No More Learning

Many of the children he studied stated that once in school they felt quite secure. Thus, unlike what occurs in genuine phobias, exposure to the alleged phobic situation does not exacerbate the sufferer's fear. Several other authors confirm this finding, and also that fear is often at its height either just before leaving home or on the journey to school. The subjects of a follow-up study by Weiss & Burke ( 1970), looking back on their problem, confirm that it arose from difficulties in family relations.
Because the situation feared is that of leaving home, the term school phobia is an obvious misnomer. 1 In order to
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1 In the early 1920s the term school phobia was applied by Burt, and applied appropriately,
to a very different condition, namely to children who were afraid of going to school because of having gone there for shelter during air-raids (referred to by Tyerman 1968).
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emphasize the family dynamic which she, like others, holds to be all-important, Johnson abandoned the term school phobia, which she herself had advocated in 1941, and replaced it with that of 'separation anxiety' ( Estes, Haylett & Johnson 1956). As a name for a clinical syndrome, however, separation anxiety is ill fitted. Of the terms at present in use 'school refusal' is probably the best, by virtue of its being at once the most descriptive and the least laden with theory.
In the course of these empirical studies a considerable body of theory has been elaborated. Three main influences are apparent.
One, that stems from Freud's classical paper on the analysis of a phobia in a five-year-old boy known as Little Hans ( Freud 1909), is couched in terms of the child's individual psychopathology and gives a central role to the process of projection. In that tradition concepts frequently drawn upon include those of dependency and overdependency, over- gratification and spoiling, linked as a rule to a theory of fixation at, or regression to, one or another level of psychological development. Sperling ( 1967), for example, points to the anal erotic (especially anal sadistic) stage of libidinal development, and Clyne ( 1966) to Winnicott's concept of an infantile transitional stage in the development of object relations.
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The second main influence on theory stems from a seminal paper by Johnson and her colleagues ( 1941). Basing their views on experience gained in the practice of child and family psychiatry, they lay especial emphasis on family interactions and the role that one or other parent is playing in instigating and maintaining the condition. They describe parents who, for emotional reasons, cling to their child and, in effect, stop him from going school.
The third main influence is learning theory which, like traditional psychoanalysis, is conceived in terms of individual psychopathology. Nevertheless, as Andrews ( 1966) points out, the practitioners of behaviour therapy are often far more alive to the importance of interpersonal relations and family dynamics than their theory would lead us to expect.
Four Patterns of Family Interaction
A reading of the clinical literature shows that, although workers may approach the problem of school refusal from very different theoretical standpoints, when they come to assess actual cases the features to which they draw attention tend to be much the
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same. It is therefore possible to treat the array of clinical findings as reasonably well authenticated and to proceed to consider how they can be understood in terms of the theory of anxious attachment outlined in earlier chapters. When viewed in that light a large majority of cases of school refusal can be understood as the products of one or more of four main patterns of family interaction:
Pattern A -- mother, or more rarely father, is a sufferer from chronic anxiety regarding attachment figures and retains the child at home to be a companion
Pattern B -- the child fears that something dreadful may happen to mother, or possibly father, while he is at school and so remains at home to prevent it happening
Pattern C -- the child fears that something dreadful may happen to himself if he is away from home and so remains at home to prevent that happening
Pattern D -- mother, or more rarely father, fears that something dreadful will happen to the child while he is at school and so keeps him at home.
Though in most cases one or another of these four interaction patterns is dominant, the patterns are not incompatible and mixed cases occur. Pattern A is the commonest and may be combined with any of the other three.
Family Interaction of Pattern A
A family pattern in which a mother or father suffers from anxiety over attachment figures and retains the child at home to be a companion is now widely recognized. In a majority of cases mother is the principal agent and for that reason, and to simplify exposition, it is mothers who are referred to in what follows. Yet it must not be forgotten that a father can also be a principal agent in the condition: Eisenberg ( 1958), Choi ( 1961), Clyne ( 1966), and Sperling ( 1967) are among those who describe illustrative cases.
A mother who retains her child at home to act as a companion for herself may do so deliberately and consciously or may be unaware of what she is doing and why.
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An example of the former is the mother of a ten-year-old boy who had been kept at home for more than a year when the family was referred to a clinic. Although initially mother claimed that she pressed her son to return to school, after the
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family had been in treatment for some months she admitted frankly that she did not want him to go. In a burst of candour she explained how for many years during her childhood she had been away in an institution and had had no one to love, how her son was the first person she had ever had to love in her life, and how she could not be expected to relinquish him now. The boy's father was aware of what was happening but preferred to stay inactive to avoid upsetting his wife. The boy also, it emerged, was well aware of the situation. 1
More often a mother is unaware, or only partly aware, of the pressures she is putting on her child and believes more or less sincerely that she is doing everything possible for his benefit. In some cases the train of events begins when the child contracts some minor ailment, and mother treats the condition as of much more consequence than it really is. The child is kept at home, ostensibly to convalesce, but is gradually presented with a picture of himself as being unfitted for the rough world of school and as being, therefore, in constant need of his mother's care. Unkind teachers, bullying boys, and chronic ill health are inculpated as the villains of the piece. This pattern and its many variants, in which a mother exploits some temporary upset or anxiety of her child, are described in almost every paper on the topic. Eisenberg ( 1958) gives vignettes of mothers who, on arrival at school with their child, exhibit intense reluctance to relinquish him and behave in such a way that he is made anxious about school and perhaps guilty at enjoying the company of anyone but mother. Weiss & Cain ( 1964) describe mothers who, while claiming to protect their children from the horrors of the world, not only burden them with their personal and marital worries but seek their undivided support. Clyne ( 1966) describes cases in which a mother develops psychosomatic symptoms herself after her child has returned to school. Others ( Estes, Haylett & Johnson 1956) have noted how, after one child has been released from his parent's grip, another child is sometimes fastened on and held.
