None of us can help the things life has done to us. They’re done before you realise it, and once they’re done they make you do other things until at last everything comes between you and what you’ld like to be, and you’ve lost your true self for ever.
EUGENE O’NEILL, Long Day’s Journey into Night
IN CHAPTER 2, in a discussion of the development of psychoanalytic theories of mourning, we draw attention to eight areas about which there has been and still is controversy. Of these the eighth and last concerns the stage of development and the processes whereby an individual arrives at a state which enables him thereafter to respond to loss in a healthy manner. Traditionally, because of Freud’s theory of libidinal stages and his classic paper linking mourning to melancholia, or depressive disorder as it would now be called, this question has always been considered in the context of trying to understand the fixation point to which depressive patients regress. In attempting to answer it, we note, most though not all psychoanalytic formulations postulate the stage as occurring in earliest infancy, and therefore carry with them the presumption that the capacity to respond to loss in a favourable manner should, if all goes well with development, be attained in this very early period. From this theoretical position a deduction that necessarily follows is that, if a child has developed favourably during the stated period, his response to a separation occurring later will be a healthy one. Thus, since all these hypotheses hold that the period in question (whether defined as a phase of orality, symbiosis, primary narcissism or primary identification, or as the one during which the depressive position is normally reached) occurs either before the first birthday or soon after it, each in effect predicts that a child who has developed favourably during that period will respond healthily to a loss sustained in the second, third or later years. This means that, in principle, these hypotheses are capable of empirical test.
Although the data from which we start see (Chapter 1) have not been collected with the purpose of testing hypotheses of this kind, in so far as our data bear on them they do not support them. Children whose previous development appears to have been reasonably favourable may nevertheless respond to a separation from mother occurring during the second, third and fourth years of life with mourning processes that have features typical of pathology; and whether the response is a pathological one or not appears to be determined in very high degree by the way a child is treated during the period of separation and after it see (Chapters 23 and 24). In adverse conditions both yearning for and reproach against the deserting mother become redirected and cognitively disconnected from the situation that elicited them and, as a result, remain active though more or less unconscious.1 Although it would be extraordinary were previous development to be without any influence on the course of mourning at these ages, there is no evidence that it is as crucial as is required by each of the hypotheses in question. Furthermore, in later chapters evidence is presented that shows that events of later years, notably loss of mother before the tenth or eleventh birthday, when combined with certain other conditions can play a causal role in the development of depressive disorder.
Whether these conclusions are confirmed or not, traditional theory remains open to questioning on at least two other grounds. The first is the assumption that an hypothesis that is valid for depressive disorder is necessarily valid also for disordered mourning. The second and more serious point at which traditional theory is vulnerable concerns both the evidence and the reasoning which have led to the belief that depressive disorder is due always to a fixation having occurred during the first year. When these propositions are examined it is found that evidence for them is weak (Bowlby 1960b). As a result the belief, derived from them, that the main determinants of disordered mourning are operative during earliest development is ill-based.
It is of much interest, therefore, that within the central tradition of psychoanalytic thinking various alternative theories regarding the developmental roots of depressive disorder, and by implication of disordered mourning also, are already implicit or explicit, for example in the work of Abraham (1924a), Gero (1936), Deutsch (1937), and Jacobson (1943).2 In these studies loss of mother or of mother’s love during childhood have been implicated. Furthermore, later studies of the childhood experiences of those who, during adult life, are prone to depression draw attention to a number of other forms of serious disturbance in a child’s relation to his parents (usually but by no means always his mother).
It is time to make plain the position adopted in this work. It stems from an examination of several more or less independent sets of data, most of which are already reviewed in this volume or else in Volume II. These are as follows:
(a) evidence regarding the patterns of affectional relationships that persons prone to disordered mourning are biased to make (Chapter 11);
(b) evidence, derived from broader studies (reviewed in Volume II, Chapters 15–19), regarding the childhood experiences of persons whose affectional relationships tend to take the forms referred to in (a):
(c) evidence regarding the types of psychosocial conditions acting at the time of or after a loss that are found to influence the course of mourning either for better or for worse (this volume, Chapter 10);
(d) evidence regarding the psychological features that are found to characterize disordered mourning itself (this volume, Chapter 9);
(e) and, finally, such fragmentary evidence as we have regarding the childhood experiences of persons whose mourning has taken a pathological course (who overlap but are not identical with persons who have developed a depressive disorder). Again and again reports of those suffering disordered mourning refer to them as having been unwanted as children, to their having been subjected to separation from or loss of parent, or to their having had an unhappy or stressful childhood for some other reason.3 Not infrequently details of these experiences are missing; yet, by making use of such information as we have and viewing it in the light of information from other sources, it is not difficult to propose what their nature may have been.
