Yet, when they did find her, they seemed not to enjoy contact with her, and often they
struggled
to get away again.
A-Secure-Base-Bowlby-Johnf
Bowlby, 1981) I describe what I believe to be some of the strengths of the framework I favour, including its close related- ness to empirical data, both clinical and develop- mental, and its compatibility with current ideas in evolutionary biology and neurophysiology; whilst what I see as the shortcomings of Mahler's framework are trenchantly criticized by Peterfre- und (1978) and Klein (1981).
In brief, Mahler's theories of normal develop- ment, including her postulated normal phases of autism and symbiosis, are shown to rest not on observation but on preconceptions based on tra- ditional psychoanalytic theory and, in doing so, to ignore almost entirely the remarkable body of new information about early infancy that has been built up from careful empirical studies over the past two decades. Although some of the
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? ? ? clinical implications of Mahler's theory are not very different from those of attachment theory, and her concept of return to base to 'refuel' is similar to that of use of an attachment figure as a secure base from which to explore, the key con- cepts with which the two frameworks are built are very different.
RESEARCH
Nothing has been so rewarding as the immense amount of careful research to which the early work on maternal deprivation has given rise. The literature is now enormous and far beyond the compass of an account of this sort to summarize. Fortunately, moreover, it is unnecessary since a comprehensive and critical review of the field has been published by Rutter (1979) who concludes by referring to the 'continuing accumulation of evidence showing the importance of deprivation and disadvantage on children's psychological de- velopment' and expressing the view that the ori- ginal arguments 'have been amply confirmed'. A principal finding of recent work is the extent to which two or more adverse experiences interact so that the risk of a psychological disturbance fol- lowing is multiplied, often many times over. An
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? ? ? example of this interactive effect of adverse ex- periences is seen in the findings of Brown and Harris (1978) derived from their studies of de- pressive disorders in women. (During the last decade this group has published many further findings of the greatest interest, see Harris (1988). )
Not only is there this strongly interactive effect of adverse experiences but there is an increased likelihood for someone who has had one adverse experience to have another. For example, 'people brought up in unhappy or disrupted homes are more likely to have illegitimate children, to be- come teenage mothers, to make unhappy mar- riages, and to divorce' (Rutter, 1979). Thus ad- verse childhood experiences have effects of at least two kinds. First they make the individual more vulnerable to later adverse experiences. Se- condly they make it more likely that he or she will meet with further such experiences. Whereas the earlier adverse experiences are likely to be wholly independent of the agency of the individual con- cerned, the later ones are likely to be the con- sequences of his or her own actions, actions that spring from those disturbances of personality to which the earlier experiences have given rise.
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? ? ? Of the many types of psychological disturbance that are traceable, at least in part, to one or an- other pattern of maternal deprivation, the effects on parental behaviour and thereby on the next generation are potentially the most serious. Thus a mother who, due to adverse experiences during childhood, grows up to be anxiously attached is prone to seek care from her own child and thereby lead the child to become anxious, guilty, and perhaps phobic (see review in Bowlby, 1973). A mother who as a child suffered neglect and fre- quent severe threats of being abandoned or beaten is more prone than others to abuse her child physically (DeLozier, 1982), resulting in the adverse effects on the child's developing person- ality recorded, amongst others, by George and Main (1979). Systematic research into the effects of childhood experiences on the way mothers and fathers treat their children has only just begun and seems likely to be one of the most fruitful of all fields for further research. Other research leads are described in a recent symposium edited by Parkes and Stevenson-Hinde (1982).
My reason for giving so much space in this ac- count to the development of theory is not only because it has occupied so much of my time but
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? ? ? because, as Kurt Lewin remarked long ago, 'There is nothing so practical as a good theory', and, of course, nothing so handicapping as a poor one. Without good theory as a guide, research is likely to be difficult to plan and to be unproduct- ive, and findings are difficult to interpret. Without a reasonably valid theory of psychopath- ology, therapeutic techniques tend to be blunt and of uncertain benefit. Without a reasonably valid theory of aetiology, systematic and agreed measures of prevention will never be supported. My hope is that in the long term the greatest value of the theory proposed may prove to be the light it throws on the conditions most likely to promote healthy personality development. Only when those conditions are clear beyond doubt will parents know what is best for their children and will communities be willing to help them provide it.
1 Ronald Hargreaves's premature death in 1962, when professor of psychiatry at Leeds, was a grievous loss to preventive psychiatry.
2 This is the term Thomas Kuhn (1974) now uses to re- place 'paradigm', the term he used in his earlier work (Kuhn, 1962).
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? ? ? 3 As Spiegel (1981) points out, my term 'defensive ex- clusion' carries a meaning very similar to Sullivan's term 'selective inattention'.
3
PSYCHOANALYSIS AS ART AND SCIENCE
During the summer of 1978 I was invited to give a number of lectures in Canada. Among the in- vitations was one from the Canadian Psycho- analytic Society to give their academic lecture to the annual meeting of the Society to be held in Quebec City. The topic I selected is one which had concerned me for some years, and about which I believe there is still a great deal of con- fused thinking.
In taking as my theme psychoanalysis as art and science I want to draw attention to what I believe to be two very different aspects of our discip- line--the art of psychoanalytic therapy and the science of psychoanalytic psychology--and in do- ing so to emphasize, on the one hand, the dis- tinctive value of each and, on the other, the gulf that divides them--in regard both to the contrast- ing criteria by which each should be judged and
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? ? ? the very different mental outlook that each de- mands. In emphasizing these distinctions, I can- not help regretting that the word psychoanalysis came early to be used ambiguously as Freud him- self described it. 'While it was originally the name of a particular therapeutic method', he writes in his autobiography (1925), 'it has now also become the name of a science--the science of unconscious mental processes'.
The distinction I am drawing, of course, is not confined to psychoanalysis. It applies in every field in which the practice of a profession or a craft gives birth to a body of scientific know- ledge--the blacksmith to metallurgy, the civil en- gineer to soil mechanics, the farmer to plant physiology, and the physician to the medical sci- ences. In each of these fields the roles differenti- ate. On the one hand are the practitioners, on the other the scientists, with a limited number of in- dividuals attempting to combine both roles. As history shows, this process of differentiation of- ten proves painful and misunderstandings are frequent. Since I believe differentiation is bound to come also in our own field, and is perhaps already overdue, let us consider some of the diffi- culties and misunderstandings to which it may all
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? ? ? too easily give rise in the hope of avoiding them or mitigating their consequences.
I start by contrasting the roles of practitioner and research scientist and do so under three headings, using the case of medicine as an example.
FOCUS OF STUDY
The aim of the practitioner is to take into account as many aspects as he can of each and every clin- ical problem with which he is called upon to deal. This requires him not only to apply any scientific principle that appears relevant but also to draw on such personal experience of the condition as he may have acquired and, especially, to attend to that unique combination of features met with in each patient. Knowing how greatly patients dif- fer, the experienced clinician recognizes that a form of treatment well suited to one would be totally inappropriate to another.
Taking all factors into account and giving each its due weight is the art of clinical judgement.
The outlook of the research scientist is quite different. In his efforts to discern general pat- terns underlying individual variety he ignores the particular and strives to simplify, risking thereby
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? ? ? over- simplification. If he is wise he will probably concentrate attention on a limited aspect of a limited problem. If in making his selection he proves sagacious, or simply lucky, he may not only elucidate the problem selected but also de- velop ideas applicable to a broader range. If his selection proves unwise or unlucky he may merely end up knowing more and more about less and less. That is the risk every researcher runs. The art of research lies in selecting a limited manageable problem and the methods that will best help solve it. This brings me to my second point.
MODES OF ACQUIRING INFORMATION
In the methods available to him for acquiring in- formation the practitioner has certain great ad- vantages over the research scientist but also cer- tain great disadvantages. Let us start with the advantages.
In his role of giving help the practitioner is per- mitted access to information of certain kinds that remain closed to the scientist: as a friend of mine is fond of saving, it's only surgeons who are al- lowed to cut you open to see what's inside. In an analogous way it is only by treating a patient
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? ? ? therapeutically that a psychoanalyst is given ac- cess to much of importance going on in a person's mind. In both professions, moreover, practition- ers are permitted to intervene in specified ways and privileged to observe what the consequences of such interventions are. These are immense ad- vantages and psychoanalysts have not been slow to exploit them.
Yet no science can prosper for long without en- listing new methods to cross-check on observa- tions made and on hypotheses born of older methods. Here the research scientist is likely to have the advantage. In the medical sciences, physiologists and pathologists have made im- mense advances by means of animal experi- ments, tissue culture, biochemical analyses, and a thousand other ingenious techniques. Indeed, it is a hallmark of a creative scientist that he devises new means by which phenomena, perhaps already well studied by other methods, can be ob- served in some new way.
It is in this area, I believe, that the ambiguous use of the word psychoanalysis has done greatest harm. For it has led some analysts to suppose that the only method of enquiry appropriate for the advancement of psychoanalytic science is that
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? ? ? of treating a patient psychoanalytically. Since I believe this to be a profound misunderstanding I shall be saying a good deal more about it. Before doing so, however, I want to say a word about the place of scepticism and faith in the respective worlds of scientist and practitioner.
