Various Therapy Principles For Working In The Prenatal Care Unit and Neonatal Intensive Care Unit

Various Therapy Principles For Working In The Prenatal Care Unit and Neonatal Intensive Care Unit


This paper demonstrates various therapy principles based on clinical experiences when working with high risk pregnant women in Prenatal Care, and premature babies, and their mothers in the Neonatal Intensive Care Unit (NICU). The development of these principles are based on the work of a variety of theorists and clinicians who have comprehensive knowledge studying on the early relationship between high risk pregnant women and their babies from the womb to birth in the NICU.

Keywords: principles, combinations, early relationship, pregnant, NICU

Being pregnant for many women and their families who are ready to be parents is an extremely exciting circumstance. For some women, their pregnancy and delivery process become the most unique and magic experiences in their lives. However, for some high risk pregnant women in Prenatal Care, this process could be an extremely long journey that is full of mixed feelings: there is hope, imagination and excitement for the baby, but there is also anxiety, tears, fear, loneliness, frustration, depression, unstable and unpredictable medical situations related to the pregnant woman and her baby, as well as guilt involved when a woman is hospitalized for months in Prenatal Care, or when her new born baby is admitted to the Neonatal Intensive Care Unit (NICU).

In order to work with these populations, my main belief and goal is to assist the patient creates a safe and relaxing physical and mental environment for them to better cope with their current difficulties. To reach this goal takes a number of steps and a trusting therapeutic relationship between the patient and music therapist. I provide the following illustrations:

Instead of working based on a pre-set agenda, understanding patient’s medical and psycho-social situations assists therapist to work flexibly at that moment in every single session

I believe that a therapist who works in intensive care units should have a strong awareness of his/her patient’s medical history before starting the session, and be flexible during each session according to the patient’s current medical and psychological situation. It happens in the NICU when the baby’s medical situation is stable five minutes before the therapist starts the session, but suddenly become unstable and critically ill due to apnea or bradycardia; or the pregnant woman suddenly begins experiencing severe contractions and must deliver the baby. Therefore, before entering the room and meeting the patient(s), the therapist should go through the patient’s medical chart, meet with her doctors, nurses and social workers to gather as much precise information about the patient’s current situation in order to deal with any potential emergency situation. Furthermore, Instead of establishing a pre-set agenda before the session, flexibility is highly recommended for the therapist when working with these patients due to propensity for sudden and unpredictable medical changes during the session. The therapist should be aware of what is happening in the present and be in the moment for the patient during every session.

Therapist should help the patients be aware of their defense mechanisms and facilitate patient to develop self-acceptance and self-actualization
In these units, the strongest feelings I sensed from the patients are guilt, frustration and fear when working with high risk pregnant women and their babies in the NICU. And I believe that unpredictable medical situations due to a variety of these patients’ health issues and past life experiences are the main reasons. Therefore, after having a comprehensive understanding of the patient’s medical and psycho-social history, it is important that the therapist be aware of the patient’s defense mechanisms, which may come from past experiences or current difficulties, in order to build up a therapeutic relationship with the patient. Goble (1970) described: “The successful therapist must help the individual to a greater ability to satisfy the basic needs, thus, move the individual up the path towards self-actualization.” (p.83). I believe that when the basic physical needs, such as air, water, food, sleep, sex are met by the pregnant women, the next vital step is for them to be aware of their defense mechanisms with the therapist and later acquire self-acceptance to feel safe and less fearful in the intensive care unit.
There are many times I hear from patients in Prenatal Care expressing their feelings of doubt and angry about themselves with statements such as: “Why is it that other people do not have to go through this painful situation? Why do I have this problem when others can smoothly go through a nigh months pregnancy?” Or “Why do I have this critically sick premature baby who has been in the NICU for six weeks? I did all I can do but it did not work!” Unlike most of women who deliver a full term healthy baby, when working in the NICU with the mother of a premature baby, I can barely hear the mother say: “This is my baby.” I consider this as defense mechanisms. As Luborsky, Landry and Arlow (2008) asserted that: “Defense Mechanisms are an automatic form of response to situations that arouse unconscious fear or the anticipation of ‘psychic danger’. Examples of common defenses include avoidance and denial” (p17). And it is a fairly complex feeling for the mother to face the reality that she had delivered a premature baby because the baby she is seeing now is not the baby she expected when she was pregnant. As Charpie (2002) stated: “There will be unimagined challenges to be faced. First there is the prior relationship to an imaginary child, and then there is the appearance of the real child” (p.31). Many mothers take a long time to accept that they have a baby that does not look as beautiful and healthy as they have been imaging. When situations arise like this, it is important for the mothers to realize their resistance of being who they are in reality, as well as to understand that every individual is different and even if she does all she can do, things may still come unexpectedly.
It is also understandable that the patient may have guilt, anxiety, or shame for considering what she has done in the past maybe causing her current difficulties, and the main purpose of working with these feelings towards self-acceptance is to reduce the risk of immediate medical influences by these feelings such as hypertension or preeclampsia for pregnant women; or for creating a bonding relationship for the mother and her new born baby in the NICU. As Lowry (1973) observed: “Mothers can accept their own human nature with all its shortcoming, with all its discrepancies from the ideal image, without feeling real concern” (p.183). When therapist and patients work through these feelings, and when the patients accept and respect themselves as who they are, as well as what they have done in the past, these feelings will be eliminated and thus reduce their medical fragility.

