No More Learning

Bowlby'spassionateanduncompromisingfeelingsweremuchinevidence at meetings of the Psycho-Analytic Society during that period. As well as the Klein-Freudsplittherewasamoregeneraldivisionabouttheaimsandmethods oftheSociety. UnderJones'sandlaterGlover'sleadershiptheSocietyhadadopted
24 Origins
something of the features of a secret cell: purist, esoteric, autocratically led, unwilling to sully itself with anything but the 'pure gold' of psychoanalysis, and refusing to have anything to do with the analytic fellow travellers represented by the Tavistock Clinic, who included several Christian psychiatrists like J. R. Rees and Suttie, and which was referred to contemptuously by the psychoanalysts as the'parson'sclinic'(Pines1991). AllthiswasanathematoBowlby,whobelieved in democratic methods and was appalled by what he saw as the Society's indifference towards the emergence of a National Health Service which was clearly going to be established after the war. He advocated full participation in the discussions between the Government and the medical profession:
We find ourselves in a rapidly changing world and yet, as a Society, we have done nothing, I repeat nothing, to meet these changes, to influence them or to adapt to them. That is not the reaction of a living organism but a moribund one. If our Society died of inertia it would only have met the fate it had invited.
(King and Steiner 1990)
Bowlby and the progressives carried the day, and Bowlby was delegated as a member of the Government's Mental Health Standing Committee, where he proceeded to have the same effect on the civil servants as he did on the older members of the Society, and he was described in a Whitehall report as 'a "live" member, with embarrassing enthusiasm for his own speciality. An advanced theorist who does not always give weight to practical considerations' (Webster 1991).
Family life
Tony Bowlby married young: a beautiful musician and actress whom he met through his sisters who were at the Royal Academy of Music. John had had several tempestuous liaisons, but as his analysis progressed and he approached his thirties, began to wish to settle down. On holiday in the New Forest he encountered the Longstaffs, a family of seven attractive daughters living with their pipe-smoking mother whose father, Dr Longstaff, the famous alpinist, had abandoned her for a younger woman. Ursula, the third daughter, intelligent and beautiful but more diffident than her older sisters, attracted his interest. On a shooting holiday in Ireland she and John fell for each other. They were married in 1938. John, like his father, was some ten years older than his
Biographical 25
bride. Ursula proved a devoted and loyal companion. Although highly intelligent and literate, she had no knowledge of psychology, and claims not to have read any of his books except the biography of Darwin on which she collaborated extensively. She also helped to supply the quotations for the chapter headings in the 'trilogy'.
The Bowlbys had four children, the day-to-day care of whom John left almost entirely to Ursula. The family was afflicted by dyslexia, a condition unrecognised at the time, and his children's academic difficulties were a source of some sorrow and frustration to their father, although they were fully compensated by their practical and technical abilities. John had had little experience of close parent-child relationships, and found fatherhood a difficult role. He was, by contrast, in his daughter Mary's words, a 'brilliant grandfather' ('Grampy's' good influence making itself felt again) - tolerant, funny and adoring. John and Ursula's grandson, Ben, in the Bowlby tradition of independence and originality, received first-class honours in engineering for designing and building his own racing car - an 'external working model' (see Chapter 4). John, a slightly remote father, followed his own father's tradition of hard work and long holidays, so much so that his eldest son asked, around the age of seven, 'Is Daddy a burglar? He always comes home after dark and never talks about his work! ' Family holidays were in Scotland, and a house was first rented and then bought on Skye where John, Ursula and the children could enjoy the walking, boating, bird-watching, shooting and fishing in beautiful and remote surroundings that repeated the pattern of his own childhood.
The Bowlbys and the Durbins had shared a house in York Terrace (where Adrian and Karen Stephens and Ernest Jones had their consulting rooms). This pattern was continued after the war when John's democratic ideas and recognition of the benefits of an extended network of friends and family when bringing up small children were realised, when he and Ursula and their growing family shared a large house in Hampstead with the Sutherlands (Jock Sutherland was soon to become director of the Tavistock Clinic) and with a young psychologist, later to become Mrs Mattie Harris, who became organising tutor of the child psychotherapy training programme at the Tavistock (Sutherland 1991).
26 Origins
The post-war years: the Tavistock Clinic
Immediately after the war the 'invisible college' of Army psychoanalysts re-grouped themselves around the Tavistock Clinic, hitherto ruled out of bounds by the autocratic Jones. An election was held and, although neither had previously worked there, Jock Sutherland was elected Director, with Bowlby as Deputy, given the specific task of developing a Department for Children.
John went about this with his usual energy, efficiency and determination. He established a clinical service, treating patients, seeing mothers and children together, spending one day a week in a well-baby clinic, supervising, and chairing case conferences. Together with Esther Bick he set up the child psychotherapy training and continued to support it, even when its Kleinian orientation began to diverge sharply from his own views.
About a third of his week was devoted to clinical and administrative duties. The rest was for research. One of John's unsung qualities was his ability to raise research funds. On the basis of his pre-war experiences in the Child Guidance Clinic, he had decided to make a systematic study of the effects of separation on the personality development of young children. He recruited James Robertson, a conscientious objector in the war who had worked as a boilerman in Anna Freud's Hampstead residential children's nursery, and who later became an analyst and filmmaker. Mary Ainsworth, later to become the co-founder of Attachment Theory, also joined the team, as did Mary Boston. The outcome of Bowlby's collaboration with Robertson was the famous film A Two-year-old Goes to Hospital, which showed the intense distress of a small child separated from her mother, made with a hand- held cine-camera without artificial light, almost impossible to watch dry-eyed, and which did so much to liberalise hospital visiting rules. As mentioned in the previous chapter, the film met with a mixed reception when shown to the Psycho-Analytical Society, the Kleinians being particularly unimpressed, a foretaste of the response Bowlby was to meet when he presented his breakthrough papers on Attachment Theory a few years later.
Bowlby's research interests, together with his Forty-four Thieves paper, made him an obvious choice when the World Health Organisation was looking for an expert to prepare a report on the mental health of homeless children. Bowlby travelled widely
Biographical 27
in Europe and the United States, meeting the leading figures in child development, and combined their views with his own in a review of the world literature, Maternal Care and Mental Health (Bowlby 1951). This was published in a popular edition as Child Care and the Growth of Love (Bowlby 1953), which became an instant best-seller, selling 450,000 in the English edition alone, and was translated into ten different languages.
