[The] evidence is now such that it leaves no room for doubt … that the prolonged deprivation of a young child of maternal care may have grave and far reaching effects on his character and so on the whole of his future life. It is a proposition exactly similar in form to those regarding the evil after-effects of German measles before birth or deprivation of vitamin D in infancy.
(Bowlby, 1953a)
Statements implying that children who experience institutionalisation and similar forms of privation in early life commonly develop psychopathic or affectionless characters are incorrect.
(Bowlby, Ainsworth, Boston and Rosenbluth, 1956b)
Psychotherapy can be seen as a branch of social psychiatry, using psychological methods to reverse or mitigate the damaging effects of environmental failure. This immediately raises two questions. First, given that the damage is already done, how can mere talk undo past miseries? Second, since many people resiliently survive unhappy childhoods without developing psychiatric disorder, are therapists justified in attributing present difficulty to previous trauma? The two quotations from Bowlby above illustrate the transition between his career as a clinician and psychoanalyst to that of a researcher and theorist. The therapist, faced with the patient in front of him, naturally attributes his difficulties to the history of environmental failures he recounts. The researcher, with a control group and a sense of a population at risk rather than just one individual, is forced to more cautious conclusions.
The answer to both questions, in brief, lies in the fact that environmental failure is not merely impressed on a passive organism, but is experienced and given meaning by the afflicted individual. Psychotherapy is concerned with the way stress is mediated psychologically – with why this person succumbs while others survive – and, by altering psychological responsiveness and the attribution of meanings, to change not the facts of history, but their context and significance. In this chapter we approach these issues through the topic of ‘maternal deprivation’, and its corollary, the view ‘that maternal care in infancy and early childhood is essential for mental health’ (Bowlby, 1952a). However self-evident it may seem to us now – and this is largely the result of Bowlby's work – the idea of maternal deprivation as a cause of mental illness was in its day a revolutionary concept which became a paradigm (Kuhn, 1962), setting the terms of debate and research in social psychiatry for the ensuing forty years.
As Rutter (1981) points out, the phrase ‘maternal deprivation’, the central concept of Bowlby's WHO report Maternal Care and Mental Health, is a misnomer. His report was concerned primarily with privation (the absence of something which is needed), rather than de-privation (the removal of something that was previously there). The distinction is important because, as we shall see, the results of the complete lack of maternal care are almost always damaging to the child and have severe long-term consequences, while deprivation is less easy to define and less predictable in its impact.
In its popular edition, Maternal Care and Mental Health was re-titled Child Care and the Growth of Love – a significant shift, since it suggests a universal message about mothers and children rather than confining itself to questions of mental health. The book is far more than a scientific work (and indeed has been criticised for its handling of the evidence – Andry, 1962), and is perhaps best seen as a landmark social document, comparable to the great nineteenth-century reports such as Elizabeth Fry's account of sanitary conditions in prisons, or Mayhew's descriptions of the plight of the London poor.
What marks out Child Care and the Growth of Love in the history of social reform is its emphasis on psychological as opposed to economic, nutritional, medical or housing difficulties as a root cause of social unhappiness:
In a society where death rates are low, the rate of employment high, and social welfare schemes adequate, it is emotional instability and the inability of parents to make effective family relationships which are the outstanding cause of children becoming deprived of a normal family life.
(Bowlby, 1952a)
The central thrust of Bowlby's work is the effort to substantiate this claim and to consider its clinical, professional, ethical and political consequences. The evidence upon which the book is based includes Bowlby's own studies of juvenile delinquents, Goldfarb's (1945) comparison of institution-raised children in the United States with those who had been placed in foster homes, and the accounts of Anna Freud and Dorothy Burlingham (1943) from their residential nursery in Hampstead. All these studies strongly supported the view that children deprived of maternal care, especially if raised in institutions from under the age of seven, may be seriously affected in their physical, intellectual, emotional and social development. Institution-raised children grow less well, and are retarded in their acquisition of language, and as they become older show evidence of impaired ability to form stable relationships – often tending to be superficially friendly but promiscuous (either metaphorically or literally) in their relationships. Based on his own finding that only two out of fourteen ‘affectionless psychopaths’ had not had prolonged periods of separation from their mothers in early childhood, Bowlby asserted that ‘prolonged separation of a child from his mother (or mother substitute) during the first five years of life stands foremost among the causes of delinquent character development’ (Bowlby, 1944; Bowlby, 1952a). It is worth noting that Bowlby was making very sweeping conclusions based on studies which had often only looked at relatively small numbers of cases – in his case fourteen, in Goldfarb's only fifteen, juvenile delinquents. By present-day standards these studies would also not be acceptable in that they often included no control groups, or, if they did, they were not rated blind by researchers who had a vested interest in establishing a link between deprivation and depravity. Bowlby was aware of these difficulties and, anticipating the modern vogue for ‘meta-analysis’, suggested that, by combining many small studies, an overall trend emerges which is likely to have some validity.
