On one such occasion, in Rome, I met with two cognitive therapists, Gio- vanni Liotti and
Vittorio
Guidano, and was sur- prised and delighted to find how much we had in common.
A-Secure-Base-Bowlby-Johnf
?
?
To obtain data each child was observed for four periods each of 30 minutes on four different days spread over three weeks.
Observers were instruc- ted to record all socially relevant behaviour, in- cluding such small movements as head-turning or stepping backwards.
In analysing the data, the children's social be- haviour was divided into four categories: ap- proach, avoidance, approach-avoid, and aggres- sion. It was also divided according to whom the behaviour was directed--another child or a care- giver. Another distinction was between behaviour initiated by the observed child and behaviour which occurred in response to a friendly ap- proach by another child or adult. Results are ex- pressed in terms of the mean number of incidents of a particular type of behaviour of the children in each group or else of the number of children in each group who showed that type of behaviour.
As regards occasions when a child initiated so- cial contact, either with another child or a care- giver, no appreciable differences were observed between the children in each group. By contrast, very striking differences were observed in the ways the children responded to a friendly ap- proach from the other. Characteristic responses
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? ? ? of the abused children were either to take straight avoiding action or else to show both approach and avoidance behaviour, either in quick succes- sion or in some combination of the two. Examples are: 'she creeps towards him but sud- denly veers away', and 'she crawls towards the caregiver but with head averted'. Thus, when the overtures come from a caregiver, the abused tod- dlers were three times more likely than the con- trols to take avoiding action; whilst seven of them, compared to only one, showed the curious combination of alternation of approach and avoidance. When the overtures came from other children, the differences were even more marked. For example, whereas none of the controls showed approach-avoidance, all ten of the abused toddlers did so.
Aggressive behaviour was fairly common in both groups of toddlers, though, as predicted, it was significantly more so in the abused group. Not only did the abused toddlers assault other children twice as often as the controls, but five of them assaulted or threatened to assault an adult, behaviour seen in none of the controls. In addi- tion the abused toddlers were notable for a par- ticularly disagreeable type of aggression, termed
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? ? ? 'harassment' (Manning, Heron, and Marshall, 1978). This consists of malicious behaviour which appears to have the sole intent of making the vic- tim show distress. Almost always it occurs sud- denly without any evident cause and so contrasts with hostility which occurs in reaction to a pro- vocation. Such attacks, coming unpredictably out of the blue, are frightening and invite retaliation. Clinical studies, referred to later, report them to be directed especially towards an adult to whom the child is becoming attached.
In view of the behaviour so far described it is not surprising to find that abused toddlers are singularly unsympathetic to age-mates in dis- tress. The studies of Zahn-Waxler and Radke- Yarrow have shown that infants and pre-school children who have affectionate and caring par- ents commonly express concern when another child is distressed and often make moves to com- fort him or her (Zahn-Waxler, Radke-Yarrow, and King, 1979). This type of behaviour was also seen at least once in five of the control children in the Main and George study; but on no occasion did any of the abused toddlers show the slightest hint of it. Instead, and unlike the controls, they reacted with some combination of fear, distress,
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? ? ? or anger; and three behaved hostilely to the cry- ing child. For example, one small boy of 2 years 8 months slapped a little girl who was crying, ex- claiming repeatedly 'Cut it out, cut it out'. He pro- ceeded then to pat her back and next to hiss at her with bared teeth; before anyone could inter- vene, his patting had turned to beating.
My reasons for giving so much attention to these observations of young children will, I am sure, be apparent. They show with unmistakable clarity how early in life certain characteristic pat- terns of social behaviour--some hopeful for the future, others ominous--become established. They leave no doubts either about what types of family experience influence development in one direction or another. Again and again we see de- tails in the behaviour of a toddler, or in what he says, that are plainly straight replicas of how that toddler has himself been treated. Indeed the tendency to treat others in the same way that we ourselves have been treated is deep in human nature; and at no time is it more evident than in the earliest years. All parents please note!
Firm evidence of how these children develop must await an appropriately designed longitudin- al study. There is evidence that, if conditions of
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? ? ? care improve, some recover sufficiently to pass for normal (Lynch and Roberts, 1982); others do not. Some have suffered serious brain damage and become diagnosed as mentally handicapped (e. g. Martin and Rodeheffer, 1980). For many others adverse conditions of care continue. Fur- thermore, once a child has developed the types of disagreeable behaviour described, it is not easy for an adult, whether parent, foster-parent, or professional, to give him the continuous affec- tionate care he needs, whilst treating such chil- dren by psychotherapy is extremely taxing. The sudden unprovoked attacks, which in older chil- dren can easily be damaging, are especially hard to take.
Some of these emotionally disturbed children, we know, reach psychiatric clinics where the ori- gin of their condition, I suspect, more often than not goes unrecognized. Amongst those who have treated these children, some of them psychotic, and who have traced the source of their troubles are Stroh (1974), Bloch (1978), and Hopkins (1984). Each notes the extreme degree of ambi- valence to be expected: one moment the child is hugging the therapist, the next he is kicking her. During adolescence and early adult life, some,
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? ? ? mostly male, become diagnosed as aggressive psychopaths and/or violent delinquents (e. g. Far- rington, 1978). Others, especially females per- haps, are found to be suffering from multiple per- sonality (Bliss, 1980). Once psychiatrists become aware of the profound and far-reaching effects of childhood abuse and rejection, and the extent to which relevant information is suppressed and falsified by parents and overlooked by clinicians, many more cases are sure to be identified.
A significant proportion of rejected and abused children grow up to perpetuate the cycle of family violence by continuing to respond in social situ- ations with the very same patterns of behaviour that they had developed during early childhood.
A type of response found to be characteristic of many abusive parents, and of a kind which we have already seen to be characteristic of abused toddlers, is reported, for example, by Frodi and Lamb (1980). In a laboratory study, in which videotapes of crying infants were shown, abusive mothers were found to respond to a crying infant with less sympathy than did a group of non-abus- ive mothers and also with more annoyance and anger. Furthermore these same adverse re- sponses were shown by the abusive mothers even
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? ? ? when they were shown video tapes of smiling in- fants, which suggested they disliked any form of interaction with an infant.
Let us turn now, rather belatedly, to the beha- viour of men who ill-treat girlfriend or wife.
Two of my social work colleagues at the Tavis- tock, Janet Mattinson and Ian Sinclair (1979), de- scribe a man, Mr S, who was apt, inexplicably and unpredictably, to attack his wife. At the time when he asked for an interview his wife had re- cently left him; she had just had their first baby. Although hesitant at first, Mr S fairly soon began telling the social worker how much he feared his own violence. He loved his wife, he said, and felt his violent behaviour to be quite unwarranted, akin to madness. Subsequently, speaking of his childhood, he described how he had been a mem- ber of a large working-class family in which he had received little more than harsh and unsym- pathetic treatment. His parents, he said, were constantly engaged in violent quarrels. Exploring in later interviews how he had felt as a child, struggling for the love he never got, he was struck by the suggestion that it was probably a mixture of anger and despair. This made sense to him, he said: it relieved him of his fear that his violence
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? ? ? was inexplicable. The outbreaks that had led to his wife's departure, it was noted, had occurred soon after the baby's birth. Since we know from other studies, e. g. Marsden and Owens (1975), that intense jealousy of a wife's attention to the children is a common precipitant of a husband's violence, Mr S's outbursts were in all likelihood triggered by the baby's arrival.
Sudden and on the surface inexplicable out- bursts of violence, similar to those of Mr S, are found to be characteristic of a significant propor- tion of men who batter wives; for example, they occurred in five out of the 19 cases investigated by Marsden and Owens (1975). The hypothesis that most of such men are ill-treated and battered children now grown up is supported by several findings. In one study (Gayford, 1975) informa- tion from the wives was that 51 out of a 100 viol- ent men had themselves been battered as chil- dren. Moreover 33 of the 100 had already been convicted of other violent offences and, as already noted, studies show that most violent offenders come from homes in which they were subjected to cruel and brutal treatment (Farrington, 1978).
Finally we find that many of the wives who are battered have come from disturbed and rejecting
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? ? ? homes, in which a significant minority were themselves battered as children (Gayford, 1975). These experiences had led them to leave home in their teens, to link up with almost the first man they met, all too often from a similar background, and quickly to become pregnant. For the unpre- pared and anxiously attached girl, having to care for a baby creates a thousand problems; moreover her attention to the baby provokes in- tense jealousy in her partner. These are some of the processes by which an inter-generational cycle of violence becomes perpetuated.
