Defense Mechanisms Used by Adolescents with Premature Babies in Neonatal ICU¹

Abstract:

Adolescent motherhood, in the context of neonatal hospitalization, causes the health professional to need to understand the specificities of this phase of the life cycle and peculiarities of the mother-hospitalized baby dyad. This study aims to analyze life experiences in the puerperium of first-time adolescent mothers with premature babies hospitalized in the neonatal ICU. We use the Clinical-Qualitative Method, with intentional sampling, in 7 adolescents aged between 13-19 years old. Semi-directed interviews were used and the data underwent thematic analysis and are discussed in a psychodynamic approach. We observed that to deal with the conflicting feelings of omnipotence, affliction, ambivalence, estrangement, shock, confusion, surprise, anger, fear, sadness, anguish, pain, guilt, joy and affection, these adolescents used primitive defense mechanisms: denial, dissociation, splitting and idealization, which are inefficient and require great expenditure of psychic energy. Identifying these defense mechanisms is fundamental to an appropriate therapeutic formulation.

Keywords:
puerperium; adolescent pregnancy; premature birth; defense mechanisms; qualitative research

Resumo:

A maternidade entre adolescentes, no contexto de internação neonatal, traz ao profissional de saúde uma demanda de compreensão sobre especificidades desta fase do ciclo vital e peculiaridades da díade mãe-bebê internado. Este artigo teve por objetivo explorar as vivências no puerpério de adolescentes primíparas com bebês prematuros internados em UTI Neonatal. Utilizamos método clínico-qualitativo com amostragem intencional fechada pelo critério de saturação. Aplicamos entrevistas semi-dirigidas em sete adolescentes entre 13 e 19 anos. Os dados foram tratados por análise temática de conteúdo e discutidos em referencial psicodinâmico. Na composição das categorias constatamos que para lidar com os sentimentos conflitantes de onipotência, aflição, ambivalência, estranhamento, choque, confusão, surpresa, impotência, medo, tristeza, angústia, dor, culpa, afeto e alegria utilizaram mecanismos de defesa de natureza primitiva: negação, dissociação, divisão (splitting) e idealização, que são ineficazes e exigem grande dispêndio de energia psíquica. A identificação desses mecanismos de defesa é fundamental para uma adequada formulação terapêutica.

Palavras-chave:
puerpério; gravidez na adolescência; nascimento prematuro; mecanismos de defesa; pesquisa qualitativa

Resumen:

Maternidad adolescente en contexto hospitalario neonatal aporta una comprensión de la demanda de profesionales acerca de características específicas de esta fase del ciclo de vida y peculiaridades de la díada madre-hijo hospitalizados. Este artículo objetivó Analizar las experiencias adolescentes primíparas posparto con bebés prematuros. Utilizamos método Clínico-cualitativo con muestreo intencional cerrado por criterio de saturación, compuesto por 7 adolescentes de 13 a 19 años. Las entrevistas semi-dirigidas y tratamiento de datos fue tomada através de análisis de contenido temático, discutido en enfoque psicodinámico. En la composición de categorías se encontró sentimientos contradictorios de omnipotencia, angustia, ambivalencia, extrañamiento, shock, confusión, sorpresa, impotencia, miedo, tristeza, angustia, dolor, culpa, el afecto, alegría y los mecanismos de defensa utilizados que son de naturaleza primitiva: la negación, disociación, división y la idealización, que son ineficientes y requieren gran gasto de energía psíquica. La identificación de estos mecanismos de defensa es fundamental para la formulación terapéutica adecuada.

Palabras clave:
puerperio; embarazo em adolescencia; nacimiento prematuro; mecanismos de defensa; investigación cualitativa

This article aims to shed light on the feelings and defense mechanisms experienced in the puerperium by first-time adolescent mothers whose premature babies were hospitalized in a Neonatal Intensive Care Unit (NICU), with a view to substantiating prophylactic measures in the psychological treatment provided to this population. The initial premise was that the birth of premature babies would cause a major emotional impact on these young mothers’ psyches, due to the unexpectedness of the situation and the adolescents’ unpreparedness for the demands made, given that this is a situation in which three points of emotional stress converge: adolescence itself, motherhood, and hospitalization in a neonatal unit.