Having established to his satisfaction that children without maternal care are indeed gravely disadvantaged, Bowlby goes on to contrast the quality of life in a family with that in an institution:
All the cuddling and playing, the intimacies of suckling by which a child learns the comfort of his mother's body, the rituals of washing and dressing by which through her pride and tenderness towards his little limbs he learns the values of his own, all these have been lacking.
(Bowlby, 1952a)
The tinge of sentimentality in this lyrical account has, as we shall see, been much criticised by feminist writers, as has his hymn of praise to what Winnicott was later to call the ‘ordinary devoted mother’:
The provision of constant attention night and day, seven days a week, 365 days in the year, is possible only for a woman who derives profound satisfaction from seeing her child grow from babyhood, through the many phases of childhood, to become an independent man or woman, and knows that it is her care which has made this possible.
(Bowlby, 1952a)
These much-quoted and sometimes derided overstatements have to be seen in context. The world was horrified in the 1990s by the revelation of the squalor and emotional deprivation in the orphanages of Romania. This was not just the result of a dictatorship but of an ideological devaluation of family life, and a belief in the power of public provision to overcome individual poverty (see Rutter et al. 2007). Bowlby was reacting against a similar trend to be seen in the post-war era, and indeed to a long tradition among the British middle classes, of which he had first-hand experience, of turning their sons and many of their daughters over first to nannies and then to institutional care in boarding schools from the age of seven. To the extent that Bowlby idealises motherhood – as opposed to offering a realistic appraisal of its central importance in child-rearing – this must be seen at least in part as a reflection of the deprivations which he and other members of his class had experienced in the nursery and at school. The long hand of the otherwise invisible nanny reached far.
The impact of Bowlby's advocacy has been enormous, and continues to the present day. It is now taken for granted, and enshrined in the 1989 Children Act, that individual care in foster homes is preferable to group care in nurseries, that ‘bad homes are better than good institutions’ (Bowlby, 1952a). In the UK institutional care for the mentally ill and mentally handicapped has largely been replaced with care within the family, or at least provision of a family-type home atmosphere, indeed there is now a case to be made that this trend has now gone too far.
Bolwby's early critics accused him of wanting to ‘pin women down in their own homes’ (Mead, 1962). While it is true that he opposed cavalier attitudes towards elective separations of mothers from children under the age of three, he could rather be seen as arguing for a much greater valuation of motherhood by society. He put a strong case for the professionalisation for all child-care workers, including workers in day nurseries and children's homes, foster mothers and child minders. These workers must be skilled in understanding a deprived child's overwhelming needs: the craving for parental love; the need to idolise parents however flawed they are in reality; the importance of maintaining contact with absent parents, however fragmentary; the right to express pain, protest about separation, and to grieve loss. They must also be able to help parents in turn to recognise their children's and their own ambivalent feelings. He is intensely critical of case workers who ‘live in the sentimental glamour of saving neglected children from wicked parents’ (Bowlby, 1952a) – a comment still relevant today to the dilemmas presented by working with sexually abused children – and of actions which ‘convert a physically neglected but psychologically well-provided child into a physically well-provided but emotionally starved one’ (Bowlby, 1952a). All these principles are now enshrined at least in the theory of child-care practice, and for this too Bowlby's work made a ground-breaking contribution.
Much of the debate about the de-institutionalisation of the mentally ill (which has now been more or less accomplished in the UK, though in general this is far from the case world-wide) centred on the question of funding. It was thought that community care must be cheaper than institutional care, and partly for this reason received governmental support. Bowlby puts forward similar economic arguments in favour of family support for troubled children
There are today governments prepared to spend up to £10 per week [this was 1952!] on the residential care of infants who would tremble to give half this sum to a widow, an unmarried mother, or a grandmother to help her care for her baby at home…. Nothing is more characteristic of both the public and voluntary attitude towards the problem than a willingness to spend large sums of money looking after children away from their homes, combined with a haggling stinginess in giving aid to the home itself.
(Bowlby, 1952a)
Although thanks to Bowlby and others, much has changed, much still remains the same. Indeed for poor parents things may be worse than in 1952: the haggling stinginess has returned, but is also accompanied by an unwillingness to spend large sums on public provision.