Let us return now to the study of Mattinson and Sinclair (1979) who describe patterns of in- teraction that they found were common in certain families.
The interviews with Mr S were part of a study undertaken in order to find out more of what is happening in the kind of intensely disturbed fam- ily that creates endless problems for the medical and social services and which is known to be ex- traordinarily difficult to help. In these families, it seemed, violence or threats of violence occurred almost daily. Time and again the couple had sep- arated only to come together again after a few days or weeks. Sometimes, after hard words from
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? ? ? his wife, a husband would go off on his own, only to hive back again a short time later. Or a wife, physically assaulted by her husband, would leave with the children but return within days to the very same situation. What seemed so extraordin- ary to the workers was the length of time some of these marriages had lasted. One question they asked themselves therefore was what was keeping the partners together.
What they found was that, whilst the violence of a husband and the angry threatening remarks of a wife seemed to dominate the scene, each partner was deeply, if anxiously, attached to the other and had developed a strategy designed to control the other and to keep him or her from de- parting. Various techniques were in use, mainly coercive, and many of them of a kind that to an outsider would appear not only extreme but counterproductive. For example, threats to desert or to commit suicide were common, and suicidal gestures not infrequent. These were usually ef- fective in the short term by ensuring the partner's concerned attention, though they also aroused his or her guilt and anger. Most of the suicide at- tempts, it was found, were reactions to specific
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? ? ? events, particularly desertions either actual or threatened.
A coercive technique, used especially by the men, was to 'imprison' the wife by such means as locking her in the house, or padlocking her clothes, or else retaining all the money and doing the shopping so as to prevent her from seeing anyone else. The intensely ambivalent attach- ment of one man who adopted this technique was such that he not only locked his wife in but he also locked her out. He would throw her out of the house telling her never to return but, after she had got to the street, would run after her and pull her back to their flat.
A third coercive technique was battering. As one man put it, in his family asking for something was always done with fists. No wife enjoyed this treatment, but some got a wry satisfaction from it. For example, one woman, when explaining why she did not wish for a separation, announced with a note of triumph in her voice that her hus- band had threatened he would come to 'get her' if she moved out. He needed her too, she insisted. In most of these marriages, it was found, each party was apt to stress how much the other needed them, whilst disclaiming their own need
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? ? ? for the partner. By need, of course, they meant what I am calling their desire for a caregiving fig- ure. What they dreaded most was loneliness.
PREVENTIVE MEASURES
This ends my description of the problems met with in violent families and the theoretical per- spective in which I believe it useful to approach them. What actions then are called for?
Much skilled and devoted work has gone into helping families in which abuse has already oc- curred, and much thought given to problems of management (Helfer and Kempe, 1976; Lynch and Roberts, 1982). Since every study has shown how very difficult and time-consuming all such work is, we ask about prospects for prevention. Here lies hope. In what follows I describe a type of service which has been pioneered in the United Kingdom and which is now spreading steadily with encouragement from government. No doubt similar services are to be found in various parts of the United States also, but naturally I know less about them.
The service pattern which is so promising, at least for some families, is one known as Home- Start (which was begun in Leicester) (Harrison,
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? ? ? 1981). 6 It is an independently organized home- visiting scheme which offers support, friendship, and practical assistance to young families experi- encing difficulties. It is staffed by volunteers who work in close liaison with the related statutory services and who also receive support and guid- ance from a professional. All visits are by invita- tion of the family and on their terms. There are no contracts and no time limits.
Each volunteer is a mother who undertakes to make regular visits to one or, at most, two famil- ies with the aim of establishing a relationship in which time and understanding can be shared. Every effort is made to encourage the parents' strengths and to reassure them that difficulties in caring for children are not unusual, and also that it is possible for family life to be enjoyable. New volunteers, who are mainly between the ages of 30 and 45, attend a preparatory course, one day a week for ten weeks, and receive regular ongoing training afterwards.
There are many advantages in the visitors be- ing volunteers. First a volunteer has time: in practice it was found in the pioneer scheme that the average time each volunteer was spending with her family in its own home was six hours a
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? ? ? week. Secondly she meets the mother on a level of equality and feels free to contribute to house- hold activities in any way that seems appropriate. Thirdly she can compare notes and talk about ex- periences with her own children. Fourthly, and very important, she can sometimes make herself available to be contacted during an evening or at a weekend.
The families visited are, of course, ones in which difficulties are either already present or appear imminent. Since the service is not aimed specifically at abusing families, a family particip- ating need not feel labelled in any way. Neverthe- less the service deals with a fair number of famil- ies who have one or more children on a register of children at risk of abuse. In the first eight years of the pioneer scheme no less than a quarter of the families visited were in that category.
Often visiting is started whilst a mother is still pregnant. Most of those visited are young, im- pulsive, and dreadfully isolated and have never experienced affection, care, or security. In such cases the principal role of the volunteer is to mother the mother and so, by example, to en- courage her to mother her own child. She will also talk and play with the children, again
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? ? ? providing the mother with an example she has never had. Perhaps later, once confidence has grown, the volunteer may assist by helping the mother acquire basic household skills she has never learned. The key to the relationship is that the volunteer is herself a mother who knows all the problems from the inside.
There are many cases which are recognized to be unsuited for inclusion in a service of this sort. 7 For those suitable the degree of success reported is most encouraging, as shown by an evaluation of the first four years' work of the pioneer service, carried out by an independent researcher whose monograph (van der Eyken, 1982) gives a full ac- count of the project. Taking a random sample of one in five of the 288 families visited, he asked those concerned how they assessed the outcome at the end of the volunteer's visiting, using a three-point scale: no change, some change, con- siderable change. The results showed that the vo- lunteers were the most pessimistic, rating only half the families as showing considerable change and one in ten as failures. The social workers who had referred cases were more hopeful, rating rather more than half as showing considerable change and the remainder as showing at least
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? ? ? some. Those most enthusiastic for the work were the health visitors (public health nurses) and the families themselves. Of the 58 families who as- sessed themselves, 47 (85 per cent) claimed a considerable change had occurred, six claimed some change and only two believed there had been none.
In a field that is both deeply troubling and no- toriously difficult these findings give hope.
1 In a study by Baldwin (1977) of 38 children who had been physically abused to an exceptionally severe degree, two-fifths of the parents had suffered physical abuse as children and more than half severe or pro- longed mental abuse. Baldwin calls attention to the marked tendency of many of these parents, when inter- viewed, to make broad generalizations about their child-hood in which an idealized picture is presented, a picture that stands in stark contrast to the grim epis- odes described when detailed questions are asked. In this field inexperienced clinicians and interviewers are likely to be gravely misled.
2 DeLozier's study has now been repeated by Mitchell (in preparation) on samples of Mexican-American mothers with closely similar results.
3 Because it is less ambiguous, I find the ethologist's term 'redirection' preferable to its clinical equivalent 'displacement'. The redirection of hostile behaviour
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? ? ? away from a more dominant animal is well known in other species.
4 There is now good evidence that, given sensitive mothering, difficult infants develop favourably, with only few exceptions (Sameroff and Chandler, 1975) and, conversely, that a potentially easy baby is likely to develop unfavourably if given insensitive care (Sroufe, 1983).
5 I am indebted for this point to Pat Crittenden (per- sonal communication) who has observed such appar- ently placatory behaviour in young abused children, some less than two years old. Similar behaviour has been observed also in young children whose mothers are seriously depressed (Pound, 1982).
6 Another initiative, serving a severely deprived area in inner London and known as Newpin, is also promising (Pound and Mills, 1985).
7 Harrison (1981) lists the following: where a parent is known to be chronically ill mentally, is suffering from a serious degenerative illness, is a recidivist, or is intent on the children being admitted to care. Also excluded are families in which the children are at risk of abuse by a mother's cohabitee.
6
ON KNOWING WHAT YOU ARE NOT SUPPOSED TO KNOW AND FEELING WHAT YOU ARE NOT SUPPOSED TO FEEL
Early in 1979 I was invited to contribute to a special number of the Canadian Journal of Psy- chiatry to honour Emeritus Professor Eric Wit- tkower who had held a chair of psychiatry at McGill University in Montreal from 1952 to 1964 and was then celebrating his eightieth birthday. This I was very glad to do. The resulting paper, with the above title, also formed the basis of lec- tures that I gave on various occasions during subsequent years.
