No More Learning

Third, if perception of inadequate relationships is the crucial issue, rather than the relationships themselves, then any psychotherapeutic technique which can alter that perception, whether directly as in cognitive therapy, or indirectly as in analytic and systemic therapies, is likely to be helpful.
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Armed with this optimism, let us look now at a number of different psychiatric disorders from the perspective of attachment theory.
ABNORMAL GRIEF
In his early work, Bowlby was keen to establish the reality of childhood mourning in the face of those who disputed whether children were able to experience the same full gamut of emotions as adults (Bowlby 1960d). The fact that adults do grieve is in itself evidence for the continuing importance of attachment throughout life. Parkes (1975; 1985; Parkes and Weiss 1983) has shown how the quality of the relationship broken by the death influences the course of mourning. Pathological grief can be divided into four distinct patterns. First is the unexpected grief syndrome: major losses which are unexpected or untimely, characterised by shock and disbelief and a persisting sense of the presence of the dead person. In the face of major trauma, securely attached people are as vulnerable as the less secure, and Parkes et al. (1991) found that 100 per cent of those referred with abnormal grief to his clinic whose capacity to trust themselves and others was good, had had sudden, unexpected or multiple bereavements. In delayed grief, seen typically in people with an avoidant attachment style, the patient characteristically lacks emotional response to the loss, feels numb and unable to cry, and cannot find any satisfaction in relationships or distractions. In the ambivalent grief syndrome, the previous relationship was stormy and difficult, often with many quarrels and much misery. Initially, the bereaved person may feel relief, and that they have 'earned their widowhood'. Later, however, intense pining and self-reproach may follow, with the sufferers blaming themselves in an omnipotent way for the death of their partners, based on the earlier unconscious or semi-conscious wishes that they would die. In chronic grief the sufferer becomes locked into a state of despair from which there seems no escape. These people have usually shown lifelong dependency on parents and partners. Often such dependency may mask ambivalence, and the unearthing of negative feelings can be the chink through which new life begins to appear.
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MRS W: I can't bear to look
Mrs W, a fifty-year-old housewife, had been in a state of chronic grief since the death of her grandmother three years previously. She was unable to carry on looking after the house or caring for her twenty-year-old daughter, herself handicapped with agoraphobia. She was tearful and apathetic, had failed to respond to antidepressants, and her husband and GP were at their wits' end. Referred for psychotherapy, she described how she had to avert her gaze on going past her grandmother's house, tried to avoid going near it although this often meant inconvenient diversions, and could not possibly visit her uncle who still lived there.
When she was a child her father had been away in the war, but on his return when she was four, her mother promptly went off with another man, and she had had no contact with her since. She was brought up by her maternal grandmother to whom she felt close, but who ruled with a rod of iron. When she was eleven, her father remarried and she was summoned to live with him and her stepmother. She was never happy with them, and she spent her teens oscillating between her grandmother and father. At eighteen she left home, made two disastrous marriages, and eventually met her present husband, twenty years her senior, who was very 'good' and 'understanding', but, she felt, was unable to understand her grief and was intolerant of her tears.
Offered brief therapy based on 'guided mourning' (Mawson et al. 1981), she brought photographs of her grandmother which, initially, she could only look at with great difficulty. Mixed with her reverence and awe towards her grandmother, a new theme began to emerge - anger at the way her mother had been 'written off' and had become a forbidden subject not to be mentioned in the grandmaternal home. With therapeutic prompting, Mrs W made enquiries about her mother, found that she had died and visited her grave. Then she happened to bump into her maternal uncle at the local supermarket and was able to talk to him for the first time since her grandmother's death. She then went to the house, at first just looking at it from the outside, later going inside. When therapy came to an end after eight sessions her depressive symptoms had lifted and she felt better 'than for years' although she remained overinvolved with her daughter.
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DEPRESSION
Attachment Theory has made an important contribution to current thinking about the social causes of depression. Freud's (1917) speculation about the relationship between current loss and melancholia has been repeatedly confirmed by studies showing how adverse life events can precipitate depression. His linking of depression with childhood loss has also been confirmed, although not without controversy. The balance of evidence (Brown and Harris 1978; Tennant 1988) suggests that early loss of their mother, especially if accompanied by disruption and lack of care, makes a person more vulnerable to depression when faced with adversity in adult life. Harris and Bifulco (1991) have tracked the interweaving of social and psychological variables in their Walthamstow study of a group of women who had lost their mothers in childhood. They found, as predicted, that this group of women had significantly raised rates of depression compared with non-bereaved women: one in three versus one in ten. The strand of social causation starts with early loss of mother, whether through death or separation, leading to lack of care in childhood. This is linked, in the teens of the patient-to-be, with high rates of pre-marital pregnancy. This in turn leads to poor choice of partner, so that when these women, often living in disadvantaged circumstances and therefore prone to large amounts of stress, experience loss they are more likely to have unsupportive or nonexistent partners, and so to develop depression.
Harris and Bifulco's 'Strand 2', the psychological, centres on a sense of hopelessness and lack of mastery in both the childhood and current circumstances of the depressed patient. As children their depressed patients had not only lost their mothers, but also felt utterly helpless - unable to protest or grieve or retrieve or be comforted, like Bowlby's little patient who, at the age of nine, on the day when his mother died, was told to go and play in his nursery and not to make such a fuss (Bowlby 1979c). When they were adults the feeling of helplessness persisted: when they became pregnant, they coped badly with it. Their perception of their current relationships played a big part in determining whether or not they became depressed; the more helpless
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they felt, the greater the chance of depression, and when they felt some degree of effectiveness they were protected from it.
Harris and Bifulco (1991) distinguish between a general sense of hopelessness and lack of mastery and what they call 'vulnerable attachment styles' - that is, difficulty in interpersonal relationships. Depression was much more likely in those who showed evidence of poor relating and especially interpersonal hostility. It seems that it is the interpersonal aspect of hopelessness (as opposed to things like managing money and housework) that matters most. We have seen that it is precisely this interpersonal dimension that is formative in insecure attachments: mothers who had difficulty in attuning to their infants and who showed unpredictable hostility were more likely to have anxiously attached children.
Brown and Harris (1978) see self-esteem as the key psychological variable in the genesis of depression. As Pedder (1982) points out, to have good self-esteem is to have internalised a two-person relationship in which one bit of the self feels good about another. This is the good internal object of psychoanalytic theory, arising out of the responsiveness of the mother - the mother who not only feeds, but recognises one as a person, is sensitive to one's feelings and moods, whom one can influence, and with whom one can, through play, create and re-create, in the 'present moment' (Hanh 1990), the spontaneity of love.