A major idea which emerges in Child Care and the Growth of Love is that of cycles of deprivation: ‘the neglected psychopathic child growing up to become the neglectful psychopathic parent… a self-perpetuating social circle’ (Bowlby, 1952a). Today's emotionally deprived child becomes tomorrow's neglectful parent. Adverse experiences become internalised by the growing child in a way that leads on to further adverse experiences, thus perpetuating the vicious circle of neurosis. Writing in an era of social optimism, and with what in hindsight must be seen as some naïvety, Bowlby argued that, with concentrated social, economic and psychological effort, society could reverse these vicious circles, so that ‘it may, in two or three generations, be possible to enable all boys and girls to grow up to become men and women who, given health and security, are capable of providing a stable and happy life for their children’ (Bowlby, 1952a).
One of the impressive features of Child Care and the Growth of Maternal Love is the way it presents psychoanalytical principles in an accessible and simple form. It is infused with the belief that it is always better to speak the truth, however painful, than to suppress it, and that to try to wipe the slate of the past clean is misguided and in any case impossible. Bowlby believed that children should be involved in any decisions about their welfare, and their own views and wishes taken into account. He thought that children should be encouraged to express their ambivalent feelings about their parents. Children often believe themselves responsible for the calamities which befall them and their families, and child-care workers need to be aware of this and help put these feelings into perspective. For a child away from home ‘the lack of a sense of time means that separation feels like an eternity’, and this too needs to be understood.
In a remarkable quotation from his psychoanalytic colleague, Winnicott, a case is made that every child has a right to a primary home experience:
without which the foundations of mental health cannot be laid down. Without someone specifically oriented to his needs the infant cannot find a working relation to external reality. Without someone to give satisfactory instinctual gratifications the infant cannot find his body, nor can he develop an integrated personality. Without one person to love and to hate he cannot come to know that it is the same person that he loves and hates, and so cannot find his sense of guilt, and his desire to repair and restore. Without a limited human and physical environment he cannot find out the extent to which his aggressive ideas actually fail to destroy, and so cannot sort out the difference between fantasy and fact. Without a father and a mother who are together, and who take joint responsibility for him, he cannot find and express his urge to separate them, nor experience relief at failing to do so.
(1952a)
These principles are as relevant today as they were when they were written. The tragedy of contemporary ‘community care’ is that, while the need to avoid the negative aspect of institutions has been grasped, the primary home experience as described by Winnicott remains elusive.
Perhaps the greatest single thread in Bowlby's work, one which comes through strongly in Child Care and the Growth of Maternal Love, is his pain and outrage at the unnecessary separation of children from their parents. He could take heart at the changes in paediatric and obstetric practice it has led to. The book ends with this passionate outcry at a ‘developed’ society which has forgotten the fundamental importance of human attachment:
Finally let the reader reflect for a moment on the astonishing practice which has been followed in obstetric wards – of separating mothers and babies immediately after birth – and ask himself whether this is the way to promote a close mother-child relationship. It is hoped that this madness of western society will never be copied by so-called less developed societies.
(Bowlby, 1952a)
Bowlby's work has excited considerable reaction, ranging from uncritical acceptance to outraged dismissal. His critics can be divided into two groups. First, there were those who questioned the social and political implications of his work, mainly from a feminist perspective. A rather different group of researchers have examined the factual basis of the concept of maternal deprivation. These workers, who include Bowlby himself, have modified and refined our understanding of the short- and long-term implications of maternal separation and mishandling for the developing child.
Feminists have aimed three broad kinds of criticism at the idea of maternal deprivation. The first, and most simple, merely accuses Bowlby of overstating his case. The studies upon which he bases his conclusions were of children who had experienced almost complete lack of maternal care. To generalise from these to the view that any separation of mother from child in the first three years of life is likely to be damaging is unwarranted (Oakley, 1981). There is abundant evidence, they claim (and, as we shall see later, the facts support this view), that when a mother entrusts her child for part of the day to the care of a trusted and known person – whether a grandmother, a metapalet in a kibbutz, or a responsible baby minder – no harm is necessarily done. They argue, on the contrary, that exclusive care by the mother alone can lead to less rather than greater security for the child, and that Bowlby was wrong in his concept of ‘monotropism’ (that is, exclusive attachment of the child to one preferred figure).
An African proverb states that ‘it takes a whole village to raise a child’. Children have a hierarchy of attachment figures, of whom the mother is usually the most important, but fathers, grandparents, siblings and other relations and friends also play a part, and in the absence of one, the child will turn to another in a way that does not equate with the emotional promiscuity of the institution-raised child. Bowlby's critics also point to the emotional burden on the mother alone with her child, who, despite (or because of) 24-hour proximity to her child may be emotionally neglectful even if she is physically attentive (Chodorow, 1978). The dangers which Bowlby repeatedly identifies in his later work – role reversal between mother and child, threats of suicide, or saying the child will be sent away – can all be seen in part as consequences of this burden and the exclusivity which he advocates for the mother-child bond.