Being the mother of a premature baby hospitalized in NICU is a condition associated with emotional stress (Baía et al., 2016; Nardi, Rodrigues, Melchiori, Salgado, & Tavano, 2015), which may give rise to feelings of despair, impotence and frustration (Al Maghaireh, Abdullah, Chan, Piaw, & Al Kawafha, 2016). Ncube, Barlow and Mayers (2016) emphasize that in the NICU, the bonds between mothers and children may be compromised and increase maternal anxiety. The premature baby who is receiving medical care is distanced from the child who was idealized throughout the pregnancy, which may cause the mother negative feelings of sadness, stress and even rejection (Wust & Viera, 2011). Motherhood among adolescents, in the context of hospitalization in a neonatal unit, causes the health professional a need to understand which encompasses specific characteristics arising from this phase of the lifecycle and specific features of the mother-hospitalized baby dyad.

For the World Health Organization (World Health Organization, 2012), pregnancy and motherhood in adolescence are phenomena which impact the adolescent’s life trajectory in regard to physical, psychic and social aspects, this being presented by the Ministry of Health (2007) as a public health problem - because it represents psychosocial and health risks to mother and child health. In one descriptive study on pregnancy in adolescence and outcomes of birth or miscarriage in 49 countries, the authors indicate that the highest rates of birth among pregnant adolescents occur in underdeveloped countries of sub-Saharan Africa and in Mexico (Sedgh, Finer, Bambolê, Eilers, & Singh, 2015). In Brazil, data from the Brazilian Institute of Geography and Statistics [IBGE] (2015) estimate that the participation of women aged between 15 and 19 years old in the country’s fertility rate is of 17.4%, a percentage which continues to be considered high.

From the biomedical point of view, some studies have associated pregnancy in adolescence with an increased risk for the occurrence of premature labor (Kawakita et al., 2016; Kirbas, Gulerman, & Daglar, 2016; Minjares-Granillo, Reza-López, Caballero-Valdez, Levario-Carrillo, & Chávez-Corral, 2016; Thomazini, Wysocki, da Cunha, da Silva, & Ruiz, 2016). In one multicentric study on perinatal results among adolescent mothers, including 29 countries of Latin America, Asia, Africa and the Middle East, the babies presented the highest risk for severe neonatal conditions (Ganchimeg et al., 2014).

Motherhood, besides being a biological-reproductive occurrence, is also a psychosocial phenomenon that has repercussions in the development of adolescents in a striking manner. An adolescent female may be or feel emotionally immature to take responsibility for the care necessary with her baby, experiencing insecurity, difficulties and lack of skills for exercising the role of mother that - added to the lack of knowledge on child development - can cause a situation of vulnerability for the child (Dias & Teixeira, 2010). Rebelliousness, worries, fear and insecurity are some of the feelings common to these mothers, given that they pass through important processes in this life phase (Chagas & Monteiro, 2007; Mazzini, Alves, Silva, & Sagim, 2008). In this period, it is necessary to deconstruct the child identity to create space for the other identity. They experience the so-called “mourning” of adolescents for the loss of their child body, of the parents of childhood and of the identity as a child (Matos & Lemgruber, 2017), which may be overcome when the young person receives support (Dias & Teixeira, 2010).

Studies undertaken in Brazil on pregnancy in adolescence confirm the international literature in relation to the biological, emotional, family and economic implications that affect the adolescent in isolation and society as a whole (Andrade, Ohara, Borba, & Ribeiro, 2015; Ganchimeg et al., 2014; Oliveira-Monteiro, Freitas, & Aznar-Farias, 2014). The data indicate that, in Brazil, 67% of adolescents with a child interrupt their studies without finishing Senior High School (IBGE, 2013). Another study on factors associated with pregnancy among low income adolescents indicated that pregnancy in adolescence is associated with living with the partner, using the contraceptive pill, initiating sexual activity at a young age, consumption of alcoholic drinks and lesser division of domestic tasks in the family (Diniz & Koller, 2012).