Whenever a family pattern of this kind is present, the parent concerned is found to be intensely anxious about the availability of her own attachment figures and unconsciously to be inverting the normal parent-child relationship by requiring the child to be the parent figure and adopting the role of child herself. Thus the child is expected to care for the parent and the parent seeks
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1 I am grateful to my colleague, Dr Marion Mackenzie, for information about this family.
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to be cared for and comforted by the child. As a rule the inversion is camouflaged. Mother claims that the person who is in special need of care and protection, and who is receiving it, is the child; and a clinician inexperienced in family work may even come to believe that the trouble arises because the child is being 'spoiled' by having his 'every whim gratified'. In effect what is happening is very different and much sadder. Unknown to herself, mother (or father) is seeking belated satisfaction of her desire for the loving care she either never had as a child or perhaps lost, and, simultaneously, is preventing the child from taking part in play or
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school activities with his peers. So far from being 'over-indulged', such children are chronically frustrated and, because allegedly given everything, are not even free to expostulate. During treatment one nine-year-old boy illustrated how he felt by repeatedly winding the window cord around himself and explaining, 'See, I'm in a spider's web and can't get out' ( Talbot 1957). Another boy, aged eleven, drew a dog on a tight leash led by a lady and made clear he felt the dog was himself, furious at being tied to his mother ( Colm 1959). 1
To present the picture thus may seem one-sided and to be unfairly biased against parents. Yet, once the parents' own difficulties are examined and the origins of these difficulties traced to the very troubled childhoods that they too have experienced, not only does their behaviour as parents become intelligible but our sympathy is enlisted. Time and again it is found that the pathological behaviour of a parent is a reaction against, or a reflection or residue of, a deeply disturbed relationship that she has had, and is perhaps still having, with her own parents. Recognition of this quickly dispels any disposition to see the parent as a villain, even though the way she is treating her child may be patently pathogenic. Instead, she is seen as the unhappy product of an unhappy home and, as such, a person fully as much sinned against as sinning.
For an adequate understanding of the dynamics and historical origins of families in which a parent inverts the relationship with the child by requiring him to care for her we should need
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1 Sometimes the term 'symbiosis' is used to describe these suffocatingly close relationships
between mother and child. The term is not happily chosen, however, since in biology it is used to denote an adaptive partnership between two organisms in which each contributes to the other's survival; whereas the relationship with which we are concerned here is certainly not to the child's advantage and often is not to the parent's either.
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to have far more systematic data than are yet available regarding the personalities and childhood histories of the parents and grandparents concerned. On grandparents no data appear to be on record, except anecdotally. As regards parents, not only are systematic data on representative samples of the parents of school-refusing children scarce, but in so far as there are any they do not distinguish between parents in terms of the four patterns of family interaction considered here. Such systematic data as are available are presented therefore only after all four patterns have been considered (see p. 282 ).
Nevertheless it is not too difficult, in the light of the theory outlined, to discern the main features of the psychopathology of parents in families showing pattern A. Once again it must be remembered that, although reference continues to be made to mothers and maternal grandmothers, almost exactly the same dynamics can occur with a father and a paternal grandmother in the principal roles, and also with one or other grandfather.
Very commonly a mother who inverts the relationship with her child has had, and may still be having, a close but intensely anxious and ambivalent relationship with her own mother. In such cases a mother believes, often with good reason, that she was unwanted or at least less wanted than one of her siblings. As a result she has felt that she has always had to fight for such affection and recognition as she has got. Yet in only a few cases in which pattern A obtains has she been wholly rejected. Far more often the maternal grandmother's feeling for
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her daughter is ambivalent; and not infrequently the older woman seems to be making strong, insistent, and unjustified demands upon her daughter. Thus, while on the one hand mother has never had the spontaneous care and affection a child desires, and usually receives, on the other she has often been put under duress to provide care for her own dominating and demanding mother. Responding to these pressures, mother may meet her mother's demands but only at the price of feeling bitter with suppressed resentment against her.
It will perhaps be noticed that the intensely ambivalent relationship between mother and grandmother, of the kind sketched above, is likely itself to be an example of an inverted parent-child relationship. For in many cases maternal grandmother is demanding from her daughter just that same parentaltype care and affection that mother, in her turn, is demanding from her school-refusing child. That this is truly so in some instances is shown by the fact that, in every series studied, there
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are cases reported of mothers (or fathers) who, when children, had themselves been school refusers. For example, in a study by Goldberg ( 1953) of seventeen cases, about half the parents are reported to have had symptoms during their childhood identical with those shown by their children. In Davidson study ( 1961) of thirty cases, mother had herself been a school refuser in three, and three other mothers had had to remain at home to look after their own sick mother or younger siblings. Sperling ( 1967) reports the case of a father who was in analysis for phobic anxieties when his son began refusing to go to school. Although at first it appeared that John was clinging to his father, it soon became clear that father was demanding that the boy keep him company. During analysis father began to recognize that his own father had treated him in exactly the same way that he was now treating his son, using him thus, presumably, in an attempt to deal with his own anxieties. Whenever possible, then, it is desirable that in future studies the childhood histories and psychopathology of grandparents should be explored.
Not unexpectedly, the marital relations of the parents of school-refusing children are usually very disturbed. Forms of disturbance vary greatly and it would take us too far from our theme adequately to discuss their variety. One form frequently described is of a wife locked in mutually ambivalent relationships both with her own mother and with her school-refusing child, and having a rather passive husband who tends to opt out of his roles as husband and father. The way this relationship comes into being is not accidental. Few men other than passive ones are willing to marry and stay married to a woman who not only consistently gives preference to the never-ending demands of her own mother but may also try to dominate her husband in the same way that her mother dominates her. As it was put by Mrs Q, who had evidently had many admirers as a girl, only her husband among them had been willing to tolerate the extent to which she was daily entangled with her own very disturbed mother and to put up with the hysterical outbursts that, engendered in her relationship with her mother, she had been wont to vent on each of her boyfriends successively.