SCEPTICISM AND FAITH
In his day-to-day work it is necessary for a scient- ist to exercise a high degree of criticism and self- criticism: and in the world he inhabits neither the data nor the theories of a leader, however ad- mired personally he may be, are exempt from challenge and criticism. There is no place for authority.
The same is not true in the practice of a profes- sion. If he is to be effective a practitioner must be prepared to act as though certain principles and certain theories were valid; and in deciding which to adopt he is likely to be guided by those with ex- perience from whom he learns. Since, moreover, there is a tendency in all of us to be impressed whenever the application of a theory appears to have been successful, practitioners are at special risk of placing greater confidence in a theory than the evidence available may justify.
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? ? ? From the standpoint of clinical practice this is no bad thing. On the contrary, there is abundant evidence that the great majority of patients are helped by the faith and hope that a practitioner brings to his work; whilst it is often the very lack of these qualities that makes so many excellent research workers sadly ill-suited to be therapists.
Yet, though faith in the validity of particular data and in particular theories is out of place in a scientist, I do not wish to imply that he is nothing but a sceptic. On the contrary, his whole way of living is founded on faith, faith that in the long run the best route to reliable knowledge is the ap- plication of scientific method.
I am, of course, aware that there are many psy- choanalysts who do not share this faith and who believe that the types of problem with which we deal lie far outside the scope of science. This is a view I respect, though I do not share: nor, of course, did Freud. Yet even those of us who are most enthusiastic about applying scientific meth- od in our field must recognize that there may well be problems that it can never solve. We simply do not know. Our task, as I see it, is to apply our method as skilfully as we can, on the one hand believing that the area of reliable knowledge will
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? ? ? thereby be expanded and, on the other, accepting that there are likely always to remain still greater areas lying beyond the scope of any existing mode of scientific enquiry.
To many of you, I am afraid, engaged in thera- peutic practice but also hoping to contribute to the advance of psychoanalytic science, the con- trasts I am drawing between the roles of practi- tioner and scientist will hardly be welcome. Yet I believe that it is only by recognizing these differ- ences and acting accordingly that the strengths of each role can be used to fullest advantage--or that any one person can occupy both of them with any hope of success. As practitioners we deal in complexity; as scientists we strive to simplify. As practitioners we use theory as a guide; as sci- entists we challenge that same theory. As practi- tioners we accept restricted modes of enquiry; as scientists we enlist every method we can.
Earlier I remarked on the need for every devel- oping science to devise new methods for obtain- ing data. The reason for this is that, however pro- ductive any one method may be, it is bound to have its limitations, whilst there is always a pro- spect that some other method may compensate for them. Thus the new method may be in no way
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? ? ? superior to the old; indeed it may have great lim- itations. Its usefulness lies simply in the fact that its strengths and its limitations are different. Per- haps I can illustrate the point by reference to my own work.
When I qualified in psychoanalysis in 1937, members of the British Society were occupied in exploring the fantasy worlds of adults and chil- dren, and it was regarded as almost outside the proper interest of an analyst to give systematic attention to a person's real experiences. That was a time when Freud's famous about-turn of 1897 regarding the aetiology of hysteria1 had led to the view that anyone who places emphasis on what a child's real experiences may have been, and per- haps still are being, was regarded as pitifully nai? ve. Almost by definition it was assumed that anyone interested in the external world could not be interested in the internal world, indeed was al- most certainly running away from it.
To me as a biologist this contrast of internal with external, of organism with environment, never appealed. Furthermore, as a psychiatrist engaged in work with children and families and deeply influenced by the insights of two analytic- ally oriented social workers, I was daily
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? ? ? confronted with the impact on children of the emotional problems from which their parents suffered. Here are two examples I still recall vividly. In one a father was deeply concerned about his 8-year-old son's masturbation and in reply to my enquiries explained how, whenever he caught him with his hand on his genitals, he put him under a cold tap. This led me to ask fath- er whether he himself had ever had any worry about masturbation, and he launched into a long and pathetic tale of how he had battled with the problem all his life. In another case a mother's punitive treatment of her 3-year-old's jealousy of the new baby was as quickly traced to the prob- lem she had always had with her own jealousy of a younger brother.
Observations of these kinds led me to conclude that it is just as necessary for analysts to study the way a child is really treated by his parents as it is to study the internal representations he has of them, indeed that the principal focus of our studies should be the interaction of the one with the other, of the internal with the external. Be- lieving that that would be possible only if we had far more systematic knowledge about the effects on a child of the experiences he has during his
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? ? ? early years within his family, I concentrated my attention on this area. The reasons that I selected as my special field of study the removal of a young child from his home to a residential nurs- ery or hospital rather than the broader field of parent-child interaction were several. First it was an event that I believed could have serious ill ef- fects on a child's personality development. Se- condly there could be no debate whether it had occurred or not, in this regard contrasting strongly with the difficulty of obtaining valid in- formation about how a parent treats a child. Thirdly it appeared to be a field in which prevent- ive measures might be possible. And perhaps I should add, fourthly, that I was stimulated by the sheer incredulity with which my views were met by some, though by no means all, of my col- leagues when I first advanced them just before the war.
The results of our ensuing studies, undertaken by two researchers both of whom subsequently qualified as analysts, James Robertson and Christoph Heinicke, are now well-known; and I believe them to have had a significant effect on psychoanalytic thinking. The points I wish to make now, however, concern research strategy.
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? ? ? Despite the pioneer work of such distinguished analysts as Anna Freud, Rene? Spitz, Ernst Kris, Margaret Mahler, and others, for long there has been a tendency in analytic circles to regard the direct observation of young children and the re- cording of what they say as no more than an aux- iliary method of research, the results of which are of interest when they confirm conclusions already reached by the traditional method of treating pa- tients but which are unable to contribute any- thing original. The notion that the direct observa- tion of children--in and out of the family set- ting--is not only a valuable method for advancing psychoanalytic science but is indispensable to it has been slow to be accepted.
The principal contributions of these direct studies, I believe, are to cast light on how chil- dren develop emotionally and socially, on what the ranges of variation are in respect to a very large number of relevant parameters, and what types of family experience tend to influence chil- dren to develop in one way rather than another. Let me give some examples of findings by col- leagues working in our sister sciences of ethology and developmental psychology that I believe to be highly germane to our clinical understanding.
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? ? ? The first example is from the work of Mary Sal- ter Ainsworth (1977), formerly at Johns Hopkins University and now at the University of Virginia. Trained initially as a clinical psychologist, Mary Ainsworth worked with us at the Tavistock dur- ing the early 50s and then spent a couple of years studying mothers and infants in Uganda. Her definitive study has concerned the development of mother-infant interaction during the first year of life in white middle-class homes in Baltimore, Maryland. She has had a personal analysis and is keenly alive to the types of problem analysts re- gard as important.
During her study of mothers and infants in Uganda Ainsworth was struck how infants, once mobile, commonly use mother as a base from which to explore. When conditions are favourable an infant moves away from mother on explorat- ory excursions and returns to her again from time to time. By eight months of age almost every in- fant observed who had had a stable mother-figure to whom to become attached showed this beha- viour; but, should mother be absent, such organ- ized excursions became much less evident or ceased. As a result of these and similar findings, both for human and for monkey infants, the
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? ? ? notion has been developed that an ordinary de- voted mother provides a child with a secure base from which he can explore and to which he can return when upset or frightened. Similar observa- tions, of course, have been made by Margaret Mahler (Mahler, Pine, and Bergman, 1975), though she interprets them in terms of a theoret- ical framework different to the one which Ainsworth and I use. This concept of the secure personal base, from which a child, an adolescent, or an adult goes out to explore and to which he returns from time to time, is one I have come to regard as crucial for an understanding of how an emotionally stable person develops and functions all through his life.
In her project in Baltimore, Ainsworth was not only able to study this kind of behaviour more closely but described many individual variations of it to be seen in a sample of 23 infants at 12 months of age. Observations were made of the in- fants' exploratory and attachment behaviour, and the balance between them, both when the infants were at home with mother and also when they were placed in a slightly strange test situation. In addition, having obtained data on the type of mothering each infant had been receiving
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? ? ? throughout his first year of life (by means of pro- longed observation sessions at three weekly inter- vals in the child's home), Ainsworth was in a pos- ition to propose hypotheses linking certain types of emotional and behavioural development at 12 months with certain types of preceding mother- ing experience.
The findings of the study (see the review by Ainsworth, 1977) show that the way a particular infant of 12 months behaves with and without his mother at home and the way he behaves with and without her in a slightly strange test situation have much in common. Drawing on observations of behaviour in both types of situation it is then possible to classify the infants into three main groups, according to two criteria: (a) how much or how little they explore when with mother or without her, and (b) how they treat moth- er--when she is present, when she departs, and, especially, when she returns.