On one such occasion, in Rome, I met with two cognitive therapists, Gio- vanni Liotti and Vittorio Guidano, and was sur- prised and delighted to find how much we had in common. One consequence of our meeting was an invitation to contribute to a volume on
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? ? ? Cognition and Psychotherapy being edited by Mi- chael Mahoney and Arthur Freeman. This provided an opportunity to expand the original brief paper and led to the version that follows.
The evidence that adverse experiences with par- ents during childhood, such as those described in the previous lecture, play a large part in causing cognitive disturbance is now substantial. For ex- ample, at least some cases in which perceptions and attributions are distorted and some states of amnesia, both minor and major, including cases of multiple personality, can be shown with con- siderable confidence to be the outcome of such experiences. Yet systematic research into these causal sequences is still scarce, and it is clearly a field calling urgently for a major research effort. Why then has it been so woefully neglected?
One adverse influence, referred to in the pre- ceding lecture, is the strong tradition within the psychoanalytic school of thought of focusing at- tention on fantasy and away from the real-life ex- periences a person may have had during child- hood. Another is the undoubted difficulty of do- ing systematic research in the field. For example, those engaged in seeing only adult patients are
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? ? ? usually ill-placed to investigate events alleged to have occurred many years earlier. Those whose childhoods have been spent amongst reasonably stable families and who, like all too many psychi- atrists and psychotherapists, are ignorant of the recent family and child development literature have no norms against which to match their pa- tients' stories. Above all clinicians are often faced with a blanket of silence, from patient and family alike, which neither their training nor their ex- perience has qualified them to penetrate. It is little wonder therefore that the likelihood that many cases of psychiatric disorder, both mild and grave, have had their origins in adverse events of childhood has been discounted or else completely ignored--not only by general psychiatrists but by psychotherapists as well. Even the fact that some children are physically or sexually assaulted by their own parents, often repeatedly and over long periods, has been missing from discussions of casual factors in psychiatry.
At long last the scene is changing. First, know- ledge of parent-child interactions in general, in- cluding a wide range of potentially pathogenic re- lationships and events, is increasing in both qual- ity and quantity as systematic research is applied.
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? ? ? Secondly, the psychological consequences for the children exposed to these relationships and events are becoming much better understood and documented. As a result there are now many oc- casions when a clinician is on reasonably firm ground in drawing aetiological conclusions. This is so especially when (a) his patient presents problems and symptoms which resemble the known consequences of certain types of experi- ence and (b) when in the course of skilled history-taking, or perhaps much later during therapy, he is told of experiences of these same types. In reaching his conclusion the reasoning a psychiatrist uses differs in no way from that of a physician who, having diagnosed a patient as suf- fering from mitral stenosis, proceeds unhesitat- ingly to attribute the condition to an attack of rheumatic fever suffered by the patient many years earlier.
When considering childhood antecedents of cog- nitive disorders a good place to start is with amnesia.
In one of his classical papers on analytic tech- nique Freud (1914) made an important generaliz- ation the truth of which probably every psycho- therapist would endorse:
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? ? ? Forgetting impressions, scenes or experiences nearly always reduces itself to shutting them off. When the patient talks about these 'forgotten' things he seldom fails to add: 'As a matter of fact I've always known it; only I've never thought of it. ' (1914, 148)
Such observations call for explanations of at least three kinds. First, are there special features that characterize the impressions, scenes, and experi- ences that tend to become shut off? Secondly, how do we best conceive of the processes by which memories become shut off and apparently forgotten? Thirdly, what are the causal condi- tions, internal and external to the personality, that activate the shutting-off process?
The scenes and experiences that tend to be- come shut off, though often continuing to be ex- tremely influential in affecting thought, feeling, and behaviour, fall into at least three distinct cat- egories: (a) those that parents wish their children not to know about; (b) those in which parents have treated children in ways the children find too unbearable to think about; (c) those in which children have done, or perhaps thought, things about which they feel unbearably guilty or ashamed.
Since a great deal of attention has for long been given to the third category, here I discuss only the first two. We start with the first.
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? ? ? Children not infrequently observe scenes that parents would prefer they did not observe; they form impressions that parents would prefer they did not form; and they have experiences that par- ents would like to believe they have not had. Evidence shows that many of these children, aware of how their parents feel, proceed then to conform to their parents' wishes by excluding from further processing such information as they already have; and that, having done so, they cease consciously to be aware that they have ever ob- served such scenes, formed such impressions, or had such experiences. Here, I believe, is a source of cognitive disturbance as common as it is neglected.
Yet evidence that parents sometimes press their children to shut off from further, conscious processing information the children already have about events that the parents wish they had never observed comes from several sources. Perhaps the most vivid concerns the efforts made by a surviving parent to obliterate his or her child's knowledge of the (other) parent's suicide.
Cain and Fast (1972) report findings from their study of a series of 14 children, aged between 4 and 14, all of whom had lost a parent by suicide
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? ? ? and all of whom had become psychiatrically dis- turbed, many of them severely so. In reviewing their data the authors were struck by the very large roles played in the children's symptomato- logy by their having been exposed to pathogenic situations of two types, namely situations in which intense guilt is likely to be engendered (not discussed here) and situations in which commu- nications between parent and child are gravely distorted.
About one quarter of the children studied had personally witnessed some aspect of the parent's death and had subsequently been subjected to pressure from the surviving parent to believe that they were mistaken in what they had seen or heard, and that the death had not been due to suicide but to some illness or accident. 'A boy who watched his father kill himself with a shot- gun . . . was told later that night by his mother that his father died of a heart attack; a girl who dis- covered her father's body hanging in a closet was told he had died in a car accident; and two broth- ers who had found their mother with her wrists slit were told she had drowned while swimming' (Cain and Fast, 1972, 102). When a child de- scribed what he had seen, the surviving parent
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? ? ? had sought to discredit it either by ridicule or by insisting that he was confused by what he had seen on television or by some bad dream he had had. Such confusion was sometimes compoun- ded, moreover, by the child hearing several dif- ferent stories about the death from different people or even from his surviving parent.
Many of the children's psychological problems seemed directly traceable to their having been ex- posed to situations of these kinds. Their prob- lems included chronic distrust of other people, inhibition of their curiosity, distrust of their own senses, and a tendency to find everything unreal.
Rosen (1955) describes an adult patient, a man of 27, who developed acute symptoms after his fiance? e had jilted him, because she had found him too moody and unpredictable. The patient began to feel that the world about him and also his own being were fragmenting, and that everything was unreal. He became depressed and suicidal; and he experienced a variety of peculiar bodily sensations, which included a feeling that he was choking. His thoughts, he said, felt like cotton-wool. Sometime during the second year of therapy the analyst, struck by a series of associ- ations the patient gave, and bearing in mind the
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? ? ? life history, ventured a reconstruction, namely that the patient's mother may have made a sui- cidal attempt during the patient's childhood that he (the patient) had witnessed. No sooner had this suggestion been offered than the patient be- came racked with convulsive sobbing. The ses- sion proved a turning point. Subsequently the pa- tient described how it had seemed to him that, when the analyst made his suggestion, it was not so much that he was restoring a memory as giv- ing him (the patient) permission to talk about something he had always in some way known about.
The authenticity of the memory was vouched for by the patient's father who admitted, when pressed, that the patient's mother had made sev- eral suicide attempts during the patient's child- hood. The one the patient had witnessed oc- curred some time during his third year. His nurse had heard sounds in the bathroom and had ar- rived in time to prevent his mother from strangling herself. It was not clear just how much the little boy had seen. But whenever later he had mentioned the event both father and nurse had disconfirmed his memories by alleging that it was something he must have imagined or had simply
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? ? ? been a bad dream. The father now claimed that he had felt it would have been harmful to his son to have remembered such an incident; but he also admitted that his attitude was dictated partly by his wish that the incident be kept secret from friends and neighbours. A year or so later the nurse had been discharged because the mother had found her presence too painful a reminder of the incident.