The second plank upon which the feminist critique rests is more complex, and consists of an attempt to locate Bowlby's ideas in an historical, anthropological and sociological context. It starts from the historical setting of post-war Europe where, as New and David (1985) put it, Bowlby got an audience: women who had been working in munitions factories, obliged to send their children for nine or ten hours daily into indifferent nurseries, men who for years had been equating peace with the haven of the family, governments which saw the social and financial potential of idealizing motherhood and family life.
The collective sense of loss, and guilt, and desire for reparation found an answer in the idea of maternal deprivation. Children had suffered terribly as a result of the war, and this needed to be faced, as had the ‘internal children’ of the adults who had witnessed the horrors of war. The valuation and at times sentimentalising of the mother-child relationship in post-war Europe could be compared with a similar process in the nineteenth century in the face of the brutality of the Industrial Revolution. Bowlby's tenderness towards little children carries echoes of Blake and Wordsworth, Dickens and Kingsley. There had to be a safe place which could be protected from the violence of the modern world; the Christian imagery of mother and child reappears, in Bowlby's work, as an icon for a secular society.
A slightly different slant was offered in the suggestion that governments welcomed the idea of maternal deprivation in that it appeared to let them off the hook of providing child care, pushing it back to individual and family responsibility. Winnicott wrote to Bowlby warning him that his views were being used to close down much-needed residential nurseries (Rodman 1987). Bowlby had not, of course, argued that money should be withdrawn, but rather transferred from institutional care to home care; unsurprisingly, however, governments were less keen on this part of the argument.
The heart of the feminist case against Bowlby is that, like Freud, he had wrongly assumed that anatomy is destiny. Implicit, they argue, in the concept of maternal deprivation is a view of the biological ‘naturalness’ of an exclusive mother-child relationship which, as Margaret Mead (1962) puts it, is a ‘reification into a set of universals of a set of ethnocentric observations on our own society’. Anthropology shows that child care is normally shared by a stable group of adults and older children – usually, but not always, related, and typically, but by no means invariably, female. Maternal care is an important but certainly not exclusive part of this. For infants to survive in non-industrial countries such shared care is essential. As an Object-Relations theorist, Bowlby rejected Freud's quasi-biological drive theory, proposing instead an evolutionary-ethological account of the mother-child bond. Feminists object that he used biology to justify what is essentially a cultural product of ‘Western’ capitalism, with its nuclear families, small numbers of children, weakened kinship networks, mobile population, and fathers away from home for long periods, or absent altogether.
A more tenuous sociological argument (Mitscherlich, 1962; Parsons, 1964) suggests that the family structure which Bowlby implicitly advocates, with strong, closely bonded mothers and children, and peripheral fathers, fits the needs of modern capitalist society. The mother controls her children by bribes and threats, thus preparing them for the social manipulations of advertising and manufactured need which an ever-expanding consumerist economy requires. Leupnitz (1988), from perhaps a slightly overstated a feminist family therapy perspective, sees this as enshrining a state of affairs in which working-class wives and mothers are typically obese, sexually dissatisfied, psychosomatically ill, and prone to depression.
Chodorow (1978) and other feminist psychotherapists have developed these ideas into a theory about the identity difficulties for both men and women flowing from family structure. Lacking a strong father with whom to identify, boys differentiate themselves from their mothers and sisters by a disparagement of women, which conceals a dread of their phantasised omnipotence. It is this, according to Horney (1924), not Freud's castration anxiety, which underlies the male fear of women and their difficulties in intimacy. The elusive search for ‘success’ is an attempt to please and appease the all-powerful mother. Girls, on the other hand, remain tied into their mothers, often taking on their pain and depression, and feeling intense guilt if they try to assert their independence and autonomy. The absent or seductive father makes moving towards him difficult or dangerous. Motherhood provides a temporary relief, but the girl again may feel caught in a mother-child dyad from which she still cannot escape, while the boy, now a father, feels excluded and jealous. As we shall see in later chapters, the Bowlbian concepts of avoidant and ambivalent attachment capture roughly these male and female patterns of anxious attachment in the modern family.
In summary, the feminist critique has questioned the logic of the implicit Bowlbian argument (one which in its simplistic form Bowlby would have been the first to repudiate) that since absent mothers lead to disturbed children, ever-present mothers will produce happy children. The feminists – in so far as it is possible to group them together – in turn have equally failed to appreciate the importance which Bowlby established for the role of the mother in her child's emotional development, both as a scientific fact and as a social and ethical principle. Bowlby's advocacy of the vital importance of mothers in the care of children, and the implications of his studies that good day-care facilities should be available for mothers who want or are forced by economic necessity to work, funded so that children can have individual and continuous relationships with care workers, should be seen as a step towards the liberation of women, increasing their range of choices and valuation by society.