Brown's group have also suggested a relationship between the age at which the mother is lost, the circumstances of the loss, and subsequent symptom formation. The earlier and more sudden the loss, the more likely the chance of depression, and the greater the chance that the depression will be psychotic rather than neurotic in character. Pedder relates this to the Kleinian notion of the 'depressive position' (see Chapter 5). Children who have not yet developed an internal image of a whole, good mother, safe from destruction by angry attacks, will, when depressed, be more likely to despair and feel overwhelmed with depression. Older children, who do have some sense of a whole mother, or who have had at least an inkling that loss is imminent, will react to her loss with anger and attempts to retrieve her through suicidal gestures or psychosomatic illness. Pedder (1982) relates this to
several particular clinical situations that must be familiar to many psychotherapists which reflect this protesting state of affairs and make mourning for the lost person very difficult. One is when a parent absents themselves by suicide; another
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when a marital partner is left unwillingly by the other; or when a psychotherapist abandons a patient without due warning. In all such cases there is a special problem to internalise any good version of the departing person.
(Pedder 1982)
Bowlby (1980) suggested there were three typical patterns of vulnerable personality arising out of anxious attachment: ambivalent attachment, compulsive care-giving and detachment. The Walthamstow study confirmed the importance of the first two, but found, contrary to expectation, that detachment actually protected against depression. There are two possible explanations for this. One is that their measures were not sensitive enough to distinguish between healthy autonomy (which is a form of mastery) and compulsive detachment (which is not). The second is that detachment may be connected more with borderline personality disorder than depression, a possibility we shall consider below.
Harris and Bifulco (1991) were studying only a small sub-group of depressed patients: although people who have been bereaved in childhood appear to be more vulnerable to low self-esteem and so to depression in later life, the majority of depressives come from intact homes. Parker's Parental Bonding Instrument (Parker 1983) is an attempt, via retrospective accounts, to reconstruct the family atmosphere in patients' childhoods, searching for qualitative features of parenting which may predispose to depression. Parker isolates a particular combination of low care and overprotection which he calls 'affectionless control' that is especially corrrelated with neurotic depression: in one study it was present in nearly 70 per cent of patients but in only 30 per cent of controls. Affectionless control conjures up a childhood in which the potential patient lacks a secure parental base, and at the same time is inhibited in exploratory behaviour, thereby reducing the two ingredients of self-esteem: good internal objects and a feeling of competence and mastery.
One of the strengths of Attachment Theory is that it brings together past and present influences, the social and the psychological, providing a comprehensive picture of the varied factors which result in the development of a psychiatric disorder. Bowlby (1988c) gives a vivid picture of this epigenetic process. There is
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[a] chain of adverse happenings. For example, when a young woman has no caring home base she may become desperate to find a boyfriend who will care for her. That, combined with her negative self-image, makes her all too likely to settle precipitately for some totally unsuitable young man. Premature pregnancy and childbirth are then likely to follow, with all the economic and emotional difficulties entailed. Moreover, in times of trouble, the effects of her previous adverse experiences are apt to lead her to make unduly intense demands on her husband and, should he fail to meet them, to treat him badly. No wonder one in three of these marriages break up.
Gloomy though these conclusions are, we must remember that a disastrous outcome is not inevitable. The more secure an attachment a woman has experienced during her early years, we can confidently predict, the greater will be her chance of escaping the slippery slope.
(Bowlby 1988c)
AGORAPHOBIA
In Separation (1973a), Bowlby puts forward a theory of agoraphobia based on the notion of anxious attachment. He sees agoraphobia, like school phobia, as an example of separation anxiety. He quotes evidence of the increased incidence of family discord in the childhoods of agoraphobics compared with controls, and suggests three possible patterns of interaction underlying the illness: role reversal between child and parent, so that the potential agoraphobic is recruited to alleviate parental separation anxiety (this may well have happened with Mrs W's daughter in the case described above); fears in the patient that something dreadful may happen to her mother while they are separated (often encouraged by parental threats of suicide or abandonment, Bowlby believed); and fear that something dreadful might happen to herself when away from parental protection.
Central to the theory and treatment of phobic disorders is the idea that painful feelings and frightening experiences are suppressed and avoided rather than faced and mastered. In what Bowlby first described as 'the suppression of family context' (Bowlby 1973a) and later 'on knowing what you are not supposed to know and feeling what you are not supposed to feel' (Bowlby 1988a), he hypothesised that the potentially phobic adult has first been exposed to trauma - such as witnessing parental suicide attempts, or being a victim of sexual abuse - and then
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subjected to intense pressure to 'forget' what has happened, either by the use of overt threats, as often happens in sexual abuse, or by denial - as, for example, when a grandmother brings up her daughter's illegitimate offspring as one of her own, and the child is led to believe that her true mother is her older sister. The use of denial means that the child does not have the experience of emotional processing of painful affect, and so cannot, as described in Chapter 6, achieve the autobiographical competence that is a hallmark of secure attachment. Liotti (1991) sees in phobic disorders a dissociation between the physiological concomitants of anxiety and the 'meaning structures' that go with them. The events which might make a child anxious cannot be linked up into mental schemata which would enable that child to face and overcome them. When, as adults, such individuals experience shock or conflict, they focus merely on the symptoms of panic, and not on the events which triggered them. He advocates an exploratory form of cognitive psychotherapy which does not merely require exposure to the feared stimulus, but also encourages self-exploration so that emotions and the relationships which evoke them can begin to be linked together in a meaningful way.
Morbid jealousy and agoraphobia
David was a fifty-year-old ex-taxi-driver who developed panic attacks whenever he was separated from his wife, even for half an hour, and could not go out of the house unaccompanied. Her life was made increasingly miserable by his possessiveness, and his ceaseless questioning of her when she returned from brief excursions to visit their daughter. During David's attacks he was convinced that he would die and frequently was rushed to hospital casualty departments with suspected heart attacks. He initially described his childhood as 'all right', that he had few childhood memories, and that 'what's past is past'. Then, in the second session, when asked again about his childhood he began to cry and talked about his terrors on being left alone by his mother who was a night-club 'hostess', about never having known his father, and his misery and confusion about the different men with whom she lived. When it was gently suggested that he must have felt very jealous of these men, and that there might be some connection between this and his present attitude towards his wife, he became extremely distressed and recounted how at the age of twelve he had attacked one of these men with a knife and was
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taken to a remand home as a result. In subsequent sessions he began to reveal his depression much more openly, and was gradually able to tolerate being on his own for increasing periods of time.