Therapist should be aware of countertransference and work on not taking things personally in order to better work with the patients
To work in the NICU means working with the whole unit in every single session, and privacy in the session is a luxury for both the therapist and the patient. In each room of the unit, in St. Luke’s hospital for example, there are typically eight to ten babies. And there are always stressed out parents; busy doctors; nurses; social workers, sick babies, who might cry constantly due to a variety of reasons; therapist; visitors; as well as the monitors attached to each baby, which might be beeping constantly in the room. All these individuals are either directly or indirectly involved to the session with the therapist. I believe that to work in this unit is to provide the service to the whole unit all the time.
When so many stressed out people are involved in a session, it causes some problems such as some doctors will come and observe the session and provide positive or negative judgments of the music you played; or the baby’s heart rate or respiratory rate suddenly become unstable when therapist is singing and playing music to try to sooth him/her; and the baby’s mother gives you a look like you are having a negative impact to her baby; or sometimes in Prenatal Care, the patient who you have had many wonderful sessions before suddenly refuses to have session for two weeks, or a friendly patient in a session throws lots of anger towards you, etc. To be a therapist who encounters these problems, first of all, it is a vital to hold principle that I apply: Very few things happen because of you. It requires the therapist to be aware of his/her countertrasference, and work on not taking things personally. Sandler (1987) demonstrated: “The best route to an understanding of the countertransference is by scrutiny of the problems encountered, especially via self-analysis of the analyst’s reactions” (p.117). I believe that what other people do or say is consciously and unconsciously based on their own feelings: anger, frustration, anxiety, insecurity, or joy, appreciation, and other emotions. When problems occur based on these feelings, to understand that these are simply projections according to other individuals’ belief systems of their own reality which have nothing personally related to the therapist, can help therapist to not internalize these emotions and inturn, not project their own negative influences in the patient.
In addition, if therapist takes things personally and feels insecure of what other people think about him/her, especially when therapist hears negative assessments about him/her (e.g., her music is terrible, she looks so bad because her shoes are so ugly; her English is so poor; I do not believe in music therapy, etc), then the therapist’s work and effectiveness may suffer. If therapist takes things personally, he/she might think: ‘That is so unfair what the patient just did this to me when I am so passionate to help her!’ Or may believe: ‘I am so hurt because the patient judges me negatively and my music made him feel so tense!’ Taking things personally triggers victim mentality of the therapist and eliminates the unconditional acceptance of the patient, which might unconsciously lead into defense mechanisms or fear when working with the patient. It also triggers the doubt and anxiety of the therapist, thus influences the session negatively. All these impacts will prevent the therapist and patient developing a basic supportive therapeutic relationship in the future. As Ruiz (2003) demonstrated: “Don’t take things personally. As you make a habit of not taking anything personally, you won’t need to place your trust in what others do or say. You will only need to trust yourself to make responsible choices” (p.47). As a therapist, to express your own feelings according to the patient’s needs and without being afraid of being rejected or judged will lead the therapist to live with happiness and inner peace, which will benefit his/her patients more and avoid a general negative atmosphere or feelings of victimization.