Bowlby's reputation was by now secure and he was able to follow his innovative instincts without anxiety. He was keen to break down the ivory towerism of the Tavistock and to foster links with local health visitors, GPs and social workers. His efforts to establish liaison were blocked until the Minister of Health issued a directive asking the London County Council to pay more attention to mental health. The Chief Medical Officer of the LCC invited Bowlby to give a lecture on the subject. He refused, saying that mental health could not be properly taught by didactic methods, but offering to join a study group if one were set up. A week later he received a message from the Chief Medical Officer: 'Your "study group" is ready. When would you like to start? ' (Mackenzie 1991).
Ainsworth (1982) believes that the idea of attachment came to Bowlby 'in a flash' when in 1952 he heard about and then read Lorenz's and Tinbergen's work in ethology, having been lent an advance copy of King Solomon's Ring by Julian Huxley. The ethological approach provided the scientific grounding that Bowlby believed was needed to update psychoanalytic theory. Seen psychobiographically, Attachment Theory might be seen as a return by Bowlby to the values of his mother which he had rejected when he became a psychoanalyst. Disappointed with his mother's self-preoccupations and favouritism, he turned to the many mothers of psychoanalysis - Klein, Riviere, Payne. But these too, partly through their own limitations, partly because they contained his hostile projections, disappointed in their turn. By marrying the biology of ethology with Freudian theory, he managed to reconcile the discordant elements in his personality: his country-loving mother with her respect for nature, and the intimidating urban medical father whose success and intelligence were inspirational but whose Gradgrindian devotion to fact and duty dominated his life. Bowlby soon organised regular attachment seminars which were attended by a talented and eclectic group including the ethologist Robert Hinde and, for a
28 Origins
time, R. D. Laing. A year as a fellow at the Centre for Behavioural Sciences in Stanford, California, gave him an opportunity to reread Freud and to prepare the breakthrough papers of the late 1950s, starting with 'The nature of the child's tie to his mother' (Bowlby 1958).
Bowlby remained active in the Psycho-Analytical Society in the post-war years. He was Deputy President to Donald Winnicott between 1956 and 1961, responsible for 'everything administrative' (Bowlby 1991). He set up and chaired the Research Committee, and initiated several other committees, including the Public Relations Committee; a committee to look at indemnity insurance for non-medical members (typical of Bowlby to be alert to the possible hazards to members uncushioned by the secure base of medicine); and the Curriculum Committee (set up to prevent trainings becoming interminable - another typically practical move).
While the society was happy to benefit from his organisational skills, Bowlby's theoretical papers, presented between 1957 and 1959, excited considerable discussion but little enthusiasm, and were received by the Kleinians with outright hostility. Typical comments were: from Guntrip, 'I think it is very good for an eminent psychoanalyst to have gone thoroughly into the relation of ethology to psychoanalysis, but my impression is that he succeeds in using it to explain everything in human behaviour except what is of vital importance for psychoanalysis' - (1962, letter to Marjorie Brierley, in Archives, Institute of Psychoanalysis); from Winnicott, although generally friendly and sympathetic to Bowlby's contribution (Malan 1991), 'I can't quite make out why it is that Bowlby's papers are building up in me a kind of revulsion although in fact he has been scrupulously fair to me in my writings'; and, from an anonymous analyst, 'Bowlby? Give me Barabbas' (Grosskurth 1986). The analysts found his patrician manner and 'orotund' (Rycroft 1992) delivery offputting, although these may well have been exaggerated in the intimidating atmosphere of the Psycho-Analytical Society at the time. Bowlby had an impish quality and a capacity for amusing tomfoolery which was clearly not evident to the analysts. Whether Bowlby did indeed betray psychoanalysis, or breathed new life into it, will form much of the discussion in subsequent chapters.
Biographical 29
The trilogy
Partly no doubt because of his hostile reception, and partly because of his growing reputation elsewhere, Bowlby spent little time in the Psycho-Analytical Society after the mid-1960s although, unlike other distinguished dissidents such as Rycroft and Meltzer, he did not discontinue his membership. While continuing his clinical role at the Tavistock, in 1963 he became a part-time member of the Medical Research Council, which enabled him to devote yet more time to writing. The years 1964 to 1979 were devoted to his monumental trilogy Attachment (1969b), Separation (1973a), and Loss (1980). These have also been bestsellers, with the first volume selling well over 100,000, the second 75,000, and the third 45,000 (Bowlby et al. 1986). Colin Murray Parkes and Dorothy Heard joined him at the Tavistock in the 1960s. Like Bowlby, Parkes had been struck by the relevance of Darwin's ideas about grief to abnormal mourning, and a fruitful partnership developed (Parkes 1964, 1971, 1975). Bowlby was much in demand as a lecturer, especially in the United States where, through the work of Ainsworth (1969), Attachment Theory was exciting increasing interest.
Bowlby held numerous important positions and consultancies, and received many honours, including the CBE, Honorary Doctorates at Cambridge and Leicester, Honorary Fellowships of the Royal Society of Medicine and College of Psychiatrists, Fellowship of the British Academy, and several Distinguished Scientist awards and medals in the United States, including that of the American Psychological Association. As befits an innovator and original thinker, he was probably slightly more honoured abroad than at home, and neither received a knighthood nor became an FRS, both of which many thought were his due (Kraemer 1991). He did, however, do 'better' than his lifelong friend and rival, his brother Tony.
He retired from the NHS and the MRC in 1972, but remained at the Tavistock Clinic, dividing his time between London and his beloved Skye. He continued to encourage students and to receive many foreign visitors. During 1980 he was Freud Memorial Professor of Psychoanalysis at University College London, a post which gave him great satisfaction. His lectures from there and his trips abroad were collected in The Making and Breaking of Affectional Bonds (1979c) and A Secure Base (1988a). Mentally and
30 Origins
physically active as ever, he began an entirely new project in his seventies, a psychobiography of Darwin (Bowlby 1990), which was published a few months before his death, and was well reviewed.
His eightieth birthday was celebrated in London with a conference with many distinguished speakers from around the world. The affection he inspired was palpable, as, garlanded with flowers, he embraced his many friends and colleagues to loud claps and cheers. A few weeks later he collapsed unconscious with a cardiac arrhythmia, but made a complete recovery, and was able to finish the Darwin biography. Three years later he suffered a stroke, while in Skye with his family, who had gathered as they did every year for the Skye Ball, where John had been a skilled exponent of Scottish reels. He died a few days later on 2 September 1990, and was buried at Trumpan on the Waternish peninsula, a hillside graveyard overlooking the cliffs of Waternish and the Ardmore peninsula. It was a favourite spot, wild and remote, from which John, with his great feeling for nature, often used to walk, and he had asked to be buried there. He had a traditional Skye funeral with three 'lifts' from the hearse to the grave. His friend Hyla Holden, a former Tavistock colleague, one of the bearers, concludes: 'his funeral and burial were in keeping with the straight-forward and loving simplicity which lay behind his formidable intellect' (Trowell 1991). His constancy and steadfastness of purpose are celebrated in the inscription on the headstone of pale grey Aberdeen granite, which reads: 'To be a pilgrim'.