There were eight children whose overall beha- viour at their first birthday Ainsworth was dis- posed to regard as promising well for the future. Such infants explored actively, especially in mother's presence, and used mother as a base by keeping note of her whereabouts, exchanging
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? ? ? glances, and from time to time returning to her to share in enjoyable mutual contact. When mother had been absent for a short time she was greeted warmly on her return. I will call these group X.
There were no less than eleven children whose overall behaviour gave cause for concern and whom I will call group Z. Three of them were passive, both at home and in the test situation; they explored little and, instead, sucked a thumb or rocked. Constantly anxious about mother's whereabouts, they cried much in her absence but were contrary and difficult on her return. The other eight in this group alternated between ap- pearing very independent and ignoring mother altogether, and then suddenly becoming anxious and trying to find her.
Yet, when they did find her, they seemed not to enjoy contact with her, and often they struggled to get away again. In fact, they presented a classical picture of ambivalence.
The remaining four of the 23 children studied were judged to occupy a position intermediate between those given a good prognosis on their first birthday and those given a guarded one. I will call them group Y.
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? ? ? Since every three weeks throughout these in- fants' short lives the researchers had spent a three-hour session in the child's home observing and recording mother and infant behaviour, they had much first-hand data from which to rate a mother's behaviour towards her child. In making these ratings Ainsworth used four distinct nine- point rating scales; but, since ratings on these scales intercorrelate highly, for present purposes one scale is sufficient--a scale that measures the degree of sensitivity or insensitivity that a mother shows to her baby's signals and communications. Whereas a sensitive mother seems constantly to be 'tuned in' to receive her baby's signals, is likely to interpret them correctly, and to respond to them both promptly and appropriately, an in- sensitive mother will often not notice her baby's signals, will misinterpret them when she does no- tice them, and will then respond tardily, inappro- priately, or not at all. When the ratings on this scale for the mothers of infants in each of the three groups are examined, it is found that the mothers of the eight infants in group X are rated uniformly high (range 5. 5 to 9. 0), those of the el- even infants in group Z are rated uniformly low (range 1. 0 to 3. 5), and those of the four in group
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? ? ? Y are in the middle (range 4. 5 to 5. 5). Differences are statistically significant.
Plainly a great deal of further work is necessary before it is possible to draw conclusions with any high degree of confidence. Nevertheless, the overall patterns of personality development and of mother-child interaction visible at 12 months are sufficiently similar to what is seen of person- ality development and of parent-child interaction in later years for it to be plausible to believe that the one is the forerunner of the other. At the least, Ainsworth's findings show that an infant, whose mother is sensitive, accessible, and re- sponsive to him, who accepts his behaviour and is co-operative in dealing with him, is far from be- ing the demanding and unhappy child that some theories might suggest. Instead, mothering of this sort is evidently compatible with a child who is developing a limited measure of self-reliance by the time of his first birthday combined with a high degree of trust in his mother and enjoyment of her company.
Conversely mothers who are insensitive to their children's signals, perhaps because they are preoccupied and worried about other things, who ignore their children, or interfere with their
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? ? ? activities in an arbitrary way, or simply reject them, are likely to have children who are un- happy or anxious or difficult. Anyone who has worked in a clinic seeing disturbed children or adolescents will hardly be surprised by that.
Although Ainsworth's finding of a correlation between a mother's responsiveness to her infant and the infant's way of behaving towards her at 12 months is highly significant statistically and has been confirmed by subsequent studies, it is always possible to argue that the partner who plays the greater role in determining whether in- teraction develops happily or not is the infant and not the mother. Some infants are born difficult, so the argument runs, and the mothers' adverse reactions to them are only to be expected.
I do not think the evidence supports this view. For example, the observations made during the first three months of these infants' lives showed no correlation between the amount of crying a baby did and the way his mother was treating him; whereas by the end of the first year mothers who had attended promptly to their crying babies had babies who cried much less than did the ba- bies of mothers who had left them to cry.
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? ? ? There are other findings, some of which are re- ferred to in Lecture 6, that also support the view that in all but a small minority of cases it is the mother who is mainly responsible for how inter- action develops.
Drawing on her own home observations, Ainsworth has given a graphic account of what can happen. For example, she describes how she has sat in homes hearing a baby crying and crying and counted the minutes until the mother has re- sponded. In some cases a mother sits it out as long as she can bear to, believing that it would be bad for the baby and make him cry more were she to attend to him--a belief that Ainsworth's findings firmly disprove. In other cases a mother may be too engaged in something else to go. In yet others it appears as though a mother has alto- gether failed to register that her baby is crying--a situation an observer finds extremely painful to sit through. Usually these are women suffering from anxiety and depression and who are really incapable of attending to anything else.
Now it will be evident to everyone that detailed and accurate observations of these kinds, which demonstrate how enormously different the ex- periences of different children can be, are
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? ? ? obtainable only by the methods used by these re- searchers. Had the observers not been present to see and hear what was going on but had relied in- stead on what the mothers told them, the pictures they would have got would in many cases have been entirely false; and all hope of finding signi- ficant correlations between the way a child devel- ops and the way he is treated by his mother and father would have vanished. Yet, as we have seen, when reliable methods of observation are used, even with quite small samples, highly significant correlations are found.
In emphasizing the determining role a mother plays in setting the pattern of interaction with her baby, to which I believe the evidence clearly points, I lay no blame. Looking after a baby, or a toddler, or an older child for that matter, is not only a skilled job but also a very hard and exact- ing one. Even for a woman who has had a happy childhood and who is now enjoying the help and support of her husband, and perhaps also of her own mother, and who has not been filled with mistaken advice about the dangers of spoiling her baby, it is a taxing one. That a woman with none of these advantages gets into an emotional hassle is hardly surprising and certainly not an occasion
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? ? ? for blame. Yet there now seems little doubt that when infants and young children are the subjects of insensitive mothering, mixed perhaps with oc- casions of outright rejection, and later to separa- tions and threats of separation the effects are de- plorable. Such experiences greatly increase a child's fear of losing his mother, increase his de- mands for her presence and also his anger at her absences, and may also lead him to despair of ever having a secure and loving relationship with anyone.
Although ideas of this sort are much more fa- miliar and also more acceptable in analytic circles today than they were a generation ago, thanks to the influence of Balint, Fairbairn, Winnicott, and many others, I am inclined to think that their im- plications, both for theory and for practice, are still a long way from being digested.
Let me illustrate the point by considering the aetiological and therapeutic problems presented by the type of patient who in the United Kingdom is likely to be described as a schizoid personality (Fairbairn, 1940) or as having a false self (Win- nicott, 1960) and in North America as being a borderline personality or suffering from
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? ? ? pathological narcissism (e. g. Kohut, 1971; Kern- berg, 1975).
The picture such a person presents is one of as- sertive independence and emotional self-suffi- ciency. On no account is he going to be beholden to anyone and, in so far as he enters into relation- ships at all, he makes sure he retains control. For much of the time he may appear to manage won- derfully well, but there may be times when he be- comes depressed or develops psychosomatic symptoms, often for no reason he knows of. Only should symptoms or a bout of depression become severe is there any possibility of his seeking treat- ment, and then more likely than not he will prefer drugs to analysts.
When such a person does come for analysis he is careful to keep the analyst at arm's length and to control what happens. What he tells us is lucid, but he avoids any reference to feeling, except per- haps to say how bored he gets. Holidays or other interruptions he welcomes as saving his time. Perhaps he finds the analysis an 'interesting exer- cise'; although he is not convinced it is much use. And in any case he could probably do a better job by analysing himself!
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? ? ? There is, of course, a large literature discussing the psychopathology of these conditions and the therapeutic problems they present; but on whatever issues there may be agreement there is none on aetiology. To take two contrasting view- points: whereas Winnicott (1960, 1974) attributes the condition squarely to early environmental failure in the form of 'not good enough mother- ing', Kernberg (1975) in his systematic treatise gives no more than a couple of easily missed paragraphs to the possible role that mothering plays in influencing development, and only a few passing references to the inadequate mothering certain of his patients may have received. That early experience may play the key role in determ- ining these conditions is not seriously examined by him.
Plainly it is of the greatest importance that in due course we should reach some consensus about this matter; and in debating the issues I be- lieve we should be foolish not to take account of data from as many sources as we can tap. For some conditions epidemiological surveys are now proving informative but I doubt whether they have anything yet to tell us about this one. At present therefore we have to make do with data
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? ? ? from our two familiar sources: (a) the analytic treatment of patients, (b) the direct observation of young children with their mothers.
As regards data obtained during treatment, I suspect it would be fruitful for some open- minded person to survey the psychoanalytic liter- ature and draw together all the case reports which record information about the childhood experiences of these patients. My guess is that, in so far as any information is given, it would strongly support Winnicott's view that these pa- tients have had disturbed childhoods in which in- adequate mothering in one form or another--and it can take many--bulks large. Since I have made no such survey, I can do no more than illustrate the kind of findings that I would confidently ex- pect. The following details come from case re- ports published by three analysts each much in- fluenced by Winnicott's views.