This debate has led to empirical investigations of the effect of day care on the child's social and emotional development. Belsky (2001) suggested that early and extensive non-maternal care might increase the risk of behavioral difficulties and insecure attachment in children. Coming at a time when many women were working outside the home, this and subsequent papers generated fierce criticism, stimulating the US National Institute of Child Health and Development (NICHD) Early Child Care Study, which permitted exploration of this question in a large and heterogenous sample. The NICHD study showed that quality of care (whether maternal or non-maternal) plays a critical role in determining outcomes, and underscored some of the positive effects of non-maternal care. As Belsky points out, however, there continues to be strong evidence that early non-maternal care increases the likelihood of behavioral and relational problems in preschool and early school years. Importantly, the quality of parenting also plays a role in mediating the relationship between time spent in non-maternal care and insecure attachment – poor quality of parental care combined with long periods of non-maternal care bodes ill for the child. Highly politicized, this issue continues to divide academics and parents.
Although still in print, it is more than half a century since Child Care and the Growth of Maternal Love was first published. The terms of the debate have changed, so that, with less physical absence, but with ever-increasing difficulties in managing their lives, mothers are subject to enormous social pressures and their children are often the first casualties of this. For a more detailed examination of maternal deprivation from a contemporary perspective, and for a discussion of how children may be helped to escape, or may remain ever more deeply trapped in deprivation, we turn now to the work of Michael Rutter.
Rutter's monograph (Rutter 1981) and numerous papers (Rutter, 1972; 1979; 1995; Rutter et al., 2009) comprise the definitive empirical evaluation and update of Bowlby's work on maternal deprivation. His contribution has been to amass further evidence, and, based on this, to tease out the many different social and psychological mechanisms which operate under the rubric of maternal deprivation.
Bowlby, it will be recalled, claimed that maternal deprivation produced physical, intellectual, behavioural and emotional damage. He further argued that even brief separations from the mother in the first five years of life had long-lasting effects, and in general that these problems perpetuated themselves in a cycle of disadvantage as maternally-deprived children themselves became parents. Rutter has examined each of these points in turn.
On the question of intellectual and physical disadvantage, and the effects of brief separation, it seems that Bowlby was only partially right, and often for the wrong reasons. While it is true that institution-raised children are intellectually disadvantaged, this is mainly in verbal as opposed to performance intelligence, and this is a consequence of the child's ‘verbal environment’, not the lack of parents per se. Children brought up in large families are similarly disadvantaged. It is lack of verbal stimulation that is the problem for the deprived children, not the lack of a mother. A similar picture emerges with ‘deprivation dwarfism’, which has been shown to be due, as might be expected, to lack of food intake rather than some mysterious emotional factor, and can be rapidly reversed by attentive feeding, whether by a nurse or mother.
Acute separation distress is also probably less damaging, and more complex than Bowlby first conceputalised it. Preparation and care by known figures reduces distress, and even without these, there is no evidence of long-term effects from a single brief separation, however painful it may be at the time. An important point comes from Hinde's rhesus monkey studies (Hinde and McGinnis, 1977), which show that the effects of separation depend on the mother-child relationship before the event: the more tense the relationship, the more damaging the separation. These findings indicate a move towards a more subtle appreciation of the nature of bonds, and away from simplistic event-pathology models. What matters is not so much the separation itself but its meaning and the context in which it happens.
A similar conclusion applies to the relationship between antisocial behaviour and maternal deprivation. First, as Rutter (1979) puts it, ‘the links are much stronger looking back than they are looking forward’. In ‘Forty-four juvenile thieves’, Bowlby found that a quarter of the thieves had had major separations from their parents in infancy, and in the subgroup of ‘affectionless psychopaths’ only two out of fourteen had not experienced maternal deprivation; however, in his later follow-up study of children who had been in a tuberculosis sanatorium he found that, compared with controls, the differences in social adjustment, while in the direction of less good adjustment for the sanitorium children, were not all that marked, and that at least half of the deprived children had made good social relationships (Bowlby et al., 1956b).
Second, the implication of the phrase ‘maternal deprivation’ is that antisocial behaviour is specifically linked to the loss of the mother. Rutter's work (1981) suggests that antisocial behaviour is linked not to maternal absence as such, but to the family discord which in divorcing families is often associated with temporary separations from the mother. Children who have lost their mothers through death have a near-normal delinquency rate, while the rate is much raised when parents divorce, especially where there is a combination of active discord and lack of affection. Here too it seems that it is the way in which the loss is handled, its antecedents (how secure the child has been with the separating parents), and the meanings the child constructs around the loss, that matter.