ATTACHMENT STYLES AND EXPRESSED EMOTION IN SCHIZOPHRENIA
It has repeatedly been stressed that Bowlby's early ideas of a simple relationship between, for example, childhood bereavement and depression, maternal deprivation and psychopathy, or anxious attachment and agoraphobia, have had to be modified into much more complex causal models in which early experience, current life situation, adverse events, personality, and mental set all contribute to outcome. It is unlikely that there is a simple relationship between particular attachment patterns in infancy and specific psychiatric diagnoses in adult life.
In considering psychoses, this multifactorial approach has to be further extended to include genetic and biochemical or even infective influences. Nevertheless, social psychiatry has firmly established the importance of the environment in determining the course of schizophrenic illness (Left and Vaughn 1983). Patients living in families in which there is high 'Expressed Emotion' (EE) - especially high levels of hostility or overinvolvement - are much more likely to relapse than those who live with calmer, less hostile, less overinvolved relations. The effect of EE is not specific to schizophrenia, and also influences, for instance, the course of manic-depression, Alzheimer's disease and diabetes. The prevalence of high EE in the general population is unknown, but in families of schizophrenic patients about one- third are high in EE. It seems at least possible that there is a relationship between EE and anxious attachment, which also affects about one-third of the population. The two main patterns of high EE, hostility and overinvolvement, correspond with those found in anxious attachment; that is, avoidant and ambivalent attachment. The mothers of avoidant infants, it will be recalled, tend to show hostility and to brush their children aside when they approach, while the ambivalent mothers are inconsistent and intrusive. Both patterns can be understood in terms of boundaries. The avoidant mothers feel invaded by their children and tend to maintain a rigid boundary around themselves, and this may lead
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to hostility when confronted with a mentally ill, and therefore in some ways child-like, grown-up child or spouse. Conversely, ambivalent parents cannot separate themselves from their children, and, if one becomes mentally ill as an adult, the pattern will repeat itself. Such parents cannot draw a firm boundary between themselves and their offspring because of overwhelming feelings of guilt.
Too many telephone calls
Mr P felt intensely guilty when his son Richard developed a severe schizophrenic illness at the age of twenty-two. He blamed himself for being so heavy-handed during Richard's teens, and, as a psychiatric nurse, felt from his reading of Laing and others that he must be a 'schizophrenogenic father'. He tolerated in an almost saint-like way very difficult behaviour from Richard, who would come into his parents' bedroom throughout the night asking for constant reassurance that he was not going to die, on one occasion brandishing a knife. Occasionally Mr P would flip from excessive tolerance into furious outbursts at his son, and then feel even more guilty. When Richard was admitted to hospital and moved later to a hostel, Mr P felt even more guilty, especially as Richard insisted that he hated the hostel and his only wish was to return home to his parents and brothers and sisters (of whom he showed in fact considerable jealousy).
Mr P had himself been an anxious child and had found separations from his mother very difficult, running away from his boarding school where he was sent at the age of nine on several occasions. Therapeutic attempts to create a boundary between Richard and his family were made very difficult because every attempt to do so was immediately interpreted by Mr P as a criticism of his parenting, and as carrying the implication that he was a negative influence on his son. But when it emerged that Richard would phone home from his hostel with unfailing regularity just when the family were sitting down to tea, Mr P was asked to take the phone off the hook for that half hour each evening. With much misgiving and strong feelings that he was rejecting his son, he agreed, without disastrous results, and with a general lightening of the relationship between Richard and his parents. Through this small change the family seemed to have come to accept that a firm boundary can be a mark of loving attachment rather than rejection.
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BORDERLINE PERSONALITY DISORDER
Patients with borderline personality disorder (BPD) form an increasing proportion of specialist out-patient psychotherapy practice, and comprise a significant part of the work of in-patient psychiatry, often consuming time and worry disproportionate to their numbers. Despite debate about its validity as a distinct nosological entity (Rutter 1987), BPD is, for the psychodynamically minded, an indispensable concept. It is defined in the American Diagnostic and Statistical Manual as comprising a constellation of symptoms and behaviours which include unstable interpersonal relationships, with violent swings between idealisation and devaluation; unstable mood states; self-injurious behaviour, including deliberate self-harm and drug abuse; angry outbursts; identity disturbance with uncertainty about goals, friends, sexual orientation; and chronic feelings of emptiness and boredom. In short, there is an atmosphere of 'stable instability' (Fonagy 1991) about these patients with which most clinicians are familiar.
Empirical studies suggest that these patients have been subjected to high levels of emotional neglect and trauma in childhood, although neither is of course confined to BPD. Bryer et al. (1987) found that 86 per cent of in-patients with a diagnosis of BPD reported histories of sexual abuse, compared with 21 per cent of other psychiatric in-patients, and Herman et al. (1989) found in out-patient BPDs that 81 per cent had been subjected to sexual abuse or physical abuse or had been witness to domestic violence, as compared with 51 per cent of other out-patients. Of those who had been traumatised in this way under the age of six, the figures were 57 per cent for BPD and 13 per cent for other diagnoses.
Psychoanalysts working with these patients (for reviews, see Fonagy 1991; Bateman 1991) have emphasised the extensive use of projective identification that arises in the transference-counter- transference matrix. The therapist is, as it were, used as a receptacle for the patient's feelings and may be filled with anger, confusion, fear and disgust in a way that, for the inexperienced, is unexpected and difficult to tolerate. The patient treats therapy in a very concrete way, and may become highly dependent on the therapist, seeking comfort in fusion with a rescuing object who is, at other times, felt to be sadistic and rejecting. These latter aspects emerge
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especially at times of breaks, or when the therapist lets the patient down, as inevitably he will through normal human error and the pressure of counter-transference.
With an approach to these patients from the perspective of Attachment Theory two issues stand out. The first concerns the oscillations of attachment (Melges and Swartz 1989) that are so characteristic of BPD, and the related question of why they persist in relationships with their families and partners (and sometimes with their 'helpers') that are so destructive. Here we are reminded of the behaviour seen in rhesus monkeys brought up on wire mothers who, when subjected to physical trauma, cling all the more tightly to the traumatising object (Harlow 1958). According to attachment theory, a frightened child will seek out their attachment figure, and if he or she is also the traumatising one a negative spiral - trauma leading to the search for security followed by more trauma - will be set up.