During one of the sessions before the vital re- construction was offered the patient had recalled the discharge of his beloved nurse as an event which he had always felt had been in some way his fault. Among many associations to it were re- current references to his having been, as a child, witness to something that had changed his life, though he did not know what. He also had the notion that his nurse had been the one witness on his behalf. Thus, although the memory had been shut away from conscious processing, it contin- ued to influence both what he thought and how he felt.
Elsewhere (Bowlby, 1973) I have drawn atten- tion to the far from negligible incidence of suicid- al attempts made by parents, and perhaps the even higher incidence of their threatening
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? ? ? suicide, and have remarked how little attention has been given to either attempts or threats in the psychiatric and psychotherapeutic literature. Per- haps there are many more cases similar to Rosen's than has yet been realized.
Among the many other situations that parents may wish a child had not observed, and that they may press him to suppose he never did, are those concerning their sexual activities. An example of this was told to me by a speech therapist who was trying to help an extremely disturbed little girl who hardly spoke at all. That she was well able to speak was, however, shown on certain dramatic occasions. She would sit a teddybear on a chair in a corner, then go over and, shaking her finger at him, would scold him in tones of extreme sever- ity: 'You're naughty--naughty Teddy--you didn't see that--you didn't see that, I tell you! ' This she repeated again and again with increasing vehe- mence. What the scenes were that Teddy was be- ing instructed he never saw was not difficult to guess: the little girl's mother was a teenage prostitute.
Clearly the purpose of these pressures by par- ents is to ensure that their children develop and maintain a wholly favourable picture of them. In
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? ? ? the examples thus far given the form of pressure exerted is crude. More frequent perhaps and just as damaging are instances in which the pressures are more subtle.
During the past two decades renewed attention has been paid to incest, both to its unrecognized high incidence and to its pathogenic effects on children. Much the commonest forms are between father and daughter or step-father and step-daughter. Among the various problems and symptoms in the children and adolescents con- cerned that are believed to be due to these experi- ences, the commonest include withdrawal from all intimate relationships, sleep disturbances, and suicidal intentions (Meiselman, 1978; Adams- Tucker, 1982). An account of conditions likely to cause cognitive disturbance was given me by a colleague, Brendan MacCarthy, but never pub- lished. He suspected that disturbance is espe- cially likely when the children are prepubertal. In what follows I draw on his conclusions.
When a sexual liaison develops between a fath- er and his adolescent daughter, MacCarthy re- ports, the liaison is usually acknowledged by the father during the course of daily life by such means as secret glances, secret touching, and
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? ? ? innuendoes. In the case of a younger child, however, a father is likely to make no such ac- knowledgements. Instead he behaves during the day as though the nightly episodes never oc- curred; and this total failure to acknowledge them is commonly maintained even long after the daughter has reached adolescence.
MacCarthy describes the case of a married wo- man, Mrs A, whom he treated for depression, re- liance on tranquillizers, and alcohol. She men- tioned the ten years of sexual interference she had suffered from her adoptive father only after she had been in therapy for four months. It had begun when she was 5 or 6, soon after her adopt- ive mother had died, and had continued until she was 16, when she had fled. Among her many problems were frigidity and finding intercourse disgusting, and a sense of inner blackness, of 'a black stain'. Her problems had become exacer- bated when her own daughter was 4 years old. Whenever the daughter became affectionate to her father and sat near him, Mrs A felt agitated, protective, and jealous; on these occasions she could never leave them alone together. During therapy she was obsequious and terrified, and in- tensely vigilant of the analyst's every move.
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? ? ? In regard to the incestuous relationship, Mrs A described how her adoptive father would never at any time during the day allude to his nocturnal visits to her room, which had always remained darkened. On the contrary, he had lectured her incessantly on the dangers of allowing boys to go too far, and on the importance of chastity before marriage. When at the age of 16 she had fled the home, he not only insisted she tell no one, but ad- ded sarcastically: 'And if you do no one will be- lieve you. ' This could well have been so since her adoptive father was a headmaster and the local mayor.
In commenting on this and similar cases MacCarthy emphasizes the cognitive split between the respected and perhaps loved father of daytime and the very different father of the strange events of the night before. Warned on no account to breathe a word to anyone, including her mother, the child looks to her father for some confirmation of those events and is naturally be- wildered when there is no response. Did it really happen or did I dream it? Have I two fathers? Small wonder if, in later years, all men are dis- trusted, and the professional stance of a male therapist is seen as a mere fac? ade that hides a
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? ? ? predatory intent. Small wonder also that the in- junction on no account to tell anyone remains op- erative, and that the expectation that in any case no one would believe you ensures silence. How often, we may wonder, do ill-informed therapists discourage a patient from telling the truth and, should she do so nonetheless, confirm her ex- pectation that no one will believe her story?
In the examples so far described the informa- tion a parent is pressing a child to shut away is information relating to events in the outside world. In other situations the information to be shut away relates to events in the child's private world of feeling. Nowhere does this occur more commonly than in situations of separation and loss.
When a parent dies the surviving parent or other relative may not only provide the children with inadequate or misleading information but he or she may also indicate that it would not be appropriate for the child even to be distressed. This may be explicit: A. Miller (1979) describes how, when a 6-year-old's mother died, his aunt told him: 'You must be brave; don't cry; now go to your room and play nicely. ' At other times the indication is only implicit. Not infrequently
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? ? ? widows or widowers, afraid to express their own distress, in effect encourage their children to shut away all the feeling they are having about their loss. Palgi (1973) describes how a small boy whose mother was chiding him for not shedding tears over his father's death retorted: 'How can I cry when I have never seen your tears? '
There are in fact many situations in which a child is expressly told not to cry. For example, a child of 5 whose nanny is leaving is told not to cry because that would make it more difficult for nanny. A child whose parents leave him in hos- pital or residential nursery insist he should not cry, otherwise they will not visit him. A child whose parents are frequently away and who leave him with one of a succession of au pair girls is not encouraged to recognize how lonely, and perhaps angry, he feels at their constant absence. When parents separate, it is often made plain to a child that he is not expected to miss the departing par- ent or to pine for the parent's return. Not only is sorrow and crying condemned as inappropriate in such situations but older children and adults may jeer at a distressed child for being a crybaby. Is there any wonder that in such circumstances feeling should become shut away?
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? ? ? All these situations are plain enough but have, I believe, been seriously neglected as causes of in- formation and feeling becoming excluded from consciousness. There are, however, other situ- ations also, more subtle and hidden but no less common, that have the same effect. One such is when a mother, who herself had a childhood de- prived of love, seeks from her own child the love she has hitherto lacked. In doing this she is in- verting the normal parent-child relationship, re- quiring the child to act as parent whilst she be- comes a child. To someone unaware of what is going on it may appear that the child is being 'overindulged', but a closer look shows that moth- er is placing a heavy burden on him. What is of special relevance here is that more often than not the child is expected to be grateful for such care as he receives and not to notice the demands be- ing made upon him. One result of this is that, in conformity with his mother's wishes, he builds up a one-sided picture of her as wholly loving and generous, thereby shutting away from conscious processing much information also reaching him that she is often selfish, demanding, and ungrate- ful. Another result is that, also in conformity with his mother's wishes, he admits to consciousness
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? ? ? only feelings of love and gratitude towards her and shuts away every feeling of anger he may have against her for expecting him to care for her and preventing him from making his own friends and living his own life.
A related situation is one in which a parent, having had a traumatic childhood, is apprehens- ive of being reminded of past miseries and so be- coming depressed. As a result her children are re- quired always to appear happy and to avoid any expression of sorrow, loneliness, or anger. As one patient put it to me after a good deal of therapy: 'I see now that I was terribly lonely as a child but I was never allowed to know it. '
Most children are indulgent towards their par- ents, preferring to see them in a favourable light and eager to overlook many deficiencies. Yet they do not willingly conform to seeing a parent only in the light the parent requires or to feeling to- wards him or her only in the way demanded. To ensure that, pressure must be exerted. Pressure can take different forms but all forms depend for their effectiveness on the child's insistent desire to be loved and protected. Alice Miller (1979), who has given these problems much attention, reports the words of an adult patient who was
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? ? ? born the eldest child of an insecure professional woman:
I was the jewel in my mother's crown. She often said: 'Maja can be relied upon, she will cope. ' And I did cope. I brought up the smaller children for her so that she could get on with her professional career. She became more and more famous, but I never saw her happy. How often I longed for her in the evenings. The little ones cried and I comforted them but I my- self never cried. Who would have wanted a crying child? I could only win my mother's love if I was competent, understanding and controlled, if I never questioned her actions nor showed her how much I missed her; that would have limited her freedom which she needed so much. That would have turned her against me.