It is important to take into account, however, a socio-anthropological dimension of pregnancy in adolescence. Heilborn et al. (2002) raise a relevant discussion in relation to the topic when they argue that this phenomenon has been seen as social problem only in recent decades, in spite of pregnancy in this age range between 15 and 19 years old having previously been considered ideal for a woman to have children. It seems to have been the changes which took place in recent decades in the social conception on age and gender which have redefined the social expectations that fall upon these young women. They have the possibility of greater schooling, insertion in the job market and exercising of sexuality uncoupled from the function of procreation, which brings a feeling of “wasting of opportunities” to pregnancy in adolescence - although this argument fails to take into account that social opportunities are not equally distributed among the social classes. Motherhood among adolescents, therefore, is configured as a heterogenous question experienced according to the different experiences of each subject, which indicates the need for studies in the qualitative ambit which may investigate the feelings that surround it.

To this end, we used the psychodynamic framework developed by Freud which refers to the study of the psychological forces which act on human behavior, emphasizing the interaction between the conscious and unconscious motivations (Bowlby, 1999). From this interaction appear the mechanisms of defense, with the aim of reducing the internal psychic tensions, that is, the distresses, as elaborated by A. Freud (1946/1996). These are fundamental for structuring the individual’s personality. However, when used unduly or excessively, these can come to function in a destructuring way. The modality and extent of the use of defense mechanisms in the light of the distresses is what will determine the normality of pathology of the distinct psychic structures.

Method

The aim of understanding the feelings and experiences in the puerperium of first-time adolescent mothers whose premature babies were hospitalized in NICU led us to use a qualitative research method. In this study, we use the Clinical-Qualitative method (CQM) (Turato, 2013), which derives from generic qualitative methods of the Social Sciences for application to the clinical-assistential field, adapted for collecting particular reports in contexts of clinical care.

CQM is based in three pillars: (1) the existentialist attitude, which values distresses and anxieties that are habitually present in human relationships; (2) the clinical attitude, that leads the researcher to lean on the patient, embracing her needs, constructing clinical diagnoses and recommending treatments; (3) the psychoanalytical attitude, which brings concepts of the psychodynamics of the human unconscious to all the phases of investigation (study design, data collection and data analysis). These three points are attitudes of the researchers and serve as a philosophical-scientific stance for investigation in social sciences applied to the contexts of health services.

Participants

The study participants were first-time adolescent mothers who met the following inclusion criteria: to be aged between 10 and 19 years old; to have a premature baby hospitalized in the NICU of a teaching hospital of tertiary or quaternary level, in which the first author was inserted; and not to present limitations of a clinical, intellectual or emotional type which might impair the reliability of the accounts. The inclusion criteria were made up of few items, carefully selected, based on the delimitation of the study object.

Under the principles of the methodological approach, delimiting exclusion criteria becomes unnecessary, in contrast with what occurs in experimental or epidemiological studies. The construction of the qualitative sample is, a priori, indifferent to certain bio-demographic data of the subjects, such as: gender, marital status, educational level, socioeconomic condition, occupation/profession, nationality/origin, religious denomination/religiosity, previous health issues and so on. These do not arrogate, therefore, inclusion or exclusion criteria, because they are not constituted in variables according to the reasoning of causal correlation, typical of the epidemiological/populational strategies or of experimental studies. However, these living conditions are recorded and may gain a connection of meaning in the light of the findings from the interview, maintaining a relationship of symbolic meaning. They are, therefore, considered in the discussion stage - thus avoiding bias in the construction of new knowledges in the social sciences.