A second, more subtle conceptualisation of the borderline predicament has been proposed by Fonagy (1991). He suggests that the borderline experience can be understood in terms of the lack in these patients of what he calls a 'mentalising capacity'. By this he means that they lack adequate internal representation of their own or others' states of mind, especially in relation to emotions. A similar idea is contained in Main's (1991) notion of deficits in 'metacognition', the ability to think about thinking. The work of Stern and the post-Bowlbian attachment researchers suggest that maternal responsiveness is internalised by the growing child so that he or she begins to build up an idea of a self that is responded to and understood, and, reciprocally, to be able to understand and take another's point of view. Where there are difficulties in responsiveness, the child is faced with levels of excitation and pain which cannot be soothed and shaped and contained by the parent (perhaps through their own depression or inability to mentalise). Also, to represent to oneself the idea that one's parent might want to hurt or exploit one would in itself be deeply painful. Deprived of the capacity for symbolic representation of their unhappiness, and therefore the opportunity for emotional processing or transcendence, the traumatised child resorts to projective identification in which the intolerable feelings of excitation and pain are 'evacuated' into those to whom he or she is attached. For the child this is the abusing parent who is clung to with 'frozen watchfulness'; for the adult patient it is their intimates, including
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the therapist. The patient is temporarily relieved of mental pain, at the price of a feeling of emptiness and boredom, to be followed, as the projections are returned or further trauma arises, by yet more episodes of intolerable discomfort leading to more projection.
These speculations are given some substance by a recent Attachment Theory-inspired study by Hobson and his colleagues (Patrick et al. 1992), in which they compared a group of twelve borderline psychotherapy patients with a similar number of depressives. They were given Parker's Parental Bonding Instrument (PBI), mentioned above, and Main's Adult Attachment Interview (AAI), described in Chapter 6. Both groups showed Parker's 'affectionless control' constellation of low parental care and overprotection, with the BPD group demonstrating this even more clearly than the depressives, a result also found by Zweig-Frank and Parris (1991). If these retrospective accounts of childhood reflect not just a person's perception of what happened but what actually took place - and there is evidence to suggest that they do (Mackinnon et al. 1991) - a picture emerges of parents who were anxious but unable to respond accurately to their children, and, from the child's perspective, of an attachment figure to whom one clings, but who does not assuage one's insecurity (Heard and Lake 1986), with resulting inhibition of exploration.
Even more interesting were the results of the AAI. It will be recalled that this is a psychodynamic snapshot of a person's attachments and reactions to loss in childhood. Based on the coherence and emotional tone of the transcript, the interview is scored not so much for actual trauma as for the way a person describes it - and so is a measure of autobiographical competence (Holmes 1992). There are four possible categories: secure; insecure-dismissive; insecure-preoccupied or - enmeshed; and a fourth category, recognised after the AAI was first developed, unresolved/disorganised/disoriented, which is judged when the subject is talking about past trauma and is rated in parallel to the other categories. Thus someone who can be quite coherent for most of their narrative can still receive an unresolved classification if their story becomes incoherent when they talk about trauma. The results showed that none of the BPD group was secure, and all were classified as enmeshed, while in the depressive group four were enmeshed, six dismissive and two secure. Only two of the depressives were unresolved/ disorganised, but nine of the BPDs were so classified.
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The combination of enmeshment with disorganisation in relation to trauma suggested that BPD patients were wrestling with an inability to find a way of describing overwhelming mental pain - implying exactly the sort of deficit in mental representation postulated by Fonagy and Main. By contrast, several of the depressives had also been traumatised, but the effect on their linguistic coherence was much less marked.
It is clear from these studies that no one diagnostic entity can be correlated with a particular childhood constellation. 'Affectionless control' occurs in both depressive and BPD; some accounts of BPD stress avoidance, others enmeshment as childhood precursors. But the evidence in general that insecure attachment is an important developmental precursor of psychopathology is increasingly strong. Herman et al. (1989) suggest that qualitative differences may relate to different diagnostic outcomes, with the most severe forms of childhood trauma and parental unresponsiveness being linked to multiple personality disorder, less severe forms with BPD, and yet milder types linked to neurotic depression and anxiety. This would be consistent with Pedder's (1982) suggestion along Kleinian lines that the greater the difficulty in integrating a parental good internal object, the greater the likelihood of severe pathology.
The Bowlbian perspective on BPD has several implications for treatment. The patient will lack a sense of a secure base. Extreme forms of avoidance or ambivalence are likely. The patient may resist any emotional involvement in therapy as a defence against the trauma that close relationships have entailed in the past, leaving the therapist with the uncomfortable feeling that he is inflicting therapy on an unwilling subject. Alternatively, the patient may cling to the therapy for dear life, leaving the therapist feeling stifled and guilty about the need to lead their own life. There may be oscillations between these two positions, so that in one session the therapist feels they are really making progress, only to be faced at the next with an indifferent patient, for whom the previous advance appeared to be an illusion. The therapist may feel paralysed, apparently of no value to the patient, and yet meeting with extreme resistance if they attempt to disengage themselves. Throughout, the overwhelming task of the therapist is, as described in the previous chapter, to remain consistent and reliable, responsive and attuned to the patient's emotional states, and to be alert to the unconscious pressure to repeat (often in subtle
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ways) the punitive and traumatising experiences of intimacy which the patient has come to expect.
Any evidence of mentalisation or symbolisation, however fragile and transient, should be taken as an encouraging sign. This may take varied forms - humour in the session, the bringing of a dream or poem, evidence of self- or other- awareness, an outside interest in a sport or hobby - all suggesting the beginnings of a nascent capacity for exploration that indicate the development of a secure base within the therapy and in the inner world. Although consistency is essential, it is also inevitable that mistakes will occur under the intense transferential pressure to which the therapist is subjected. As described in the previous chapter, if handled favourably, these can provide an opportunity for the patient to re-live earlier losses and traumata in a way that they can now be grieved and processed emotionally. This should not lead to complacency on the part of the therapist, however. Winnicott's reminder to omnipotent therapists that 'we help our patients by failing' should be balanced by Bob Dylan's dictum that 'there ain't no success like failure, and failure ain't no success at all'. Finally, therapists should never underestimate the responsibility implicit in allowing attachment to develop in these patients. As Gallwey (1985) puts it:
Any experience of being taken on, encouraged to become deeply attached, and then terminated suddenly may be catastrophic to patients who have managed to keep themselves going by avoiding precisely that type of hazard, which no amount of interpreting in the short term can possibly alleviate.