The importance of these refinements of the maternal deprivation hypothesis is that they mark a move away from Bowlby's medical analogy, exemplified by the Vitamin D-rickets comparison, to a psychological model which takes account of an individual's history, and of the way untoward events are ‘processed’ psychologically. It seems more plausi-ble that maternal deprivation should act as a general ‘vulnerability factor’ (see Brown and Harris, 1978) in a complex and cascading network, raising a child's threshold to later psychological disturbance, rather than as a causative agent in a simple, linear, one-to-one model.
Delinquency is such a complex phenomenon, dependent on non-psychological issues such as policing policy, quality of schools, employment prospects, housing and so on, that it would be unlikely to be the result of any one single factor, however important childhood deprivation may be.
For children unfortunate enough to be entirely deprived of maternal care, however, the research evidence does tend to confirm Bowlby's original claims. Tizard's (1977) follow-up studies on institution-raised children show that, as the maternal deprivation hypothesis predicted, these eight-year-olds were more attention-seeking, restless, disobedient and unpopular compared with controls, while as infants they had shown excessive clinging and diffuse attachment behaviour. Her studies also indicate that, as Bowlby suggested, the period from six months to four years may be critical for the capacity to form stable relationships, since children who had been adopted after four, despite forming close and loving bonds with their adoptive parents, remained antisocial in their behaviour at school. The Romanian orphan studies came to similar conclusions (Rutter et al., 2007).
Developmental research generally confirms Bowlby's concept of cycles of disadvantage. People brought up in unhappy or disrupted homes are more likely to become teenage mothers, make unhappy marriages and to divorce, although it is important to acknowledge that these maybe adaptive strategies in sub-optimal circumstances (Belsky, 1997). Parents who physically abuse their children tend to have had childhoods characterised by neglect, rejection and violence. When girls from disrupted homes become mothers they tend to talk less to their babies, touch them less, and look at them less (Wolkind et al., 1977). Not all children from unhappy homes suffer and fail in this way. Complex non-linear models are needed to chart developmental pathways that take into account the child's temperament and genetic makeup, and those of the parents, the impact of events and their appraisal, and the prevailing wider social environment. These ‘epigenetic’ (Waddington, 1977) routes through childhood lead in more or less positive directions. A number of varied influences will determine which path a particular child takes (Rutter, 1981). Figure 2.1 attempts to summarise these.
Unsurprisingly, there is good evidence that parents' own childhood experiences strongly influence the way they respond to their children. Events around birth are also important: mothers separated from their babies soon after birth are less confident and competent as mothers in the subsequent months. The sex and birth position of the child matter: parents are more relaxed and less punitive with second children than with first-borns. Male children are generally more vulnerable to family discord than are females. The death of a parent is more damaging for a same-sex child than if they are the opposite sex. Temperament, with its genetic underpinnings, plays an important part too: children who are less adaptable and more prone to negative moods are more likely to be targets of parental criticism than their more easy-going siblings, and are more likely to develop childhood psychiatric disorders especially when exposed to adversity (Caspi et al., 2003). Even in discordant homes, if the child has a good relationship with one parent or with a grandparent, this acts as a protective factor against conduct disorder (Fonagy et al., 1995). Finally, the social environment is important. Inner-city areas have much higher rates of childhood psychiatric disorder than country or small-town areas, and even within inner cities some schools are much more successful in helping their pupils to avoid delinquency than others.
Key issues for adult psychotherapists are: the need to clarify more precisely the links between early childhood difficulty and emotional disorder in later life (Rutter, 1986); the question of how some people survive and are even strengthened (‘steeled’) by adversity, while others lack such resilience (Rutter, 1985); and developing models that will suggest when, and where, and in what form, psychotherapeutic intervention is likely to produce change.
Social psychiatry tends to emphasise present adversity in the causation of neurosis, while psychoanalytic explanations stress past trauma. The evidence suggests that both current and past difficulties are important; self-esteem may be a crucial factor linking the two. Looking at adverse experiences in childhood, those who – despite loss or difficulty – manage to maintain a sense of self-esteem, do well. Self-esteem in turn rests on two main foundations: self-efficacy (Knox, 2011) and good relationships. Success at school – in social relationships (especially as sense of humour), athletic prowess, musical ability or scholastic achievement – is correlated with better adjustment in institution-raised children in adult life (Rutter and Quinton, 1984). There are likely to be a series of interlocking benign or vicious circles here. Good self-esteem means a child will be likely to cope with deprivation – chronic illness in a parent, for example – and the fact of coping will in itself enhance self-esteem, and give the individual a feeling that they will be able to cope when faced with further challenges in the future.