No doubt the mirror-image of this relationship, in which the husband is entangled with his mother and the wife is the passive one, also occurs. In either case sexual relations are likely to be sparse or absent.
Let us return to our main theme, the relationship of one or
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other parent, usually mother, to the school-refusing child. When that is examined it is found, time and again, that mother treats the child as though he were a replica of her own mother, the child's maternal grandmother. Not only does mother seek from her child the care and comfort she had sought, perhaps in vain, from maternal grandmother, but she may behave towards him as though he were the dominant figure. While at one moment she may be smouldering with resentment at what she feels to be her child's rebuff, as she does at those from her mother, at the next she may be treating him with the same anxious deference that she shows an elderly mother who rules the family by means of invalidism.
Examples of parents who are part of a family showing one or another variant of pattern A are to be found throughout the literature. Talbot ( 1957) calls attention to the mother who allows her child to dominate her in exactly the same way that she has always allowed her own mother to. In their account of the case of a boy of nine, Johnsonet al. ( 1941) describe a mother whose own mother had been in bed for years with a hysterical disorder and had demanded her daughter's constant attention. The boy's mother was hypochondriacal about him, on the one hand, insisting on endless medical examinations, and, on the other, under the guise of believing that he was in greater need of love from her than were her other children, she made extreme demands upon him. During a late phase of her treatment, however, this mother was able to describe how she had always longed for love herself, how she felt she was unable to give it, and how she even competed with her son for attention. In describing another variant of the pattern Davidson ( 1961) reports how a mother referred to her school-refusing daughter protectively as 'small and white like Grandma'. Weiss & Cain ( 1964) observe that a mother is inclined to treat her child as her confidant in regard to her difficult family relationships and that the child is apt to respond by adopting an inappropriately grown-up manner, both to his parents and to strangers.
Although in such cases it may appear at first sight that a mother's attitude to her school- refusing child is one of undiluted loving care, greater knowledge of the family may show another side. Clyne ( 1966), who writes from experience in general practice, notes that, whereas the mother's 'need for dependence' remains fairly constant, her child's response alternates: at times he is clinging, at others he is obviously striving towards independence. To the latter, mother can respond
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in various ways, by clinging to him more intensely, by inducing him to feel guilty, or by becoming angry with him or even rejecting him. When the facts become known it is sometimes found not only that a mother's relationship to her child is intensely ambivalent, but that she is treating him far more violently than anyone had imagined. Talbot ( 1957) describes how a mother may be observed to swing from one extreme to the other in her way of treating her child, kissing him one moment and beating him the next. In fact, as we shall see when we consider family patterns B and C, which often coexist with pattern A, many school-refusing children are being subjected to great duress. Before considering these other patterns it may be useful to list some of the processes that, singly or together, account for the hostile treatment that many a school-refusing child receives from an emotionally disturbed parent. A mother's hostile treatment of her school-refusing child can be understood as a product of one or more of at least three closely related processes:
a. redirecting (displacing) anger, engendered initially by own mother, against the child;
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b. misattributing to child the rejecting characteristics and/ or the demanding characteristics of own mother, and being angry with the child accordingly;
c. modelling angry behaviour towards child on the angry behaviour exhibited by own mother.
Let us consider each of these processes in turn.
a. Inevitably, a mother brought up and caught in a disturbed family network keenly resents
her own mother's meagre affection for her and also the intense demands that are made upon her. At the same time, however, she feels unable to express her anger openly, either because she is terrified of how her parent will respond or else because she fears making her ill. Either way, mother boils with unexpressed resentment and sooner or later finds a figure on whom to vent it. Not infrequently it is her school-refusing child who becomes the target.
b. In some cases it is apparent that the charges a mother levels against her child are replicas of those she levels, overtly or covertly, at grandmother. For example, a mother may first attribute dreadfully unreasonable demands to her child and then lash out at him for the demands he is alleged to make; when to an
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external observer the child is behaving little differently from any other child of the same age who is placed in similar circumstances. Similarly, a mother may misattribute rejection or ingratitude to her child. Such misattributions can be understood as the result of the parent's treating her child as an attachment figure, and, in so doing, assimilating the child to the model she has of how attachment figures can be expected to behave. This process is identical to what happens in the transference relationship during psychoanalytic treatment (see Chapter 14).
3. In Chapter 15 the process is described by which a mother may come unwittingly to model her behaviour towards her child on the way her own mother has treated her. As an illustration the case was described of Mrs Q who, during hysterical outbursts, was apt to threaten her son, Stephen, with the same dire threats she had herself suffered from her mother. In the literature on school refusal several writers, and notably Estes, Haylett & Johnson ( 1956), invoke that process as an explanation of why a mother's angry behaviour takes the particular form it does.
In the families of school-refusing children, threats by a parent against a child, or perhaps against members of the family in general, are common. Indeed, once their frequency and effects are appreciated, threats are found to be the key to an understanding of most of the clinical problems presented by families showing patterns B and C.
Family Interaction of Pattern B
In families showing pattern B a child fears that something dreadful may happen to mother, or possibly father, while he is at school and remains at home in order to prevent it. The pattern is probably the second most frequent of the four; and it occurs fairly often in conjunction with pattern A.
Empirical studies show that it is common for school-refusing children to state that the reason they do not go to school is a fear of what may happen to mother while they are away from home. Talbot ( 1957) in her study of twenty-four children writes: 'Over and over again we are told by every child studied, whether five years old or fifteen, that he is afraid something dreadful will happen to mother or other close relative, such as grandmother or father. ' Hersov ( 1960b), in his careful study of children aged from seven to sixteen years, reports that fear of
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some harm befalling mother was the commonest single explanation given by children of why they did not attend school;
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it was given by seventeen out of fifty children. Among others. to describe such cases are E. Klein ( 1945), Lazarus ( 1960), Kennedy ( 1965), Clyne ( 1966), and Sperling ( 1961; 1967).