BOWLBY THE MAN
What was John Bowlby like? In his work his greatest achievement was his bringing together of psychoanalysis and, via ethology, evolutionary biology. A similar capacity to reconcile divergent elements is to be found in his personality which, although remarkably coherent and consistent, contained many contradictory aspects: reserved, yet capable of inspiring great affection; quintessentially 'English' and yet thoroughly cosmopolitan in outlook; conventional in manner yet revolutionary in spirit; equally at home with the sophistication of Hampstead and in the wilds of Skye; outstandingly intelligent and yet not in a
Biographical 31
conventional sense an intellectual; a man of action who devoted his life to the inner world; determined in his convictions and yet without overt aggression; an explorer of the psyche who mistrusted the purely subjective; someone who believed passionately in the importance of expressing emotion, whose own feelings were an enigma; an enfant terrible who was always slightly formal.
It is hard to get an impression of Bowlby as a therapist because personal clinical material is so sparse in his writings. He is fierce in his opposition to rigid and punitive methods of child-rearing, detests the way in which children are deprived of love and affection in the name of not 'spoiling' them, and insists on the enduring nature of dependency which he refuses to see as a childlike quality to be outgrown, but rather an essential aspect of human nature. One guesses that he had first-hand experience of the child-rearing philosophy he rejects so vigorously. He consistently advocates flexibility and acceptance:
An immense amount of friction and anger in small children and loss of temper on the part of their parents can be avoided by such simple procedures as presenting a legitimate plaything before we intervene to remove his mother's best china, or coaxing him to bed by tactful humouring instead of demanding prompt obedience, or by permitting him to select his own diet and eat it in his own way, including, if he likes it, having a feeding bottle until he is two years of age or over. The amount of fuss and irritation which comes from expecting small children to conform to our own ideas of what, how, and when they eat is ridiculous and tragic.
(Bowlby 1979c)
The dangers of suppressing feelings is repeatedly emphasised by Bowlby:
a main reason why some find expressing grief extremely difficult is that the family in which they have been brought up, and with which they still mix, is one in which the attachment behaviour of the child is regarded unsympathetically as something to be grown out of as soon as possible . . . crying
32 Origins
and other protests over separation are apt to be dubbed as babyish, and anger and jealousy as reprehensible.
(Bowlby 1979c)
Bowlby describes one such patient:
I well remember how a silent inhibited girl in her early twenties given to unpredictable moods and hysterical outbursts at home responded to my comment 'it seems to be as though your mother never really loved you' (she was the second daughter, to be followed in quick succession by two much wanted sons). In a flood of tears she confirmed my view by quoting, verbatim, remarks made by her mother from childhood to the present day, and [describing] the despair, jealousy, and rage her mother's treatment roused in her.
(Bowlby 1979)
Bowlby himself came from a family in which there were two daughters, to be followed in quick succession by two much wanted sons, with a mother whose love her children may well have doubted (with the possible exception of Tony), so he probably knew what he was talking about. Even if he did not have a particularly loving mother, Bowlby had learned enough from her, and perhaps from his much-loved nursemaid Minnie who left when he was no more than four, to know what it takes to be one. In adult life he relied greatly on his wife Ursula'sintuitionandsensitivity. Inaposthumouslypublishedself-portraitBowlby modestly asserts:
I am not strong on intuition. Instead, I tend to apply such theories as I hold in an effort to understand the patient's problems. This works well when the theories are applicable but can be a big handicap when they are not. Perhaps my saving graces have been that I am a good listener and not too dogmatic about theory. As a result several of my patients have succeeded in teaching me a great deal I did not know. . . . I often shudder to think how inept I have been as a therapist and how I have ignored or misunderstood material a patient has presented. Clearly, the best therapy is done by a therapist who is naturally intuitive and also guided by the appropriate theory. Fortunately, nowadays I meet many such people in clinical seminars, and among supervisees.
(Bowlby 1991)
Biographical 33
One such was Victoria Hamilton, who confirms Bowlby's listening skills, painting a vivid portrait:
a very unassuming person who at the same time displayed an unusual acuity. . . . My most constant image of John Bowlby . . . is of him sitting back in a chair, his legs crossed indicating an expression of relaxed concentration, and a very alert face. He had penetrating but responsive eyes, beneath raised eyebrows which expressed both interest and a slight air of surprise and expectation . . . a remarkable ability to listen to the thoughts and beliefs of others, combined with a capacity for objectivity and a rare facility with the English language. He could step back from an idea and reformulate it in a succinct articulate way. . . . Despite his somewhat military manner, expressed in a certain abruptness and stiffness very far from 'small talk', he was perfectly able to 'take turns', the essential ingredient of conversation.
(Hamilton 1991)
A lifelong friend, Jock Sutherland (1991), describes his first encounter with John during the war, in which he appeared 'somewhat formal and even aloof'. Sutherland and Eric Trist, another of John's half-century friends, speculated that Bowlby's description of the 'affectionless character' was based on empathic understanding (rather as Freud's discovery of the Oedipus complex was based on his own rivalry with his father):
We speculated that John's own early experience must have included a degree, if not of actual deprivation, of some inhibition of his readiness to express emotional affection . . . so that he developed in some measure a protective shell of not showing his feelings as readily as many people do. . . . John's slightly formal and even detached manner struck many people on first knowing him Eric Trist and I were always convinced he was the possessor of a deep and powerful fund of affection - the source of his intensely caring concern for those who worked with him.
(Sutherland 1991)
John Byng-Hall, another Tavistock colleague, sees Bowlby as a perfect embodiment of his idea of the secure base, capable of holding together family therapists and child psychotherapists despite their very different philosophies, alert to real dangers faced
34 Origins
by patients and therapists, and above all 'very reliable. I have images of him, even last winter [i. e. in his eighty-second year], shaking the rain off his green mackintosh and hat as he arrived on time for some evening meeting; while others sent their apologies' (Byng-Hall 1991).
Those clocks that Bowlby had grown up with did have their uses.