The sample was selected intentionally and the number of participants was determined by the criteria of the theoretical saturation of information (Glaser & Strauss, 1999), which means that the interviews were undertaken until the contents presented became repetitive for responding to this study’s objective - that is, no additional data was being found which could contribute to the development of the properties of each category under discussion.

In consensus with senior researchers and colleagues from the research group of the Clinical-Qualitative Research Laboratory, it was considered that sufficient material had been obtained, and with sufficient density, for analyzing the premises raised (Fontanella et al., 2011). In the end, the sample was made up of seven adolescent mothers aged between 13 and 19 years old who - besides providing a satisfactory set of content for interpretation - met the inclusion criteria.

Instruments

For data collection, we used the semi-directed interview, with open questions, and an in-depth approach involving an excerpt of the study object, allied with the observation of the nonverbal language during the interaction (Fontanella, Campos, & Turato, 2006). The interview script included some open questions and bio-demographical data obtained from the participants’ own accounts. The researcher’s observations regarding global behavior and nonverbal language of the participants were recorded in a field diary.

Procedure

Data collection. The data were collected in a teaching hospital of tertiary and quaternary level, of the Unified Health System (SUS), in the nonmetropolitan region of the State of São Paulo, that treats women in the areas of obstetrics, gynecology and oncology; it covers more than 100 cities of the region, corresponding to 5 million people. Over 3800 births for high and low risk pregnant women take place there every year. The neonatal ICU has a routine for daily visiting, in which skin to skin contact between mother and baby and breast-feeding and/or expressing milk is encouraged.

The adolescent mothers were invited to participate in the study when they were in the hospital visiting the babies hospitalized in the NICU, while they were waiting for the neonatology team to clear them for visiting. All had had prior contact with the hospitalized baby and nobody declined to participate.

The interviews were audio-recorded and lasted approximately 50 minutes. They were held by the first author in a private room during the waiting period prior to visiting - prioritizing the participants’ privacy throughout the interview. Firstly, rapport was established through mutual presentation in relation to personal identification data, and the terms of consent/assent were read. The invitation to the adolescents interviewed to speak began with a guiding question: “Tell me about your pregnancy and the birth of your baby”.

Data analysis. The material produced was treated using the technique of thematic content analysis, according to the steps described below. The audio from the interviews was transcribed literally by the interviewer herself in a process conducted concomitantly with data collection. The audio recordings and reading of the written material from the interviews and the field diaries were analyzed using the technique of evenly-suspended attention. Comments and impressions that emerged in this phase were annotated throughout the text itself. The first author then created initial categorizations and subcategorizations of statements that pointed to a single meaning and led them for discussion with research peers, always hiding data which could have identified the participants. The definition of the categories was undertaken exhaustively and meticulously in order to refine the material, which was then validated by other qualitativist researchers (Faria-Schutzer, Surita, Alves, Vieira, & Turato, 2015).

We sought to respect the two principles of clinical-qualitative research (Turato, 2013): the emic character and polysemic character of construction of knowledge in the social sciences. The emic character, introduced by linguists and anthropologists, points out that all scientific understanding of the human phenomenon must come from the perspective of the “insider”. In this case, the methodological validity is rigorous with the perspective of our patients being considered as themselves, without imposition from our part as researchers. In its turn, the characteristic of the polysemy of the qualitative research gave us the freedom to bring the meanings which were presented to us in this particular temporal-spacial excerpt of the clientele who were users of our neonatal triage service, in a specific time period. In the social sciences, it is known that other subjects, in other days and other places, could say different things. In contrast with the Natural Sciences, where the relationships are unambiguous, that is, one seeks causal connections (mathematized cause-effect correlations), in the humanistic focus we know that in the search for connections of meaning, the relations of meanings are necessarily multiple, as the human being attributes various symbols to things, according to the point where she is in her psychological and sociological history.