Though the finding is no longer in question, there remains much disagreement as to why a child should come to fear such happenings. Explanations are of two main types. Though the processes each type invokes are very different, they are not incompatible, so that it is possible that in some cases both types of explanation are applicable.
The first type of explanation, and one habitually advanced by psychoanalysts, of why a child should become afraid of harm befalling his mother is that he harbours unconscious hostile wishes against her and is afraid lest his wishes come true. This is the explanation explicitly favoured by Broadwin ( 1932), E. Klein ( 1945), Waldfogel, Coolidge & Hahn ( 1957), Davidson ( 1961), Clyne ( 1966), and Sperling ( 1967), and also by those holding the views of Melanie Klein.
A second type of explanation is more mundane: it attributes what a child fears to his real experiences. For example, a child may come to fear that his mother may become seriously ill or die after seeing or hearing about the illness or death of a relative or neighbour, especially when mother is herself in ill health. Alternatively, a child may come to fear some disaster after hearing his mother make alarming threats about what may happen to her in certain circumstances. For example, if her child does not do what is asked of him, she will become ill; or, because 'things at home are so awful', she will desert the family or commit suicide.
Much of the scanty evidence available is open to an interpretation of either of these principal types; but it seems most unwise to adopt an explanation solely in terms of unconscious wishes before an explanation in terms of experience has been thoroughly investigated and shown to be inadequate. In point of fact, evidence suggests that in an overwhelming proportion of cases the eventualities a child fears can be understood wholly, or at least in part, in terms of his actual experiences. The extent to which unconscious hostile wishes may or may not also be making a contribution becomes then a matter for investigation in each individual case.
Experiences that can lead a child to fear that something dreadful may happen to mother are of two main kinds: first, actual events, such as illnesses or deaths, and, second, threats. Not infrequently the effects of the two are interlaced.
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As regards actual events, many workers have reported that an episode of school-refusing often begins at a time when, or soon after, mother herself has been ill or a close relative or friend has died. Talbot ( 1957) cites the case of an adolescent girl who, on going to kiss her grandmother goodbye before leaving for school, suddenly realized her grandmother was dead. Sperling ( 1961) reports a rather similar case. Lazarus ( 1960), writing from the viewpoint of a behaviour therapist, describes as typical the case of a girl of nine whose 'central fear was the possibility of losing her mother through death' and whose refusal had been preceded by no fewer than three deaths, that of a schoolfriend by drowning, of a neighbouring friend by
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meningitis, and of a man killed in a car accident before her eyes. Hersov ( 1960b) reports 'the death, departure or illness of a parent, most often the mother', as the precipitating factor in nine out of his fifty cases. Davidson ( 1961), who gave especial attention to this factor, reports that, in her series of thirty cases, mother herself had been dangerously ill in six, and, in another nine, a close relative or friend had died within a few months of the child's refusal to attend school. Thus half her cases were preceded by an event of this kind. 1
Davidson is one of those who adopt the wish-fulfilment theory of the child's fears and she draws on her own findings to support it. Mother's actual illness or a friend's death, she argues, heightens the child's fear that his unconscious hostile wishes are coming true or might come true. Yet it will be seen that the facts are no less compatible with a theory of the second type. For example, when mother herself is ill, it is not unnatural for a child to be afraid that she may become worse. When a grandmother or neighbour dies suddenly, it is not unnatural for a child to fear that mother may die equally suddenly. Therefore factors external to the child as well as factors internal to him must always be considered.
Although it is natural enough for a child to feel some measure of fear when mother is ill or a relative dies suddenly, especially when the two events occur together, it must be recognized that not all children exposed to such conditions
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1 Davidson strongly emphasizes how easy it is for a clinician inexperienced in the field to
overlook vital information. Not only do parents often fail to volunteer information about illness or death that may later seem highly relevant, but they may even deny such occurrences when first asked about them.
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develop intense or prolonged fear that mother will come to harm; nor do they often remain at home to make sure that she does not. Clearly, then, further factors are operative. Though in some cases they may be internal to the child, there is good evidence that in a great many cases these further factors that make for intense and prolonged fear that mother will come to harm derive also from the child's actual experience.
One such factor may be misplaced attempts to conceal from a child the seriousness of a parent's illness or the truth about the death of a relative or friend. The more concealment the more a child is likely to worry. Both Talbot ( 1957) and Weiss & Cain ( 1964) remark on the extent to which the parents of schoolrefusing children are apt to dissemble and evade. As one of the patients in the latter study put it, 'I never know who to believe in my family. There are too many white lies told. I have to watch and listen when they don't know I'm around. '
Another factor, and one likely to enhance to a much higher degree a child's anxiety about harm befalling his mother, is his having been threatened that, if he is not good, she will fall ill or die. In such a case, mother's illness seems to show the child all too clearly that what mother has always said would happen is in fact coming to pass; and a friend's death is taken as a lesson that mother's predictions are not idle ones: illness and death are real and may strike mother at any time.
It is already argued in Chapter 15 that the high incidence and intensely frightening effects of parental threats have hitherto been gravely neglected as likely explanations of children's fears;
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and the case of Stephen Q, himself a school refuser for a time, is reported to show how easy it is for parents and children to hide from clinicians information of the greatest relevance. On this issue the perspective adopted by Talbot ( 1957) and by Weiss & Cain ( 1964), who are among the very few to refer to the role of threats in cases of school refusal, is nearest that adopted here. Talbot in particular describes the many and varied threats to which some of these children are subjected-that mother will beat the child, kill him, desert him; or, alternatively, that the child by his inconsiderate and wicked ways will be the death of his mother. 'My mother wants me to stay home but she tells me I'm killing her,' was the way one little girl described her predicament.
A case of protracted school refusal in which threats of several kinds were being used, including mother's threats to desert her children, has been reported recently by two of my colleagues
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at the Tavistock, Paul Argles & Marion Mackenzie ( 1970). By identifying the problem as one of disturbed family relationships and treating it as such, not only were the clinicians able to help the family to reorganize its way of living but they were able also to gain access to crucial information about the pathological interactions that were current in the family.