In analysing the data, the children's social be- haviour was divided into four categories: ap- proach, avoidance, approach-avoid, and aggres- sion. It was also divided according to whom the behaviour was directed--another child or a care- giver. Another distinction was between behaviour initiated by the observed child and behaviour which occurred in response to a friendly ap- proach by another child or adult. Results are ex- pressed in terms of the mean number of incidents of a particular type of behaviour of the children in each group or else of the number of children in each group who showed that type of behaviour.
As regards occasions when a child initiated so- cial contact, either with another child or a care- giver, no appreciable differences were observed between the children in each group. By contrast, very striking differences were observed in the ways the children responded to a friendly ap- proach from the other. Characteristic responses
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? ? ? of the abused children were either to take straight avoiding action or else to show both approach and avoidance behaviour, either in quick succes- sion or in some combination of the two. Examples are: 'she creeps towards him but sud- denly veers away', and 'she crawls towards the caregiver but with head averted'. Thus, when the overtures come from a caregiver, the abused tod- dlers were three times more likely than the con- trols to take avoiding action; whilst seven of them, compared to only one, showed the curious combination of alternation of approach and avoidance. When the overtures came from other children, the differences were even more marked. For example, whereas none of the controls showed approach-avoidance, all ten of the abused toddlers did so.
Aggressive behaviour was fairly common in both groups of toddlers, though, as predicted, it was significantly more so in the abused group. Not only did the abused toddlers assault other children twice as often as the controls, but five of them assaulted or threatened to assault an adult, behaviour seen in none of the controls. In addi- tion the abused toddlers were notable for a par- ticularly disagreeable type of aggression, termed
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? ? ? 'harassment' (Manning, Heron, and Marshall, 1978). This consists of malicious behaviour which appears to have the sole intent of making the vic- tim show distress. Almost always it occurs sud- denly without any evident cause and so contrasts with hostility which occurs in reaction to a pro- vocation. Such attacks, coming unpredictably out of the blue, are frightening and invite retaliation. Clinical studies, referred to later, report them to be directed especially towards an adult to whom the child is becoming attached.
In view of the behaviour so far described it is not surprising to find that abused toddlers are singularly unsympathetic to age-mates in dis- tress. The studies of Zahn-Waxler and Radke- Yarrow have shown that infants and pre-school children who have affectionate and caring par- ents commonly express concern when another child is distressed and often make moves to com- fort him or her (Zahn-Waxler, Radke-Yarrow, and King, 1979). This type of behaviour was also seen at least once in five of the control children in the Main and George study; but on no occasion did any of the abused toddlers show the slightest hint of it. Instead, and unlike the controls, they reacted with some combination of fear, distress,
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? ? ? or anger; and three behaved hostilely to the cry- ing child. For example, one small boy of 2 years 8 months slapped a little girl who was crying, ex- claiming repeatedly 'Cut it out, cut it out'. He pro- ceeded then to pat her back and next to hiss at her with bared teeth; before anyone could inter- vene, his patting had turned to beating.
My reasons for giving so much attention to these observations of young children will, I am sure, be apparent. They show with unmistakable clarity how early in life certain characteristic pat- terns of social behaviour--some hopeful for the future, others ominous--become established. They leave no doubts either about what types of family experience influence development in one direction or another. Again and again we see de- tails in the behaviour of a toddler, or in what he says, that are plainly straight replicas of how that toddler has himself been treated. Indeed the tendency to treat others in the same way that we ourselves have been treated is deep in human nature; and at no time is it more evident than in the earliest years. All parents please note!
Firm evidence of how these children develop must await an appropriately designed longitudin- al study. There is evidence that, if conditions of
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? ? ? care improve, some recover sufficiently to pass for normal (Lynch and Roberts, 1982); others do not. Some have suffered serious brain damage and become diagnosed as mentally handicapped (e. g. Martin and Rodeheffer, 1980). For many others adverse conditions of care continue. Fur- thermore, once a child has developed the types of disagreeable behaviour described, it is not easy for an adult, whether parent, foster-parent, or professional, to give him the continuous affec- tionate care he needs, whilst treating such chil- dren by psychotherapy is extremely taxing. The sudden unprovoked attacks, which in older chil- dren can easily be damaging, are especially hard to take.
Some of these emotionally disturbed children, we know, reach psychiatric clinics where the ori- gin of their condition, I suspect, more often than not goes unrecognized. Amongst those who have treated these children, some of them psychotic, and who have traced the source of their troubles are Stroh (1974), Bloch (1978), and Hopkins (1984). Each notes the extreme degree of ambi- valence to be expected: one moment the child is hugging the therapist, the next he is kicking her. During adolescence and early adult life, some,
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? ? ? mostly male, become diagnosed as aggressive psychopaths and/or violent delinquents (e. g. Far- rington, 1978). Others, especially females per- haps, are found to be suffering from multiple per- sonality (Bliss, 1980). Once psychiatrists become aware of the profound and far-reaching effects of childhood abuse and rejection, and the extent to which relevant information is suppressed and falsified by parents and overlooked by clinicians, many more cases are sure to be identified.
A significant proportion of rejected and abused children grow up to perpetuate the cycle of family violence by continuing to respond in social situ- ations with the very same patterns of behaviour that they had developed during early childhood.
A type of response found to be characteristic of many abusive parents, and of a kind which we have already seen to be characteristic of abused toddlers, is reported, for example, by Frodi and Lamb (1980). In a laboratory study, in which videotapes of crying infants were shown, abusive mothers were found to respond to a crying infant with less sympathy than did a group of non-abus- ive mothers and also with more annoyance and anger. Furthermore these same adverse re- sponses were shown by the abusive mothers even
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? ? ? when they were shown video tapes of smiling in- fants, which suggested they disliked any form of interaction with an infant.
Let us turn now, rather belatedly, to the beha- viour of men who ill-treat girlfriend or wife.
Two of my social work colleagues at the Tavis- tock, Janet Mattinson and Ian Sinclair (1979), de- scribe a man, Mr S, who was apt, inexplicably and unpredictably, to attack his wife. At the time when he asked for an interview his wife had re- cently left him; she had just had their first baby. Although hesitant at first, Mr S fairly soon began telling the social worker how much he feared his own violence. He loved his wife, he said, and felt his violent behaviour to be quite unwarranted, akin to madness. Subsequently, speaking of his childhood, he described how he had been a mem- ber of a large working-class family in which he had received little more than harsh and unsym- pathetic treatment. His parents, he said, were constantly engaged in violent quarrels. Exploring in later interviews how he had felt as a child, struggling for the love he never got, he was struck by the suggestion that it was probably a mixture of anger and despair. This made sense to him, he said: it relieved him of his fear that his violence
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? ? ? was inexplicable. The outbreaks that had led to his wife's departure, it was noted, had occurred soon after the baby's birth. Since we know from other studies, e. g. Marsden and Owens (1975), that intense jealousy of a wife's attention to the children is a common precipitant of a husband's violence, Mr S's outbursts were in all likelihood triggered by the baby's arrival.
Sudden and on the surface inexplicable out- bursts of violence, similar to those of Mr S, are found to be characteristic of a significant propor- tion of men who batter wives; for example, they occurred in five out of the 19 cases investigated by Marsden and Owens (1975). The hypothesis that most of such men are ill-treated and battered children now grown up is supported by several findings. In one study (Gayford, 1975) informa- tion from the wives was that 51 out of a 100 viol- ent men had themselves been battered as chil- dren. Moreover 33 of the 100 had already been convicted of other violent offences and, as already noted, studies show that most violent offenders come from homes in which they were subjected to cruel and brutal treatment (Farrington, 1978).
Finally we find that many of the wives who are battered have come from disturbed and rejecting
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? ? ? homes, in which a significant minority were themselves battered as children (Gayford, 1975). These experiences had led them to leave home in their teens, to link up with almost the first man they met, all too often from a similar background, and quickly to become pregnant. For the unpre- pared and anxiously attached girl, having to care for a baby creates a thousand problems; moreover her attention to the baby provokes in- tense jealousy in her partner. These are some of the processes by which an inter-generational cycle of violence becomes perpetuated.