ATTACHMENT THEORY AND COMMUNITY PSYCHIATRY
We saw in Chapter 3 how Bowlby's recognition of the traumatic effects of loss and separation led to a revolution in child care, with a move towards home-based treatments and a recognition of the potentially damaging effects of institutions which cannot cater for a child's need to form secure attachments. Although the overall effects of this perspective were undoubtedly beneficial, it was used by many local authorities and government agencies anxious to save money to close down residential homes for children without providing adequate alternatives. Winnicott was
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sufficiently alarmed by this trend to write to Bowlby in 1955 asking him to tone down his insistence on the dangers of residential care (Rodman 1987).
A comparable revolution has taken place over the past twenty years in the provision of care for the mentally ill. Mental hospitals have been replaced by 'community care', in which patients live with their families or in hostels and group homes, and attend day centers and community clubs. Psychiatric beds are available only for 'acute' episodes of illness or distress, to tide patients through brief periods of crisis. Although many patients have benefited from the enhanced self-respect of living independent lives, there have been losses as well as gains. The emphasis on a version of autonomy that is akin to avoidance has overlooked the continuing need for dependence, which Bowlby saw as lifelong, not confined to the young and the sick. Many patients were intensely dependent on their institutions, and, due partly to their illness, partly to the increasing isolation of modern life, are unable in the 'community' to re-create the network of emotional bonds they found in the mental hospitals.
We have seen repeatedly how there has been a movement from Bowlby's early formulations of a problem in fairly simple and concrete terms, through a series of reservations and doubts, to a much more subtle appreciation of the issues involved. For example, it was not the separation from the mother alone that was damaging when a child went to hospital, but the unfamiliarity of the ward and the punitive discouragement of protest. Similarly, anxious attachment is the result not so much of gross disruptions of care or threats of abandonment (although these are of course harmful), but more a fine-tuned failure of maternal attunement and responsiveness. The problem with institutions is not that they are intrinsically harmful, any more than the 'community' is always beneficial, but the way that care is often delivered in them. We have to look much more carefully at the actual quality of experience that a patient has, whether it is in hospital or in 'the community', before deciding whether or not it is bad. Winnicott's list of components of a 'primary home experience' quoted in Child Care and the Growth of Maternal Love (1953b) (see page 43), is as follows. Does the patient have someone to turn to who is specifically orientated towards their needs?
Are the patient's basic physiological needs and physical health adequately catered for? Are the patient's needs to hate and to love recognised, and are
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there clear limits against which the patient can test strengths and weaknesses, and learn to differentiate between reality and phantasy? Is the patient cared for by a team that communicate with one another and in which the 'maternal' and 'paternal' functions are differentiated and harmonious?
Continuity of care is a key issue. In the past the 'stone mother' (Rey 1975) of the institution provided a backdrop of stability for the chronically mentally ill as staff and psychiatric fashions came and went. As patients moved out into the community it was hoped that a network of hostels, day centers, day hospitals, drop-in centers and other facilities could provide a network of care where they would similarly feel at home. These places offer warmth (physical and emotional), security, stimulation and responsiveness: somewhere where one can just 'be'. But these qualities are hard to quantify - and cost money.
The move now is towards discrete 'packages' of care, often on a sessional basis, which are more 'cost-effective' and financially calculable. The Community Care Bill 1993 stipulates that each chronically mentally ill patient shall have a 'care manager' who is responsible for his or her needs and who will arrange such packages of care as are appropriate. On the basis of sound Bowlbian principles, this might be thought to offer the opportunity for a patient to develop a primary attachment bond with a principal care-giver, and to get away from the impersonality and rigidity of institutions. But it may well illustrate the difficulty of translating psychological theories into policy decisions. The reality of the new arrangements is likely to be very far from the Bowlbian ideal. Each care worker will have a large case load of patients living in the community for whom they will be responsible. Staff turnover is likely to be high and the chance of staff burn-out great. Ripped away from the concrete care of a stable if inflexible institution to which they were attached, very damaged patients will be expected to develop an internal secure base which, given the nature of their illness and its antecedents, they are likely to find impossible. The care workers are likely to be working largely alone, unsupported and unsupervised and yet expected to deliver good outcomes. Their position will be not unlike that of the unsupported mothers whom the feminists accused Bowlby of idealising in their critique of maternal deprivation (see Chapter 3). The need for support for carers, and a recognition that psychologically damaged patients who have lost their attachments
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will need many years of connection to a stable and secure place before that experience can be hoped to be internalised enough for them to 'move on', has not been sufficiently recognised by policy makers in search of quick and easy solutions to the problems of mental illness and personal growth.
A similar conflict between the need for stable attachments and the complexity and commercial pressures of modern life affect acute psychiatric admission wards (Holmes 1993). Two examples illustrate the point. Hospital nurses work on a shift system, which means that a patient newly admitted to hospital may be looked after by an ever-changing group of carers, thereby reinforcing that patient's difficulties in attachment and sense of isolation. Second, the introduction of market forces into health care means that there is a huge pressure for rapid turnover of patients and to increase 'throughput' in psychiatric beds. However, this is inimical precisely to the needs of patients for the gradual formation of an attachment to a ward and to a group of carers, a process which takes much time and professional skill if the many tentative advances and retreats, and the small but significant gains which underlie difficulty and destructiveness, are to be understood. Kernberg (1975) calls these divergent pressures the 'concentric' (that is, familial) and 'non-concentric' (namely, administrative) vectors within a caring environment. It would be Utopian to wish for a system of care in which all non-concentric pressures were subservient to the needs of patients and workers for a secure base within which to work. Nevertheless, for a caring environment to be 'good enough', there has at least to be the opportunity to discuss, protest and mourn the unavoidable limitations of political and social reality, an area where the psychotherapist has, through consultation and conducting sensitivity groups, a vital contribution to make to the practice of general psychiatry. It is to these wider issues and to the social implications of Attachment Theory that, in the final chapter, we shall now turn.