The family, a multi-problem one, had been known to medical and social agencies for several years. At the time when systematic therapeutic work was begun Susan, aged thirteen, had been refusing to go to school for eighteen months. She lived with her mother, aged forty- seven, who had worked as a charwoman but was now incapacitated with ulcerated legs, and a younger brother, Arthur, aged eleven. Father, who had always had a chronic physical disability, had been dying of cancer at home during the preceding year. By her first marriage mother had had two sons, now in their twenties. Shortly before Susan began refusing school and following friction, mother had evicted the elder son with his wife and two small children from the house.
Prior to father's death, which occurred just before casework began, all attempts to help the family over Susan's nonattendance at school had been rebuffed. At the time of father's death, however, a new initiative was taken, conceived in terms of crisis intervention ( Caplan 1964); and this met with a more hopeful reception. At this time the child care officer responsible for Susan arranged that all three members of the family would be present when a clinical team visited the home in order to make an assessment and, if possible, to plan a therapeutic programme.
During the assessment interview mother began with bitter recriminations against Susan for not attending school, interspersed with threatening remarks to the effect that Susan was responsible for her (mother's) physical ailments. Many other mutually disparaging remarks were passed and only towards the end of the interview, and with much skilled assistance from the team, was it possible for members of the family to describe their loneliness and anxiety, and their concern for each other. They agreed to regular weekly visits from the caseworker for a set period of three months, and also that all three members would always be present. Both in making these arrangements and in subsequent work the caseworker played a very active part.
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During the first half-dozen sessions, during which the caseworker had himself to broach the problems stemming from father's illness and death, the pattern of family interaction became clear.
Prominent in this pattern were the threats that accounted for Susan's non-attendance at school. Frequently, when mother tried to exert discipline, she would blame the children for their father's death and imply that the same would happen to her if they did not behave. She also admitted threatening to desert them and giving her threats substance by putting on her coat and leaving the house. In response to these threats both children became more defiant and disobedient. During these sessions not only did each of the three members of the family express strong hostility towards the other two, but at times all three banded together and turned angrily on the caseworker.
At the seventh session Susan for the first time was absent. It then transpired that she was at school but that Arthur was unwell and had stayed at home. Gradually it became clear that, for a year or more, the two children had been taking it in turns to stand guard over mother to make sure that she did not desert them. Susan stayed at home by day and visited friends during the evenings; whereas Arthur went to school by day and stayed at home after he had returned. Many of the children's quarrels, about which mother complained bitterly, turned on which of them should be on duty.
Once it became clear that Susan's school refusal was a response to mother's threats to desert, and it became possible to discuss in the family how these threats were affecting the children, much changed. Already by the eighth session it emerged that, for the first time for eighteen months, both children were attending school simultaneously. When, during that session, Arthur returned from school, he was most solicitous as to how his mother had been faring while left on her own; and she was able to reassure him.
A month later, at the end of the agreed three-month spell of work together, Susan was attending school three or four days a week. At a visit six months later, during the summer holidays, the family was found in much better shape. Mother's ulcers had healed and she had renewed contact with her married son. Arthur was helping mother to redecorate the flat; Susan was on holiday with relatives. When school began again both children attended more or less regularly.
This and other cases illustrate how, as soon as family inter-
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viewing is adopted as a regular practice, the family origins of many intractable childhood problems are brought to light; whereas as long as each member of the family is seen only separately, interaction patterns of the greatest pathogenic significance can remain hidden. Inappropriate clinical techniques, together with strongly held theory that gives no place to the effects of family pathology, go far to explain why, with only few exceptions, those practising child psychiatry and psychoanalysis have been so very slow to recognize that a majority of children who are referred for psychiatric problems have been, and often are still being, subjected to strong pathogenic influences within their families.
Recognition of the crucial role that parents' threats play in many cases of school refusal makes it possible to read many a published case report in a new light. In some of these, for example those of E. Klein ( 1945), children are described who have a parent who is threatening that he or she will leave home or else that the child's bad behaviour will lead the parent to become ill
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or die; despite the evidence presented, however, when the psychopathology of the children's condition is discussed, the threats are given little or no weight. In other reports cases are discussed in which it might be thought that by far the most likely explanation of why a child is afraid that harm will befall his mother is that he has heard her threaten to desert the family or to commit suicide. Yet it is clear that that possibility was never considered by the clinician, even when a child was giving the most explicit hints. As an example, one of our authors gives an interesting account of a boy of ten who told him, 'very confidentially', that one reason for his occasional reluctance to go to school was his dislike of leaving his mother alone as it was 'just possible that she might run away' and he might not find her when he returned. Yet the possibility that the boy had heard his mother make such a threat seems never to have crossed the author's mind. Another author tells of a boy who, on hearing music that reminded him of the funeral of a neighbour who had committed suicide while her child was at school, suddenly felt 'funny' and very sad, and had an irresistible urge to see his mother. The writer, after confidently explaining the fear in terms of the wish-fulfilment theory, adds, almost as an afterthought: 'There was a rather strong probability that Peter might have sensed the depressive mood of his mother and that his sudden phobia was also a sort of realistic protection of her. ' Let a spade be called a
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spade: it seems more than likely that Peter had heard his mother threaten suicide.
So far in our consideration of cases falling into pattern B both the evidence presented and the argument have strongly favoured the view that refusal to go to school in such cases is a response mainly to events at home. Does this mean, then, that the wish-fulfilment theory is totally discarded? Or is it possible that the theory may have some application, even if only a limited one?
Those who support the wish-fulfilment theory very naturally point to evidence that many school-refusing children do in fact entertain hostile wishes towards a parent. And it can be agreed that, in so far as this is so, there are valid reasons for expecting the child's anxiety about his parent's safety to be increased. In some cases, therefore, the wish-fulfilment theory may apply as a partial explanation. Nevertheless, even in those cases, it is necessary to probe further, since children do not become hostile to parents for no reason.
