care nurseries because of early and prolonged separation from their mother (that severs and interferes with bonding and attachment) are more likely to be maltreated than full-term infants (e.g., Klein & Stern, 1971; Fanaroff, Kennell, & Klaus, 1972; Stern, 1973; Hunter, Kilstrom, Kraybill, & Loda, 1978; Fontana, 1980)o Caplan and his associates, the so-called Harvard Group (Caplan, 1960; Kaplan, 1961; Kaplan & Mason, 1960; Mason, 1963; Caplan, Mason, & Kaplan, 1965), concerned over the impact of emotional crisis on the quality of the coping patterns of the individual, selected prematurity as one of the earliest life hazards for purposes of their investigation. In the early sixties the Harvard Group conducted a thorough investigation with mothers of premature infants in order to identify mothers embarked on a maladaptive course. It attempted to identify (a) the specific psychological tasks involved in prematurity, and (b) the range of adaptive and maladaptive coping patterns.
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The four psychological tasks (identified in the crisis of premature birth) to be accomplished by the mother of the premature baby in order to secure a positive crisis outcome were: (a) preparing for the possibility of losing the baby; (b) dealing with the negative feelings elicited by the event; (c) acknowledging the turning point in the infant's health and resuming relationship with him or her, and (d) caring for the special needs of the premature baby on the understanding that eventually he or she is likely to become a regular infant (Kaplan & Mason, 1960; Caplan et al., 1965). The adaptive coping patterns identified are geared to the accomplishment of the tasks that will secure a healthy mother-child relationship (Kaplan & Mason, 1960; Caplan et al., 1965), In this article the adaptive and maladaptive coping patterns identified by the Harvard Group are analyzed and reinterpreted in terms of a new crisis model designated as the Perceived Personal Control crisis intervention model (Tadmor, 1984; Tadmor & Brandes, 1984; Tadmor, Brandes, & Hofman, in press), and of a recent study of 25 mothers of premature babies during their hospitalization. Furthermore, preventive intervention in line with the Perceived Personal Control crisis intervention model implemented by medical caregivers in the hospital setting, is discussed. The perceived personal control construct is a synthesis of Lazarus' (1968) notion of idiosyncratic perception and Caplan's (1964) notion of the availability of a coping response that mediates between the appraisal of the event and the response to it. Thus, the perceived personal control construct implies (a) the availability of a coping response and, (b) the perception of the threatening event as capable of modification. Perceived personal control is defined in line with Averill (1973) as the availability of a response to (a) modify the event, and/or (b) modify its threatening characteristics. The availability of perceived control is viewed as the key factor in determining the degree of crisis to be elicited when the individual is exposed to a stressful life event. This construct implies perceived personal control over affective, cognitive, and behavioral variables that mediate between the perception of a hazard and the quality of the coping response. Affective emotional control is the availability of natural and organized support systems to regulate and monitor the individual's adaptation work. Cognitive control is the accessible information coupled with the person's share in the decision making process. Behavioral control is designated as active participation and task oriented activity in the handling of the stressful event. For purposes of clarification, adaptive coping patterns of the mother
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of the premature baby are differentiated on cognitive, affective, and behavioral levels aimed at enhancing her perceived personal control. In reality, however, these processes are interrelated and overlapping. Adaptive coping patterns on the affective level. The availability of a supportive "social surround" is a prerequisite to attaining perceived control on the affective level. The social surround consists of (a) natural supports, namely, the husband and other family members, (b) organized supports, namely, medical caregivers and veteran mothers of premature babies, who share with the new mother her concerns and hopes with respect to the baby's chances of survival. The availability of a network of natural and organized support systems will secure the accomplishment of the following tasks: (a) reality-oriented appraisal of the baby's condition, yielding moderate to high anxiety level regulated by incoming information., (b) active exploration of reality-based evaluation which prevents excessive use of denial defenses with periodical withdrawal and rest periods; (c) periodical engagement in anticipatory grief regulated by incoming information about the baby's chances of survival; (d) acknowledgement and free expression of negative feelings likely to be triggered by the premature delivery, such as failure, frustration, guilt, anger, fear that the baby may die, or be handicapped; (e) revelation of strong maternal feelings towards the baby coupled with considerable protest at being separated from the baby; (f) open expression of fear in handling such a tiny baby; (g) expressing a hopeful expectation and a positive outlook based on the experiences of other mothers of premature babies that have successfully mastered the predicament, as well as on daily progress reports on the baby's condition; (h) safeguarding the quality of the relationships with other members of the family in spite of the present predicament; and (i) overcoming blame and guilt feelings by active intervention of the "social surround." Adaptive coping patterns on the cognitive level. The mother of a premature baby has to acquire a realistic appraisal of the situation. Perception of objective assessment of the baby's health state is acquired by the following activities: (a) active exploration of reality issues; (b) continuous search for new information, and by keeping the problem in consciousness; (c) re-evaluation of the baby's condition with the acquisition of updated information; (d) information gathering with respect to the objective reason of the premature birth, likely to enable the mother to ascribe the cause of premature delivery to objective factors excluding the need to resort to self-blame or blame of others; (e) acquisition of updated progress reports with respect to the health state of