One report is by Donald Winnicott's widow Clare Winnicott (1980). The patient, a profes- sional woman of 41, presented a classical picture of the emotionally self-sufficient personality who recently had developed a variety of psychosomat- ic symptoms. Only after a good deal of analysis did she divulge the events of her childhood. Since
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? ? ? her mother was in full-time work, she was looked after by a German girl who left suddenly when the patient was 21/2. Then, after six months of un- certainty, she was taken by her mother to have tea with a friend and later found her mother had disappeared and she was alone in a strange bed. Next day she was taken to the boarding school where her mother's friend worked as matron, and she stayed there till she was 9, usually spending the holidays there also. She appears to have settled in well (ominous words! ) and coped very successfully; but from that time forward her emo- tional life had dried up.
A second report, by Jonathan Pedder (1976), is of a young teacher in her mid-twenties whose personality and symptomatology bear a strong resemblance to Clare Winnicott's patient. Al- though at the initial interview she had given an idealized picture of her childhood, it soon emerged that at the age of 18 months she had been sent to stay with an aunt during her moth- er's next pregnancy. After six months there she had come to feel that her aunt was more of a mother to her than was her real mother and she had found returning home a painful experience. Thereafter, until she was 10, she had been
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? ? ? terrified of another separation; but then she had 'switched off' her anxiety 'like a tap', as she put it, and with the anxiety had disappeared most of her emotional life as well.
The third report, by Elizabeth Lind (1973), con- cerns a young graduate of 23 who, though severely depressed and planning suicide, main- tained that his state of mind was less an illness than 'a philosophy of life'. He was the eldest of a large family; and by the time he was 3 two sib- lings had already been born. His parents, he said, quarrelled both frequently and violently. When the family was young, father had been working long hours away from home training for a profes- sion. Mother was always unpredictable. Often she was so distraught by her quarrelling children that she would lock herself in her room for days on end. Several times she had left home, taking the daughters with her but leaving the sons behind.
He had been told that he had been an unhappy baby, a poor feeder and sleeper, who had often been left alone to cry for long periods. His crying, it was said, had been just an attempt to gain con- trol of his parents and to be spoilt. On one occa- sion he had had appendicitis and he remembered lying awake all night moaning; but his parents
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? ? ? had done nothing and by next morning he was seriously ill. Later, during therapy, he recalled how disturbed he used to be at hearing his young- er brothers and sisters being left to cry and how he hated his parents for it and felt like killing them.
He had always felt like a lost child and had been puzzled to understand why he had been re- jected. His first day at school, he said, had been the worst in his life. It had seemed a final rejec- tion by his mother; all day he had felt desperate and had never stopped crying. After that he had gradually come to hide all desires for love and support: he had refused ever to ask for help or to have anything done for him.
Now, during therapy, he was frightened he might break down and cry and want to be mothered. This would lead his therapist, he felt sure, to regard him as a nuisance and his beha- viour simply as attention-seeking; and, were he to say anything personal to her, he fully expected her to be offended and perhaps lock herself in her room.
In all three cases the patient's recent break- down had followed the collapse of a significant but fragile relationship about which each
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? ? ? member of the pair had had reservations and to the ending of which each of the patients had, him or herself, obviously contributed.
In treating these patients all three analysts ad- opted Winnicott's technique of permitting the free expression of what are traditionally termed 'dependency feelings', with the result that each patient in due course developed an intense and anxious attachment to his or her analyst (to use the terminology I prefer, (Bowlby, 1969, 1973)). This enabled each patient to recover the emotion- al life he or she had lost during childhood and with it to recover a sense of 'real self'. Therapeut- ically the results were good.
Admittedly, the findings from these three cases prove nothing. Nevertheless they are suggestive and, so far as they go, support Winnicott's theory of aetiology. Even so it is always open to critics to cast doubt on the validity of what a patient recalls about his childhood and to question whether the sequence of events recounted had the effect on his feeling life that he so explicitly claims. (It is worth nothing that the events that each of these three patients held to be a turning point had oc- curred after their second birthdays. )
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? ? ? Now it seems clear that the controversies about aetiology are never going to be settled as long as we rely solely on the retrospective and perhaps biased evidence derived from the analyses of pa- tients, whether they be adults or children. What is needed is evidence of a different kind to provide some sort of cross-check. This is where I believe the direct observations of young children and their mothers are potentially so useful. Is there any evidence from that source that suggests that a child's feeling life can become numbed by the types of experience described? The answer, of course, is that there is a great deal.
Here naturally I point first to the observations made by James Robertson (1953) and confirmed later by Christoph Heinicke and Ilse Westheimer (1965) on how children between the ages of 12 and 36 months behave when removed from home to the care of strange people in a strange place, such as a residential nursery or hospital, with no one person to act as a mother-substitute. In such conditions a child comes in time to act as if neither mothering nor contact with humans has much significance for him. As his caretakers come and go he ceases to attach himself to any- one and after his return home stays remote from
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? ? ? his parents for days, and perhaps for much longer if he is treated unsympathetically.
There is reason to believe, moreover, that a young child can develop this kind of defensive numbing in response to a mother who rejects him and without any major separation. Examples of this sequence are to be found in observations re- corded by Mahler (1971). More definitive findings are reported by Mary Main (1977), a colleague of Mary Ainsworth's, who has made a special study of a group of children in the age-range 12 to 20 months, each of whom not only failed to greet his mother after she had left him with a stranger for a few minutes but deliberately avoided her. View- ing some of Main's videotaped records I was as- tonished to see to what lengths some of these children went. One approached her mother briefly but with head averted and then retreated from her. Another, instead of approaching his mother, placed himself facing into the corner of the room, as though complying with a punish- ment, and then knelt down with his face to the floor. In every case videotaped records of these mothers playing with their toddlers during a later session showed them to differ from the mothers of non-avoidant toddlers: they appeared 'angry,
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? ? ? inexpressive and disliking of physical contact with the infant'. Some scolded in angry tones, some mocked, others spoke sarcastically to or about their child. An obvious possibility is that by keeping away from his mother in this way a child is avoiding being treated in a hostile way again.
Thus, so far as the cross-checks provided by direct observations of young children and their mothers go, they tend to support a Winnicott- type theory. Put briefly, and in my own words, the child, and later the adult, becomes afraid to allow himself to become attached to anyone for fear of a further rejection with all the agony, the anxiety, and the anger to which that would lead. As a result there is a massive block against his ex- pressing or even feeling his natural desire for a close trusting relationship, for care, comfort, and love--which I regard as the subjective manifesta- tions of a major system of instinctive behaviour.
An explanation of this kind, although much less complex than some proposed in the literat- ure, accounts well for how these people behave both in the world at large and with ourselves as analysts. Inevitably they bring their fear of enter- ing into a trusting relationship with them to ana- lysis, which we experience as a massive
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? ? ? resistance. Then, when at length their feelings are recovered, they more than half expect that we shall treat them as they recall being treated by their parents. In consequence they live in dread of being rejected and become intensely angry should they suspect us of deserting them. Not in- frequently, moreover, the way they treat us--with abuse and rejection--is found to be a version of the treatment to which they recall having them- selves been subjected as children.
You will see that in the explanation of how these patients behave during analysis I have ad- vanced a number of interlocking hypotheses. In a research programme each requires scrutiny and testing in the light of further data. Among the many methods that I would expect to prove of value is the study, in a therapeutic setting, of par- ents and children interacting with one another. In addition, there remains an important place for further observations to be made during the ana- lysis of individual patients; though I believe that, if clinical research is to yield its full potential, it has to be pursued in a far more systematic and directed way than hitherto.
To give an example: it would be of value were a detailed record to be kept of the responses of one
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? ? ? or more of these patients before and after each successive weekend, each vacation, and each un- expected interruption of the sessions, with an equally detailed record of how the analyst dealt with them. This would enable us to know the rep- ertoire of responses a given patient presents on these occasions, and also the changes in response he presents over time. It would also be especially valuable if we were to have a detailed account of the conditions in which a major therapeutic change occurs. If, perhaps in a collaborative pro- gramme, records could be kept on a number of such patients, it might be possible to discover whether a frank and detailed discussion of the painful experiences a patient recalls having had in his relationships with his parents and the ef- fects these appear to have had and still to be hav- ing on the ways he treats other people, including of course ourselves, promotes therapeutic change, as I predict, or hinders it, as is believed by some analysts.
Naturally, in embarking on this or any other research programme an analyst must bear in mind his professional responsibilities; for with patients who present a false self these can be very onerous. Winnicott describes the 'period of
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? ? ? extreme dependence' through which such pa- tients go during therapy and gives warning that 'analysts who are not prepared to go and meet the heavy needs of patients who become dependent in this way must be careful so to choose their cases that they do not include false self types'.
This brings me back to the art of therapy. To provide, by being ourselves, the conditions in which a patient of this kind can discover and re- cover what Winnicott calls his real self, and I call his attachment desires and feelings, is not easy. On the one hand, we have really to be trustworthy and we have also genuinely to respect all those yearnings for affection and intimacy that each of us has but which in these patients have become lost. On the other, we must not offer more than we can give and we must not move faster than the patient can bear. To achieve this balance requires all the intuition, imagination, and empathy of which we are capable. But it also requires a firm grasp of what the patient's problems are and what we are trying to do. This is why it is so very important that the problems of aetiology and psy- chopathology should be clarified as far as the ap- plication of scientific method makes possible and, further, that analysts should be thoroughly
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? ?