Ethical Considerations

The study was approved by the Research Ethics Committee of the Universidade Estadual de Campinas (CAAE: 0479.0.146.000-07). All the participants signed either the Terms of Assent (adolescents aged up to, but not completing, 18 years) or the Terms of Free and Informed Consent (adolescents aged between 18 and 19 years old), containing information on the study’s objectives and procedures. For reasons of anonymity, the names of the study participants have been omitted.

Results and Discussion

Table 1 presents the interviewees’ sociodemographic data. The young mothers were referred to the hospital for undertaking prenatal treatment in an outpatient center that specializes in prenatal care for adolescents. Interviewee number seven undertook her prenatal clinical visits in a separate health service.

Table 1:
Participants’ sociodemographic characteristics

Participant	Age	Marital situation	Occupation	Educational level	Lives with who?
1	13	Single	Student	In BE	Parents
2	16	Single	Student	In BE	Mother and stepfather
3	16	Single	Student	In BE	Parents
4	16	Married	Student	In BE	Husband
5	17	Separated	Student	In BE	Mother
6	19	Single	Production assistant	BE incomplete	Father
7	19	Married	Housewife	BE incomplete	Husband

• Note BE = Basic Education (Primary and Junior High School).

In the psychological plane, we identified feelings of omnipotence, affliction, ambivalence, estrangement, shock, confusion, surprise, impotence, fear, sadness, distress, pain, guilt, warmth and happiness. The participants used mechanisms of denial, dissociation, splitting and idealization. They revealed the wish to be good mothers and exercise motherhood, although they did not yet feel themselves to be full-time mothers, due to their babies being in the NICU. This information will be presented and discussed in detail below based on the categories produced: (1) The late discovery of the pregnancy: “My pregnancy was lightning” and (2) The symbolization of the child: “She was a present to me”.

The late discovery of the pregnancy: “My pregnancy was lightning!”

The significant hormonal changes that take place in the face of adolescence provoke, generally, periods of intense physical energy, enthusiasm, fear, worry, rebelliousness, opposition, irritability, moments of depression and sexual sensitivity (Chagas & Monteiro, 2007). To avoid contact with these feelings, frequently, the adolescent puts on omnipotence, which is magical thinking that one can do everything. The adolescent exchanges the use of the capability to think about problems, which would be tiresome, for a magical form which gives her the illusory sensation of well-being and of resolving them through the omnipotence (Zimerman, 2001).

In this psychodynamic context, pregnancy is presented as one of the possible risks, as even when use is not made of contraceptive methods, the adolescent finds it difficult to believe that it could happen to her. Hence the perplexity when the pregnancy occurs and the relative delay in diagnosis of this state: “I discovered that I was pregnant at 12 weeks and it was a surprise” (Participant 1); “I was 20 weeks pregnant … It was a shock for me” (Participant 2); “I was 19 weeks . . . (Participant 3); “I was already 15 weeks pregnant and I had no idea!” (Participant 5); “I was 16 weeks pregnant and didn’t know at all” (Participant 7).

To carry a baby in one’s womb for 4 - 5 months and not notice the bodily changes that this entails suggests the use of a mechanism of denial. This mechanism is characterized by avoiding awareness of aspects of physical reality which are difficult to face, neglecting sensory data (Gabbard, Beck, & Holmes, 2007). These adolescents seem unconsciously to deny the pregnancy, in order to avoid entering into contact with a fact which could provoke in them - in principle - fear due to the unexpectedness of the situation and its consequences.

According to Mazzini et al. (2008), the denial of the possibility of being pregnant is a predominant factor in adolescence. However, if the pregnancy occurs, it is because there existed in the adolescent (woman) an unconscious desire to become a mother, regardless of whether the discourse manifested is compatible or not with this motivation. As the desire does not belong to the sphere of the conscious, an interplay occurs between the will (conscious) and desire (unconscious), which can result in pregnancy (Szejer & Stewart, 2002). Pregnancy does not occur by chance - the woman may conceive a child without having wished for this consciously, as the call from her body, her unconscious wish for fertility was inscribed in herself, without her having any perception of this (Tachibana, Santos, & Duarte, 2006). One can infer, therefore, that the unconscious desire for motherhood blooms in these adolescents along with the awakening of sexuality.