In cases where a child is anxious about his parent's safety, not only are those who adopt the wish-fulfilment theory apt to neglect the part played by mother's threats, but they are apt also to overlook the immense frustration and provocation to which school-refusing children are often subjected. For any child to be required day after day to stay at home to keep his mother company or to make sure that she does not desert or commit suicide is the greatest of strains; and almost inevitably angry feelings are engendered. That point is made repeatedly by Johnson. In one of her papers ( Johnsonet al. 1941) she describes the treatment of a nine-year- old boy and his mother. During treatment Jack expressed much rage against his mother because of her demands upon him and because of her resentment when he strove to be independent. Almost simultaneously, during her own treatment, mother came to recognize that Jack's rages against her were an exact replica of how she herself had always reacted to the insistent demands made upon her by her own mother, who had also begrudged her doing anything on her own.
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In conclusion, therefore, it can be said that, whenever a school-refusing child expresses anxiety about the continuing presence or safety of a parent, it is likely to be a fairly straightforward response to events occurring in his family; and that, in so far as an increased degree of anxiety stems from fear that unconscious hostile wishes may be realized, these unconscious
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wishes are themselves likely to arise in response to events within the family. For these reasons, events within the family have first claim to a clinician's attention.
The remaining two patterns of family interaction probably occur less frequently than patterns A and B and can be dealt with more briefly.
Family Interaction of Pattern C
In families of pattern C a child is afraid of leaving home for fear of what might happen to himself were he to do so. Here again threats by parents, either overt or covert, usually provide the explanation.
Wolfenstein ( 1955) gives a vivid account of a case in which threats to get rid of the child were overt and, in her view, accounted for his symptoms.
Tommy, aged six years, refused to stay in nursery school or to be separated from his mother in any other way. About the time of his birth mother had lost both her parents by death, and a few months later her husband deserted. Thenceforward mother and child had lived an isolated life together. Throughout, mother was in two minds whether to keep Tommy with her or to place him in a foster home: 'While she thought constantly of getting rid of Tommy, she also clung to him desperately. He was, as she said, all she had, her whole life. ' Mother's relationship to her own mother had evidently been an extremely disturbed one; internal evidence suggests that she herself may also have been subjected to threats of being abandoned.
Mother's threats to abandon Tommy were no secret: ' Tommy not only overheard his mother discuss with neighbours the possibility of placing him, he also was repeatedly threatened with this when he misbehaved. ' Tommy's response was one of intense anxiety combined with overactive provocative behaviour and hectic laughter. During therapy he was deeply concerned that he might be sent away and often played a game in which he abandoned the therapist. To his teachers he was sometimes violent, and he shouted at them to 'Get out of here! ' In both these regards his behaviour seems clearly to have been modelled on that of his mother towards himself. Wolfenstein is in no doubt that 'the central and overpowering anxiety' in Tommy's life 'was the well-justified fear of being abandoned by his mother'. His refusal to go to school was thus a simple and intelligible response.
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Robert S. Weiss (personal communication), who is studying mothers who are struggling to bring up children without a partner to help them, reports that a large proportion of them admit that, at times when they are more than usually anxious or depressed, they entertain ideas of getting rid of their children. This being so, it seems not unlikely that, in fits of desperation,
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many of them express these ideas within earshot of their children and thereby engender deep anxieties. Unless she has very great confidence in an interviewer, however, a mother is most unlikely to admit to this.
There is in fact reason to suspect that, as in cases of pattern B, there are many children who are being subjected to threats the existence of which is kept a closely guarded secret from all those who may be called upon to help. An example, in which the secret was divulged by the child when drugged, is given by Tyerman ( 1968):
Eric was thirteen, a conscientious pupil at the technical school, and popular with both teachers and classmates. He went to church regularly with his parents and was a welcome member of the youth club. Then suddenly he refused to go to school, saying he was frightened that on the way his heart would stop beating and he would die. . . . He had read in the newspapers, he said, of people dropping dead in the street, and he was frightened that this was going to happen to him. He was eating and sleeping normally, his mother reported; but nothing seemed to interest him, and he was very preoccupied with thoughts of death. . . . His parents seemed to love each other and to love him. It appeared a happy home, and no source of tension could be discovered. There was no sign of hostility towards Eric in the school or at home, and his behaviour remained a mystery. He was not improved by taking phenobarbitone, or by talking to the psychiatrist or myself; and so an abreaction with sodium pentothal was carried out by the consultant psychiatrist.
During the abreaction Eric described a distressing event which had occurred about a week before he complained of this fear of dying. Apparently his father had accused him of stealing money out of his pockets. When Eric denied it, his father said he was going to punish him -- not for stealing, but for lying. Eric told the psychiatrist that he had not taken the money, but that he had later confessed to having done so in order to escape being beaten. When he had made his confes-
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sion -- which was, in fact, his only lie -- his father said he must be punished. He drew up a document which said that he and his wife irrevocably gave up all rights to Eric, and that they wished the children's officer to take him into one of the local authority's homes. They then put Eric into the car and drove to see the children's officer. It was lunch-time and his office was closed. The boy was thereupon taken backwards and forwards from office to car until he was in tears and almost hysterical. His father then told him that as he seemed to be suitably sorry he could stay at home.
The parents did not accept invitations to come for further interviews and the boy's story remained uncorroborated. Nevertheless, those with experience in the field are likely to think the boy's story to be true, at least in substance.
Tyerman remarks that neither the parents nor the boy had mentioned the incident in earlier interviews, presumably because the parents were ashamed of their actions and the boy was afraid to tell. If we are right in thinking the boy's story true, the case illustrates yet again how very easy it is even for experienced clinicians to be misled into supposing that a child's fears have no basis in reality. It calls attention also to a main reason why clinicians have resorted so readily to theories that invoke unconscious wishes, phantasy, and projection and have been
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correspondingly so slow to recognize the role of situational factors, either of the present or of the past.