The hypotheses advanced here regarding the childhood experiences that predispose an individual towards a pathological response to loss are, it is held, both consistent with such evidence as we have from all these different fields and also capable of empirical test.
Before detailing hypotheses, however, it may be useful to remind the reader of the overall theoretical position adopted in this work (set out in earlier volumes, notably the final chapter of Volume II, ‘Pathways for the Growth of Personality’), and to indicate how it applies to our problem:
(a) Disturbances of personality, which include a bias to respond to loss with disordered mourning, are seen as the outcome of one or more deviations in development that can originate or grow worse during any of the years of infancy, childhood and adolescence.
(b) Deviations result from adverse experiences a child has in his family of origin (or during substitute care), notably discontinuities in his relationships and certain ways in which parent-figures may respond, or fail to respond, to his desire for love and care.
(c) Deviations consist of disturbances in the way the attachment behaviour of the individual concerned becomes organized, usually in the direction either of anxious and insecure attachment or else of a vehement assertion of self-sufficiency.
(d) Although deviations, once established, tend to persist, they remain sensitive in some degree to later experience and, as a result, can change either in a more favourable direction or in an even less favourable one.
(e) Amongst types of later experience that can affect development favourably are any opportunities that arise that give the individual—child, adolescent or adult—a chance to make a relatively secure attachment, though whether he can make use of such opportunities turns both on the way his attachment behaviour is already organized and on the nature of the relationship that is currently offered.
We turn now to the relevant childhood experiences found as antecedents of the three patterns of vulnerable personality described in the previous chapter: personalities exhibiting anxious and ambivalent attachments; personalities disposed towards compulsive caregiving; and personalities assertive of independence of all affectional ties.
The childhood experiences of persons prone to make anxious and ambivalent attachments are considered at length in Chapters 15 to 19 of Volume II. Evidence is presented that individuals of this sort are far more likely than are those who grow up secure to have had parents who, for reasons stemming from their own childhoods and/or from difficulties in the marriage, found their children’s desire for love and care a burden and responded to them irritably—by ignoring, scolding or moralizing. In addition, anxious persons are more likely than others to have had further upsetting experiences as well. For example, some will have received daily care from a succession of different people; some will have experienced limited periods of residential care in which they received little or no substitute mothering; some will have had parents who separated or were divorced;4 yet others will have suffered a childhood bereavement see (Chapter 17).
Nevertheless, although those who make anxious and ambivalent attachments are likely to have experienced discontinuities in parenting and/or often to have been rejected by their parents, the rejection is more likely to have been intermittent and partial than complete. As a result the children, still hoping for love and care yet deeply anxious lest they be neglected or deserted, increase their demands for attention and affection, refuse to be left alone and protest more or less angrily when they are.
This is a picture of childhood experience and development which is the exact opposite of the one of overindulgence and spoiling which has not only been widespread as a popular belief but which, most unfortunately, became incorporated early into psychoanalytic theory. Amongst the many undesirable results of this is that childhood experiences that, it is now clear, play an influential part in predisposing a person towards responding to loss by disordered mourning have either been overlooked or given but scant attention.
An adult patient suffering disordered mourning who described a relationship with her mother which I believe is not atypical is Julia, who (as described in Chapter 9), after her mother died, had retained, unused, a red gown from which she had pictured her mother emerging.5
Julia, an educated black secretary, was first seen eight months after her mother died. Amongst her symptoms were loss of interest, extreme preoccupation with her mother’s image, insomnia and disturbing dreams about her mother from which she awoke in a panic feeling her mother ‘might not be gone’. Although Julia had maintained a cheerful façade toward others, it seems likely that her condition would have progressed to one of chronic mourning.
During therapy Julia gave the following account of her life. She was the youngest child in a family which seems to have had many difficulties. For example, when she was six months old her mother had been bedridden for a year because of severe burns and her father had taken to drink; Julia herself had been cared for by her elder siblings. After leaving school she had remained at home to look after her mother who was by then a widow crippled with diabetes. To do so had entailed Julia’s surrendering college scholarships and also offers of marriage and, instead, becoming something of a martyr. Constantly anxious about her mother’s health, she had slept at the foot of her mother’s bed so that during the night she could frequently check that her mother was still alive. During the day she had made similar checks by means of the telephone.