In brief, Mahler's theories of normal develop- ment, including her postulated normal phases of autism and symbiosis, are shown to rest not on observation but on preconceptions based on tra- ditional psychoanalytic theory and, in doing so, to ignore almost entirely the remarkable body of new information about early infancy that has been built up from careful empirical studies over the past two decades. Although some of the
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? ? ? clinical implications of Mahler's theory are not very different from those of attachment theory, and her concept of return to base to 'refuel' is similar to that of use of an attachment figure as a secure base from which to explore, the key con- cepts with which the two frameworks are built are very different.
RESEARCH
Nothing has been so rewarding as the immense amount of careful research to which the early work on maternal deprivation has given rise. The literature is now enormous and far beyond the compass of an account of this sort to summarize. Fortunately, moreover, it is unnecessary since a comprehensive and critical review of the field has been published by Rutter (1979) who concludes by referring to the 'continuing accumulation of evidence showing the importance of deprivation and disadvantage on children's psychological de- velopment' and expressing the view that the ori- ginal arguments 'have been amply confirmed'. A principal finding of recent work is the extent to which two or more adverse experiences interact so that the risk of a psychological disturbance fol- lowing is multiplied, often many times over. An
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? ? ? example of this interactive effect of adverse ex- periences is seen in the findings of Brown and Harris (1978) derived from their studies of de- pressive disorders in women. (During the last decade this group has published many further findings of the greatest interest, see Harris (1988). )
Not only is there this strongly interactive effect of adverse experiences but there is an increased likelihood for someone who has had one adverse experience to have another. For example, 'people brought up in unhappy or disrupted homes are more likely to have illegitimate children, to be- come teenage mothers, to make unhappy mar- riages, and to divorce' (Rutter, 1979). Thus ad- verse childhood experiences have effects of at least two kinds. First they make the individual more vulnerable to later adverse experiences. Se- condly they make it more likely that he or she will meet with further such experiences. Whereas the earlier adverse experiences are likely to be wholly independent of the agency of the individual con- cerned, the later ones are likely to be the con- sequences of his or her own actions, actions that spring from those disturbances of personality to which the earlier experiences have given rise.
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? ? ? Of the many types of psychological disturbance that are traceable, at least in part, to one or an- other pattern of maternal deprivation, the effects on parental behaviour and thereby on the next generation are potentially the most serious. Thus a mother who, due to adverse experiences during childhood, grows up to be anxiously attached is prone to seek care from her own child and thereby lead the child to become anxious, guilty, and perhaps phobic (see review in Bowlby, 1973). A mother who as a child suffered neglect and fre- quent severe threats of being abandoned or beaten is more prone than others to abuse her child physically (DeLozier, 1982), resulting in the adverse effects on the child's developing person- ality recorded, amongst others, by George and Main (1979). Systematic research into the effects of childhood experiences on the way mothers and fathers treat their children has only just begun and seems likely to be one of the most fruitful of all fields for further research. Other research leads are described in a recent symposium edited by Parkes and Stevenson-Hinde (1982).
My reason for giving so much space in this ac- count to the development of theory is not only because it has occupied so much of my time but
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? ? ? because, as Kurt Lewin remarked long ago, 'There is nothing so practical as a good theory', and, of course, nothing so handicapping as a poor one. Without good theory as a guide, research is likely to be difficult to plan and to be unproduct- ive, and findings are difficult to interpret. Without a reasonably valid theory of psychopath- ology, therapeutic techniques tend to be blunt and of uncertain benefit. Without a reasonably valid theory of aetiology, systematic and agreed measures of prevention will never be supported. My hope is that in the long term the greatest value of the theory proposed may prove to be the light it throws on the conditions most likely to promote healthy personality development. Only when those conditions are clear beyond doubt will parents know what is best for their children and will communities be willing to help them provide it.
1 Ronald Hargreaves's premature death in 1962, when professor of psychiatry at Leeds, was a grievous loss to preventive psychiatry.
2 This is the term Thomas Kuhn (1974) now uses to re- place 'paradigm', the term he used in his earlier work (Kuhn, 1962).
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? ? ? 3 As Spiegel (1981) points out, my term 'defensive ex- clusion' carries a meaning very similar to Sullivan's term 'selective inattention'.
3
PSYCHOANALYSIS AS ART AND SCIENCE
During the summer of 1978 I was invited to give a number of lectures in Canada. Among the in- vitations was one from the Canadian Psycho- analytic Society to give their academic lecture to the annual meeting of the Society to be held in Quebec City. The topic I selected is one which had concerned me for some years, and about which I believe there is still a great deal of con- fused thinking.
In taking as my theme psychoanalysis as art and science I want to draw attention to what I believe to be two very different aspects of our discip- line--the art of psychoanalytic therapy and the science of psychoanalytic psychology--and in do- ing so to emphasize, on the one hand, the dis- tinctive value of each and, on the other, the gulf that divides them--in regard both to the contrast- ing criteria by which each should be judged and
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? ? ? the very different mental outlook that each de- mands. In emphasizing these distinctions, I can- not help regretting that the word psychoanalysis came early to be used ambiguously as Freud him- self described it. 'While it was originally the name of a particular therapeutic method', he writes in his autobiography (1925), 'it has now also become the name of a science--the science of unconscious mental processes'.
The distinction I am drawing, of course, is not confined to psychoanalysis. It applies in every field in which the practice of a profession or a craft gives birth to a body of scientific know- ledge--the blacksmith to metallurgy, the civil en- gineer to soil mechanics, the farmer to plant physiology, and the physician to the medical sci- ences. In each of these fields the roles differenti- ate. On the one hand are the practitioners, on the other the scientists, with a limited number of in- dividuals attempting to combine both roles. As history shows, this process of differentiation of- ten proves painful and misunderstandings are frequent. Since I believe differentiation is bound to come also in our own field, and is perhaps already overdue, let us consider some of the diffi- culties and misunderstandings to which it may all
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? ? ? too easily give rise in the hope of avoiding them or mitigating their consequences.
I start by contrasting the roles of practitioner and research scientist and do so under three headings, using the case of medicine as an example.
FOCUS OF STUDY
The aim of the practitioner is to take into account as many aspects as he can of each and every clin- ical problem with which he is called upon to deal. This requires him not only to apply any scientific principle that appears relevant but also to draw on such personal experience of the condition as he may have acquired and, especially, to attend to that unique combination of features met with in each patient. Knowing how greatly patients dif- fer, the experienced clinician recognizes that a form of treatment well suited to one would be totally inappropriate to another.
Taking all factors into account and giving each its due weight is the art of clinical judgement.
The outlook of the research scientist is quite different. In his efforts to discern general pat- terns underlying individual variety he ignores the particular and strives to simplify, risking thereby
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? ? ? over- simplification. If he is wise he will probably concentrate attention on a limited aspect of a limited problem. If in making his selection he proves sagacious, or simply lucky, he may not only elucidate the problem selected but also de- velop ideas applicable to a broader range. If his selection proves unwise or unlucky he may merely end up knowing more and more about less and less. That is the risk every researcher runs. The art of research lies in selecting a limited manageable problem and the methods that will best help solve it. This brings me to my second point.
MODES OF ACQUIRING INFORMATION
In the methods available to him for acquiring in- formation the practitioner has certain great ad- vantages over the research scientist but also cer- tain great disadvantages. Let us start with the advantages.
In his role of giving help the practitioner is per- mitted access to information of certain kinds that remain closed to the scientist: as a friend of mine is fond of saving, it's only surgeons who are al- lowed to cut you open to see what's inside. In an analogous way it is only by treating a patient
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? ? ? therapeutically that a psychoanalyst is given ac- cess to much of importance going on in a person's mind. In both professions, moreover, practition- ers are permitted to intervene in specified ways and privileged to observe what the consequences of such interventions are. These are immense ad- vantages and psychoanalysts have not been slow to exploit them.
Yet no science can prosper for long without en- listing new methods to cross-check on observa- tions made and on hypotheses born of older methods. Here the research scientist is likely to have the advantage. In the medical sciences, physiologists and pathologists have made im- mense advances by means of animal experi- ments, tissue culture, biochemical analyses, and a thousand other ingenious techniques. Indeed, it is a hallmark of a creative scientist that he devises new means by which phenomena, perhaps already well studied by other methods, can be ob- served in some new way.
It is in this area, I believe, that the ambiguous use of the word psychoanalysis has done greatest harm. For it has led some analysts to suppose that the only method of enquiry appropriate for the advancement of psychoanalytic science is that
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? ? ? of treating a patient psychoanalytically. Since I believe this to be a profound misunderstanding I shall be saying a good deal more about it. Before doing so, however, I want to say a word about the place of scepticism and faith in the respective worlds of scientist and practitioner.