Chapter 10
Attachment Theory and society
Man and woman power devoted to the production of material goods counts a plus in all our economic indices. Man and woman power devoted to the production of happy, healthy, and self-reliant children in their own homes does not count at all. We have created a topsy turvy world. . . . The society we live in is . . . in evolutionary terms . . . a very peculiar one. There is a great danger that we shall adopt mistaken norms. For, just as a society in which there is a chronic insufficiency of food may take a deplorably inadequate level of nutrition as its norm, so may a society in which parents of young children are left on their own with a chronic insufficiency of help take this state of affairs as its norm.
(Bowlby 1988a)
Running throughout Bowlby's life and work there is a strong moral and social vision. His credo might be summarised as follows, couched, as it so often was, in the language of preventive medicine. The emotional deprivation of children is a social ill, distorting and degrading the fabric of social life. It is society's responsibility and duty to remedy this ill by appropriate social medicine. This requires the recognition of the problem through the acceptance of the findings of psychological science; training cadres of child-care workers and psychotherapists who are sensitive to the emotional needs of children and their parents; helping people to find security in their lives through the fostering of close emotional bonds; encouragement of the expression of grief and disappointment when they are disrupted. Devaluation of the need for love and intimacy through the scorning of 'spoiling' and 'dependency' contribute to emotional deprivation. The celebration of mother-love and of our mutual
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dependency as a species should be encouraged. In these ways the vicious circles of deprivation can be broken, this generation's insecure young people no longer condemned to reproduce their own insecurities in the next.
These attitudes permeate almost every paragraph Bowlby wrote and informed his purposes in whatever sphere they were applied. In two articles written soon after the end of the war (Bowlby 1946b, 1947a) he made his social views even more explicit. In 'The therapeutic approach in sociology' he puts forward his uncompromising environmentalism:
whether a person grows up with a strong capacity to make good personal relations - to be good - or whether he grows up with a very indifferent capacity for this depends very greatly on something which has never traditionally been regarded as part of ethics - namely on what his relation to his mother was in early life.
(Bowlby 1947a)
He picks up Kurt Lewin's concept of the 'social field' and applies it to delinquency: good environments create good citizens, bad ones, bad. He contrasts three styles of social arrangements: democratic, authoritarian and laissez-faire. Only the democratic - one in which leaders and teachers listen and are responsive to the people - is effective:
Any organisation, industrial, commercial, national, religious or academic, organised on authoritarian lines must therefore be regarded as inimical to the promotion of good personal relations, of goodness. And that goes for our daily lives . . . in so far as we are authoritarian in our attitude towards others we are promoting bad personal relations and evil.
(Bowlby 1947a)
Poised in that statement can be felt the full weight of Bowlby's two contrary sets of experiences. On the one side are his 'town' mother with her overwhelming sense of 'rightness' inherited from 'Grampy', his remote and rather frightening father, the boarding schools, the Navy, the medical hierarchy, the narrow horizons of Psycho-Analytical Society, military authoritarianism; on the other, his intellectual curiosity, inner calm, independence and resilience, his 'country' mother with her love of nature, the 'invisible college'
202 Imlications
of Army psychiatrists, his personal optimism and that of the times. He continues:
the drive of the organism towards achieving good personal relations is just as real and persistent as its drive towards physical health. People don't get well because doctors say they ought to get well: they get well because the living organism has a powerful biological drive to throw off noxious influences.
(Bowlby 1947a)
In his celebration of democracy, Bowlby makes a link between the kind of responsiveness and attunement that good parents provide for their children, and the social arrangements which he saw as most likely to produce flourishing citizens. In 'Psychology and democracy' (1946b), with characteristic boldness and simplicity he tackles the central dilemma of political science: how to reconcile the need for social co-operation with the equally pressing but to some extent incompatible need for individual freedom. He compares the task of the political leader with that of the trusted parent who fosters collaboration among children by showing them that renouncing selfish individual pleasures will result in the ultimately greater enjoyment of shared play. Social co-operation depends on the combination of a population who, through positive childhood experiences, have learned to love and trust, with leaders who, through their democratic attitudes, are prepared to listen to the people, to show they are valued and respected.
All this may sound simplistically anodyne to our late-twentieth- century ears, attuned as we are to the ever-increasing toll of destruction and chaos man has wreaked upon himself and his environment. The Bowlbian ideal of a mother exclusively devoted to the care of her children is, in a contemporary perspective, both unrealistic and undesirable. The pattern of 'absent father - patriarchal society' (Leupnitz 1988) produces mothers who are stretched to their emotional and economic limits, barely able to provide any kind of secure base for their children. New family patterns, unimagined by Bowlby, are emerging, often with fathers who may be biologically unrelated to the children in their care, increasing the likelihood of insecurity or frank physical and sexual abuse. Bowlby's simple formulation of aggression as a response to the threat of loss seems to lack explanatory weight in the face of increasing social chaos. Yet the fundamental principles of Attachment Theory - that parents
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need security themselves if they are to provide it for their children, that the threat to security is a potent cause of rage and destruction - remain valid, despite changing conditions. Bowlby may have been mistaken and simplistic in thinking that his experience with disturbed children could be translated simply from the language of psychology to that of sociology, but the challenge thrown down at them by him at the start of this chapter remains.
The Freud (1929) of Civilization and its Discontents came late (Pedder 1992) but decisively to the view that destructiveness and aggression were inherent features of the human psyche:
I can no longer understand how we can have overlooked the ubiquity of non-erotic aggressivity and destructiveness and can have failed to give it its due place in our interpretation of life. . . . In consequence of this primary mutual hostility of human beings, civilized society is perpetually threatened with disintegration.
(Freud 1929)
In his early work (Durbin and Bowlby 1938), Bowlby accounts for aggression in ethological terms as arising from the need for territorial defence and (what amounts to the same thing) defence of breeding and feeding rights. Later, from the perspective of Attachment Theory, he seems to abandon the notion of primary aggressivity altogether, perhaps as part of his overall project to distance himself from the Kleinian approach (Bowlby 1973a). Instead, he sees aggression as springing from insecure attachment. Anxious attachment is a defence, a compromise between the need for security in a dangerous world and the inability of the parent to provide a secure base. Similarly, despair or rage are seen as part of the grief response, frustrated attempts to recover the lost object. In the Bowlbian perspective meaning is imperative: the world must be patterned into some meaningful shape at all costs; what little security there is must be husbanded, shielded from envious eyes; loss cannot be comprehended as total and arbitrary, but construed as recoverable, however much distortion of reality this requires. The avoidant child keeps his distance, warily watching the parent whom he both needs and fears. The ambivalent child clings helplessly to his unpredictable mother. Neither feels free to explore creatively. The disorganised child is defenceless, overwhelmed by stimulus which cannot be organised
204 Imlications
into any meaningful pattern. Here, where there may have been absolute privation of care in the pre-attachment phase (that is, before six months) may be found the germs of purposeless destruction and rage.