Let us return now to the study of Mattinson and Sinclair (1979) who describe patterns of in- teraction that they found were common in certain families.
The interviews with Mr S were part of a study undertaken in order to find out more of what is happening in the kind of intensely disturbed fam- ily that creates endless problems for the medical and social services and which is known to be ex- traordinarily difficult to help. In these families, it seemed, violence or threats of violence occurred almost daily. Time and again the couple had sep- arated only to come together again after a few days or weeks. Sometimes, after hard words from
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? ? ? his wife, a husband would go off on his own, only to hive back again a short time later. Or a wife, physically assaulted by her husband, would leave with the children but return within days to the very same situation. What seemed so extraordin- ary to the workers was the length of time some of these marriages had lasted. One question they asked themselves therefore was what was keeping the partners together.
What they found was that, whilst the violence of a husband and the angry threatening remarks of a wife seemed to dominate the scene, each partner was deeply, if anxiously, attached to the other and had developed a strategy designed to control the other and to keep him or her from de- parting. Various techniques were in use, mainly coercive, and many of them of a kind that to an outsider would appear not only extreme but counterproductive. For example, threats to desert or to commit suicide were common, and suicidal gestures not infrequent. These were usually ef- fective in the short term by ensuring the partner's concerned attention, though they also aroused his or her guilt and anger. Most of the suicide at- tempts, it was found, were reactions to specific
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? ? ? events, particularly desertions either actual or threatened.
A coercive technique, used especially by the men, was to 'imprison' the wife by such means as locking her in the house, or padlocking her clothes, or else retaining all the money and doing the shopping so as to prevent her from seeing anyone else. The intensely ambivalent attach- ment of one man who adopted this technique was such that he not only locked his wife in but he also locked her out. He would throw her out of the house telling her never to return but, after she had got to the street, would run after her and pull her back to their flat.
A third coercive technique was battering. As one man put it, in his family asking for something was always done with fists. No wife enjoyed this treatment, but some got a wry satisfaction from it. For example, one woman, when explaining why she did not wish for a separation, announced with a note of triumph in her voice that her hus- band had threatened he would come to 'get her' if she moved out. He needed her too, she insisted. In most of these marriages, it was found, each party was apt to stress how much the other needed them, whilst disclaiming their own need
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? ? ? for the partner. By need, of course, they meant what I am calling their desire for a caregiving fig- ure. What they dreaded most was loneliness.
PREVENTIVE MEASURES
This ends my description of the problems met with in violent families and the theoretical per- spective in which I believe it useful to approach them. What actions then are called for?
Much skilled and devoted work has gone into helping families in which abuse has already oc- curred, and much thought given to problems of management (Helfer and Kempe, 1976; Lynch and Roberts, 1982). Since every study has shown how very difficult and time-consuming all such work is, we ask about prospects for prevention. Here lies hope. In what follows I describe a type of service which has been pioneered in the United Kingdom and which is now spreading steadily with encouragement from government. No doubt similar services are to be found in various parts of the United States also, but naturally I know less about them.
The service pattern which is so promising, at least for some families, is one known as Home- Start (which was begun in Leicester) (Harrison,
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? ? ? 1981). 6 It is an independently organized home- visiting scheme which offers support, friendship, and practical assistance to young families experi- encing difficulties. It is staffed by volunteers who work in close liaison with the related statutory services and who also receive support and guid- ance from a professional. All visits are by invita- tion of the family and on their terms. There are no contracts and no time limits.
Each volunteer is a mother who undertakes to make regular visits to one or, at most, two famil- ies with the aim of establishing a relationship in which time and understanding can be shared. Every effort is made to encourage the parents' strengths and to reassure them that difficulties in caring for children are not unusual, and also that it is possible for family life to be enjoyable. New volunteers, who are mainly between the ages of 30 and 45, attend a preparatory course, one day a week for ten weeks, and receive regular ongoing training afterwards.
There are many advantages in the visitors be- ing volunteers. First a volunteer has time: in practice it was found in the pioneer scheme that the average time each volunteer was spending with her family in its own home was six hours a
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? ? ? week. Secondly she meets the mother on a level of equality and feels free to contribute to house- hold activities in any way that seems appropriate. Thirdly she can compare notes and talk about ex- periences with her own children. Fourthly, and very important, she can sometimes make herself available to be contacted during an evening or at a weekend.
The families visited are, of course, ones in which difficulties are either already present or appear imminent. Since the service is not aimed specifically at abusing families, a family particip- ating need not feel labelled in any way. Neverthe- less the service deals with a fair number of famil- ies who have one or more children on a register of children at risk of abuse. In the first eight years of the pioneer scheme no less than a quarter of the families visited were in that category.
Often visiting is started whilst a mother is still pregnant. Most of those visited are young, im- pulsive, and dreadfully isolated and have never experienced affection, care, or security. In such cases the principal role of the volunteer is to mother the mother and so, by example, to en- courage her to mother her own child. She will also talk and play with the children, again
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? ? ? providing the mother with an example she has never had. Perhaps later, once confidence has grown, the volunteer may assist by helping the mother acquire basic household skills she has never learned. The key to the relationship is that the volunteer is herself a mother who knows all the problems from the inside.
There are many cases which are recognized to be unsuited for inclusion in a service of this sort. 7 For those suitable the degree of success reported is most encouraging, as shown by an evaluation of the first four years' work of the pioneer service, carried out by an independent researcher whose monograph (van der Eyken, 1982) gives a full ac- count of the project. Taking a random sample of one in five of the 288 families visited, he asked those concerned how they assessed the outcome at the end of the volunteer's visiting, using a three-point scale: no change, some change, con- siderable change. The results showed that the vo- lunteers were the most pessimistic, rating only half the families as showing considerable change and one in ten as failures. The social workers who had referred cases were more hopeful, rating rather more than half as showing considerable change and the remainder as showing at least
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? ? ? some. Those most enthusiastic for the work were the health visitors (public health nurses) and the families themselves. Of the 58 families who as- sessed themselves, 47 (85 per cent) claimed a considerable change had occurred, six claimed some change and only two believed there had been none.
In a field that is both deeply troubling and no- toriously difficult these findings give hope.
1 In a study by Baldwin (1977) of 38 children who had been physically abused to an exceptionally severe degree, two-fifths of the parents had suffered physical abuse as children and more than half severe or pro- longed mental abuse. Baldwin calls attention to the marked tendency of many of these parents, when inter- viewed, to make broad generalizations about their child-hood in which an idealized picture is presented, a picture that stands in stark contrast to the grim epis- odes described when detailed questions are asked. In this field inexperienced clinicians and interviewers are likely to be gravely misled.
2 DeLozier's study has now been repeated by Mitchell (in preparation) on samples of Mexican-American mothers with closely similar results.
3 Because it is less ambiguous, I find the ethologist's term 'redirection' preferable to its clinical equivalent 'displacement'. The redirection of hostile behaviour
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? ? ? away from a more dominant animal is well known in other species.
4 There is now good evidence that, given sensitive mothering, difficult infants develop favourably, with only few exceptions (Sameroff and Chandler, 1975) and, conversely, that a potentially easy baby is likely to develop unfavourably if given insensitive care (Sroufe, 1983).
5 I am indebted for this point to Pat Crittenden (per- sonal communication) who has observed such appar- ently placatory behaviour in young abused children, some less than two years old. Similar behaviour has been observed also in young children whose mothers are seriously depressed (Pound, 1982).
6 Another initiative, serving a severely deprived area in inner London and known as Newpin, is also promising (Pound and Mills, 1985).
7 Harrison (1981) lists the following: where a parent is known to be chronically ill mentally, is suffering from a serious degenerative illness, is a recidivist, or is intent on the children being admitted to care. Also excluded are families in which the children are at risk of abuse by a mother's cohabitee.
6
ON KNOWING WHAT YOU ARE NOT SUPPOSED TO KNOW AND FEELING WHAT YOU ARE NOT SUPPOSED TO FEEL
Early in 1979 I was invited to contribute to a special number of the Canadian Journal of Psy- chiatry to honour Emeritus Professor Eric Wit- tkower who had held a chair of psychiatry at McGill University in Montreal from 1952 to 1964 and was then celebrating his eightieth birthday. This I was very glad to do. The resulting paper, with the above title, also formed the basis of lec- tures that I gave on various occasions during subsequent years.