Family Interaction of Pattern D
In families showing this pattern mother, or more rarely father, fears that something dreadful will happen to the child and so keeps him at home. In many such cases the parent's fear has been much exacerbated by the child's having been ill, occasionally seriously but more often only slightly.
Explanations of why a parent should have fears for his child again fall into two types. One, traditionally adopted by psychoanalysts, is the wish-fulfilment theory, namely that what a parent fears is that his own unconscious hostile wishes towards the child may come true. The other is that a parent is unusually apprehensive of danger befalling his child because he is reminded of some tragedy that happened in the past.
As we saw when considering the converse case of why a child should fear that harm will befall his parents, the two theories are not incompatible. In any one case either or both may apply.
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Many cases of pattern D are on record in which the parent's anxiety stems from some past event. For example, Eisenberg ( 1958) describes a father whose anxiety about his son's safety was closely linked to the sudden death of his brother at the age of seventeen, for which he had felt responsible. Other examples are given by Davidson ( 1961). In one, the case of a girl of eleven, it emerged after ten months of treatment that mother's sister had died at the age of eleven. The girl herself offered this as the explanation of why she thought her maternal grandmother had suddenly become so fussy and over-protective of her. Talbot ( 1957) refers to parents still deeply preoccupied with deaths in the family that had occurred years earlier. Almost everyone practising family psychiatry who is alive to the issue will have met with similar cases.
Yet there are also cases in which the wish-fulfilment theory is certainly applicable. An example from my own experience is the intense apprehension felt by Mrs Q that Stephen might die, which was found to be a direct reaction to her own impulse to throw her baby out of the window, an impulse she had been both wholly conscious of and horrified at. What Mrs Qhad not been aware of was that her hostility to Stephen arose, in all probability, from her having redirected (displaced) towards her infant angry feelings engendered in her initially by the way her own mother behaved.
Parents of School-refusing Children: Results of Psychiatric Examination
In view of all that has been said it will come as no surprise to find, when a sample of parents of school-refusing children is examined psychiatrically, that the incidence of psychiatric disturbance is high and that, with the exception of the least severe cases, marital disharmony is universal.
Of fifty mothers studied by Hersov ( 1960b) eight had had previous psychiatric treatment (five for depressive and three for hysterical conditions) and a further seventeen were found to
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suffer from anxiety and depression of marked degree. Of the series of thirty mothers studied by Davidson ( 1961) twelve showed symptoms of depression, including two who had been hospitalized. In a series of eighteen cases of children showing marked anxiety over separation, Britton ( 1969) reports that ten mothers had been under psychiatric treatment and another six exhibited psychiatric symptoms.
The incidence of disturbance among fathers is less pronounced though by no means negligible. Of the fifty fathers
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studied by Hersov ( 1960b) eight showed psychiatric symptoms: two had had severe depressions with suicidal attempts, two others had suffered less severe depression, and another four suffered from anxiety symptoms. Davidson ( 1961) reports that eleven out of thirty fathers suffered from neurotic symptoms.
In his valuable review of the literature Malmquist ( 1965) gives much evidence of a similar kind. He is insistent that the problem is one that involves the whole family and he protests at the tendency to give too little attention to the role of father.
This completes our review of what is known of the families of children who refuse to leave home to go to school. When cases are considered in the light of the four patterns of family interaction described, it is seen, first, that, once the facts are known and the family pattern is identified, a child's behaviour is usually readily intelligible in terms of the situation he finds himself in; and, second, that many of the judgements hitherto made about such children by clinicians -- that they have been spoiled by over-indulgence, that they are afraid to grow up, that they are importunately greedy, that they wish to remain a baby tied to mother for ever, that they are fixated and regressed -- are as mistaken as they are unjust.
Two classical cases of childhood phobia: a reappraisal
In the light of our review of the family patterns that lie behind almost every case of school phobia, it is of interest to look afresh at two cases of childhood phobia that, reported during the first quarter of this century, have shaped all later theorizing. In the tradition of psychoanalysis, the classical case is that of the five-year-old Little Hans, described by Freud ( 1909). In the tradition of learning theory, a classical case is that of Peter, aged two years and ten months, described by Mary Cover Jones ( 1924b), a student of Watson.
In view of the key role that anxious attachment is held in this work to have played in all the cases of childhood phobia so far considered, is there evidence, we may ask, of its having played a part also in either of these famous cases? In what follows it is argued that in both cases there is clear presumptive evidence that it did and that, because theoretical expectations led each researcher to attend to other aspects of the case, those aspects on which weight is placed here were either overlooked or relegated to a subordinate position.
In both children the presenting symptom was an animal -283-
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phobia. The pattern of family interaction present in the first case is likely to have been pattern B, and that in the second case pattern C.
The Case of Little Hans
A key paper in the development of psychoanalytic theorizing is Freud's study of a horse phobia in a five-year-old boy. The theory that Freud advances in that paper ( 1909) is that Little Hans's fear of being bitten by a horse had resulted from the repression and subsequent projection of his aggressive impulses, comprising hostility directed towards his father and sadism directed towards his mother. Later, he concluded: 'The motive force of the repression was fear of castration' ( 1926a, SE 20: 108). Although the origin of the hostility, oedipal or preoedipal, may have been debated by other analysts, the outline of the theory has persisted and remains the basis for all later psychoanalytic theorizing about phobias. What evidence, we may now ask, is there that anxiety about the availability of attachment figures was playing a larger part in Hans's condition than Freud realized? When the case report is read afresh in the light of our discussion of school refusal, it seems probable that anxious attachment was indeed contributing a great deal to Little Hans's problem. Most of his anxiety, it is suggested, arose from threats by his mother to desert the family. This view is advanced on two grounds:
--the sequence in which symptoms developed and statements made by Little Hans himself ( SE 10: 22-4)
--evidence in father's account that mother was in the habit of using threats of an alarming kind to discipline the boy and that those included threats to abandon him ( SE 10: 44-5).