Therapist should be aware of the patient’s transference and create a harmonic therapeutic relationship focusing on the here-and-now
The analysis of the transference is a cornerstone concept in psychoanalysis. As Luborsky et al. (2008) presented: “The transference contains patterns from the past that may be remembered through actions or through repetition of the past, rather through recollection” (p.18). There are lots of high risk pregnant women or women who delivered premature babies who have had several miscarriages, abortions; or have delivered preterm babies in the past. There are some women even experienced the loss of their babies in the NICU. The majority of the patients do not mention these experiences to the therapist but these experiences trigger a great deal of fear and anxiety, or shame in the mother. When working with the therapist in the session, these feelings might also drive transference. While working with those patients with related unpleasant past experiences, it is vital that the therapist be aware of the patient’s transference to assist the patient to focus on the here-and-now situation to build up a communicative trusting therapeutic relationship. I believe that by being authentic and also keeping the boundary according to the patient’s needs and being present with the patient with a nonjudgmental attitude towards the patient will facilitate the patient to have positive transference to the therapist, and resulting stabilize the patient’s current medical situation. As Scovel and Gardstrom (2005) noted: “The therapist’s role is to be immediately accessible to the client and to focus on the here-and-now experiences created in the therapeutic relationship” (p.125). Only when a trusting, non-threaten relationship is established, can therapist move into a deeper relaxing stage with the patient.

Therapist should provide patients good quality listening and verbal intervention.
High quality listening is important during the process of the session and alone with the verbal intervention; it assists both the therapist and the patient to formulize a co- creative relationship. It not only makes the patient feel the presence of the therapist and helps build up a respectful and strong therapeutic relationship, but also makes the patient feel understood by the therapist, as well as immediately gathering the precise information of the patient’s medical, psychological, physical, and emotional changes for the therapist to better understand the patient’s latest situation, which are not accessible on a chart or machine. It assists the therapist to be flexible and work better in the here-and-now for the patient according to this moment.
Verbal intervention is also a significant aspect in therapy process. I have had a few sessions with some patients who had real resistance towards music but had strong intension to communicate with the therapist verbally. Paul (2005) also stated: “Verbal processing provides the opportunity to increase awareness of understanding about internal (thoughts, observations, and feelings) an external events (within the music and interpersonal area of experience)” (p.18). Even though verbal processing may happen actively or passively, through verbal intervention and high quality of listening, nevertheless, patient and therapist will both obtain additional opportunities to understand self and others, thus bringing authenticities through another path, which is different than music intervention in the session.

Therapist should respect cultural difference, different spiritual belief systems without judgment
Elliott (2002) claimed that: “For many contemporary theorists, social relationships do more than just influence the development if subjectivity. Rather, the human subject’s inner world is constituted through these relations” (p.26). Every aspect of physical, emotional, spiritual and psychological existence is socially related and can determine the patient’s health. These social components alone with the belief systems formulize people’s basic cultural background. When working in a multicultural country, a therapist has lots of opportunities to be exposed to patients from different countries with all kind of religions and cultural backgrounds. Even when the therapist and the patient are now living the same city with the same culture, the place of where they come from still plays an important part in this moment. I have had a patient who was originally from Japan, who was hospitalized for six weeks without seeing any visitors besides her husband. She informed me the reason was because in some places in Japan where she comes from, some people believe that to inform friends and having friends come to the hospital to visit when a woman is pregnant and has a high possibility to deliver an unhealthy baby is considered to be extremely bad luck for the friends. Accordingly, the patient felt really ashamed about this. As Ayers (2003) illustrated: “Culture plays a decisive part in the construction if an emotion, and views of shame from a societal perspective focus primary upon it as a means of adaptation” (p.20). When this patient had no visitors during her long period of hospitalization, the advent of a music therapist, who she can share emotions with, and respect her with nonjudgmental attitude, becomes a significant event during her pregnancy.
I also had a patient who did not want to hear or sing the Buddhism song in the session because she told me she was Christian. As a therapist, to understand and respect all these cultural difference, as well as different spiritual systems is helpful for understand the patients more, and can help motivate the therapeutic relationship towards a deeper level.
To accept different spiritual belief systems, and different cultural backgrounds also provides empathic understanding of the patient internally. Raskin, Rogers and Witty (2008) found that: “Empathic understanding in client-centered therapy is an active, immediate, continuous process with both cognitive and affective aspects” (p.154). I believe that people open themselves to therapy because they consciously or unconsciously believe the connections with the therapist, and the variety of approaches applied by the therapist, such as music, dance, or drama, will assist them to move towards a healthy self. Also, the empathic understanding from the therapist creates a safe environment for the patient to process her fear and anxieties based on each patient’s different believe system. Lewis and Pucelik (1990) supported: “By identifying and then using these difference, you will run less a risk of making the mistake of judging another’s behavior solely by the standard’s of your own mode” (p.62). And I further believe all the major religions have some basic similar concepts that assists people to connect, learn, communicate, and love. And these components can build up connections in a variety of means to be utilized in therapy to reach the healthy part of every patient.