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the baby, likely to facilitate the acknowledgement of the turning point in the baby's chance for survival in order to resume relationship with the baby; and (f) understanding of the specific needs of the premature baby, allowing energy to be consistently directed to find a solution and formulating a detailed plan of action that is likely to be instrumental in dealing with the current predicament. Adaptive coping on the behavioral level. Tension reduction is achieved by active participation and task oriented activities: (a) frequent visits to the intensive care nursery (ICN). (Visiting patterns were found to be an excellent index of the whole area of task accomplishment and best predictor with respect to the quality of motherchild relationship; (b) handling, fondling, feeding, talking, performing physiotherapy, and actively participating in the care of the baby; (c) actively invoking help from others, such as family members, medical caregivers, and other mothers of premature babies; (d) expressing milk for the premature baby and bringing it to the ICN; (e) contemplating explicit detailed plans for the future; and (f) ensuring that daily activities and normal functioning are not impaired by the recent predicament, except periodically because of worsening of the baby's condition. Maladaptive coping patterns on the affective level. Absence of a supportive social surround to share and regulate the adaptation work may result in the following maladaptive practices: (a) avoidance and denial of the predicament or its significance derived from judgment based upon wish-fulfilment rather than reality-based evaluation, producing a low anxiety level and pretended euphoria; (b) avoidance and denial of negative feelings, dealing with them by projection or blame when they do break through; (c) emotional detachment from the baby; (d) expression of self-confidence in caring for the baby out of ignorance of the premature baby's special needs; (e) hopeful expectation based on fantasy and wish-fulfilment; (f) impairment of relationships with other members of family. (The disordered relationship is seen as an attempt to deal with the crisis at the emotional expense of someone else within the family); and (g) tension is reduced by utilization of blame, aggression, and hostility (Caplan, 1960). Maladaptive coping patterns on the cognitive level. Lack of objective appraisal of the situation may result in the following maladaptive practices: (a) the mother welcomes vague reassurance from the neonatologist and bases her appraisal of the baby's health state on wish fulfilment, fantasy, and "misdiagnosis"; (b) the cause of premature birth is ascribed to acts of family members, physicians, or self; (c) unrealistic appraisal of the baby's chances of survival is likely to impair the
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acknowledgement of the turning point in the baby's condition and thus to impede attachment behavior to the baby; (d) misunderstanding of the specific needs of the premature baby is likely to affect the mother's perception of the baby as either a regular baby or one handicapped for life; and (e) excessive utilization of denial is likely to impede plans for the future. Maladaptive coping patterns on the behavioral level. Tension is reduced by hostility and blame and nontask oriented activities: (a) infrequent visits to ICN while the mother is hospitalized and after discharge; (b) lack of handling, talking, or actively participating in the care of the infant; (c) inability to seek or accept help from family members, medical caregivers, or other parents of premature babies. (If advice or help is offered it is likely to be rejected (Caplan, 1960)); (d) no attempts are made to express milk for the baby; (e) preoccupation with the present impedes formulation of plans for the future; and (f) daily activities in other areas of functioning are impaired. Crisis theorists suggest that unhealthy coping patterns are not unavoidable or irreversible and that adaptive coping skills can be acquired by preventive intervention: (a) in the short run, appropriate preventive intervention implemented by obstetricians, neonatologists, and nurses geared to assist the mother of the premature baby in the accomplishment of the specific psychological tasks of premature birth; (b) in the long run, by social action, namely, introducing hospital policies, practices, and structures facilitating not only a positive crisis outcome but also safeguarding bonding between the mother and her premature baby.
The Short Run: Preventive Intervention Implemented by Medical Caregivers The crux of a preventive invervention approach as formulated by Caplan as early as 1960 and which follows as a central theme in his subsequent writing (1964, 1974) lies in its implementation by caregivers in general, and medical caregivers in particular. It is assumed that crisis intervention does not require sophisticated knowledge of psychodynamics of the individual but rather understanding of the current manifestation of crisis and the specific tasks involved. Furthermore, a central role is reserved for the medical caregivers in preventive intervention because they can time adequate intervention to coincide with the peak of the individual's susceptibility, and thus can enhance the quality and the effectiveness of intervention.
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It is also assumed that the manipulation of situational variables, such as support systems (natural and organized), information, a person's share in the decision-making process, and task-oriented activity, makes it possible to enhance the perceived control of the mother and to assist her in the accomplishment of the specific psychological tasks associated with premature birth. The following preventive intervention protocols are implemented by medical caregivers trained in the principles of the PPC model and the specific psychological tasks of mothers of premature babies. Natural support systems. The obstetrician, obstetric nurses, and midwives convene the family, in particular the husband or a supportive other, and guide and encourage them to take an active role in the process. During the confinement period, the obstetrician makes the husband a full partner in the decision-making process with respect to the management of labor and mode of delivery, and encourages him to sustain his wife with his physical presence and emotional support. Furthermore, the husband is guided to assist his wife in the completion of the specific psychological tasks involved in prematurity, and he is encouraged to take an active role in caring for the baby. During the delivery period the obstetrician and midwives encourage the husband (if both parents consent) to participate during the birth process, whether delivery is spontaneous or by caesarean birth. The obstetrician makes provisions for a nurse to prepare the parents for the tasks which lie ahead. Such preparation is particularly important for parents who have not attended childbirth preparation classes. Early contact. The neonatologist shows the baby to the parents at birth and relates general information with respect to the baby's immediate health state. As soon as the mother feels up to it, she is wheeled to the ICN for an early contact with the baby. Information. After thorough examination and necessary medical interventions in the ICN, the neonatologist presents detailed, factual information to the mother most likely to be confined to bed from 6 to 18 hours whether she had a spontaneous or caesarean birth, respectively. The information is objective, consisting of simple unambivalent terminology, aimed at assisting the parents to acquire a realistic appraisal of the baby's condition. The neonatologist, refraining from vague reassurance which reinforces the mother's own tendency to deny and evade reality, explains the objective causes of premature delivery. Thereafter, the neonatologist makes himself available to the parents on a daily basis to provide them with progress reports on the baby's condi-