Conversely, as Beck et al. (1979) and Ryle (1990) argue, depressed people tend to expect themselves to cope badly, perceive themselves as doing so, may in fact do, all of which will be experienced as depression-reinforcing ‘failure’.
Linked with coping and competence, the second important childhood component of self-esteem derives from good relationships. Both will influence their choice of partner and the kinds of relationship they have. Psychotherapists have long suggested that a history of at least one good relationship in the past predicts good outcome in therapy (Malan, 1976). An important point about people blessed with self-efficacy and capable of sustaining good relationships is that they tend to generalise, so that one positive feature will reinforce good self-esteem, despite an otherwise gloomy picture. The opposite is the case in depression (Brown and Harris, 1978), where adverse experiences often permeate out across the psychic landscape into a global feeling of hopelessness.
Bion mocked early psychoanalytic fellow-travellers like Suttie for their simplistic overemphasis on past trauma: ‘doctor put it in the past’ (Pines, 1991). Equal in importance is the quality of a person's current intimate relationships, although of course those with favourable developmental experiences will be more likely to achieve these. Vulnerable women who experience loss are protected from depression by the presence of a confiding relationship with a spouse or partner (Brown and Harris, 1978). Parker and Hadzi-Pavlovic (1984) found that those whose parents have died in childhood are less prone to depression in adult life if they have an affectionate spouse. Rutter and Quinton (1984) report similar findings for institution-raised women, who in general have more psychosocial difficulties than controls, and were much more likely to react badly to stress, unless they had a supportive husband in a harmonious marriage. This suggests another vicious circle, since maternally deprived girls are more likely to marry unstable and similarly deprived men. Childhood difficulty leads to low self-esteem, which makes for a poor choice of sexual partner, which in turn leaves women unprotected from stress in adult life. As Bowlby (1952a) puts it, there are ‘strong unconscious drives which lead husbands and wives to create the very problems of which they complain’, and so produce ‘the distorted light in which they see the behaviour of their spouse’.
There are important implications of these findings for psychotherapy. There is an implicit contradiction in the psychoanalytic emphasis on the overwhelming importance of early experience – and even more so phantasies in early childhood – in determining adult difficulty and the claims for the efficacy of psychoanalytic therapy. If continuity between childhood and adult life is so strong, how is psychoanalysis likely to reverse it? Evidence suggests a much more subtle relationship between past and present, in which a person's current partner plays a crucial role in determining outcome. Caspi et al. (2006) found that ‘difficult’ children were more likely to demonstrate ill-tempered parenting and poor social control in adult life, but this only emerged if they were married to non-assertive men. Difficult behaviour in childhood made it more likely that these women would marry non-assertive men, but when they did not, then poor parenting was avoided. As we shall see in Chapter 8, therapy, through empathy, affect co-regulation and limit-setting, may play a similar role to marriage in helping to modify maladaptive behaviours. This may be particularly applicable to those whose early experiences have made it hard for them, despite a longing for intimacy, to sustain close relationships at all (Parker et al., 1992).
Apart from very severe cases, there is no simple correlation between childhood mental states and adult difficulty. There are a number of environmental, and to some extent accidental, mediating factors which determine whether outcomes are favourable or not: the area a person grows up in, the school they go to, whether or not they happen to meet the right person at the right time. Nor is there a simple relationship between environmental stress and disturbance; the meaning and context of a particular event is critical. A teenager who storms out of the house after a row about what time he should come home, followed by the threat of ‘you'll be the death of me’, and who returns to find that his father has died suddenly is going to be more vulnerable to difficult relationships (perhaps characterised by avoidance and inhibition of anger and therefore poor conflict resolution), than one whose parent dies peacefully over several months with good opportunities for grieving. Also, it is important to see the ‘victim’ of deprivation not as a passive recipient of stress but as an active agent, in a dynamic relationship with his environment, trying to make sense of experience, to master it and to cope as best he can, but also, via the benign and vicious circles of neurosis, as an active participant in his own downfall or deliverance.
Maternal deprivation emerges from this account not as the cause of neurosis, as perhaps Bowlby initially thought, but as one, albeit vital, vulnerability factor among many in a complex web of developmental influences. Since nothing succeeds like success, and nothing fails like failure, these influences may summate in retrospect to give the impression of a simple choice between primrose or thorny paths, but there are in fact many ‘roads less travelled’ (Frost, 1954) and it is the psychothera-pist's task to explore these. The circularity of neurotic patterns both in the present and over time is a central unifying concept, and suggests how and why many different kinds of intervention may be effective. Analytic therapy may be an example of how one good relationship can counteract many adverse influences: the nature of that good relationship will be considered further in later chapters. Cognitive-behavioural therapy concentrates on increasing a person's sense of self-efficacy, and reducing the generalisation of bad feelings so that self-esteem remains intact despite loss. Family and marital therapy tackle relationships directly, thereby enhancing the buffering against stress. All types of time-limited therapy assume that if a person can be helped to re-engage with the benign cycles of normal life (although feminists argue that the definition of what constitutes a ‘normal’ family needs to be contested), then outcomes will be good, since, in Bowlby's (1952a) words, ‘there is in almost all families a strong urge to live together in greater accord, and this provides a powerful motive for favourable change’.