Julia seems always to have been ‘picked on’ by her mother, who is described as having been ‘extremely demanding, domineering, critical and often disparaging and humiliating’ and for whom the elder children had had little time. Not surprisingly Julia, as she confessed later, had often wished her mother dead; amongst the dreams she had and recounted during therapy was one in which she had pushed her mother in her wheelchair over a cliff.
In this record, as occurs so often in clinical literature, although we are told of the tyrannical ways of Julia’s mother, no content is given of what she actually said. What, we wonder, were the words and phrases in which mother expressed her demands and criticisms? In what terms and tones did she disparage and humiliate Julia? Using clinical experience as a guide, we should expect that, at the least, mother would have belittled Julia’s efforts to help, complained that she was being neglected, and have blamed Julia for every setback in her condition. If my hypotheses are valid, informed enquiry would probably have revealed much else in a similar vein.
In earlier discussion of the childhood experiences that lead to the most intense anxiety, especial emphasis is laid on a parent’s threats to abandon a child or commit suicide. When exposed to such threats, which are often made deliberately by an exasperated mother in an attempt to control him, a child becomes extremely anxious lest he lose her for ever. He is likely also to become angry with her, though until adolescence he is unlikely to express it overtly and directly. Whether the resulting behaviour is one of anxious conformity or of angry rebellion, with a veneer of not caring, turns partly on whether there is genuine parental affection in addition to the threats and partly on the sex, age and temperament of the child. In either case the individual has been brought up to believe unquestioningly that, if his mother disappears, the blame lies firmly on his own shoulders. Small wonder therefore if, when his mother does die, or in later life his spouse, he should blame himself for its having happened.
In addition to the children who are exposed to these crude and frightening threats are others whose parents use more subtle pressure. A threat not to love a child unless he conforms to requirements is one such. To this can be added insistence that the child is intrinsically unlovable and no one but a dedicated and self-sacrificing parent would put up with his presence.
A special case of an intensely ‘dependent’ relationship is one in which a parent has been using techniques of these kinds to coerce a child to care for her (for reasons that are easy to understand once the parent’s own childhood experiences are known, see Volume II, Chapter 18). The following account of a 45-year-old bachelor who became severely depressed after his mother’s death illustrates how this type of relationship can develop and also how it leads to a pathological response to loss. In this case information came from the patient himself during the course of therapy, which began two years after his bereavement.6
As an only child whose father had departed while he was still an infant, Mr D had been brought up solely by his mother; and the two had lived alone together until her death. Initially during therapy he spoke of her as though she were an other-worldly and superior being. Later, however, it became evident that behind this idealized picture there was a woman who in a tyrannical way had demanded his absolute obedience whilst simultaneously ridiculing any attempt he might make at an independent existence. Mr D had grown up to believe he was a burden on his mother, was undeserving of her love and attention, and could only be accepted by her if he exerted his every effort. After reaching adult life he had remained living with her ‘in a near-servile capacity’ and had supported her financially until her death.
After she died he had despaired of his future, had given up his job and had only gone out either to buy food or else to visit doctors for a variety of somatic complaints. When his savings were gone he sold his belongings and moved into a shabby furnished room.
In commenting on the case, Bemporad notes how Mr D had accepted both his mother’s valuation of himself and the role she had demanded he take. Viewed in the perspective adopted here we note in addition how he had also accepted his mother’s valuation of herself and how she had bound him to her by a number of interlocking techniques. On the one hand she had made her love and approval turn on his conforming to her every requirement, especially that he care constantly for her; on the other she had led him to believe that he was intrinsically unlovable and would therefore never win the love of anyone else.
In the case neither of Mr D nor of Julia does the therapist discuss the possibility that the patient’s mother may have used threats to abandon the patient as a means of achieving her ends. Yet I believe that, unless this possibility is specifically explored and no evidence for it found, it is unwise to assume that no such threats were ever made.
In addition to pressures illustrated in these cases, or discussed, there are yet others which a parent can use to ensure a child’s obedience. For example, it is very easy to induce a sense of guilt by insisting to a child from his earliest years that his bad behaviour is making his mother (or father) ill and will, if continued, lead to her (or his) death. This leads to a consideration of the childhood experiences of those who grow up compulsively disposed towards caring for others.