SPRINGS OF ACTION AND THOUGHT
It seems to be a characteristic of many outstanding men and women that they retain the freshness and innocence of childhood, however clothed it is with responsibility and the burdens of maturity. This was certainly true of Bowlby's great hero, Darwin (Bowlby 1990), with whom he strongly identified, and had much in common, although he would have been embarrassed by the comparison. Like Darwin, Bowlby had a boyhood love of outdoor sports, of the countryside and of exploration, with a keenness of intellect that was not precociously evident. Like Darwin, Bowlby had a strong and successful medical father; both seem to have aroused in their sons a rebelliousness hedged about with caution. Both were younger sons, with clever and rather overshadowing older brothers and sisters. Darwin's mother died when he was eight; Bowlby's was (at least in her London life) remote and self- centered. Both lived in times of social turmoil and had a strongly held but restrained sense of social justice, and of the responsibilities of the fortunate towards the disadvantaged, in the best Whig tradition. They both believed passionately in the power of reason to illuminate both the natural and social world. Bowlby admired Darwin's openness to all available evidence, as shown by the long hours he spent in smoke-filled public houses discussing breeding methods with pigeon fanciers in search of support for his theory of natural selection. Bowlby, too, mixed with mothers in nurseries and baby clinics, ever observant of patterns of attachment. Both showed generosity towards their supporters, and lacked rancour towards their detractors. Finally, it might be said of their theories that they have the quality of immediacy and 'obviousness' - of which it might be said, 'Why on earth did no one think of that before? ' In retrospect it seems obvious that species have evolved by natural selection, that people are attached to one another and suffer when they separate - but it took child-like simplicity of
Biographical 35
vision combined with mature determination and attention to detail to root out the obvious and to create for it a secure theoretical base.
Bowlby describes an early boyhood memory of Darwin's concerning showing off:
He recalls 'thinking that people were admiring me, in one instance for perseverance, and another for boldness in climbing a low tree, and what is odder, a consciousness, as if instinctive, that I was vain, and a contempt for myself'. This reference to self-contempt for being vain thus early in his life is of much significance, since we find it persisting as a major feature of his character into his final years.
(Bowlby 1990)
Here we see Bowlby's extreme sensitivity to the uncertainties, miseries and vulnerability of childhood, to the gulf between a child's fragile self- esteem and a potentially hostile or indifferent world. Bowlby cared intensely about the mental pain of children, and his life's work was directed towards trying to prevent, remove and alleviate it. Behind the disturbed child's tough, 'affectionless' carapace Bowlby had a sixth sense for the sadness and sense of betrayal. Apparently bolder than Darwin, Bowlby kept his vulnerability well hidden. But in his rebelliousness we see perhaps the protest of the child who has been hurt and neglected. In his application and indefatigability we find the attempt to make good the unthinking damage the adult world so often does to children.
Many of Bowlby's metaphors were medical. Famously, 'mother- love is as important for mental health as are vitamins and proteins for physical health' (Bowlby 1953); 'deprived children . . . are a source of social infection as real and serious as are carriers of diphtheria and typhoid' (Bowlby 1953); 'the basic fact that people really do want to live happily together . . . gives confidence [to the family therapist], much as a knowledge of the miraculous healing powers of the body gives confidence to the surgeon' (Bowlby 1948).
Bowlby's ideas were forged in the era of two world wars. Millions died in the first war. The enormity of the loss went unmourned by society in the triumphalism of Versailles and the manic activity of the twenties. The second war saw the horror of the Holocaust, countless more deaths, and the disruption of the lives of children throughout Europe. As early as the 1930s, Bowlby
36 Origins
saw loss and separation as the key issues for psychotherapy and psychiatry. It was the men - the fathers, sons, brothers, husbands, lovers - who died; it was a men's world that went to war. And yet in Bowlby's work men are conspicuous by their absence. It is maternal deprivation that made Bowlby's name. Bowlby's strong identification with his much-absent father comes through in his medical imagery, but he does not emerge as a live figure in the family drama as depicted by Bowlby, or indeed by the other outstanding analysts of his generation, Klein and Winnicott. Bowlby's contribution, and that of his contemporaries, has been to rehabilitate the female principle, the missing mother who until then was absent from social and psychoanalytic discourse (Freud's main preoccupation was with fathers and their children). In his concept of maternal deprivation it is as though Bowlby was simultaneously reproving and idealising his neglectful mother. Unlike Winnicott he seems uncertain of his intuitive feminine side, just as he may have mistrusted his mother with her fickle and uneven affections. In his theories of motherhood it is as though Bowlby is enacting the male role - the guardian of evidence and objectivity - without really examining it.
His father is there in the metaphors but not at the meal table. Bowlby's maleness is in the counter-transferential blind spot through which he sees mother and child, but not himself seeing them - a typical example of the modern 'patriarchal but father-absent' family (Leupnitz 1988). To consider these and other issues we must now turn to the topic for which Bowlby is best known, that misnamed miscreant, maternal deprivation.
Chapter 3
Maternal deprivation
[The] evidence is now such that it leaves no room for doubt . . . that the prolonged deprivation of a young child of maternal care may have grave and far reaching effects on his character and so on the whole of his future life. It is a proposition exactly similar in form to those regarding the evil after-effects of German measles before birth or deprivation of vitamin D in infancy.
(Bowlby 1953)
Statements implying that children who experience institutionalisation and similar forms of privation in early life commonly develop psychopathic or affectionless characters are incorrect.
(Bowlby, Ainsworth, Boston and Rosenbluth 1956)
Psychotherapy can be seen as a branch of social psychiatry, using psychological methods to reverse or mitigate the damaging effects of environmental failure. This immediately raises two questions. First, given that the damage is already done, how can mere talk undo past miseries? Second, given that many people survive unhappy childhoods without developing psychiatric disorder, are therapists justified in attributing present difficulty to previous trauma? The two quotations from Bowlby above illustrate the transition between his career as a clinician and psychoanalyst to that of a researcher and theorist. The therapist, faced with the patient in front of him, naturally attributes his difficulties to the history of environmental failures he recounts. The researcher, with a control group and a sense of a population at risk rather than just one individual, is forced to more cautious conclusions.
The answer to both questions, in brief, lies in the fact that environmental failure is not merely impressed on a passive organism,
38 Origins
but is experienced and given meaning by the afflicted individual. Psychotherapy is concerned with the way that stress is mediated psychologically - with why this person succumbs while others survive - and, by altering psychological responsiveness and the attribution of meanings, to change not the facts of history, but their context and significance. In this chapter I shall approach these issues through a discussion of 'maternal deprivation', and its corollary, 'that maternal care in infancy and early childhood is essential for mental health' (Bowlby 1952). However self-evident it may seem to us now - and this is largely the result of Bowlby's work - the idea of maternal deprivation as a cause of mental illness was in its day a revolutionary concept which became a paradigm (Kuhn 1962), setting the terms of debate and research in social psychiatry for the ensuing forty years.