We have moved from simple privation to the complexities of relationships, from loss to the nature of the bond that is broken, from a simple model of environmental trauma to a consideration of its psychological impact. The stage is set for Bowlby's move from maternal deprivation to Attachment Theory, and after a short literary diversion, we shall, in the next and following two chapters, follow him there.
Dickens' Oliver Twist, with its mixture of realism, caricature, and fairytale, can be seen as a classic account of maternal deprivation. Oliver, orphaned at birth, brought up ‘by hand’ for the first few months of his life, spends his childhood in the ‘parochial’ orphanage, ‘where twenty or thirty other juvenile offenders against the poor laws rolled about the floor all day, without the inconvenience of too much food or too much clothing’. Protesting against the ‘tortures of slow starvation’, he ‘asks for more’, is sent out to work for his pains. After running away from further cruelty, he falls among thieves and so begins his career as a delinquent, much as Bowlby would have predicted; but here, despite many reversals and cruel twists, his fortunes change. He is rescued first by the kindly Mr Brownlow, and a second time by the loving Rose Maylie. He is recognised as being in some way different from the run of juvenile thieves. In two crucial passages he is watched over by these parental figures in his sleep:
The boy stirred, and smiled in his sleep, as though these marks of pity and compassion had awakened some pleasant dream of a love and affection he had never known … some brief memory of a happier existence, long gone by.
Later, anticipating Winnicott's (1965) concept of ‘alone in the presence of the mother’ – a watching maternal presence that provides the security needed for ‘dreaming’ (metaphorical as well as literal) to flourish – Oliver once again sleeps after a terrifying escapade of attempted robbery in which he is wounded, watched over by the tender Rose Maylie:
It is an undoubted fact, that although our sense of touch and sight be dead, yet our sleeping thoughts, and visionary scenes that pass before us, will be influenced … by the mere silent presence of some external object.
[Italics in the original]
The book ends happily, of course, with Oliver's affluent parentage established, evil (in the shape of Monks, Sykes and the Bumbles) vanquished, and with the beginning of secure attachment:
Mr Brownlow … from day to day filling the mind of his adopted child with stores of knowledge, and becoming attached to him, more and more, as his nature developed itself. …
[My italics]
The universality of Dickens' message means that each generation can bring to the story their own themes and preoccupations. For the Victorians it was a social tract documenting the iniquities of the poor laws, and a contrast between the cruelties of the bad father and the benign love of Mr Brownlow; but this is no sentimental Victorian morality tale. The powers of good and evil are evenly balanced. Mr Brownlow's benign Bowlbian view of the perfectibility of human nature is contrasted with the cynical realism of his friend Mr Grimwig, who, at least in the short run, wins his wager that Oliver will take Mr Brownlow's money and run.
A Kleinian reading might see in its exaggerations and description of unbearable hunger an account of the ‘bad breast’ and the projection into it of the child's hatred and rage. As Oliver's bad feelings are balanced by good ‘therapeutic’ experience, so he becomes strengthened in his resolve to escape from the clutches of Fagin and Sykes, and sees them and the Bumbles no longer as phantasmagoric creatures of enormous power but as the seedy petty criminals for which they are.
A Bowlbian perspective on Oliver Twist might home in on the mystery of Oliver's parentage. The book opens with the description of a place – the orphanage where Oliver was raised. It ends with a name – Agnes, Oliver's mother, a name on a tomb:
There is no coffin in that tomb … But, if the spirits of the dead ever come back to earth, to visit spots hallowed by the love – the love beyond the grave – of those whom they knew in life, I believe that the shade of Agnes sometimes hovers round that solemn nook.
In finding his story, Oliver has found his lost mother even though he has never met her in reality, and can never do so, not even in her coffin. The movement from the concrete attachment to person and place of childhood to the possession as adults of a story, of a name which has been internalised, is a theme common to literature and to psychotherapy. The book is closed, the parents who both nurtured and failed in their nurturing are no longer with us, but as internal objects they remain, for good or ill. Therapy reawakens past attachments so that they can live inside us again. The progress from attachment to narrative is part of the Bowlbian story too: we shall examine it more closely as our account progresses.