Another point which calls our attention is that the adolescents did not perceive themselves as women capable of reproducing, as the following accounts suggest: “We only did it once!” (Participant 7); “We were not having sex much.” (Participant 5). This may involve a denial of oneself as a woman and also the technique of dissociation, which causes the exercising of sexual activity and the possibility of the occurrence of pregnancy to be perceived as separate phenomena. This mechanism consists of destroying the meaning of continuity in the areas of identity, memory, consciousness or perception as a way of maintaining the illusion of psychological control in the light of the lack of support and loss of control (Gabbard et al., 2007). Through the mechanism of dissociation, these adolescents kept the fact that they were having sexual relations and that they perceive themselves as women capable of becoming pregnant far from their consciousness. It may be supposed that, for various motives specific to each one of them, it was not possible to consciously verbalize the desire to become pregnant.

Nevertheless, one can infer that unconsciously the pregnancy was wished for, although not planned, and ended up happening through the process of acting out. This psychological process substitutes certain repressed desires and feelings in acts and motor actions (Zimerman, 2001). In this case, one can presume that they pass from a representation, idea, yearning or desire, compartmentalized through the mechanism of splitting, to the act per se: “He is my first boyfriend, and what I failed to prevent happened, you know?” (Participant 3); “I didn’t think anything, and it happened!” (Participant 7). When the individual is confronted with the contradictions in her behavior, thoughts or feelings, she faces the differences with a mild denial or with indifference. This defense stops the conflict originating from the incompatibility of two polarized aspects of the self or of the other (Gabbard et al., 2007).

These adolescents’ accounts also point to a certain ignorance of their own body which may be in the service of this process of denial. It seems that the perception of the first signs of pregnancy requires a certain time (Brandão & Heilborn, 2006), not being an immediate deduction that occurs after a single unprotected sexual act: “I used to do ballet, I stopped, and I thought I was getting fat because of that.” (Participant 2); “My menstrual cycle was one month yes, one month no” (Participant 4); “I was on a diet . . . I was taking medications.” (Participant 7).

Analyzing the interviews, some aspects stand out: sporadic sexual relations, not always with the same partner, diets for losing weight through ingesting medications, provoking fluctuations in weight, irregular menstruation and loss of blood, mistaken for menstrual cycles. These aspects made it difficult to perceive bodily changes, directly influencing the late discovery of the pregnancy, causing this point to be loaded with intense emotions of estrangement and fear related to the baby: “And the fear that I had of something happening to him” (Participant 3); “I was frightened, I thought that he would die” (Participant 5); “It was strange, I was scared of something happening to him, as a result of discovering about this so late.” (Participant 2). The fear of something happening to the baby seems to point to a feeling of guilt for the unconscious denial of maternity. In this case, the premature illness and hospitalization of the baby was seen as punishment: “I know that it was a thing that happened and that should not have happened” (Participant 3); “I was so terrified that I thought it would be better if he was not born, but afterwards regretted that, and what if he died?” (Participant 7).

Pregnancy is a time of crisis, as it is permeated with unpredictability, to the extent that traumatic events can occur such as the birth of a premature child. In the context of the NICU, negative feelings and stress experienced by the mothers of the hospitalized babies are the main reasons for which deferral takes place of the transition to motherhood and the exercising of their parental functions (Al Maghaireh et al., 2016). The late discovery of the pregnancy, “My pregnancy was lightning, it was only 2 months!” (Participant 2), as well as premature birth, “he was born at 24 weeks . . .” (Participant 1); “He was born at 29 weeks . . .” (Participant 3); “He had 24 weeks . . .” (Participant 4), seems to have left little time for these young women to prepare themselves psychologically for the arrival of their first child, which may have been strengthened by the hospitalization in the NICU.