CHILD CARE AND THE GROWTH OF LOVE
As Rutter (1981) points out, the phrase 'maternal deprivation', the central concept of Bowlby's WHO report Maternal Care and Mental Health, is a misnomer. His report was concerned primarily with privation (the absence of something which is needed), rather than de-privation (the removal of something that was previously there). The distinction is important because, as we shall see, the results of the complete lack of maternal care are almost always damaging to the child and have severe long-term consequences, while deprivation is less easy to define and much less predictable in its impact.
In its popular edition, Maternal Care and Mental Health was retitled Child Care and the Growth of Love - a significant shift, since it suggests a universal message about mothers and children rather than confining itself to questions of mental health. The book is far more than a scientific work (and indeed has been criticised for its handling of the evidence - Andry 1962), and is perhaps best seen as a landmark social document, comparable to the great nineteenth-century reports such as Elizabeth Fry's account of sanitary conditions in prisons, or Mayhew's descriptions of the plight of the London poor.
What marks Child Care and the Growth of Love out in the history of social reform is its emphasis on psychological as opposed to economic, nutritional, medical or housing difficulties as a root cause of social unhappiness:
Maternal deprivation 39
In a society where death rates are low, the rate of employment high, and social welfare schemes adequate, it is emotional instability and the inability of parents to make effective family relationships which are the outstanding cause of children becoming deprived of a normal family life.
(Bowlby 1952)
The evidence
The central thrust of Bowlby's work is the effort to substantiate this claim and to consider its clinical, professional, ethical and political consequences. The evidence upon which the book is based includes Bowlby's own studies of juvenile delinquents, Goldfarb's comparison of institution-raised children in the United States with those who had been placed in foster homes, and the accounts of Anna Freud and Dorothy Burlingham from their residential nursery in Hampstead. All these studies strongly support the view that children deprived of maternal care, especially if raised in institutions from under the age of seven, may be seriously affected in their physical, intellectual, emotional and social development. Institution-raised children grow less well, and are retarded in their acquisition of language, and as they become older show evidence of impaired ability to form stable relationships - often tending to be superficially friendly but promiscuous (either metaphorically or literally) in their relationships. Based on his own finding that only two out of fourteen 'affectionless psychopaths' had not had prolonged periods of separation from their mothers in early childhood Bowlby asserts that 'prolonged separation of a child from his mother (or mother substitute) during the first five years of life stands foremost among the causes of delinquent character development' (Bowlby 1944; Bowlby 1952). It is worth noting that Bowlby was making very sweeping conclusions based on studies which had often only looked at relatively small numbers of cases - in his case fourteen, in Goldfarb's only fifteen, juvenile delinquents. By present-day standards these studies would also not be acceptable in that they often included no control groups, or, if they did, they were not rated blind by the researchers, who had a vested interest in establishing a link between deprivation and depravity. Bowlby was aware of these difficulties and,
40 Origins
anticipating the modern vogue for 'metaanalysis' (based roughly on the Maoist principle that '600 million Chinese people cannot be wrong'), suggested that, by combining many small studies, an overall trend emerges which is likely to have some validity.
Family care versus institutional care
Having established to his satisfaction that children without maternal care are indeed gravely disadvantaged, Bowlby goes on to contrast the quality of life in a family with that in an institution:
All the cuddling and playing, the intimacies of suckling by which a child learns the comfort of his mother's body, the rituals of washing and dressing by which through her pride and tenderness towards his little limbs he learns the values of his own, all these have been lacking.
(Bowlby 1952)
The tinge of sentimentality in this lyrical account has, as we shall see, been much criticised by feminist writers, as has his hymn of praise to what Winnicott was later to call the 'ordinary devoted mother':
The provision of constant attention night and day, seven days a week, 365 days in the year, is possible only for a woman who derives profound satisfaction from seeing her child grow from babyhood, through the many phases of childhood, to become an independent man or woman, and knows that it is her care which has made this possible.
(Bowlby 1952)
These much-quoted and sometimes derided overstatements have to be seen in context. The world was horrified in the 1990s by the revelation of the squalor and emotional deprivation in the orphanages of Romania. This was not just the result of a dictatorship but of an ideological devaluation of family life, and a belief in the power of public provision to overcome individual poverty. Bowlby was reacting against a similar trend to be seen throughout Europe and the United States in the post-war era, and indeed to a long tradition among the British middle classes, of which he had first-hand experience, of turning their sons and
Maternal deprivation 41
many of their daughters over first to nannies and then to institutional care in boarding schools from the age of seven! To the extent that Bowlby idealises motherhood - as opposed to offering a realistic appraisal of its central importance in child- rearing - this must be seen at least in part as a reflection of the deprivations which he and other members of his class had experienced in the nursery and at school. The long hand of the otherwise invisible nanny reached far.
The impact of Bowlby's advocacy has been enormous, and continues to the present day. It is now taken for granted, and enshrined in the 1989 Children Act, that individual care in foster homes is preferable to group care in nurseries, that 'bad homes are better than good institutions' (Bowlby 1952). The battle to replace institutional care for the mentally ill and mentally handicapped with care within the family, or at least provision of a family-type home atmosphere, is still being waged.
The need for professionalisation of child care
Critics have accused Bowlby of wanting to 'pin women down in their own homes' (Mead 1962). While it is true that he criticises cavalier attitudes towards elective separations of mothers from children under the age of three, he could rather be seen as arguing for a much greater valuation by society of motherhood - indeed, as being recruited in support of the feminist demand for state provision of 'wages for housework'. Whatever his views on housewives, he puts a strong case for the professionalisation for all child-care workers, including workers in day nurseries and children's homes, foster mothers and (we would now add, since this argument has also not been fully won) child minders. These workers must be skilled in understanding a deprived child's overwhelming needs: the craving for parental love; the need to idolise parents however flawed they are in reality; the importance of maintaining contact with absent parents, however fragmentary; the right to express pain, protest about separation, and to grieve loss. They must also be able to help parents in turn to recognise their children's and their own ambivalent feelings. He is intensely critical of case workers who 'live in the sentimental glamour of saving neglected children from wicked parents' (Bowlby 1952) (a comment still relevant today to the dilemmas presented by working with sexually abused children), and of actions which
42 Origins
'convert a physically neglected but psychologically well-provided child into a physically well-provided but emotionally starved one' (Bowlby 1952). All these principles are now enshrined at least in the theory of child-care practice, and for this too Bowlby is largely responsible.