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tion. In the ICN the parents receive a reference booklet describing the specific problems encountered by premature babies. The obstetrician makes daily calls to the ICN to be updated about the infant's condition and he relates this information to the mother on his daily visits and he encourages her to seek additional information in order for her to be prepared to face all possible outcomes and to reduce anxiety derived from uncertainty. Frequent visits. The obstetrician encourages the mother to make frequent visits to the ICN. On her first visit she is usually accompanied by her partner, an obstetric nurse, or the lactation counselor and she is prepared in advance with respect to the size and the physical appearance of the baby as well as the instruments that the baby may be attached to. Negative feelings. The obstetric medical personnel, as well as the social worker, encourage the mother to acknowledge her negative feelings, to openly discuss feelings of inadequacy, failure, guilt, anger, and frustration, and to see such feelings as legitimate and normal reactions. Support of medical caregivers. The obstetrician, and subsequently the neonatologist, support the mother engaged in anticipatory grief, sustain her in her sorrow, and provide her with reassurance and the positive expectation that she may have the strength and resources to face all possible outcomes with courage. Blame. The neonatologist is aware of the mother's tendency to blame herself or others for her misfortune. Blaming others may be a device instrumental in reducing tension momentarily; however, in the long run, it m a y have adverse effects on the family's chances of mastering the crisis. Consequently, blame is discouraged and counterbalanced by ascribing the causes of premature birth to objective factors. Help. The mother is assisted in the task of admitting that she needs help. The very admittance implies that she has come to grips with reality and now can focus on the special needs of the premature baby. The neonatologist points out her helpers in the family and in the community, and he instructs her as to the kind of help she can expect from them. Express milk. The neonatologist, the nurses, and the lactation counselor encourage the mother strongly committed to nurse her baby, to express milk and bring it to the ICN. They provide the mother with anticipatory guidance with respect to the physical and emotional difficulties that lie ahead in a process which may seem futile at time, since it consists of expressing milk for a baby whose chances of survival m a y
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be slim, and who may temporarily be fed intraveneously with fluids other than milk. The ICN nurses encourage the mother to talk, touch, feed, and actively participate in the care of the baby, and in this way help her in a safe and accepting atmosphere to acquire the skills needed to care for her baby. Special needs. The neonatologist provides the parents with information with respect to the specific needs of the premature infant, such as frequent feedings, special diet, follow-up in the outpatient clinic, etc. However, the neonatologist impresses upon her that the extra care prescribed is temporary and that eventually the baby is likely to become a regular baby. Turning point. The neonatologist assists the parents to identify and acknowledge the turning point in the baby's health condition. The completion of this task will set in motion the resumption of the attachment process and enhance the quality and intensity of the relationship with the baby. Support of a veteran. The obstetrician summons a mother who has successfully mastered the specific tasks of dealing with her premature baby to visit the new mother, to support, and share with her the commonality of their plight. The "veteran" is instructed to provide anticipatory guidance in the process of mastering the predicament and to place special emphasis on the following tasks: 1. Prepare her for the ups and downs in the baby's condition even after the turning point and for the fears and anxieties triggered by constant uncertainty and doubts. 2. Alert her to the possibility that attachment, especially after the baby is brought home, may be artificial at first, and that this is normal finder circumstances of prolonged separation. Eventually, it is expected that bonding will proceed and take its normal course. 3. Impress upon her that once at home, she may develop an unprecedented sense of obligation in caring for the premature baby, derived from a sense of guilt for failing to produce a full-term baby. The seemingly miraculous survival of the baby, may add further to the mother's sense of special obligation. This sense of having to "make up to him or her" is likely to disappear gradually, turning into a sense of pride and accomplishment as the baby gains weight and is perceived as a regular infant. 4. Raise awareness with respect to the emotional and physical difficulties which lie ahead in embarking on an adaptive course. On the emotional level, consciousness of the problem and facing it with courage are not easy undertakings, nor are the frequent visits to the ICN at
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a time when the baby's chances of survival cannot be guaranteed. These tasks can hardly be accomplished without the support of the family and medical caregivers. On the physical level, frequent visits to the ICN, long waits to get to talk to the pediatrician, or to be allowed access into ICN, and frequent expressing of milk, present additional burdens for the family of the premature baby. These difficulties, stemming from an adaptive and active coping pattern, are immensely reduced by anticipatory guidance. According to testimonials of mothers of premature babies guided on this path, the emotional turmoil is minimized by the mere fact of knowing what to expect and what to do at a time of great emotional distress and confusion. Preventive Intervention in the L o n g R u n : Social A c t i o n
Social action with respect to premature birth involves adopting hospital practices, services, and structures to safeguard a positive crisis outcome and to facilitate bonding between the mother and her premature baby. The implications of this proposition are threefold: 1. The ICN should be located in the same building and preferably on the same floor with the maternity department to enable (a) early and frequent visits to the ICN by the mother, who most likely has undergone caesarean birth which curtails her mobility; (b) a continuous flow of information from the neonatologist to the mother; and (c) opening channels of communication between the neonatologist and the obstetrician about the infant's health state. 2. The design of the ICN should be such as to promote close and prolonged contact between the premature baby and its parents. Such a design will have to give up the "large room design," in order to foster the necessary prolonged contact with parents, uninterrupted by medical attention given to any other infants on the floor. 3. The neonatologist and the social worker should encourage the formation of organized support groups of mothers of premature babies who have mastered the crisis successfully. When needed, support group mothers can be summoned to visit new mothers encountering similar predicaments so that these support mothers can offer assistance and anticipatory guidance in the process which lies ahead. The support mothers also can organize weekly meetings with parents of premature babies, staff, and veterans for purposes of sharing, support, and guidance. In conclusion, premature delivery is likely to be perceived as an uncontrollable event. Once the premature contractions cannot be re-
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strained with medication, or once the obstetrician decides that it is in the best interest of the mother's or child's health to initiate delivery, premature birth has to proceed as scheduled. Its threatening characteristics, however, can be greatly reduced, and its emotional sequelae greatly minimized by utilization of preventive intervention, implemented by natural and organized support systems, as well as by introducing policies, services, and structures conducive to securing a positive crisis outcome.