On the other hand, the account: “I planned everything to have a perfect pregnancy” (Participant 6) shows that this adolescent expected everything to take place as planned, without giving any space for the unimaginable. She did not think that anything could escape her control, such as the premature birth and the gastroschisis in the baby: “I was not prepared” (Participant 6).

In the lifecycle of women, four critical periods of transition occur: adolescence, the first sexual relations, pregnancy and menopause - which cause complex changes requiring the need for adaptations, interpersonal readjustments, intrapsychic readjustments, and change of identity. For these adolescents, the process of pregnancy seems to have been experienced as a time of crisis that went beyond the normal crisis of adolescence (Aberastury & Knobel, 1981), as it includes motherhood. They stopped being daughters in order to become women and mothers of premature babies who required special care in order to survive: “She was so little and thin!” (Participant 5); “He had to be intubated.” (Participant 3); “He was born weighing 750g!” (Participant 4).

In this case, the baby’s premature birth triggered feelings of sadness and ambivalence, which seemed to be associated with the defense mechanism of splitting: “I get very sad, when I am at home with my head here, and my body there” (Participant 2); “I go home, but part of me stays here. Does he feel scared of being left alone?” (Participant 7). It is important to emphasize that the parents’ perception about the baby’s admission to NICU may be influenced by the hospital environment (Al Maghaireh et al., 2016), particularly among adolescent mothers, which relates to the quality of the team’s care in relation to the parents of the babies. In this regard, the health team and the mother’s adaptation to the hospital routine may contribute to the demystification of the perception of a baby who is very fragile (Marchetti & Moreira, 2015).

Generally speaking, in adolescence, one makes plans for the future and sets up goals and objectives. For these adolescents, this period seems to have been permeated by feelings of intense affliction. The descriptions above express pain in relation to the impossibility of being with the child and the feeling that it is not possible - in a context such as that of hospitalization - to be whole in any other place.

The symbolization of the child: “She was a present for me …”

According to Folle and Geib (2004), symbolically, the maternal care is anchored in the emergence of the family and in the commitment to the child’s biopsychosocial development. This is constituted in a set of actions that should provide conditions to the child to develop well. The account: “My stress is not being able to hold him, breast-feed him like the other mothers do, having to leave, and leave him here . . .” (Participant 3) is configured as an affirmation of motherhood and the desire to process motherhood. Equally, the affect found in the accounts: “She was a present for me!” (Participant 2); “She is a present from God in my life” (Participant 3); “I prayed every day to be able to take care of my child” (Participant 4), indicates these adolescents’ desire to be good mothers and to care for their children well. They show a wish to continue with life, in which distresses and difficulties weigh on them that the task of being the mother to a premature baby will entail: “It will be difficult to care for him when he comes home” (Participant 5). This process is perceived as omnipotence and is easily substituted with impotence.

Motherhood consists of a commitment of the person to herself even in the expectation of preserving self-preservation. The feeling experienced through the experience of motherhood is related to a natural narcissistic desire, as pregnancy, the fruit of the instincts of life and love, would be a way of feeling oneself to be recognized, as well as seeing a commitment with immortality through a fruit which is “one’s own” (Mackey & Tiller, 1998). However, these young women do not yet feel that they are full mothers, as the hospitalization of their babies stops them from feeling as they would like to: “I’m not being able to be a mother completely!” (Participant 7).

Paradoxically, when they imagine the mother-child relationship after hospitalization, they say “I will take care of her!” (Participant 2); “I am going to do everything I can for my child!” (Participant 5). The expectation of the context of leaving the NICU suggests that this time is supported psychically by the mechanism of idealization, in which the notion permeates that, after hospitalization, they will do everything and be everything, marking a possible omnipotence of motherhood. This mechanism, which consists of attributing perfect or nearly perfect qualities to the situation that they will face (Gabbard et al., 2007), leads us to think that from the initial negation comes the idealization of how everyday life will be with their babies, as even the adolescents who are still kept by their parents, and who, because of this, may have restrictions, imagine a future of exclusivity for their children, as if, in this phase, there were a state of external pregnancy where both - mother and child - will be wrapped by an imaginary placenta.