On one such occasion, in Rome, I met with two cognitive therapists, Gio- vanni Liotti and Vittorio Guidano, and was sur- prised and delighted to find how much we had in common. One consequence of our meeting was an invitation to contribute to a volume on
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? ? ? Cognition and Psychotherapy being edited by Mi- chael Mahoney and Arthur Freeman. This provided an opportunity to expand the original brief paper and led to the version that follows.
The evidence that adverse experiences with par- ents during childhood, such as those described in the previous lecture, play a large part in causing cognitive disturbance is now substantial. For ex- ample, at least some cases in which perceptions and attributions are distorted and some states of amnesia, both minor and major, including cases of multiple personality, can be shown with con- siderable confidence to be the outcome of such experiences. Yet systematic research into these causal sequences is still scarce, and it is clearly a field calling urgently for a major research effort. Why then has it been so woefully neglected?
One adverse influence, referred to in the pre- ceding lecture, is the strong tradition within the psychoanalytic school of thought of focusing at- tention on fantasy and away from the real-life ex- periences a person may have had during child- hood. Another is the undoubted difficulty of do- ing systematic research in the field. For example, those engaged in seeing only adult patients are
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? ? ? usually ill-placed to investigate events alleged to have occurred many years earlier. Those whose childhoods have been spent amongst reasonably stable families and who, like all too many psychi- atrists and psychotherapists, are ignorant of the recent family and child development literature have no norms against which to match their pa- tients' stories. Above all clinicians are often faced with a blanket of silence, from patient and family alike, which neither their training nor their ex- perience has qualified them to penetrate. It is little wonder therefore that the likelihood that many cases of psychiatric disorder, both mild and grave, have had their origins in adverse events of childhood has been discounted or else completely ignored--not only by general psychiatrists but by psychotherapists as well. Even the fact that some children are physically or sexually assaulted by their own parents, often repeatedly and over long periods, has been missing from discussions of casual factors in psychiatry.
At long last the scene is changing. First, know- ledge of parent-child interactions in general, in- cluding a wide range of potentially pathogenic re- lationships and events, is increasing in both qual- ity and quantity as systematic research is applied.
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? ? ? Secondly, the psychological consequences for the children exposed to these relationships and events are becoming much better understood and documented. As a result there are now many oc- casions when a clinician is on reasonably firm ground in drawing aetiological conclusions. This is so especially when (a) his patient presents problems and symptoms which resemble the known consequences of certain types of experi- ence and (b) when in the course of skilled history-taking, or perhaps much later during therapy, he is told of experiences of these same types. In reaching his conclusion the reasoning a psychiatrist uses differs in no way from that of a physician who, having diagnosed a patient as suf- fering from mitral stenosis, proceeds unhesitat- ingly to attribute the condition to an attack of rheumatic fever suffered by the patient many years earlier.
When considering childhood antecedents of cog- nitive disorders a good place to start is with amnesia.
In one of his classical papers on analytic tech- nique Freud (1914) made an important generaliz- ation the truth of which probably every psycho- therapist would endorse:
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? ? ? Forgetting impressions, scenes or experiences nearly always reduces itself to shutting them off. When the patient talks about these 'forgotten' things he seldom fails to add: 'As a matter of fact I've always known it; only I've never thought of it. ' (1914, 148)
Such observations call for explanations of at least three kinds. First, are there special features that characterize the impressions, scenes, and experi- ences that tend to become shut off? Secondly, how do we best conceive of the processes by which memories become shut off and apparently forgotten? Thirdly, what are the causal condi- tions, internal and external to the personality, that activate the shutting-off process?
The scenes and experiences that tend to be- come shut off, though often continuing to be ex- tremely influential in affecting thought, feeling, and behaviour, fall into at least three distinct cat- egories: (a) those that parents wish their children not to know about; (b) those in which parents have treated children in ways the children find too unbearable to think about; (c) those in which children have done, or perhaps thought, things about which they feel unbearably guilty or ashamed.
Since a great deal of attention has for long been given to the third category, here I discuss only the first two. We start with the first.
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? ? ? Children not infrequently observe scenes that parents would prefer they did not observe; they form impressions that parents would prefer they did not form; and they have experiences that par- ents would like to believe they have not had. Evidence shows that many of these children, aware of how their parents feel, proceed then to conform to their parents' wishes by excluding from further processing such information as they already have; and that, having done so, they cease consciously to be aware that they have ever ob- served such scenes, formed such impressions, or had such experiences. Here, I believe, is a source of cognitive disturbance as common as it is neglected.
Yet evidence that parents sometimes press their children to shut off from further, conscious processing information the children already have about events that the parents wish they had never observed comes from several sources. Perhaps the most vivid concerns the efforts made by a surviving parent to obliterate his or her child's knowledge of the (other) parent's suicide.
Cain and Fast (1972) report findings from their study of a series of 14 children, aged between 4 and 14, all of whom had lost a parent by suicide
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? ? ? and all of whom had become psychiatrically dis- turbed, many of them severely so. In reviewing their data the authors were struck by the very large roles played in the children's symptomato- logy by their having been exposed to pathogenic situations of two types, namely situations in which intense guilt is likely to be engendered (not discussed here) and situations in which commu- nications between parent and child are gravely distorted.
About one quarter of the children studied had personally witnessed some aspect of the parent's death and had subsequently been subjected to pressure from the surviving parent to believe that they were mistaken in what they had seen or heard, and that the death had not been due to suicide but to some illness or accident. 'A boy who watched his father kill himself with a shot- gun . . . was told later that night by his mother that his father died of a heart attack; a girl who dis- covered her father's body hanging in a closet was told he had died in a car accident; and two broth- ers who had found their mother with her wrists slit were told she had drowned while swimming' (Cain and Fast, 1972, 102). When a child de- scribed what he had seen, the surviving parent
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? ? ? had sought to discredit it either by ridicule or by insisting that he was confused by what he had seen on television or by some bad dream he had had. Such confusion was sometimes compoun- ded, moreover, by the child hearing several dif- ferent stories about the death from different people or even from his surviving parent.
Many of the children's psychological problems seemed directly traceable to their having been ex- posed to situations of these kinds. Their prob- lems included chronic distrust of other people, inhibition of their curiosity, distrust of their own senses, and a tendency to find everything unreal.
Rosen (1955) describes an adult patient, a man of 27, who developed acute symptoms after his fiance? e had jilted him, because she had found him too moody and unpredictable. The patient began to feel that the world about him and also his own being were fragmenting, and that everything was unreal. He became depressed and suicidal; and he experienced a variety of peculiar bodily sensations, which included a feeling that he was choking. His thoughts, he said, felt like cotton-wool. Sometime during the second year of therapy the analyst, struck by a series of associ- ations the patient gave, and bearing in mind the
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? ? ? life history, ventured a reconstruction, namely that the patient's mother may have made a sui- cidal attempt during the patient's childhood that he (the patient) had witnessed. No sooner had this suggestion been offered than the patient be- came racked with convulsive sobbing. The ses- sion proved a turning point. Subsequently the pa- tient described how it had seemed to him that, when the analyst made his suggestion, it was not so much that he was restoring a memory as giv- ing him (the patient) permission to talk about something he had always in some way known about.
The authenticity of the memory was vouched for by the patient's father who admitted, when pressed, that the patient's mother had made sev- eral suicide attempts during the patient's child- hood. The one the patient had witnessed oc- curred some time during his third year. His nurse had heard sounds in the bathroom and had ar- rived in time to prevent his mother from strangling herself. It was not clear just how much the little boy had seen. But whenever later he had mentioned the event both father and nurse had disconfirmed his memories by alleging that it was something he must have imagined or had simply
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? ? ? been a bad dream. The father now claimed that he had felt it would have been harmful to his son to have remembered such an incident; but he also admitted that his attitude was dictated partly by his wish that the incident be kept secret from friends and neighbours. A year or so later the nurse had been discharged because the mother had found her presence too painful a reminder of the incident.
During one of the sessions before the vital re- construction was offered the patient had recalled the discharge of his beloved nurse as an event which he had always felt had been in some way his fault. Among many associations to it were re- current references to his having been, as a child, witness to something that had changed his life, though he did not know what. He also had the notion that his nurse had been the one witness on his behalf. Thus, although the memory had been shut away from conscious processing, it contin- ued to influence both what he thought and how he felt.