SCEPTICISM AND FAITH
In his day-to-day work it is necessary for a scient- ist to exercise a high degree of criticism and self- criticism: and in the world he inhabits neither the data nor the theories of a leader, however ad- mired personally he may be, are exempt from challenge and criticism. There is no place for authority.
The same is not true in the practice of a profes- sion. If he is to be effective a practitioner must be prepared to act as though certain principles and certain theories were valid; and in deciding which to adopt he is likely to be guided by those with ex- perience from whom he learns. Since, moreover, there is a tendency in all of us to be impressed whenever the application of a theory appears to have been successful, practitioners are at special risk of placing greater confidence in a theory than the evidence available may justify.
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? ? ? From the standpoint of clinical practice this is no bad thing. On the contrary, there is abundant evidence that the great majority of patients are helped by the faith and hope that a practitioner brings to his work; whilst it is often the very lack of these qualities that makes so many excellent research workers sadly ill-suited to be therapists.
Yet, though faith in the validity of particular data and in particular theories is out of place in a scientist, I do not wish to imply that he is nothing but a sceptic. On the contrary, his whole way of living is founded on faith, faith that in the long run the best route to reliable knowledge is the ap- plication of scientific method.
I am, of course, aware that there are many psy- choanalysts who do not share this faith and who believe that the types of problem with which we deal lie far outside the scope of science. This is a view I respect, though I do not share: nor, of course, did Freud. Yet even those of us who are most enthusiastic about applying scientific meth- od in our field must recognize that there may well be problems that it can never solve. We simply do not know. Our task, as I see it, is to apply our method as skilfully as we can, on the one hand believing that the area of reliable knowledge will
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? ? ? thereby be expanded and, on the other, accepting that there are likely always to remain still greater areas lying beyond the scope of any existing mode of scientific enquiry.
To many of you, I am afraid, engaged in thera- peutic practice but also hoping to contribute to the advance of psychoanalytic science, the con- trasts I am drawing between the roles of practi- tioner and scientist will hardly be welcome. Yet I believe that it is only by recognizing these differ- ences and acting accordingly that the strengths of each role can be used to fullest advantage--or that any one person can occupy both of them with any hope of success. As practitioners we deal in complexity; as scientists we strive to simplify. As practitioners we use theory as a guide; as sci- entists we challenge that same theory. As practi- tioners we accept restricted modes of enquiry; as scientists we enlist every method we can.
Earlier I remarked on the need for every devel- oping science to devise new methods for obtain- ing data. The reason for this is that, however pro- ductive any one method may be, it is bound to have its limitations, whilst there is always a pro- spect that some other method may compensate for them. Thus the new method may be in no way
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? ? ? superior to the old; indeed it may have great lim- itations. Its usefulness lies simply in the fact that its strengths and its limitations are different. Per- haps I can illustrate the point by reference to my own work.
When I qualified in psychoanalysis in 1937, members of the British Society were occupied in exploring the fantasy worlds of adults and chil- dren, and it was regarded as almost outside the proper interest of an analyst to give systematic attention to a person's real experiences. That was a time when Freud's famous about-turn of 1897 regarding the aetiology of hysteria1 had led to the view that anyone who places emphasis on what a child's real experiences may have been, and per- haps still are being, was regarded as pitifully nai? ve. Almost by definition it was assumed that anyone interested in the external world could not be interested in the internal world, indeed was al- most certainly running away from it.
To me as a biologist this contrast of internal with external, of organism with environment, never appealed. Furthermore, as a psychiatrist engaged in work with children and families and deeply influenced by the insights of two analytic- ally oriented social workers, I was daily
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? ? ? confronted with the impact on children of the emotional problems from which their parents suffered. Here are two examples I still recall vividly. In one a father was deeply concerned about his 8-year-old son's masturbation and in reply to my enquiries explained how, whenever he caught him with his hand on his genitals, he put him under a cold tap. This led me to ask fath- er whether he himself had ever had any worry about masturbation, and he launched into a long and pathetic tale of how he had battled with the problem all his life. In another case a mother's punitive treatment of her 3-year-old's jealousy of the new baby was as quickly traced to the prob- lem she had always had with her own jealousy of a younger brother.
Observations of these kinds led me to conclude that it is just as necessary for analysts to study the way a child is really treated by his parents as it is to study the internal representations he has of them, indeed that the principal focus of our studies should be the interaction of the one with the other, of the internal with the external. Be- lieving that that would be possible only if we had far more systematic knowledge about the effects on a child of the experiences he has during his
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? ? ? early years within his family, I concentrated my attention on this area. The reasons that I selected as my special field of study the removal of a young child from his home to a residential nurs- ery or hospital rather than the broader field of parent-child interaction were several. First it was an event that I believed could have serious ill ef- fects on a child's personality development. Se- condly there could be no debate whether it had occurred or not, in this regard contrasting strongly with the difficulty of obtaining valid in- formation about how a parent treats a child. Thirdly it appeared to be a field in which prevent- ive measures might be possible. And perhaps I should add, fourthly, that I was stimulated by the sheer incredulity with which my views were met by some, though by no means all, of my col- leagues when I first advanced them just before the war.
The results of our ensuing studies, undertaken by two researchers both of whom subsequently qualified as analysts, James Robertson and Christoph Heinicke, are now well-known; and I believe them to have had a significant effect on psychoanalytic thinking. The points I wish to make now, however, concern research strategy.
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? ? ? Despite the pioneer work of such distinguished analysts as Anna Freud, Rene? Spitz, Ernst Kris, Margaret Mahler, and others, for long there has been a tendency in analytic circles to regard the direct observation of young children and the re- cording of what they say as no more than an aux- iliary method of research, the results of which are of interest when they confirm conclusions already reached by the traditional method of treating pa- tients but which are unable to contribute any- thing original. The notion that the direct observa- tion of children--in and out of the family set- ting--is not only a valuable method for advancing psychoanalytic science but is indispensable to it has been slow to be accepted.
The principal contributions of these direct studies, I believe, are to cast light on how chil- dren develop emotionally and socially, on what the ranges of variation are in respect to a very large number of relevant parameters, and what types of family experience tend to influence chil- dren to develop in one way rather than another. Let me give some examples of findings by col- leagues working in our sister sciences of ethology and developmental psychology that I believe to be highly germane to our clinical understanding.
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? ? ? The first example is from the work of Mary Sal- ter Ainsworth (1977), formerly at Johns Hopkins University and now at the University of Virginia. Trained initially as a clinical psychologist, Mary Ainsworth worked with us at the Tavistock dur- ing the early 50s and then spent a couple of years studying mothers and infants in Uganda. Her definitive study has concerned the development of mother-infant interaction during the first year of life in white middle-class homes in Baltimore, Maryland. She has had a personal analysis and is keenly alive to the types of problem analysts re- gard as important.
During her study of mothers and infants in Uganda Ainsworth was struck how infants, once mobile, commonly use mother as a base from which to explore. When conditions are favourable an infant moves away from mother on explorat- ory excursions and returns to her again from time to time. By eight months of age almost every in- fant observed who had had a stable mother-figure to whom to become attached showed this beha- viour; but, should mother be absent, such organ- ized excursions became much less evident or ceased. As a result of these and similar findings, both for human and for monkey infants, the
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? ? ? notion has been developed that an ordinary de- voted mother provides a child with a secure base from which he can explore and to which he can return when upset or frightened. Similar observa- tions, of course, have been made by Margaret Mahler (Mahler, Pine, and Bergman, 1975), though she interprets them in terms of a theoret- ical framework different to the one which Ainsworth and I use. This concept of the secure personal base, from which a child, an adolescent, or an adult goes out to explore and to which he returns from time to time, is one I have come to regard as crucial for an understanding of how an emotionally stable person develops and functions all through his life.
In her project in Baltimore, Ainsworth was not only able to study this kind of behaviour more closely but described many individual variations of it to be seen in a sample of 23 infants at 12 months of age. Observations were made of the in- fants' exploratory and attachment behaviour, and the balance between them, both when the infants were at home with mother and also when they were placed in a slightly strange test situation. In addition, having obtained data on the type of mothering each infant had been receiving
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? ? ? throughout his first year of life (by means of pro- longed observation sessions at three weekly inter- vals in the child's home), Ainsworth was in a pos- ition to propose hypotheses linking certain types of emotional and behavioural development at 12 months with certain types of preceding mother- ing experience.
The findings of the study (see the review by Ainsworth, 1977) show that the way a particular infant of 12 months behaves with and without his mother at home and the way he behaves with and without her in a slightly strange test situation have much in common. Drawing on observations of behaviour in both types of situation it is then possible to classify the infants into three main groups, according to two criteria: (a) how much or how little they explore when with mother or without her, and (b) how they treat moth- er--when she is present, when she departs, and, especially, when she returns.
There were eight children whose overall beha- viour at their first birthday Ainsworth was dis- posed to regard as promising well for the future. Such infants explored actively, especially in mother's presence, and used mother as a base by keeping note of her whereabouts, exchanging
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? ? ? glances, and from time to time returning to her to share in enjoyable mutual contact. When mother had been absent for a short time she was greeted warmly on her return. I will call these group X.