No systematic study seems to have been made of the childhood experiences that contribute to this disposition. Nevertheless, clinical experience and the study of individuals diagnosed as cases of school refusal or agoraphobia (Volume II, Chapters 18 and 19) point unmistakably in certain directions.
At least two, rather different, types of childhood experience are found in the histories of those who become compulsive caregivers.
One is intermittent and inadequate mothering during early childhood which may culminate in total loss. Since this is discussed in later chapters (21 and 23) it is unnecessary to go further here.
Another type of experience is when pressure is put on a child to care for a sick, anxious or hypochondriacal parent. In some such cases the child is made to feel that he himself is responsible for his parent’s being ill and therefore has an obligation to act as caregiver. In others, whilst not held responsible for the illness, he is none the less made to feel he has a responsibility to care for his parent. Since in a majority of cases the parent is the mother, what follows is written as though that were always so.
In some cases the mother is physically ill. In one such, a woman became pregnant most unexpectedly in her mid-forties and, after a difficult pregnancy and labour, suffered chronically from high blood-pressure. The baby, a boy (who had obviously been unwanted), during his childhood was left in no doubt that it was he who had made his mother ill and that it was therefore his responsibility to care for her. This he did devotedly until she died when he was adolescent. Once he had left school and was earning he became strongly drawn to a much older woman who had herself lived a deeply troubled life; and he proceeded to shoulder the responsibility of caring for her.
In another such case the mother of a five-year-old boy had severe diabetes. One night she fell into a diabetic coma and was removed by ambulance to hospital, where she recovered. Subsequently mother came to rely on her son to help her with her insulin injections and to care for her in other ways. This he did, constantly haunted by the memory of his mother being taken from the house in what to him had seemed a dying state. Intensely anxious lest something similar should recur when he was asleep or out of the house, he stayed awake at night and began refusing to attend school; at the age of ten he was referred to the Tavistock Clinic as a ‘school phobic’.
This case illustrates the similarity there is between the family experiences that lead to the form of personality now under discussion and the family experiences of individuals diagnosed as suffering from either school or agoraphobia.7 In the backgrounds of each there is likely to be a parent who has used, and who may still be using, strong pressure to invert the relationship by requiring the son or daughter to do the caregiving. In both types of case the more that moral and other pressure has been applied to the son or daughter the more tied to the parent he or she becomes, the more anxious and guilty about leaving home and the more bitterly resentful in his heart at being treated thus. Furthermore, should the parent in fact become seriously ill, it is almost inevitable that the caregiver should become even more frightened and guilt-ridden. Finally, should the parent die it is easy for the caregiver to take all the blame and, directing resentment against himself, to develop chronic mourning.
The evidence regarding the family experiences and patterns of affectional relationships of patients who come to be diagnosed as either school phobics or agoraphobics, and the current events that precipitate them into an emotional crisis, evidence that is set out in Chapters 18 and 19 of Volume II, is at each point consistent with the views expressed in this chapter. It is therefore of particular interest that, in a significant proportion both of children and of adults diagnosed as phobic, the acute condition has been preceded by the sudden illness or death of a parent or other close relative, usually, writes Roth (1959), of’a parent upon whom the patient has been extremely dependent’.
Because no systematic studies have been undertaken of the childhood experiences of persons given to asserting their emotional self-sufficiency we are once again dependent for information on a heterogeneous collection of clinical reports. From them, however, certain patterns emerge fairly clearly.
As in the case of compulsive caregiving, two rather different types of childhood experience seem to be prevalent. One is the loss of a parent during childhood, with the child being left thereafter to fend for himself. The other is the unsympathetic and critical attitude that a parent may take towards her child’s natural desires for love, attention and support. Not infrequently, it seems, a person who grows up to assert his independence of affectional ties has been exposed to a combination of experiences of these kinds.
Families differ enormously in the extent to which they take account of the role of affectional bonds and attachment behaviour in the lives of family members. In one family there may be deep respect for affectional bonds, ready response to expressions of attachment behaviour, and sympathetic understanding of the anxiety, anger and distress aroused by temporary separation from a loved figure or by permanent loss. Open expression of thought and feeling is encouraged and loving support provided when asked for. In another family, by contrast, affectional bonds are little valued, attachment behaviour is regarded as childish and weak and is rebuffed, all expression of feeling is frowned upon and contempt expressed for those who cry. Because they are condemned and despised, a child comes ultimately to inhibit his attachment behaviour and to bottle up his feelings. Furthermore he comes, like his parents, to view his yearning for love as a weakness, his anger as a sin and his grief as childish.