Government action
Much of the debate about the de-institutionalisation of the mentally ill has centred on the question of funding. It was thought that community care must be cheaper than institutional care, and partly for this reason it received governmental support. Bowlby puts forward similar economic arguments in favour of family support for troubled children:
There are today governments prepared to spend up to ? 10 per week [this was 1952! ] on the residential care of infants who would tremble to give half this sum to a widow, an unmarried mother, or a grandmother to help her care for her baby at home. . . . Nothing is more characteristic of both the public and voluntary attitude towards the problem than a willingness to spend large sums of money looking after children away from their homes, combined with a haggling stinginess in giving aid to the home itself.
(Bowlby 1952)
Although, thanks to Bowlby and others, much has changed, much remains the same. For some things may be worse than in 1952: the haggling stinginess has returned, but is now accompanied by an unwillingness to spend large sums on public provision. The 1989 Children Act creates a partnership between parents and the local authorities to provide for 'children in need', a` la Bowlby, with cash payments if necessary, but no extra funding has been made available for this.
Vicious and benign circles
A major idea which emerges in Child Care and the Growth of Love is that of cycles of deprivation: 'the neglected psychopathic child growing up to become the neglectful psychopathic parent . . . a self-perpetuating social circle' (Bowlby 1952). Today's emotionally deprived child becomes tomorrow's neglectful parent: adverse experiences become internalised by the growing child in a way that leads on to further adverse experiences,
Maternal deprivation 43
thus perpetuating the vicious circle of neurosis. Writing in an era of social optimism, and with what, sadly, in hindsight must be seen as some nai? vety, Bowlby argued that, with concentrated social, economic and psychological effort, society could put these vicious circles into reverse, so that 'it may, in two or three generations, be possible to enable all boys and girls to grow up to become men and women who, given health and security, are capable of providing a stable and happy life for their children' (Bowlby 1952).
Psychoanalytical principles
One of the impressive features of Child Care and the Growth of Love is the way it presents psychoanalytical principles in an accessible and simple form. It is infused with the belief that it is always better to speak the truth, however painful, than to suppress it, and that to try to wipe the slate of the past clean is misguided and in any case impossible. Bowlby believed that children should be involved in any decisions about their welfare, and their own views and wishes taken into account - a principle which has only reached the statute book half a century later in the Children Act of 1989. He thought that children should be encouraged to express their ambivalent feelings about their parents. Children often believe themselves responsible for the calamities which befall them and their families, and child-care workers need to be aware of this and help put these feelings into perspective. For a child away from home 'the lack of a sense of time means that separation feels like an eternity', and this too needs to be understood. In a remarkable quotation from his psychoanalytic colleague Winnicott, a case is made that every child has a right to a primary home experience:
without which the foundations of mental health cannot be laid down. Without someone specifically oriented to his needs the infant cannot find a working relation to external reality. Without someone to give satisfactory instinctual gratifications the infant cannot find his body, nor can he develop an integrated personality. Without one person to love and to hate he cannot come to know that it is the same person that he loves and hates, and so cannot find his sense of guilt, and his desire to repair and restore. Without a limited human and physical environment he cannot find out the extent to which his aggressive ideas actually fail to destroy, and so cannot sort out the difference between fantasy and fact. Without a father and
44 Origins
a mother who are together, and who take joint responsibility for him, he cannot find and express his urge to separate them, nor experience relief at failing to do so.
(Winnicott and Britton in Bowlby 1952)
These principles are as relevant today as they were when they were written. The tragedy of contemporary 'community care' is that, while the need to avoid the negative aspect of institutions has been grasped, the primary home experience as described by Winnicott remains elusive.
Bowlby's outrage
Perhaps the greatest single thread in Bowlby's work, one which comes through strongly in Child Care and the Growth of Love, is his pain and outrage at the unnecessary separation of children from their parents. He could take heart at the changes in pediatric and obstetric practice it has led to. The book ends with this passionate outcry at a 'developed' society which has forgotten the fundamental importance of human attachment:
Finally let the reader reflect for a moment on the astonishing practice which has been followed in obstetric wards - of separating mothers and babies immediately after birth - and ask himself whether this is the way to promote a close mother- child relationship. It is hoped that this madness of western society will never be copied by so-called less developed societies.
(Bowlby 1952)
Sadly, there is increasing evidence that Bowlby's fears are being realised.
Bowlby's work has excited considerable reaction, ranging from uncritical acceptance to outraged dismissal. His critics can be divided into two groups. First, there are those who question the social and political implications of his work, mainly from a feminist perspective. A rather different group of researchers have examined the factual basis of the concept of maternal deprivation. These workers, who include Bowlby himself, have modified and refined our understanding of the short- and long-term implications of maternal separation and mishandling for the developing child.
Maternal deprivation 45
THE FEMINIST CRITIQUE
Feminists have aimed three broad kinds of criticism at the idea of maternal deprivation. The first, and most simple, merely accuses Bowlby of overstating his case. The studies upon which he bases his conclusions were of children who had experienced almost complete lack of maternal care. To generalise from these to the view that any separation of mother from child in the first three years of life is likely to be damaging is unwarranted (Oakley 1981). There is abundant evidence, they claim (and, as we shall see later, the facts support this view), that when a mother entrusts her child for part of the day to the care of a trusted and known person - whether a grandmother, a metapalet in a kibbutz, or a responsible baby minder - no harm is done. They argue, on the contrary, that exclusive care by the mother alone can lead to less rather than greater security for the child, and that Bowlby was wrong in his concept of 'monotropism' (that is, exclusive attachment of the child to one preferred figure). The reality is that the child has a hierarchy of attachment figures, of whom the mother is usually the most important, but that fathers, grandparents, siblings and other relations and friends also play a part, and that in the absence of one, the child will turn to another in a way that does not equate with the emotional promiscuity of the institution-raised child. They also point to the emotional burden on the mother alone with her child, who, despite (or because of) 24-hour proximity to her child may be emotionally neglectful even if she is physically attentive (Chodorow 1978). The dangers which Bowlby repeatedly identifies in his later work - role reversal between mother and child, threats of suicide, or saying the child will be sent away - can all be seen in part as consequences of this burden and the exclusivity which he advocates for the mother-child bond.