References Averill, J.R. (1973). Personal control over aversive stimuli and its relation to stress. Psychological Bulletin, 80, 286-303. Caplan, G. (1960). Patterns of parental response to the crisis of premature birth. Psychiatry: Journal for the Study of Interpersonal Processes, 23, 365-373. Caplan, G. (1964). Principles of preventive psychiatry. New York.. Basic Books. Caplan, G., Mason, E.A., & Kaplan, D.M. (1965). Four studies of crisis in parents ofprematures. Community Mental Health Journal, 1,149-161. Caplan, G. (1974). Support systems and community mental health: Lectures on concept development. New York: Behavioral Publications. Fanaroff, M.B., Kennell, J.H., & Klaus, M.D. (1972). Follow-up the predictive value of maternal visiting patterns. Pediatrics, 49, 287-290. Fontana, V.J. (1980, January). Child abuse: Prevention in teen-age parent. Journal of Medicine, pp. 53-56. Hertzel, B.S., Bruer, B., & Poidevin, L.D.S. (1961). A survey of the relationship between certain common antenatal complications in primiparae and stressful life events. Journal of Psychosomatic Research, 5, 175-182. Hunter, S.R., Kilstrom, N., Kraybill, E.N., & Loda, F. (1978). Antecedents of child abuse and neglect in premature infants: A prospective study in a newborn intensive unit. Pediatrics, 61,629-635. Kaplan, D.M. (1961). Observations on crisis theory and practice. Social casework, 151-155. Kaplan, D.M. & Mason, E.A. (1960). Maternal reactions to premature birth viewed as an acute emotional disorder. American Journal Orthopsychiatry, 30, 539-552. Klein, M., & Stern, L. (1971). Low birth weight and the battered child syndrome. American Journal of Disease Children, 122, 15-18. Lazarus, R.S. (1968). Emotions and adaptations: Conceptual and empirical relation. In W.J. Arnold (Ed.), Nebraska Symposium on Motivation, Lincoln: University of Nebraska Press. Mason, E.A. (1963). A method of predicting crisis outcome for mothers of premature babies. Public Health Reports, 78, 1031-1035. Prugh, D.G. (1953). Emotional problems of the premature infant's parents. Nursing Outlook, 1,461-464. Stern, L. (1973, May). Prematurity as a factor in child abuse. HospitalPractice, 117-123. Tadmor, C.S. (1984). The perceived personal control crisis intervention model. Training of and application by physicians and nurses to a high risk population of caesarean birth in a hospital setting. Unpublished doctoral dissertation, The Hebrew University, Jerusalem, Israel.
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Tadmor, C.S., & Brandes, J.M. (1984). The perceived personal control crisis intervention model in the prevention of emotional dysfunction for a high risk population of caesarean birth. Journal of Primary Prevention, 4, 240-251. Tadmor, C.S., Brandes, J.M., & Hofman, J.E. (in press). Preventive intervention for a caesarean birth population. The Journal of Preventive Psychiatry. Wortis, H. (1960). Discussion. American Journal of Orthopsychiatry, 30, 547-552.
Premature Birth: A Crisis Intervention A p p r o a c h CIPORAH S. TADMOR and JOSEPH M. BRANDES ABSTRACT: The study of mothers of premature babies allows for the formulation of the specific psychological tasks that make for adaptive or maladaptive coping patterns. In line with a novel theoretical model of crisis denoted as the Perceived Personal Control Model (PPC), a preventive intervention program was implemented by medical caregivers trained in the underlying principles of the PPC model. That model as well as Social Action to facilitate the accomplishment of the adaptive psychological tasks of the target population are discussed.