Some individuals who are exposed to the latter type of family experience during childhood grow up to be tough and hard. They may become competent and to all appearances self-reliant, and they may go through life without overt sign of breakdown. Yet they are likely to be difficult to live and work with, for they have little understanding either of others or of themselves and are readily aroused to smouldering jealousy and resentment. Moreover, should they develop trust enough to confess it to a therapist, their feeling of being isolated and unloved may be sad in the extreme; whilst, especially in later years, they are at risk of depression, alcoholism and suicide. Even when they do not become psychiatric casualties themselves they can often be responsible for the breakdown of others—spouse, children or employees. Winnicott (1960) has used the term ‘false self’ to describe the self such a person experiences and which, willingly or unwillingly, he presents to the world. This term is much to be preferred to ‘narcissistic’ which is another sometimes used by psychoanalysts to describe these individuals.
Not everyone exposed to this type of childhood experience develops a highly organized personality, however. In many the hardness and self-reliance are more brittle and it is from amongst these persons, it seems likely, that a substantial proportion of all those who at some time in their life develop a pathological response to loss are recruited. A prolonged absence of conscious grieving is the likely form. Examples are given in Chapter 9—see the accounts of Mrs F and Mr AA.
The following account of a young man of 23, whose efforts at self-sufficiency were fast failing, describes many features that I believe to be typical of individuals of this sort. The account is presented, not as one of disordered mourning, but because of the telling details it gives of how this young man recalled having been treated as a child and of how he had reacted.8
When seen by a psychiatrist prior to being admitted to hospital Mr G was severely depressed and spoke unemotionally about the likelihood of killing himself. A year previously he had made a half-hearted attempt; next time, he remarked, he would make sure of it. When offered admission he accepted it in a flat passive way, maintaining however that his state of mind was less an illness than ‘a philosophy of life’. At that time there seemed a serious possibility of schizophrenia.
He was a tall handsome young man who in hospital never showed psychotic features; but he soon made himself fairly conspicuous by combining co-operative with unconventional behaviour.
In two interviews with his psychotherapist prior to starting treatment he described what to her appeared as having been ‘a lifetime of anxiously pretending to be an independent person’. Although at school he had been good at both work and sport, he had been extremely uneasy about competing and had deliberately refrained from winning; nevertheless he had got to university and had taken a degree. Although he could never tolerate being alone, to be with others created conflict. On the one hand he was eager to be recognized; on the other he was petrified lest his contributions should fall flat. Often, he said, he would become cynical and sarcastic.
For a time he had been engaged to be married; but this also produced conflict. For not only was he intensely afraid of his fiancée leaving him but he was afraid also of becoming too dependent on her. When she looked elsewhere he became extremely jealous; and he then tried to cure himself of jealousy by urging her to be unfaithful to him. When he realized she had followed his prompting he had felt extremely anxious: ‘not anger,’ he claimed, ‘but something went out of me’.
Mr G was the eldest of a large Catholic family; and by the time he was three two siblings had already been born. His parents, he said, quarrelled both frequently and violently. When the family was young father had been working long hours away from home training for a profession. Mother was always unpredictable. Often she was so distraught by her quarrelling children that she would lock herself in her room for days on end. Several times she had left home, taking the daughters with her but leaving the sons with father.
He had been told that he had been an unhappy baby, a poor feeder and sleeper, who had often been left alone to cry for long periods. His crying, it was said, had been just an attempt to gain control of his parents and to be spoilt. On one occasion he had had appendicitis and he remembered lying awake all night moaning; but his parents had done nothing and by next morning he was seriously ill. Later, during therapy, he recalled how disturbed he used to be at hearing his younger brothers and sisters being left to cry and how he hated his parents for it and felt like killing them.
He had always felt like a lost child and had been puzzled to understand why he had been rejected, or at least should have felt rejected. His first day at school, he said, had been the worst in his life. It had seemed a final rejection by his mother; all day he had felt desperate and had never stopped crying. After that he had gradually come to hide all desires for love and support; he had refused ever to ask for help or to have anything done for him.