S. Freud (1899/1987), on discussing the dynamics of the mental apparatus, stated that when reality is too difficult, the defensive mechanisms of the ego are condemned to falsify the internal perception and give an imperfect and deformed representation of reality. Nevertheless, the defensive conducts are not exclusively pathological, and normally contribute to adjustment, adaptation and balance of the personality. All the defense mechanisms require expenditure of psychic energy. However, the mechanisms considered most mature are those that require the least expenditure of energy, to the extent that they are successful and generate the cessation of that which is rejected. At the same time, the mechanisms considered primitive require great expenditure of energy through the repetition or perturbation of the process of rejection. Negative feelings and stress are the main reasons for which there occurs a deferral of the transition to motherhood and the exercising of their parental functions among mothers of babies in NICU (Al Maghaireh et al., 2016).

The puerpural experience of these young mothers was marked by the suffering and by the need to rethink life based on new perspectives, which include responsibilities for a child - for which responsibilities they were not prepared. They had a troubled and little-elborated pregnancy, due to the sudden and late discovery and to the premature birth. The prematurity of the babies stopped them from performing motherhood full-time as they wanted to, and the hospitalization and medical care required had a strong psychological impact on them. One can perceive, in the accounts of the adolescents interviewed, that the symbolical representation of a woman’s body submitted to other conditions of age and of psychosocial roles does not appear. These are girls who are made into women prematurely, who will have to elaborate the losses of adolescence and construct another identity in which care for the child will have to be prioritized, as the unconscious desire for motherhood was made real through the “present” which came into the world. At this point in their lives, this experience indicated meanings of impotence for managing the emotional demands caused by the situation, using primitive defense mechanisms which expend much psychic energy.

The knowledge produced based on this study may contribute to the management that the profession will be able to carry out among adolescent mothers whose babies are hospitalized in NICU. Knowing the defensive style of these first-time adolescent mothers with premature babies is fundamental for appropriate therapeutic formulation in the ambit of psychology, which permeates the medical condition within the context of a highly specialized hospital and which may contribute to the psychic elaboration of the adolescent in a more mature way.

As it arises from qualitative methodology, this study has limitations in the sense of presenting a point of view in the light of various possibilities of approach regarding the question presented here. Besides this, as it is a cross-sectional study, the participants were interviewed at a specific point in their lives in which various conflicts could arise in the intrapsychic and interrelational spheres, which directly affected the results presented here - although they do not remove their validity.

It is suggested that further studies could consider the experience of the partner of the adolescent mother regarding fatherhood and the hospitalization of the baby in NICU, or on psychological aspects of the health team that receives the baby and adolescent mother. Furthermore, a longitudinal monitoring of these young mothers over time could reveal new understandings on the complex phenomenon of pregnancy in adolescence.

Referências

• Aberastury, A., & Knobel, M. (1981). Adolescência normal: Um enfoque psicanalítico (S. M. G. Ballve, Trad., 10a ed.). Porto Alegre, RS: Artmed.
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  » https://doi.org/10.1111/jocn.13259
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  Support: São Paulo Research Foundation (FAPESP, process nº 2008/09536-2).

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  How to cite this article: Chvatal, V.L.S., Vasconcellos, J.F.J, Rivoredo, C. R. S., & Turato, E. R. (2017). Defense mechanisms used by adolescents with premature babies in neonatal ICU. Paidéia (Ribeirão Preto), 27(Suppl.1), 430-438. doi:10.1590/1982-432727s1201708

Publication Dates

• Publication in this collection
  Dec 2017

History

• Received
  21 Mar 2017
• Reviewed
  15 Sept 2017
• Accepted
  18 Oct 2017