Premature birth is defined as a potentially hazardous circumstance characterized by a sudden, unanticipated onset likely to involve a loss or a threat of loss of a child. The psychological definition of premature birth advanced here departs from the medical formulation which defines premature delivery as a pregnancy terminated before the completion of 36 weeks of gestation. The difference between the psychological and medical definitions of prematurity is significant in the sense that from a psychological point of view, premature delivery is viewed as a potentially stressful event only when there is a threat of loss of the infant (Caplan, Mason, & Kaplan, 1965). In line with this definition the scope of the preventive intervention formulated in this paper focuses on the mothers of medium to large premature babies (1,000-2,500 grams). These prematures, in contrast to the very small premature babies (500-1,000 grams), have a good chance of survival. Focus on this target population, namely mothers of medium to large premature babies and their families, is dictated by the following concerns: Increased mortality and morbidity risks in premature infants conThe authors are with the Department of Obstetrics at the Rambam Medical Center and the Samuel Neaman Institute for Advanced Studies in Science and Technology at the Technion Israel Institute of Technology, in Halfa, Israel. Reprint requests may be addressed to the author at the Center. The authors wish to express their appreciation to Professor Gerald Caplan, Chairman, of Department of Adolescent and Child Psychiatry, Hadassah University Hospital, Jerusalem, for his guidance in preparing this manuscript. The authors wish to thank Professors I. Timor and the medical and nursing stafffrom the Department of Obstetrics "A" in Rambam Medical Center, as well as Professor M. Zeltzer, Dr. J. Katzir, and P. Sugov (neonatologists) and the ICN nursing staff who are actively involved in the implementation of preventive intervention. 244
© 1986 HumanSciencesPress
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sist of realistic hazards capable of triggering an emotional crisis in the mother and her family. Emotional crisis is defined by Caplan (1964) as a temporary period of emotional disequilibrium in an individual facing a difficult and important task which he or she is not equipped to deal with. Furthermore, crisis is viewed as a crossroads in the individual's life span, entailing the potential for personality growth or emotional impairment (Caplan, 1964, 1974). Premature delivery is precipitated by a series of unanticipated, rapidly evolving events for which the expectant mother is not likely to be prepared, such as hospitalization, confinement to bed, medication aimed at suppressing premature contractions, a series of unfamiliar tests, and most likely a caesarean birth. Clinical evidence appears to support the notion that disturbance in mother-child relationships can be traced back to such periods of crisis as prematurity. The child is likely to be perceived as a constant reminder of the mother's failure to deliver at full term (Prugh, 1953, Caplan; 1960). The disordered relationship with the child can be seen as an attempt to deal with premature birth (Caplan, 1974). Premature delivery in itself may be the result of stress. There is some evidence to suggest that mothers of premature babies are at high risk even before the birth of the premature baby (Wortis, 1960). The relationship between stressful life events and premature delivery is advanced at least by one study (Hertzel, Bruer, & Poidevin, 1961). Recent findings have shown a link between early disruption of mother-child relationship and later child maltreatment. The data suggest that low birth weight infants requiring special care in intensive care nurseries because of early and prolonged separation from their mother (that severs and interferes with bonding and attachment) are more likely to be maltreated than full-term infants (e.g., Klein & Stern, 1971; Fanaroff, Kennell, & Klaus, 1972; Stern, 1973; Hunter, Kilstrom, Kraybill, & Loda, 1978; Fontana, 1980)o Caplan and his associates, the so-called Harvard Group (Caplan, 1960; Kaplan, 1961; Kaplan & Mason, 1960; Mason, 1963; Caplan, Mason, & Kaplan, 1965), concerned over the impact of emotional crisis on the quality of the coping patterns of the individual, selected prematurity as one of the earliest life hazards for purposes of their investigation. In the early sixties the Harvard Group conducted a thorough investigation with mothers of premature infants in order to identify mothers embarked on a maladaptive course. It attempted to identify (a) the specific psychological tasks involved in prematurity, and (b) the range of adaptive and maladaptive coping patterns.
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The four psychological tasks (identified in the crisis of premature birth) to be accomplished by the mother of the premature baby in order to secure a positive crisis outcome were: (a) preparing for the possibility of losing the baby; (b) dealing with the negative feelings elicited by the event; (c) acknowledging the turning point in the infant's health and resuming relationship with him or her, and (d) caring for the special needs of the premature baby on the understanding that eventually he or she is likely to become a regular infant (Kaplan & Mason, 1960; Caplan et al., 1965). The adaptive coping patterns identified are geared to the accomplishment of the tasks that will secure a healthy mother-child relationship (Kaplan & Mason, 1960; Caplan et al., 1965), In this article the adaptive and maladaptive coping patterns identified by the Harvard Group are analyzed and reinterpreted in terms of a new crisis model designated as the Perceived Personal Control crisis intervention model (Tadmor, 1984; Tadmor & Brandes, 1984; Tadmor, Brandes, & Hofman, in press), and of a recent study of 25 mothers of premature babies during their hospitalization. Furthermore, preventive intervention in line with the Perceived Personal Control crisis intervention model implemented by medical caregivers in the hospital setting, is discussed. The perceived personal control construct is a synthesis of Lazarus' (1968) notion of idiosyncratic perception and Caplan's (1964) notion of the availability of a coping response that mediates between the appraisal of the event and the response to it. Thus, the perceived personal control construct implies (a) the availability of a coping response and, (b) the perception of the threatening event as capable of modification. Perceived personal control is defined in line with Averill (1973) as the availability of a response to (a) modify the event, and/or (b) modify its threatening characteristics. The availability of perceived control is viewed as the key factor in determining the degree of crisis to be elicited when the individual is exposed to a stressful life event. This construct implies perceived personal control over affective, cognitive, and behavioral variables that mediate between the perception of a hazard and the quality of the coping response. Affective emotional control is the availability of natural and organized support systems to regulate and monitor the individual's adaptation work. Cognitive control is the accessible information coupled with the person's share in the decision making process. Behavioral control is designated as active participation and task oriented activity in the handling of the stressful event. For purposes of clarification, adaptive coping patterns of the mother