Every individual has a healthy part internally and using different approaches to work towards the healthy part of the person allows the patient to self-express, to experience possible peak experiences, thus better cope with current difficulties in the hospital.
I believe that everyone has a healthy part inside of him/her and that is the motivation that drives them to come to therapy. Even though there are different levels of pain, fear, and anxiety involved with each individual, bringing positive and comfortable moments for the patient is one of the paths for them to acknowledge their healthy part and become optimistic about their current situation.
The most common fear that almost all my patients in Prenatal Care and NICU have is fear of delivery before twenty-five weeks of pregnancy, or fear of their baby’s death in the NICU. The separation causes so much stress to the family, especially for the mother of the baby, who is either carrying the baby in her womb, or who visits the NICU to see her baby every single day. Meanwhile, the infant also goes thorough different experiences with other premature babies while being hospitalized in the NICU, which is fairly different than if he/she is taken home by his/her parents after a normal delivery. Priestley (1994) cited from Klein that: “The infant deals with this anxiety by splitting off the good, warm, comforting, gratifying experience of its mother from the painful, hungry, wet, cold lack-of-a-mother experiences” (p.162). Therefore, to create a bonding relationship for the mother and her baby, especially when the mother is holding her baby brings lots of positive and relaxing imageries for the mother.
To work with this population, my purpose is not to make them have negative and painful imagery, because they need to relax and remain calm in order to reduce their physical risks. To create a safe space for the mother and her baby, especially when the mother is pregnant; or holding her baby in the NICU brings their happiness, joy, and a feeling of gratitude of the connection, and bonding with her baby and her as an entity. Thorsen’s (1983) study found that “The situations in which peak-experience are most frequent are situations associated with love, parental, childbirth, natural, music, aesthetic and erotic experiences, experiences associated with bodily activities” (as cited in Maslow, 1976).
I have had many patients who, while listening to live music with verbal instructions, and holing their baby, have imagined their favorite places to take their baby’s away from the NICU. They create a safe and comfortable place for themselves in the imagery to escape the stressful situations in Prenatal Care and NICU. For instance, a patient could see her baby grow up to two years old having a joyful time in the park with her; and one patient imaged that the baby was five years old and could walk stably on the beach and so she could just relax on the beach with a warm temperature and blue ocean. I witnessed the patients smiling many times while I asked how old was their baby and where did she want to take the baby to travel in her images. This not only produces relaxed responses and emotions in the patient, but also makes the medical situation much more stable (e.g., the decrease of high blood pressure of the pregnant women; the increase of a baby’s low oxygen level) after the imagery.
During these moments, patients create these imageries and express themselves freely with their baby and the therapist, and this experience influences their situation physically and mentally to bring them hope towards the future and better deal with their current difficulties.

There are a variety of principles available in the psychology domain nowadays to help work with mothers and babies in Prenatal Care Unit and NICU. And I believe that to work with different patients within this population requires the therapist to be able to apply different principles. These principles come from various theorists and can be intercrossed and utilized according to the patients’ needs. For instance, to be aware of countertransference in order to not taking things personally, and to respect cultural differences, as well as to work on the here-and-now moment are principles to always
consider the patient’s needs first in the work. And working with high risk pregnant women and premature baby in hospital settings specifically demands that the therapist understand the principles and skills listed above, and be capable to expand more advanced principles based on more clinical work with these populations in the future.