The second plank upon which the feminist critique rests is more complex, and consists of an attempt to locate Bowlby's ideas in an historical, anthropological and sociological context. It starts from the historical context of post-war Europe where, as New and David (1985) put it, Bowlby
got an audience: women who had been working in munitions factories, obliged to send their children for nine or ten hours daily into indifferent nurseries, men who for years had been equating peace with the haven of the
46 Origins
family, governments which saw the social and financial potential of idealizing motherhood and family life.
The collective sense of loss, and guilt, and desire for reparation found an answer in the idea of maternal deprivation. Children had suffered terribly as a result of the war, and this needed to be faced, as had the 'internal children' of the adults who had witnessed the horrors of war. The valuation and at times sentimentalising of the mother-child relationship in post-war Europe could be compared with a similar process in the nineteenth century in the face of the brutality of the Industrial Revolution. Bowlby's tenderness towards little children carries echoes of Blake and Wordsworth, Dickens and Kingsley. There had to be a safe place which could be protected from the violence of the modern world, and the Christian imagery of mother and child reappears, in his work, as an icon for a secular society.
A slightly different slant was offered in the suggestion that governments welcomed the idea of maternal deprivation in that it appeared to let them off the hook of providing child care, pushing it back to individual and family responsibility. Winnicott wrote to Bowlby warning him that his views were being used to close down much-needed residential nurseries (Rodman 1987). Bowlby had not, of course, argued that money should be withdrawn, but rather transferred from institutional care to home care, but, as in the more recent case of the mentally ill and handicapped, governments were less keen on this part of the argument.
The heart of the feminist case against Bowlby is that, like Freud, he had wrongly assumed that anatomy is destiny. Implicit, they argue, in the concept of maternal deprivation is a view of the biological 'naturalness' of an exclusive mother-child relationship which, as Margaret Mead (1962) puts it, is a 'reification into a set of universals of a set of ethnocentric observations on our own society'. Anthropology shows that what is normal is for child care to be shared by a stable group of adults and older children, usually, but not always, related, and usually, but by no means always, female. Maternal care is an important but certainly not exclusive part of this. For infants to survive in non-industrial countries such shared care is essential. As an Object-Relations theorist Bowlby rejects Freudian drive theory, but, once attachment theory was developed, offered an evolutionary-
Maternal deprivation 47
ethological account of the mother-child bond. Feminists object that he is using biology to justify what is essentially a cultural product of our own 'patriarchal but father-absent' society (Leupnitz 1988), with its nuclear families, small numbers of children, weakened kinship networks, mobile population, and fathers who are away from home for long periods, or absent altogether.
A more tenuous sociological argument (Mitscherlich 1963; Parsons 1964) suggests that the family structure which Bowlby implicitly advocates, with strong, closely bonded mothers and children, and peripheral fathers, fits the needs of modern capitalist society. Paternal authority has been replaced by that of the headmaster or boss in school, office and factory, producing a docile workforce, while the mother controls her children by bribes and threats, thus preparing them for the social manipulations of advertising and manufactured need which an ever-expanding consumerist economy requires. This pattern is offered as the norm for 'adequate' family functioning, as it is in the functionalist account offered by such influential writers as Parsons (1964). Leupnitz, from a feminist family therapy perspective, sees this as enshrining a state of affairs that suits men, but leaves wives who are obese, sexually dissatisfied, psychosomatically ill, and prone to depression (Leupnitz 1988).
Child Care and the Growth of Love was written about children who had lost their mothers, usually for good, and described the psychological consequences of that privation. Until recently, Europe had enjoyed an unprecedented period of peace and stability (warfare, starvation, genocide and mass migration have continued apace, exported to the developing world). The problems facing the modern family are not so much maternal deprivation as of paternal deprivation due to weak, absent or abusive fathers, and 'implosion' of the children onto unsupported mothers. Chodorow (1978) and other feminist psychotherapists have written about the psychological consequences of these changes. In summary, they lead to identity difficulties for both men and women. Lacking a strong father with whom to identify, boys differentiate themselves from their mothers and sisters by a disparagement of women, which conceals a dread of their phantasised omnipotence. It is this, according to Horney (1924), not Freud's castration anxiety, which underlies male fear of women and their difficulties in intimacy. The elusive search for 'success' is an attempt to please
48 Origins
and appease the all-powerful mother. Girls, on the other hand, remain tied into their mothers, often taking on their pain and depression, and feeling intense guilt if they try to assert their independence and autonomy. The absent or seductive father makes a move towards him difficult or dangerous. Motherhood provides a temporary relief, but the girl again may feel caught in a mother- child dyad from which she still cannot escape, while the boy, now a father, feels excluded and jealous. As we shall see in later chapters, the Bowlbian concepts of avoidant and ambivalent attachment capture roughly these male and female patterns of anxious attachment in the modern family.
In summary, the feminist critique has questioned the logic of the implicit Bowlbian argument (one which in its simplistic form Bowlby would have been the first to repudiate) that since absent mothers lead to disturbed children, ever-present mothers will produce happy children. The feminists - in so far as it is possible to group them together - in turn have tended to overstate their case and failed to appreciate the importance which Bowlby has established for the role of the mother in her child's emotional development, both as a scientific fact and as a social and ethical principle. Bowlby's advocacy of the vital importance of mothers in the care of children, and the implications of his studies that good day-care facilities should be available for mothers who want or are forced by economic necessity to work, funded so that children can have individual and continuous relationships with care workers, should be seen as a step towards the liberation of women, increasing their range of choices and valuation by society.
Although still in print, it is now nearly fifty years since Child Care and the Growth of Love was first published. The terms of the debate have changed, so that, with less physical absence, but with ever-increasing difficulties in managing their lives, mothers are subject to enormous social pressures and their children are often the first casualties of this. For a more detailed examination of maternal deprivation from a contemporary perspective, and to a discussion of how children may be helped to escape or may remain ever more deeply trapped in deprivation we must turn now to the work of Michael Rutter.
Maternal deprivation 49
MATERNAL DEPRIVATION REASSESSED
Rutter's monograph (Rutter 1981) and numerous papers (for example, Rutter 1972; Rutter 1979) comprise the definitive empirical evaluation and update of Bowlby's work on maternal deprivation. His contribution has been to amass further evidence, and, based on this, to begin to tease out the many different social and psychological mechanisms which operate under the rubric of maternal deprivation.
Bowlby, it will be recalled, claimed that maternal deprivation produced physical, intellectual, behavioural and emotional damage. He further argued that even brief separations from the mother in the first five years of life had long-lasting effects, and in general that these problems perpetuated themselves in a cycle of disadvantage as such children themselves became parents. Rutter has examined each of these points in turn.