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of the premature baby are differentiated on cognitive, affective, and behavioral levels aimed at enhancing her perceived personal control. In reality, however, these processes are interrelated and overlapping. Adaptive coping patterns on the affective level. The availability of a supportive "social surround" is a prerequisite to attaining perceived control on the affective level. The social surround consists of (a) natural supports, namely, the husband and other family members, (b) organized supports, namely, medical caregivers and veteran mothers of premature babies, who share with the new mother her concerns and hopes with respect to the baby's chances of survival. The availability of a network of natural and organized support systems will secure the accomplishment of the following tasks: (a) reality-oriented appraisal of the baby's condition, yielding moderate to high anxiety level regulated by incoming information., (b) active exploration of reality-based evaluation which prevents excessive use of denial defenses with periodical withdrawal and rest periods; (c) periodical engagement in anticipatory grief regulated by incoming information about the baby's chances of survival; (d) acknowledgement and free expression of negative feelings likely to be triggered by the premature delivery, such as failure, frustration, guilt, anger, fear that the baby may die, or be handicapped; (e) revelation of strong maternal feelings towards the baby coupled with considerable protest at being separated from the baby; (f) open expression of fear in handling such a tiny baby; (g) expressing a hopeful expectation and a positive outlook based on the experiences of other mothers of premature babies that have successfully mastered the predicament, as well as on daily progress reports on the baby's condition; (h) safeguarding the quality of the relationships with other members of the family in spite of the present predicament; and (i) overcoming blame and guilt feelings by active intervention of the "social surround." Adaptive coping patterns on the cognitive level. The mother of a premature baby has to acquire a realistic appraisal of the situation. Perception of objective assessment of the baby's health state is acquired by the following activities: (a) active exploration of reality issues; (b) continuous search for new information, and by keeping the problem in consciousness; (c) re-evaluation of the baby's condition with the acquisition of updated information; (d) information gathering with respect to the objective reason of the premature birth, likely to enable the mother to ascribe the cause of premature delivery to objective factors excluding the need to resort to self-blame or blame of others; (e) acquisition of updated progress reports with respect to the health state of
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the baby, likely to facilitate the acknowledgement of the turning point in the baby's chance for survival in order to resume relationship with the baby; and (f) understanding of the specific needs of the premature baby, allowing energy to be consistently directed to find a solution and formulating a detailed plan of action that is likely to be instrumental in dealing with the current predicament. Adaptive coping on the behavioral level. Tension reduction is achieved by active participation and task oriented activities: (a) frequent visits to the intensive care nursery (ICN). (Visiting patterns were found to be an excellent index of the whole area of task accomplishment and best predictor with respect to the quality of motherchild relationship; (b) handling, fondling, feeding, talking, performing physiotherapy, and actively participating in the care of the baby; (c) actively invoking help from others, such as family members, medical caregivers, and other mothers of premature babies; (d) expressing milk for the premature baby and bringing it to the ICN; (e) contemplating explicit detailed plans for the future; and (f) ensuring that daily activities and normal functioning are not impaired by the recent predicament, except periodically because of worsening of the baby's condition. Maladaptive coping patterns on the affective level. Absence of a supportive social surround to share and regulate the adaptation work may result in the following maladaptive practices: (a) avoidance and denial of the predicament or its significance derived from judgment based upon wish-fulfilment rather than reality-based evaluation, producing a low anxiety level and pretended euphoria; (b) avoidance and denial of negative feelings, dealing with them by projection or blame when they do break through; (c) emotional detachment from the baby; (d) expression of self-confidence in caring for the baby out of ignorance of the premature baby's special needs; (e) hopeful expectation based on fantasy and wish-fulfilment; (f) impairment of relationships with other members of family. (The disordered relationship is seen as an attempt to deal with the crisis at the emotional expense of someone else within the family); and (g) tension is reduced by utilization of blame, aggression, and hostility (Caplan, 1960). Maladaptive coping patterns on the cognitive level. Lack of objective appraisal of the situation may result in the following maladaptive practices: (a) the mother welcomes vague reassurance from the neonatologist and bases her appraisal of the baby's health state on wish fulfilment, fantasy, and "misdiagnosis"; (b) the cause of premature birth is ascribed to acts of family members, physicians, or self; (c) unrealistic appraisal of the baby's chances of survival is likely to impair the
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acknowledgement of the turning point in the baby's condition and thus to impede attachment behavior to the baby; (d) misunderstanding of the specific needs of the premature baby is likely to affect the mother's perception of the baby as either a regular baby or one handicapped for life; and (e) excessive utilization of denial is likely to impede plans for the future. Maladaptive coping patterns on the behavioral level. Tension is reduced by hostility and blame and nontask oriented activities: (a) infrequent visits to ICN while the mother is hospitalized and after discharge; (b) lack of handling, talking, or actively participating in the care of the infant; (c) inability to seek or accept help from family members, medical caregivers, or other parents of premature babies. (If advice or help is offered it is likely to be rejected (Caplan, 1960)); (d) no attempts are made to express milk for the baby; (e) preoccupation with the present impedes formulation of plans for the future; and (f) daily activities in other areas of functioning are impaired. Crisis theorists suggest that unhealthy coping patterns are not unavoidable or irreversible and that adaptive coping skills can be acquired by preventive intervention: (a) in the short run, appropriate preventive intervention implemented by obstetricians, neonatologists, and nurses geared to assist the mother of the premature baby in the accomplishment of the specific psychological tasks of premature birth; (b) in the long run, by social action, namely, introducing hospital policies, practices, and structures facilitating not only a positive crisis outcome but also safeguarding bonding between the mother and her premature baby.
The Short Run: Preventive Intervention Implemented by Medical Caregivers The crux of a preventive invervention approach as formulated by Caplan as early as 1960 and which follows as a central theme in his subsequent writing (1964, 1974) lies in its implementation by caregivers in general, and medical caregivers in particular. It is assumed that crisis intervention does not require sophisticated knowledge of psychodynamics of the individual but rather understanding of the current manifestation of crisis and the specific tasks involved. Furthermore, a central role is reserved for the medical caregivers in preventive intervention because they can time adequate intervention to coincide with the peak of the individual's susceptibility, and thus can enhance the quality and the effectiveness of intervention.