Elsewhere (Bowlby, 1973) I have drawn atten- tion to the far from negligible incidence of suicid- al attempts made by parents, and perhaps the even higher incidence of their threatening
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? ? ? suicide, and have remarked how little attention has been given to either attempts or threats in the psychiatric and psychotherapeutic literature. Per- haps there are many more cases similar to Rosen's than has yet been realized.
Among the many other situations that parents may wish a child had not observed, and that they may press him to suppose he never did, are those concerning their sexual activities. An example of this was told to me by a speech therapist who was trying to help an extremely disturbed little girl who hardly spoke at all. That she was well able to speak was, however, shown on certain dramatic occasions. She would sit a teddybear on a chair in a corner, then go over and, shaking her finger at him, would scold him in tones of extreme sever- ity: 'You're naughty--naughty Teddy--you didn't see that--you didn't see that, I tell you! ' This she repeated again and again with increasing vehe- mence. What the scenes were that Teddy was be- ing instructed he never saw was not difficult to guess: the little girl's mother was a teenage prostitute.
Clearly the purpose of these pressures by par- ents is to ensure that their children develop and maintain a wholly favourable picture of them. In
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? ? ? the examples thus far given the form of pressure exerted is crude. More frequent perhaps and just as damaging are instances in which the pressures are more subtle.
During the past two decades renewed attention has been paid to incest, both to its unrecognized high incidence and to its pathogenic effects on children. Much the commonest forms are between father and daughter or step-father and step-daughter. Among the various problems and symptoms in the children and adolescents con- cerned that are believed to be due to these experi- ences, the commonest include withdrawal from all intimate relationships, sleep disturbances, and suicidal intentions (Meiselman, 1978; Adams- Tucker, 1982). An account of conditions likely to cause cognitive disturbance was given me by a colleague, Brendan MacCarthy, but never pub- lished. He suspected that disturbance is espe- cially likely when the children are prepubertal. In what follows I draw on his conclusions.
When a sexual liaison develops between a fath- er and his adolescent daughter, MacCarthy re- ports, the liaison is usually acknowledged by the father during the course of daily life by such means as secret glances, secret touching, and
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? ? ? innuendoes. In the case of a younger child, however, a father is likely to make no such ac- knowledgements. Instead he behaves during the day as though the nightly episodes never oc- curred; and this total failure to acknowledge them is commonly maintained even long after the daughter has reached adolescence.
MacCarthy describes the case of a married wo- man, Mrs A, whom he treated for depression, re- liance on tranquillizers, and alcohol. She men- tioned the ten years of sexual interference she had suffered from her adoptive father only after she had been in therapy for four months. It had begun when she was 5 or 6, soon after her adopt- ive mother had died, and had continued until she was 16, when she had fled. Among her many problems were frigidity and finding intercourse disgusting, and a sense of inner blackness, of 'a black stain'. Her problems had become exacer- bated when her own daughter was 4 years old. Whenever the daughter became affectionate to her father and sat near him, Mrs A felt agitated, protective, and jealous; on these occasions she could never leave them alone together. During therapy she was obsequious and terrified, and in- tensely vigilant of the analyst's every move.
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? ? ? In regard to the incestuous relationship, Mrs A described how her adoptive father would never at any time during the day allude to his nocturnal visits to her room, which had always remained darkened. On the contrary, he had lectured her incessantly on the dangers of allowing boys to go too far, and on the importance of chastity before marriage. When at the age of 16 she had fled the home, he not only insisted she tell no one, but ad- ded sarcastically: 'And if you do no one will be- lieve you. ' This could well have been so since her adoptive father was a headmaster and the local mayor.
In commenting on this and similar cases MacCarthy emphasizes the cognitive split between the respected and perhaps loved father of daytime and the very different father of the strange events of the night before. Warned on no account to breathe a word to anyone, including her mother, the child looks to her father for some confirmation of those events and is naturally be- wildered when there is no response. Did it really happen or did I dream it? Have I two fathers? Small wonder if, in later years, all men are dis- trusted, and the professional stance of a male therapist is seen as a mere fac? ade that hides a
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? ? ? predatory intent. Small wonder also that the in- junction on no account to tell anyone remains op- erative, and that the expectation that in any case no one would believe you ensures silence. How often, we may wonder, do ill-informed therapists discourage a patient from telling the truth and, should she do so nonetheless, confirm her ex- pectation that no one will believe her story?
In the examples so far described the informa- tion a parent is pressing a child to shut away is information relating to events in the outside world. In other situations the information to be shut away relates to events in the child's private world of feeling. Nowhere does this occur more commonly than in situations of separation and loss.
When a parent dies the surviving parent or other relative may not only provide the children with inadequate or misleading information but he or she may also indicate that it would not be appropriate for the child even to be distressed. This may be explicit: A. Miller (1979) describes how, when a 6-year-old's mother died, his aunt told him: 'You must be brave; don't cry; now go to your room and play nicely. ' At other times the indication is only implicit. Not infrequently
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? ? ? widows or widowers, afraid to express their own distress, in effect encourage their children to shut away all the feeling they are having about their loss. Palgi (1973) describes how a small boy whose mother was chiding him for not shedding tears over his father's death retorted: 'How can I cry when I have never seen your tears? '
There are in fact many situations in which a child is expressly told not to cry. For example, a child of 5 whose nanny is leaving is told not to cry because that would make it more difficult for nanny. A child whose parents leave him in hos- pital or residential nursery insist he should not cry, otherwise they will not visit him. A child whose parents are frequently away and who leave him with one of a succession of au pair girls is not encouraged to recognize how lonely, and perhaps angry, he feels at their constant absence. When parents separate, it is often made plain to a child that he is not expected to miss the departing par- ent or to pine for the parent's return. Not only is sorrow and crying condemned as inappropriate in such situations but older children and adults may jeer at a distressed child for being a crybaby. Is there any wonder that in such circumstances feeling should become shut away?
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? ? ? All these situations are plain enough but have, I believe, been seriously neglected as causes of in- formation and feeling becoming excluded from consciousness. There are, however, other situ- ations also, more subtle and hidden but no less common, that have the same effect. One such is when a mother, who herself had a childhood de- prived of love, seeks from her own child the love she has hitherto lacked. In doing this she is in- verting the normal parent-child relationship, re- quiring the child to act as parent whilst she be- comes a child. To someone unaware of what is going on it may appear that the child is being 'overindulged', but a closer look shows that moth- er is placing a heavy burden on him. What is of special relevance here is that more often than not the child is expected to be grateful for such care as he receives and not to notice the demands be- ing made upon him. One result of this is that, in conformity with his mother's wishes, he builds up a one-sided picture of her as wholly loving and generous, thereby shutting away from conscious processing much information also reaching him that she is often selfish, demanding, and ungrate- ful. Another result is that, also in conformity with his mother's wishes, he admits to consciousness
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? ? ? only feelings of love and gratitude towards her and shuts away every feeling of anger he may have against her for expecting him to care for her and preventing him from making his own friends and living his own life.
A related situation is one in which a parent, having had a traumatic childhood, is apprehens- ive of being reminded of past miseries and so be- coming depressed. As a result her children are re- quired always to appear happy and to avoid any expression of sorrow, loneliness, or anger. As one patient put it to me after a good deal of therapy: 'I see now that I was terribly lonely as a child but I was never allowed to know it. '
Most children are indulgent towards their par- ents, preferring to see them in a favourable light and eager to overlook many deficiencies. Yet they do not willingly conform to seeing a parent only in the light the parent requires or to feeling to- wards him or her only in the way demanded. To ensure that, pressure must be exerted. Pressure can take different forms but all forms depend for their effectiveness on the child's insistent desire to be loved and protected. Alice Miller (1979), who has given these problems much attention, reports the words of an adult patient who was
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? ? ? born the eldest child of an insecure professional woman:
I was the jewel in my mother's crown. She often said: 'Maja can be relied upon, she will cope. ' And I did cope. I brought up the smaller children for her so that she could get on with her professional career. She became more and more famous, but I never saw her happy. How often I longed for her in the evenings. The little ones cried and I comforted them but I my- self never cried. Who would have wanted a crying child? I could only win my mother's love if I was competent, understanding and controlled, if I never questioned her actions nor showed her how much I missed her; that would have limited her freedom which she needed so much. That would have turned her against me.