By analogy, societies can also be seen as dealing with problems of security in many defensive ways. Insularity, suspiciousness, splitting, inability to relate generously, vengeance, chaos, internecine struggles, intolerance, exhaustion, corruption - countless examples of these phenomena can be found in social and political life just as much as in individual psychology, and each has its 'meaning', ideologies that evade, justify, excuse. Since, according to Attachment Theory, adults have attachment needs no less pressing at times of stress than those of children, the same processes which lead to insecure attachment in infants can be seen operating at a societal level. Attachment Theory offers a mechanism that connects the political with the personal. As Marris puts it:
This is the . . . link between sociological and psychological understanding: the experience of attachment, which so profoundly influences the growth of personality, is itself both the product of a culture, and a determinant of how that culture will be reproduced in the next generation - not only the culture of attachment itself, but all our ideas of order, authority, security, and control.
(Marris 1991)
Attachment Theory shows how the minutiae of interpersonal experience become internalised as personality, or attachment style. Much remains to be understood about the precise ways in which handling in the parent- infant relationship influences future character, but there is little doubt that there is a connection between them. Facing outwards as well as in, Attachment Theory also suggests an articulatien between intrafamilial experience and social forces. In their personal relationships people face uncertainty or security, poverty or riches, loss or plenitude, violence or compassion, unpredictability or responsiveness, neglect or care. This will affect their capacity to care for their children, which in turn affects how secure or insecure those children will be when they become adults. The insecurity or otherwise of its citizens will affect the general cultural and economic conditions of society, and thus the cycle is complete as these factors have their impact on child care in the next generation.
Marris (1991) has used this model of cycles of security or insecurity as a metaphor for the increasing polarisation between
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the secure and the marginalised in modern societies (and this could be extended to international polarisation between rich and poor nations). On the basis of his work in inner cities, Marris argues that cycles of disadvantage, deriving from social factors which include poverty, poor housing, unemployment, cultural deprivation, educational disadvantage, bad health and diet, are experienced as an emptiness or evacuation of meaning, equivalent to that felt by a bereaved person whose meaning-structures are destroyed by loss. As he puts it:
the more likely our environment is to engender unintelligible, unexpected, and disruptive events, the less support we have, and the more our confidence in attachment has been undermined or distorted by the experiences of childhood, then the more likely it is that our vital organisations or meaning will be overwhelmed, or crippled in their development. Or to put this the other way about - a society that best protected its members from grief and depression would organise its relationships so that they were as stable, predictable, understandable, and careful of attachments as is humanly possible. And the qualities of behaviour that would need to inform such relationships - sensitivity, responsiveness, mutual understanding, consistency, ability to negotiate - are very much the same as those which create secure attachment. I believe such a familial conception of social order is attractive to most of us: our need to nurture and to be nurtured, to make attachment secure, to see the meaning of our lives confirmed by the meaning of society at large, all respond to it. Yet at the same time we have powerful impulses pulling us in the opposite direction, towards an unequal, unsupportive distribution of uncertainty.
(Marris 1991)
Where security is in short supply it is contested, whether in families (Byng-Hall 1991c) or society. For Freud, rivalry and ambivalence are inherent properties of the Oedipal situation and therefore of the human condition. For Bowlby, ambivalence is the result of maternal privation, not found with the 'ordinary devoted mother', who is adequately supported by her spouse, family and society. Nevertheless, suboptimal child rearing is widespread, and the ambivalently attached child clings ferociously to a mother whose attention might otherwise be diverted elsewhere - towards her other children, her partner or her own inner concerns. Between
206 Imlications
parents and children there is an inherent asymmetry. It is a parent's job to provide a secure base for children, but not vice versa. Bowlby repeatedly points to role reversal between parent and child as one of the commoner manifestations of anxious attachment, one that inevitably inhibits the exploratory capacities of the child. Sexual and physical abuse of children are extreme examples of exploitation of this asymmetry. The exploitation of women by men is another example, in which a little boy's helplessness in relation to his mother and the fear that engenders when there is no feeling of a secure base is reversed (and avenged) when he grows up and can use his physical strength to dominate a woman.
So too, Marris argues, in an unequal society, there is competition for security. Security becomes a commodity to which the rich cling, pushing insecurity to the margins of society, which then acts as a buffer zone between themselves and the vagaries of international finance and world trade which determine ultimately their economic fate (Marris 1991). And yet if we take seriously the Bowlbian vision of an essential interdependence of attachments, then this too will be seen as a defensive distortion, a variant of anxious attachment that perverts the notion of a secure base and inhibits the creative development of society. As Rustin (1991) puts it:
The idea of development and fulfilment of the person through relationship, both internal and external . . . is a distinctively social one. . . . It goes against the widespread idea that society will be better when and if we merely give more opportunity and goods to the individual. It is the quality of relationships that individuals can generally have with others around them . . . which make for contentment and creativity, not merely gratifications of various kinds. The most beautiful house with a swimming pool is obtained at serious psychic price when there has to be an armed man at the gate to keep out intruders. Serious damage must also be done to the quality of experience of 'liberty' when its defence depends on threats to inflict total destruction.
(Rustin 1991)
We are living in an era in which much that we have taken for granted is breaking down. All that is solid melts into air. It is the
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time of the breaking of nations. Alongside the sense of freedom, the celebration of ethnic and cultural pride and a recognition of the need to mourn past traumata, there is an increase in destructive nationalism and tribal violence. Increasingly polluted by the products of the scramble for security, the Earth itself - Mother Earth - is no longer a safe haven on which we can depend to detoxify our waste and provide a base for new growth (Lovelock 1979).
For Freud, a deep awareness of natural beauty - the oceanic feeling - was an idealisation, a projection of a pure pleasure ego uncontaminated by pain, separation and rage. He was always uncertain about the boundaries between normality and neurosis, and particularly about the distinction between aesthetic experience and pathological states (Rycroft 1985). For Freud, the basic goal of life was the search for happiness based on physical satisfaction - he saw this as inevitably doomed to disappointment. Bowlby's emphasis on security provides a more realisable aim. His vision of the harmonious reciprocity of the responsive mother and her infant offers a metaphor for a balanced relationship between man and his environment that is healthy and not based on splitting and idealisation. A secure child can cope with temporary separation and sub-optimal conditions by healthy protest and non- defensive grief. If a secure base can be achieved, exploration of possible ways out of our political and ecological crisis is possible. In a prescient statement about the dangers of nuclear weapons, Bowlby wrote:
All our previous experience points inescapably to the conclusion that neither moral exhortation nor fear of punishment will succeed in controlling the use of this weapon. Persons bent on suicide and nations bent on war, even suicidal war, are deterred by neither. The hope for the future lies in a far more profound understanding of the nature of the emotional forces involved and the development of scientific social techniques for modifying them.