On the question of intellectual and physical disadvantage, and the effects of brief separation, it seems that Bowlby was only partially right, and often for the wrong reasons. While it is true that institution-raised children are intellectually disadvantaged, this is mainly in verbal as opposed to performance intelligence, and this is a consequence of the child's 'verbal environment', not the lack of parents per se. Children brought up in large families are similarly disadvantaged. It is lack of verbal stimulation that is the problem for the deprived children, not lack of mother. A similar picture emerges with 'deprivation dwarfism', which has been shown to be due, as might be expected, to lack of food intake rather than some mysterious emotional factor, and can be rapidly reversed by attentive feeding, whether by a nurse or mother.
Acute separation distress is also probably less damaging, and more complex than Bowlby first saw it. Preparation and care by known figures reduces distress, and even without these there is no evidence of long-term effects from a single brief separation however painful it may be at the time. An important point comes from Hinde's rhesus monkey studies (Hinde and McGinnis 1977), which show that the effects of separation depend on the mother- child relationship before the event: the more tense the relationship, the more damaging the separation. These kinds of findings indicate a move towards a more subtle appreciation of the nature of bonds, and away from simplistic event-pathology models. What matters is not so much the
50 Origins
separation itself but its meaning and the context in which it happens.
A similar conclusion applies to the relationship between antisocial behaviour and maternal deprivation. First, as Rutter (1979) puts it, 'the links are much stronger looking back than they are looking forward'. In 'Forty-four juvenile thieves', Bowlby found that a quarter of the thieves had had major separations from their parents in infancy, and in the sub-group of 'affectionless psychopaths' only two out of fourteen had not experienced maternal deprivation. In his later follow-up study of children who had been in a tuberculosis sanatorium he found that, compared with controls, the differences in social adjustment, while in the direction of less good adjustment for the sanitorium children, were not all that marked, and that at least half of the deprived children had made good social relationships (Bowlby et al. 1956). Second, the implication of the phrase 'maternal deprivation' is that antisocial behaviour is specifically linked to the loss of mother. Rutter's work (1971) suggests that antisocial behaviour is linked not to maternal absence as such, but to family discord which in divorcing families is often associated with temporary separations from mother. Children who have lost their mothers through death have a near-normal delinquency rate, while the rate is much raised when parents divorce, especially where there is a combination of active discord and lack of affection. Here too, presumably, it is the way in which the loss is handled, its antecedents (how secure the child has been with the separating parents), and meaning for the child that matter.
The importance of these refinements of the maternal deprivation hypothesis is that they mark a move away from Bowlby's medical analogy, exemplified by the Vitamin D-rickets comparison, to a psychological model which takes account of an individual's history, and of the way untoward events are 'processed' psychologically. It seems more plausible that maternal deprivation should act as a general 'vulnerability factor' (cf. Brown and Harris 1978) which raises a child's threshold to disturbance rather than as a causative agent in any simple sense. Delinquency is such a complex phenomenon, dependent on non-psychological issues such as policing policy, quality of schools and housing that it would be unlikely to be the result of any one single factor, however important childhood deprivation may be.
Maternal deprivation 51
For children unfortunate enough to be entirely deprived of maternal care, recent research has served to confirm Bowlby's original claims. Tizard's (1977) follow-up studies on institution- raised children have shown that, as the maternal deprivation hypothesis predicted, these eight-year-olds were more attention- seeking, restless, disobedient and unpopular compared with controls, while as infants they had shown excessive clinging and diffuse attachment behaviour. Her studies also indicate that, as Bowlby suggested, the period six months to four years may be critical for the capacity to form stable relationships, since children who had been adopted after four, despite forming close and loving bonds with their adoptive parents, remained antisocial in their behaviour at school.
DEVELOPMENTAL PATHWAYS THROUGH CHILDHOOD
Subsequent studies have also generally confirmed Bowlby's concept of cycles of disadvantage. People brought up in unhappy or disrupted homes are more likely to have illegitimate children, become teenage mothers, make unhappy marriages and to divorce. Parents who physically abuse their children tend to have had childhoods characterised by neglect, rejection and violence. Girls from disrupted homes when they become mothers tend to talk less to their babies, touch them less and look at them less (Wolkind et al. 1977). But not all children from unhappy homes suffer and fail in this way. A complex model is needed to explain individual differences that takes into account the child, the parent, events and their appraisal, and the social environment. This can be conceptualised as a series of pathways through childhood that lead in a more or less positive direction. A number of varied influences will determine which path a particular child takes (Rutter 1981). Figure 3. 1 attempts to summarise these.
As will be discussed in more detail in Chapter 6, there is good evidence that parents' own childhood experiences are important in influencing the way they respond to their child. Events around the birth are also important: mothers separated from their babies soon after birth are less confident and competent as mothers in the subsequent months. The sex and birth position of the child matter: parents are more relaxed and less punitive with second children than with first-borns. Male children are generally more vulnerable to family discord than are females. The death of a
Figure 3. 1 Developmental pathways from maternal deprivation
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parent is more damaging for a same-sex child than if they are the opposite sex. Temperament plays an important part too: children who are less adaptable and more prone to negative moods are more likely to be targets of parental criticism than their more easy-going siblings, and are more likely to develop a childhood psychiatric disorder. Even in discordant homes, if the child has a good relationship with one parent or with a grandparent, this acts as a protective factor against conduct disorder. Finally, the social environment is important. Inner-city areas have much higher rates of childhood psychiatric disorder than country or small- town areas, and even within inner cities some schools are much more successful in helping their pupils to avoid delinquency than others.
IMPLICATIONS FOR PSYCHOTHERAPY
Key issues for adult psychotherapists are the need to clarify more precisely the links between early childhood difficulty and emotional disorder in later life (Rutter 1986); the question of how some people survive and are even strengthened ('steeled') by adversity, while others go under (Rutter 1985); and the need for a model that will suggest at what points in the process psychotherapeutic intervention is likely to produce change (Holmes 1991).
Social psychiatry tends to emphasise present adversity in the causation of neurosis, while psychoanalytic explanations stress the past. The evidence suggests that both current and past difficulties are important, and that self-esteem is a crucial factor linking the two. Looking at adverse experiences in childhood, those who, despite loss or difficulty, manage to maintain a sense of self-esteem do well. Self-esteem in turn rests on two main foundations: self-efficacy and good relationships. Success at school - in social relationships (especially the capacity to generate humour), athletic prowess, musical ability or scholastic achievement - is correlated with better adjustment in institution- raised children in adult life (Rutter and Quinton 1984).