Although the title of the paper is the 'Analysis of a Phobia in a Five-year-old Boy', Freud himself saw the child only once and the 'analysis' was conducted by Hans father. The published paper comprises father's stenographic protocol, with a running commentary and a long concluding discussion by Freud.
The parents themselves had for some years been supporters of Freud, were in fact among his first (Jones 1955), and Freud had treated mother for a neurosis before her marriage. There was a younger sister, Hanna, born three and a half years after Hans and of whom he was jealous.
Hans was four and three-quarters when father became worried
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about him and consulted Freud. The problem as presented was Hans's fear that a horse would bite him in the street. Father recounted how a few days earlier Hans had been out to Scho? nbrunn with his mother, which he usually enjoyed. On this occasion, however, he had not wished to go, had cried, and had been frightened in the street when going there. On the return journey 'he said to his mother, after much internal struggling: "I was afraid a horse would bite me. "' That evening before bedtime he had remarked apprehensively: 'The horse'll come into the room. '
The symptoms, as might be expected, had not come out of the blue. According to father's record, Hans had been upset throughout the preceding week. It had begun when Hans had woken up one morning in tears. Asked why he was crying he had said to his mother: 'When I was asleep I thought you were gone and I had no Mummy to coax with. ' ( Coax was Hans expression for cuddle. ) Some days later his nursemaid had taken him to the local park, as usual. But in the street he had begun to cry and asked to be taken home, saying that he wanted to 'coax' with his mother. When later that day he had been asked why he had refused to go any further, he would not say. During that evening he had again become very frightened and cried,
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and he had demanded to stay with his mother. The next day, his mother, eager to find out what was wrong, had taken him on the visit to Scho? nbrunn, when the horse phobia was first noticed.
Looking back further into the history, we find that the week preceding the onset of the phobia had not been the first time that Hans had expressed fear that his mother might disappear. Six months earlier, during the summer holiday, he had made remarks such as 'Suppose I was to have no Mummy' or 'Suppose you were to go away'. Looking further back still, Hans's father recalled that, when Hanna was born, Hans, aged three and a half, had been kept away from his mother. In father's opinion, Hans's 'present anxiety, which prevents him leaving the neighbourhood of the house, is in reality the longing for [his mother] which he felt then'. Freud endorses that opinion and describes Hans's 'enormously intensified affection' for his mother as 'the fundamental phenomenon in his condition' ( SE 10: 24-5; also 96 and 114 ).
Thus, both the sequence of events leading up to the phobia and Hans's own statements make it clear that, distinct from and preceding any fear of horses, Hans was afraid that his mother
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might go away and leave him. Since, in the light of present knowledge, the expression of such fear should alert to the possibility that mother might have uttered threats, explicit or implicit, to leave the family, it is of interest to ask whether there is any evidence of her having done so.
Early in the record it becomes apparent that mother is inclined to use rather alarming threats. For example, when Hans is only three she is described as having threatened him that, if he touched his penis, she would send for the doctor to cut it off ( SE 10: 7-8). And we know too that, over a year later, at the time the phobia was first reported, mother was still trying to break him of the habit (p. 24 ). She is said to have 'warned him' not to touch his penis, though we are not told the nature of the warnings she was then uttering.
Three months later, however, and buried deep in the 'analytic' record, Hans lifts the curtain. He had come into father's bed one morning and in the course of talk had told his father: 'When you're away I'm afraid you're not coming home. ' Father expostulates: 'And have I ever threatened you that I shan't come home? ' 'Not you,' retorts Hans, 'but Mummy. Mummy's told me she won't come back. ' Father concedes the point. 'She said that', he replies, 'because you were naughty. ' 'Yes,' assents Hans ( SE 10: 44-5).
In the passage following father reflects, reasonably enough: 'His motive for at the most just venturing outside the house but not going away from it, and for turning round at the first attack of anxiety when he is half-way, is his fear of not finding his parents at home because they have gone away. ' Soon after, however, father reverts to an explanation along oedipal lines.
Even Hans's expressed fear that a horse might bite him is consonant with the view that fear of mother's departure was the principal source of his anxiety. This is shown by an incident that had occurred during the summer holiday of the previous year and to which Hans referred, by way of refutation, when father was trying to reassure him that horses do not bite. When Lizzi, a little girl who was staying in a neighbouring house, had gone away, the luggage had been taken to the station in a cart pulled by a white horse. Lizzi's father was there and had warned her: 'Don't put your finger to the white horse or it'll bite you' ( SE 10: 29). Thus, we find
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Hans's fear of being bitten by a horse is closely linked in his mind to someone's departure. There is other evidence also that horses are identified with departures (e. g. p. 45 ).
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On all these issues, it is evident that Freud was thinking along lines very different from those proposed here. Hans's insistent desire to remain with his mother is seen, not in terms of anxious attachment, but as the expression of his love for his mother, held to have been genitally sexual in character, having reached an extreme 'pitch of intensity' ( SE 10: 110-11). The dream that his mother had gone away and left him is held to have been, not an expression of Hans's fear that his mother would carry out a threat to desert the family, but an expression of his fear of the punishment due to him for his incestuous wishes ( SE 10: 118). The episode when Hans heard a neighbour warn that the white horse might bite is linked to a postulated wish that his father should go away, not to a fear lest his mother desert. Mother's displays of affection to Hans and her allowing him to come into bed with her are seen, not simply as a natural and comforting expression of motherly feeling, but as actions that might have encouraged, in a rather unfortunate way, Hans oedipal wishes ( SE 10: 28).
A tailpiece that tends to support the present hypothesis is that, subsequent to these events, Hans parents separated and later divorced ( SE 10: 148). (The fact that Hans was separated from his younger sister suggests that mother may have kept the little girl with her and left Hans with his father.