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It is also assumed that the manipulation of situational variables, such as support systems (natural and organized), information, a person's share in the decision-making process, and task-oriented activity, makes it possible to enhance the perceived control of the mother and to assist her in the accomplishment of the specific psychological tasks associated with premature birth. The following preventive intervention protocols are implemented by medical caregivers trained in the principles of the PPC model and the specific psychological tasks of mothers of premature babies. Natural support systems. The obstetrician, obstetric nurses, and midwives convene the family, in particular the husband or a supportive other, and guide and encourage them to take an active role in the process. During the confinement period, the obstetrician makes the husband a full partner in the decision-making process with respect to the management of labor and mode of delivery, and encourages him to sustain his wife with his physical presence and emotional support. Furthermore, the husband is guided to assist his wife in the completion of the specific psychological tasks involved in prematurity, and he is encouraged to take an active role in caring for the baby. During the delivery period the obstetrician and midwives encourage the husband (if both parents consent) to participate during the birth process, whether delivery is spontaneous or by caesarean birth. The obstetrician makes provisions for a nurse to prepare the parents for the tasks which lie ahead. Such preparation is particularly important for parents who have not attended childbirth preparation classes. Early contact. The neonatologist shows the baby to the parents at birth and relates general information with respect to the baby's immediate health state. As soon as the mother feels up to it, she is wheeled to the ICN for an early contact with the baby. Information. After thorough examination and necessary medical interventions in the ICN, the neonatologist presents detailed, factual information to the mother most likely to be confined to bed from 6 to 18 hours whether she had a spontaneous or caesarean birth, respectively. The information is objective, consisting of simple unambivalent terminology, aimed at assisting the parents to acquire a realistic appraisal of the baby's condition. The neonatologist, refraining from vague reassurance which reinforces the mother's own tendency to deny and evade reality, explains the objective causes of premature delivery. Thereafter, the neonatologist makes himself available to the parents on a daily basis to provide them with progress reports on the baby's condi-
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tion. In the ICN the parents receive a reference booklet describing the specific problems encountered by premature babies. The obstetrician makes daily calls to the ICN to be updated about the infant's condition and he relates this information to the mother on his daily visits and he encourages her to seek additional information in order for her to be prepared to face all possible outcomes and to reduce anxiety derived from uncertainty. Frequent visits. The obstetrician encourages the mother to make frequent visits to the ICN. On her first visit she is usually accompanied by her partner, an obstetric nurse, or the lactation counselor and she is prepared in advance with respect to the size and the physical appearance of the baby as well as the instruments that the baby may be attached to. Negative feelings. The obstetric medical personnel, as well as the social worker, encourage the mother to acknowledge her negative feelings, to openly discuss feelings of inadequacy, failure, guilt, anger, and frustration, and to see such feelings as legitimate and normal reactions. Support of medical caregivers. The obstetrician, and subsequently the neonatologist, support the mother engaged in anticipatory grief, sustain her in her sorrow, and provide her with reassurance and the positive expectation that she may have the strength and resources to face all possible outcomes with courage. Blame. The neonatologist is aware of the mother's tendency to blame herself or others for her misfortune. Blaming others may be a device instrumental in reducing tension momentarily; however, in the long run, it m a y have adverse effects on the family's chances of mastering the crisis. Consequently, blame is discouraged and counterbalanced by ascribing the causes of premature birth to objective factors. Help. The mother is assisted in the task of admitting that she needs help. The very admittance implies that she has come to grips with reality and now can focus on the special needs of the premature baby. The neonatologist points out her helpers in the family and in the community, and he instructs her as to the kind of help she can expect from them. Express milk. The neonatologist, the nurses, and the lactation counselor encourage the mother strongly committed to nurse her baby, to express milk and bring it to the ICN. They provide the mother with anticipatory guidance with respect to the physical and emotional difficulties that lie ahead in a process which may seem futile at time, since it consists of expressing milk for a baby whose chances of survival m a y
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be slim, and who may temporarily be fed intraveneously with fluids other than milk. The ICN nurses encourage the mother to talk, touch, feed, and actively participate in the care of the baby, and in this way help her in a safe and accepting atmosphere to acquire the skills needed to care for her baby. Special needs. The neonatologist provides the parents with information with respect to the specific needs of the premature infant, such as frequent feedings, special diet, follow-up in the outpatient clinic, etc. However, the neonatologist impresses upon her that the extra care prescribed is temporary and that eventually the baby is likely to become a regular baby. Turning point. The neonatologist assists the parents to identify and acknowledge the turning point in the baby's health condition. The completion of this task will set in motion the resumption of the attachment process and enhance the quality and intensity of the relationship with the baby. Support of a veteran. The obstetrician summons a mother who has successfully mastered the specific tasks of dealing with her premature baby to visit the new mother, to support, and share with her the commonality of their plight. The "veteran" is instructed to provide anticipatory guidance in the process of mastering the predicament and to place special emphasis on the following tasks: 1. Prepare her for the ups and downs in the baby's condition even after the turning point and for the fears and anxieties triggered by constant uncertainty and doubts. 2. Alert her to the possibility that attachment, especially after the baby is brought home, may be artificial at first, and that this is normal finder circumstances of prolonged separation. Eventually, it is expected that bonding will proceed and take its normal course. 3. Impress upon her that once at home, she may develop an unprecedented sense of obligation in caring for the premature baby, derived from a sense of guilt for failing to produce a full-term baby. The seemingly miraculous survival of the baby, may add further to the mother's sense of special obligation. This sense of having to "make up to him or her" is likely to disappear gradually, turning into a sense of pride and accomplishment as the baby gains weight and is perceived as a regular infant. 4. Raise awareness with respect to the emotional and physical difficulties which lie ahead in embarking on an adaptive course. On the emotional level, consciousness of the problem and facing it with courage are not easy undertakings, nor are the frequent visits to the ICN at