(Bowlby 1947a)
A small but significant example of the kind of 'understanding' and 'technique' which Bowlby advocates can be found in Middleton's (1991) description of Sherif's Boys Camp Experiment, in which thirty teenagers were taken for a month's camping in the wilderness by a group of psychologists working as camp attendants. The boys were divided into two groups who ate, slept
208 Imlications
and played separately. Rather like in Golding's Lord of the Flies, two distinct cultures of behaviour, slang and group identity developed. When members of the two groups met, scuffles broke out. The experimenters then arranged for the food lorry to break down some miles from the camp, which meant that the two groups had to collaborate in bringing essential supplies to their base. The results were as follows:
After some initial prevarication and quarrelling, the two groups coalesced into a larger and sufficiently coherent and cohesive group for this essential task. As this happened the stereotyping, antipathy and intense competition between the groups also dissolved as they worked together in pursuit of their mutual interest.
(Middleton 1991)
The discovery of a superordinate goal enabled the two groups to collaborate. The leadership provided them with a secure base from which they could explore ways collectively to solve their common problem.
The ecological vicious circle the world faces is one in which, confronted with a threat to the environment and therefore to the fundaments of security, nations, and where nations break down tribal groups, fight ever more desperately to extract what resources they can from it. This is rather like the children of abusive parents who, in their fear, cling to the very object that causes their distress. The common objective of global security needs to be made real if this vicious cycle is to be put into reverse, just as the skilled therapist will see that both abusive parent and child are in search of a safety that neither can provide for the other, and, as far as possible will try to remedy this herself, or mobilise others who can do so. If we feel locally secure, with a home base which we know will be respected and protected, there will be less need to project of insecurity onto others. Secure as inhabitants of our locality, we become free to explore our citizenship of the world. As the Sicilian writer Gesualdo Bufalino puts it:
Now I finally know this simple truth: that it is not only my right but my duty to declare myself a citizen of Everywhere as well as of a hamlet tucked away in the Far South between the Iblei Mountains and the sea; that it is my right and duty to
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allow a place in my spirit for both the majestic music of the universe and that of the jet gushing from a fountain in the middle of a little village square, on the far southern bastions of the West.
(Bufalino 1992)
For Freud, our biological heritage was a shackle, creating an inevitable conflict between our selfish and drive-driven nature and the repressions of culture. In his vision of alienation we are prisoners of our paleocortex. Bowlby's more benign picture (the contrast between the two men is partly a reflection of the differing cultural heritage - one a European Jew, the other a member of the English upper middle classes) implies a need to re-establish connections with our evolutionary past. Humans survived and evolved on the basis of bonding and mutual support. Competition and the neglect of these basic ties threaten to destroy us. Nomads and agriculturalists, explorers and stay-at-homes, male and female, men and women of contemplation and of action, pursuers of the inner and outer worlds, psychologists and politicians, yogis and commissars - we all share a need for common security. We are all attached inescapably to an Earth in whose 'environment of evolutionary adaptedness' we originated, and which we now threaten with destruction as we are caught in the vortex of a negative spiral of insecurity.
Chapter 11 Epilogue
Sow a thought and you may reap an act; sow an act and you reap a habit; sow a habit and you reap a personality; sow a personality and you reap a destiny.
(Buddhist proverb; Jones 1985)
We ended the previous chapter with a rhetorical flourish which John Bowlby, however much he approved of its sentiment, would probably have considered overstated, insufficiently underpinned by close-grained scientific fact. This is perhaps excusable as we near the end of this book. As suggested in the Introduction, the biographer is both patient and therapist to his subject. At the end of therapy a patient will often yearn for a 'verdict' and ask, implicitly or explicitly, 'Well, what do you really think of me, what is your opinion? ' But the therapist has already done his work, said all he can say in the course of the therapy. What more can he add? In the CAT model of brief therapy (Ryle 1990), this dilemma is met by the introduction of the 'farewell letter' which the therapist presents to the patient in the penultimate session. This attempts to summarise the patient's strengths and weaknesses, the progress that has been made in therapy, and some predictions for the future. This heterodoxy is not, it should be noted, the exclusive preserve of eclectic therapists like Ryle: Clifford Scott records that the most moving moment of his analysis with Melanie Klein in the 1930s occurred when she read out to him a long interpretation she had written over the weekend. 'This was proof that I was in her as well as she was in me' (Grosskurth 1986).
Here, then, presumptuously perhaps (but is not any therapy - or biography - an act of presumption? ), is an attempt at a farewell
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letter for John Bowlby, with which the reader, like the patient in CAT, is also invited to disagree, add to, reject, treasure or do what they will.
Dear John,
We are nearing the end of our time together. I would like to say how much I have enjoyed working with you and how much I have learned from our collaboration. I hope you feel that justice has been done to your work and that the boundaries of privacy which, from an early age, you placed around your feelings have been handled with sensitivity.
Like many outstanding psychologists you come from a background that was not entirely easy, although it offered you many opportunities. Perhaps one of them was the fact that your family was so delightfully unpsychological. As Gwen Raverat, granddaughter of your hero, Darwin, said of her father and his brothers (all of whom were distinguished scientists):
'They had [no] idea of the complications of psychology. They found it difficult to conceive of a mixture of motives; or of a man who says one thing and means another; or of a person who is sometimes honest and sometimes dishonest; because they were so completely single-hearted themselves.
(Raverat 1952)
Perhaps it was because you were so familiar with those to whom psychology is a mystery that you were such a good populariser. Some of your life's work at least can be understood in terms of the problems which presented themselves to you as a small child. You were the middle boy between a very bright and vigorous older brother and a younger brother who was considered backward. Your compassion for the weak and your undoubted ambition and competitiveness bear the impress of the mould you shared with them. Your father was a distant, awe-inspiring figure, whose voice you are said to have inherited and in whose footsteps you followed into the medical profession.