There were no less than eleven children whose overall behaviour gave cause for concern and whom I will call group Z. Three of them were passive, both at home and in the test situation; they explored little and, instead, sucked a thumb or rocked. Constantly anxious about mother's whereabouts, they cried much in her absence but were contrary and difficult on her return. The other eight in this group alternated between ap- pearing very independent and ignoring mother altogether, and then suddenly becoming anxious and trying to find her.
Yet, when they did find her, they seemed not to enjoy contact with her, and often they struggled to get away again. In fact, they presented a classical picture of ambivalence.
The remaining four of the 23 children studied were judged to occupy a position intermediate between those given a good prognosis on their first birthday and those given a guarded one. I will call them group Y.
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? ? ? Since every three weeks throughout these in- fants' short lives the researchers had spent a three-hour session in the child's home observing and recording mother and infant behaviour, they had much first-hand data from which to rate a mother's behaviour towards her child. In making these ratings Ainsworth used four distinct nine- point rating scales; but, since ratings on these scales intercorrelate highly, for present purposes one scale is sufficient--a scale that measures the degree of sensitivity or insensitivity that a mother shows to her baby's signals and communications. Whereas a sensitive mother seems constantly to be 'tuned in' to receive her baby's signals, is likely to interpret them correctly, and to respond to them both promptly and appropriately, an in- sensitive mother will often not notice her baby's signals, will misinterpret them when she does no- tice them, and will then respond tardily, inappro- priately, or not at all. When the ratings on this scale for the mothers of infants in each of the three groups are examined, it is found that the mothers of the eight infants in group X are rated uniformly high (range 5. 5 to 9. 0), those of the el- even infants in group Z are rated uniformly low (range 1. 0 to 3. 5), and those of the four in group
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? ? ? Y are in the middle (range 4. 5 to 5. 5). Differences are statistically significant.
Plainly a great deal of further work is necessary before it is possible to draw conclusions with any high degree of confidence. Nevertheless, the overall patterns of personality development and of mother-child interaction visible at 12 months are sufficiently similar to what is seen of person- ality development and of parent-child interaction in later years for it to be plausible to believe that the one is the forerunner of the other. At the least, Ainsworth's findings show that an infant, whose mother is sensitive, accessible, and re- sponsive to him, who accepts his behaviour and is co-operative in dealing with him, is far from be- ing the demanding and unhappy child that some theories might suggest. Instead, mothering of this sort is evidently compatible with a child who is developing a limited measure of self-reliance by the time of his first birthday combined with a high degree of trust in his mother and enjoyment of her company.
Conversely mothers who are insensitive to their children's signals, perhaps because they are preoccupied and worried about other things, who ignore their children, or interfere with their
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? ? ? activities in an arbitrary way, or simply reject them, are likely to have children who are un- happy or anxious or difficult. Anyone who has worked in a clinic seeing disturbed children or adolescents will hardly be surprised by that.
Although Ainsworth's finding of a correlation between a mother's responsiveness to her infant and the infant's way of behaving towards her at 12 months is highly significant statistically and has been confirmed by subsequent studies, it is always possible to argue that the partner who plays the greater role in determining whether in- teraction develops happily or not is the infant and not the mother. Some infants are born difficult, so the argument runs, and the mothers' adverse reactions to them are only to be expected.
I do not think the evidence supports this view. For example, the observations made during the first three months of these infants' lives showed no correlation between the amount of crying a baby did and the way his mother was treating him; whereas by the end of the first year mothers who had attended promptly to their crying babies had babies who cried much less than did the ba- bies of mothers who had left them to cry.
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? ? ? There are other findings, some of which are re- ferred to in Lecture 6, that also support the view that in all but a small minority of cases it is the mother who is mainly responsible for how inter- action develops.
Drawing on her own home observations, Ainsworth has given a graphic account of what can happen. For example, she describes how she has sat in homes hearing a baby crying and crying and counted the minutes until the mother has re- sponded. In some cases a mother sits it out as long as she can bear to, believing that it would be bad for the baby and make him cry more were she to attend to him--a belief that Ainsworth's findings firmly disprove. In other cases a mother may be too engaged in something else to go. In yet others it appears as though a mother has alto- gether failed to register that her baby is crying--a situation an observer finds extremely painful to sit through. Usually these are women suffering from anxiety and depression and who are really incapable of attending to anything else.
Now it will be evident to everyone that detailed and accurate observations of these kinds, which demonstrate how enormously different the ex- periences of different children can be, are
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? ? ? obtainable only by the methods used by these re- searchers. Had the observers not been present to see and hear what was going on but had relied in- stead on what the mothers told them, the pictures they would have got would in many cases have been entirely false; and all hope of finding signi- ficant correlations between the way a child devel- ops and the way he is treated by his mother and father would have vanished. Yet, as we have seen, when reliable methods of observation are used, even with quite small samples, highly significant correlations are found.
In emphasizing the determining role a mother plays in setting the pattern of interaction with her baby, to which I believe the evidence clearly points, I lay no blame. Looking after a baby, or a toddler, or an older child for that matter, is not only a skilled job but also a very hard and exact- ing one. Even for a woman who has had a happy childhood and who is now enjoying the help and support of her husband, and perhaps also of her own mother, and who has not been filled with mistaken advice about the dangers of spoiling her baby, it is a taxing one. That a woman with none of these advantages gets into an emotional hassle is hardly surprising and certainly not an occasion
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? ? ? for blame. Yet there now seems little doubt that when infants and young children are the subjects of insensitive mothering, mixed perhaps with oc- casions of outright rejection, and later to separa- tions and threats of separation the effects are de- plorable. Such experiences greatly increase a child's fear of losing his mother, increase his de- mands for her presence and also his anger at her absences, and may also lead him to despair of ever having a secure and loving relationship with anyone.
Although ideas of this sort are much more fa- miliar and also more acceptable in analytic circles today than they were a generation ago, thanks to the influence of Balint, Fairbairn, Winnicott, and many others, I am inclined to think that their im- plications, both for theory and for practice, are still a long way from being digested.
Let me illustrate the point by considering the aetiological and therapeutic problems presented by the type of patient who in the United Kingdom is likely to be described as a schizoid personality (Fairbairn, 1940) or as having a false self (Win- nicott, 1960) and in North America as being a borderline personality or suffering from
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? ? ? pathological narcissism (e. g. Kohut, 1971; Kern- berg, 1975).
The picture such a person presents is one of as- sertive independence and emotional self-suffi- ciency. On no account is he going to be beholden to anyone and, in so far as he enters into relation- ships at all, he makes sure he retains control. For much of the time he may appear to manage won- derfully well, but there may be times when he be- comes depressed or develops psychosomatic symptoms, often for no reason he knows of. Only should symptoms or a bout of depression become severe is there any possibility of his seeking treat- ment, and then more likely than not he will prefer drugs to analysts.
When such a person does come for analysis he is careful to keep the analyst at arm's length and to control what happens. What he tells us is lucid, but he avoids any reference to feeling, except per- haps to say how bored he gets. Holidays or other interruptions he welcomes as saving his time. Perhaps he finds the analysis an 'interesting exer- cise'; although he is not convinced it is much use. And in any case he could probably do a better job by analysing himself!
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? ? ? There is, of course, a large literature discussing the psychopathology of these conditions and the therapeutic problems they present; but on whatever issues there may be agreement there is none on aetiology. To take two contrasting view- points: whereas Winnicott (1960, 1974) attributes the condition squarely to early environmental failure in the form of 'not good enough mother- ing', Kernberg (1975) in his systematic treatise gives no more than a couple of easily missed paragraphs to the possible role that mothering plays in influencing development, and only a few passing references to the inadequate mothering certain of his patients may have received. That early experience may play the key role in determ- ining these conditions is not seriously examined by him.
Plainly it is of the greatest importance that in due course we should reach some consensus about this matter; and in debating the issues I be- lieve we should be foolish not to take account of data from as many sources as we can tap. For some conditions epidemiological surveys are now proving informative but I doubt whether they have anything yet to tell us about this one. At present therefore we have to make do with data
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? ? ? from our two familiar sources: (a) the analytic treatment of patients, (b) the direct observation of young children with their mothers.
As regards data obtained during treatment, I suspect it would be fruitful for some open- minded person to survey the psychoanalytic liter- ature and draw together all the case reports which record information about the childhood experiences of these patients. My guess is that, in so far as any information is given, it would strongly support Winnicott's view that these pa- tients have had disturbed childhoods in which in- adequate mothering in one form or another--and it can take many--bulks large. Since I have made no such survey, I can do no more than illustrate the kind of findings that I would confidently ex- pect. The following details come from case re- ports published by three analysts each much in- fluenced by Winnicott's views.
One report is by Donald Winnicott's widow Clare Winnicott (1980). The patient, a profes- sional woman of 41, presented a classical picture of the emotionally self-sufficient personality who recently had developed a variety of psychosomat- ic symptoms. Only after a good deal of analysis did she divulge the events of her childhood. Since
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? ? ? her mother was in full-time work, she was looked after by a German girl who left suddenly when the patient was 21/2. Then, after six months of un- certainty, she was taken by her mother to have tea with a friend and later found her mother had disappeared and she was alone in a strange bed. Next day she was taken to the boarding school where her mother's friend worked as matron, and she stayed there till she was 9, usually spending the holidays there also. She appears to have settled in well (ominous words! ) and coped very successfully; but from that time forward her emo- tional life had dried up.