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a time when the baby's chances of survival cannot be guaranteed. These tasks can hardly be accomplished without the support of the family and medical caregivers. On the physical level, frequent visits to the ICN, long waits to get to talk to the pediatrician, or to be allowed access into ICN, and frequent expressing of milk, present additional burdens for the family of the premature baby. These difficulties, stemming from an adaptive and active coping pattern, are immensely reduced by anticipatory guidance. According to testimonials of mothers of premature babies guided on this path, the emotional turmoil is minimized by the mere fact of knowing what to expect and what to do at a time of great emotional distress and confusion. Preventive Intervention in the L o n g R u n : Social A c t i o n
Social action with respect to premature birth involves adopting hospital practices, services, and structures to safeguard a positive crisis outcome and to facilitate bonding between the mother and her premature baby. The implications of this proposition are threefold: 1. The ICN should be located in the same building and preferably on the same floor with the maternity department to enable (a) early and frequent visits to the ICN by the mother, who most likely has undergone caesarean birth which curtails her mobility; (b) a continuous flow of information from the neonatologist to the mother; and (c) opening channels of communication between the neonatologist and the obstetrician about the infant's health state. 2. The design of the ICN should be such as to promote close and prolonged contact between the premature baby and its parents. Such a design will have to give up the "large room design," in order to foster the necessary prolonged contact with parents, uninterrupted by medical attention given to any other infants on the floor. 3. The neonatologist and the social worker should encourage the formation of organized support groups of mothers of premature babies who have mastered the crisis successfully. When needed, support group mothers can be summoned to visit new mothers encountering similar predicaments so that these support mothers can offer assistance and anticipatory guidance in the process which lies ahead. The support mothers also can organize weekly meetings with parents of premature babies, staff, and veterans for purposes of sharing, support, and guidance. In conclusion, premature delivery is likely to be perceived as an uncontrollable event. Once the premature contractions cannot be re-
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strained with medication, or once the obstetrician decides that it is in the best interest of the mother's or child's health to initiate delivery, premature birth has to proceed as scheduled. Its threatening characteristics, however, can be greatly reduced, and its emotional sequelae greatly minimized by utilization of preventive intervention, implemented by natural and organized support systems, as well as by introducing policies, services, and structures conducive to securing a positive crisis outcome.
References Averill, J.R. (1973). Personal control over aversive stimuli and its relation to stress. Psychological Bulletin, 80, 286-303. Caplan, G. (1960). Patterns of parental response to the crisis of premature birth. Psychiatry: Journal for the Study of Interpersonal Processes, 23, 365-373. Caplan, G. (1964). Principles of preventive psychiatry. New York.. Basic Books. Caplan, G., Mason, E.A., & Kaplan, D.M. (1965). Four studies of crisis in parents ofprematures. Community Mental Health Journal, 1,149-161. Caplan, G. (1974). Support systems and community mental health: Lectures on concept development. New York: Behavioral Publications. Fanaroff, M.B., Kennell, J.H., & Klaus, M.D. (1972). Follow-up the predictive value of maternal visiting patterns. Pediatrics, 49, 287-290. Fontana, V.J. (1980, January). Child abuse: Prevention in teen-age parent. Journal of Medicine, pp. 53-56. Hertzel, B.S., Bruer, B., & Poidevin, L.D.S. (1961). A survey of the relationship between certain common antenatal complications in primiparae and stressful life events. Journal of Psychosomatic Research, 5, 175-182. Hunter, S.R., Kilstrom, N., Kraybill, E.N., & Loda, F. (1978). Antecedents of child abuse and neglect in premature infants: A prospective study in a newborn intensive unit. Pediatrics, 61,629-635. Kaplan, D.M. (1961). Observations on crisis theory and practice. Social casework, 151-155. Kaplan, D.M. & Mason, E.A. (1960). Maternal reactions to premature birth viewed as an acute emotional disorder. American Journal Orthopsychiatry, 30, 539-552. Klein, M., & Stern, L. (1971). Low birth weight and the battered child syndrome. American Journal of Disease Children, 122, 15-18. Lazarus, R.S. (1968). Emotions and adaptations: Conceptual and empirical relation. In W.J. Arnold (Ed.), Nebraska Symposium on Motivation, Lincoln: University of Nebraska Press. Mason, E.A. (1963). A method of predicting crisis outcome for mothers of premature babies. Public Health Reports, 78, 1031-1035. Prugh, D.G. (1953). Emotional problems of the premature infant's parents. Nursing Outlook, 1,461-464. Stern, L. (1973, May). Prematurity as a factor in child abuse. HospitalPractice, 117-123. Tadmor, C.S. (1984). The perceived personal control crisis intervention model. Training of and application by physicians and nurses to a high risk population of caesarean birth in a hospital setting. Unpublished doctoral dissertation, The Hebrew University, Jerusalem, Israel.
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Tadmor, C.S., & Brandes, J.M. (1984). The perceived personal control crisis intervention model in the prevention of emotional dysfunction for a high risk population of caesarean birth. Journal of Primary Prevention, 4, 240-251. Tadmor, C.S., Brandes, J.M., & Hofman, J.E. (in press). Preventive intervention for a caesarean birth population. The Journal of Preventive Psychiatry. Wortis, H. (1960). Discussion. American Journal of Orthopsychiatry, 30, 547-552.