A second report, by Jonathan Pedder (1976), is of a young teacher in her mid-twenties whose personality and symptomatology bear a strong resemblance to Clare Winnicott's patient. Al- though at the initial interview she had given an idealized picture of her childhood, it soon emerged that at the age of 18 months she had been sent to stay with an aunt during her moth- er's next pregnancy. After six months there she had come to feel that her aunt was more of a mother to her than was her real mother and she had found returning home a painful experience. Thereafter, until she was 10, she had been
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? ? ? terrified of another separation; but then she had 'switched off' her anxiety 'like a tap', as she put it, and with the anxiety had disappeared most of her emotional life as well.
The third report, by Elizabeth Lind (1973), con- cerns a young graduate of 23 who, though severely depressed and planning suicide, main- tained that his state of mind was less an illness than 'a philosophy of life'. He was the eldest of a large family; and by the time he was 3 two sib- lings had already been born. His parents, he said, quarrelled both frequently and violently. When the family was young, father had been working long hours away from home training for a profes- sion. Mother was always unpredictable. Often she was so distraught by her quarrelling children that she would lock herself in her room for days on end. Several times she had left home, taking the daughters with her but leaving the sons behind.
He had been told that he had been an unhappy baby, a poor feeder and sleeper, who had often been left alone to cry for long periods. His crying, it was said, had been just an attempt to gain con- trol of his parents and to be spoilt. On one occa- sion he had had appendicitis and he remembered lying awake all night moaning; but his parents
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? ? ? had done nothing and by next morning he was seriously ill. Later, during therapy, he recalled how disturbed he used to be at hearing his young- er brothers and sisters being left to cry and how he hated his parents for it and felt like killing them.
He had always felt like a lost child and had been puzzled to understand why he had been re- jected. His first day at school, he said, had been the worst in his life. It had seemed a final rejec- tion by his mother; all day he had felt desperate and had never stopped crying. After that he had gradually come to hide all desires for love and support: he had refused ever to ask for help or to have anything done for him.
Now, during therapy, he was frightened he might break down and cry and want to be mothered. This would lead his therapist, he felt sure, to regard him as a nuisance and his beha- viour simply as attention-seeking; and, were he to say anything personal to her, he fully expected her to be offended and perhaps lock herself in her room.
In all three cases the patient's recent break- down had followed the collapse of a significant but fragile relationship about which each
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? ? ? member of the pair had had reservations and to the ending of which each of the patients had, him or herself, obviously contributed.
In treating these patients all three analysts ad- opted Winnicott's technique of permitting the free expression of what are traditionally termed 'dependency feelings', with the result that each patient in due course developed an intense and anxious attachment to his or her analyst (to use the terminology I prefer, (Bowlby, 1969, 1973)). This enabled each patient to recover the emotion- al life he or she had lost during childhood and with it to recover a sense of 'real self'. Therapeut- ically the results were good.
Admittedly, the findings from these three cases prove nothing. Nevertheless they are suggestive and, so far as they go, support Winnicott's theory of aetiology. Even so it is always open to critics to cast doubt on the validity of what a patient recalls about his childhood and to question whether the sequence of events recounted had the effect on his feeling life that he so explicitly claims. (It is worth nothing that the events that each of these three patients held to be a turning point had oc- curred after their second birthdays. )
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? ? ? Now it seems clear that the controversies about aetiology are never going to be settled as long as we rely solely on the retrospective and perhaps biased evidence derived from the analyses of pa- tients, whether they be adults or children. What is needed is evidence of a different kind to provide some sort of cross-check. This is where I believe the direct observations of young children and their mothers are potentially so useful. Is there any evidence from that source that suggests that a child's feeling life can become numbed by the types of experience described? The answer, of course, is that there is a great deal.
Here naturally I point first to the observations made by James Robertson (1953) and confirmed later by Christoph Heinicke and Ilse Westheimer (1965) on how children between the ages of 12 and 36 months behave when removed from home to the care of strange people in a strange place, such as a residential nursery or hospital, with no one person to act as a mother-substitute. In such conditions a child comes in time to act as if neither mothering nor contact with humans has much significance for him. As his caretakers come and go he ceases to attach himself to any- one and after his return home stays remote from
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? ? ? his parents for days, and perhaps for much longer if he is treated unsympathetically.
There is reason to believe, moreover, that a young child can develop this kind of defensive numbing in response to a mother who rejects him and without any major separation. Examples of this sequence are to be found in observations re- corded by Mahler (1971). More definitive findings are reported by Mary Main (1977), a colleague of Mary Ainsworth's, who has made a special study of a group of children in the age-range 12 to 20 months, each of whom not only failed to greet his mother after she had left him with a stranger for a few minutes but deliberately avoided her. View- ing some of Main's videotaped records I was as- tonished to see to what lengths some of these children went. One approached her mother briefly but with head averted and then retreated from her. Another, instead of approaching his mother, placed himself facing into the corner of the room, as though complying with a punish- ment, and then knelt down with his face to the floor. In every case videotaped records of these mothers playing with their toddlers during a later session showed them to differ from the mothers of non-avoidant toddlers: they appeared 'angry,
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? ? ? inexpressive and disliking of physical contact with the infant'. Some scolded in angry tones, some mocked, others spoke sarcastically to or about their child. An obvious possibility is that by keeping away from his mother in this way a child is avoiding being treated in a hostile way again.
Thus, so far as the cross-checks provided by direct observations of young children and their mothers go, they tend to support a Winnicott- type theory. Put briefly, and in my own words, the child, and later the adult, becomes afraid to allow himself to become attached to anyone for fear of a further rejection with all the agony, the anxiety, and the anger to which that would lead. As a result there is a massive block against his ex- pressing or even feeling his natural desire for a close trusting relationship, for care, comfort, and love--which I regard as the subjective manifesta- tions of a major system of instinctive behaviour.
An explanation of this kind, although much less complex than some proposed in the literat- ure, accounts well for how these people behave both in the world at large and with ourselves as analysts. Inevitably they bring their fear of enter- ing into a trusting relationship with them to ana- lysis, which we experience as a massive
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? ? ? resistance. Then, when at length their feelings are recovered, they more than half expect that we shall treat them as they recall being treated by their parents. In consequence they live in dread of being rejected and become intensely angry should they suspect us of deserting them. Not in- frequently, moreover, the way they treat us--with abuse and rejection--is found to be a version of the treatment to which they recall having them- selves been subjected as children.
You will see that in the explanation of how these patients behave during analysis I have ad- vanced a number of interlocking hypotheses. In a research programme each requires scrutiny and testing in the light of further data. Among the many methods that I would expect to prove of value is the study, in a therapeutic setting, of par- ents and children interacting with one another. In addition, there remains an important place for further observations to be made during the ana- lysis of individual patients; though I believe that, if clinical research is to yield its full potential, it has to be pursued in a far more systematic and directed way than hitherto.
To give an example: it would be of value were a detailed record to be kept of the responses of one
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? ? ? or more of these patients before and after each successive weekend, each vacation, and each un- expected interruption of the sessions, with an equally detailed record of how the analyst dealt with them. This would enable us to know the rep- ertoire of responses a given patient presents on these occasions, and also the changes in response he presents over time. It would also be especially valuable if we were to have a detailed account of the conditions in which a major therapeutic change occurs. If, perhaps in a collaborative pro- gramme, records could be kept on a number of such patients, it might be possible to discover whether a frank and detailed discussion of the painful experiences a patient recalls having had in his relationships with his parents and the ef- fects these appear to have had and still to be hav- ing on the ways he treats other people, including of course ourselves, promotes therapeutic change, as I predict, or hinders it, as is believed by some analysts.
Naturally, in embarking on this or any other research programme an analyst must bear in mind his professional responsibilities; for with patients who present a false self these can be very onerous. Winnicott describes the 'period of
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? ? ? extreme dependence' through which such pa- tients go during therapy and gives warning that 'analysts who are not prepared to go and meet the heavy needs of patients who become dependent in this way must be careful so to choose their cases that they do not include false self types'.
This brings me back to the art of therapy. To provide, by being ourselves, the conditions in which a patient of this kind can discover and re- cover what Winnicott calls his real self, and I call his attachment desires and feelings, is not easy. On the one hand, we have really to be trustworthy and we have also genuinely to respect all those yearnings for affection and intimacy that each of us has but which in these patients have become lost. On the other, we must not offer more than we can give and we must not move faster than the patient can bear. To achieve this balance requires all the intuition, imagination, and empathy of which we are capable. But it also requires a firm grasp of what the patient's problems are and what we are trying to do. This is why it is so very important that the problems of aetiology and psy- chopathology should be clarified as far as the ap- plication of scientific method makes possible and, further, that analysts should be thoroughly
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