Now, during therapy, he was frightened he might break down and cry and want to be mothered. This would lead his therapist, he felt sure, to regard him as a nuisance and his behaviour simply as attention-seeking; and were he to say anything personal to her, she would be offended and perhaps would lock herself in her room.
Treatment progressed unexpectedly fast. This was due probably in part to the ‘false self’ being not too firmly organized and in part to his therapist, following Winnicott, having a clear understanding of what his true desires and feelings were. Subsequently, in an account he gave of himself prior to treatment, he described how over many years he had been vaguely aware of there being ‘two me’s, the real me . . . petrified to reveal itself . . . [which] hated the other me . . . which complied with social demands’. The real me, he said, would sometimes emerge briefly, for example when he felt empathy for someone in the same situation as himself. There had been occasions, he wrote, when he felt he might be inspired ‘to undertake some great mission to reform mankind from a loveless miserable world’. It remains unstated in the published account what had led to Mr G’s breakdown. Evidence strongly suggests, however, that it was the end of his engagement, even if, as seems probable, he himself had played a major part in bringing it about.9
Returning now to our theme, we note that, already in Chapter 9 there are accounts of individuals whose mourning was progressing unfavourably and who had described how, thanks to childhood experience, they had developed a protective shell for themselves, e.g. Mrs I, or had been taught to bottle up feeling, e.g. Mrs Y. Towards the end of Chapter 10, moreover, there are accounts by bereaved people of the obstacles to grieving created by the enjoinders of relatives and friends that they pull themselves together and stop crying. Conversely, we have learned how helpful it is to a bereaved person when opportunity is given him to dwell on every detail of the past, to express yearning, anger and sorrow and to weep.
In the light of these considerations, and also of reports of the effects on young children of a parent insisting they do not cry see (Chapters 1 and 23), the hypothesis is advanced that a major determinant of how a person responds to a loss is the way his attachment behaviour, and all the feeling that goes with it, was evaluated by his parents and responded to during his infancy, childhood and adolescence. Especially adverse effects are attributed to disparaging and sarcastic remarks by parents and parent-surrogates made whenever a child is distressed and seeks comfort. The injunctions ‘Don’t cry’, ‘Don’t be a cry-baby’, ‘I won’t love you if you cry’, can, it is postulated, do untold harm, especially when uttered in contemptuous tones. Instead of being permitted to share occasions of fear, unhappiness and grief, an individual treated thus is driven in on himself to bear his sorrows alone. The earlier in life this starts, moreover, and the more insistent the pressure the more damage, I believe, will be done.
In this chapter it has been convenient to consider under separate headings the various types of childhood experience that evidence suggests are responsible, in large part, for the various forms of personality identified as prone to develop disordered mourning. Naturally, in real life, every combination of such experiences may occur and, stemming from them, a corresponding variety of forms of disturbed personality. In the next chapter the main features of disordered mourning and the psychological processes responsible for it are examined in the light of the theoretical position outlined in Chapter 4.
1 In traditional terminology it would be said that yearning and reproach become displaced and repressed.
2 For a comprehensive review of psychoanalytic thinking about depressive disorders, see Mendelson (1974).
3A recent study of the responses of analysands to the death of their analysts, by Lord, Ritvo and Solnit (1978), shows a strong association between a history of loss and deprivation during early childhood and disordered mourning. Of 27 patients studied, ten responded with ‘complicated and prolonged mourning’ and eleven with ‘normal’ mourning. All ten of the former group ‘had been exposed to significant emotional deprivation, which included either actual or psychological abandonment, or both’. This contrasted with a much lower incidence of such experiences in those responding with normal mourning.
4 In the Harvard bereavement study, Parkes et al. (in preparation) report that those with a high score for ambivalence see (Chapter 11) were significantly more likely to have had parents who had been separated or divorced than were those with a low score; the incidence was 27 per cent and o per cent respectively. There was also a significant difference for loss of mother by death, the incidence of that being 33 per cent and 17 per cent respectively. By contrast the incident of loss of father by death was reversed: namely, 7 per cent and 30 per cent respectively.
5 This account, rewritten, is taken from Volkan (1975, pp. 340–4).
6 This account, rewritten, is taken from Bemporad (1971).
7 Since writing Chapter 19, Volume II, in which the close links between the phobic conditions of childhood and of adult life are discussed, further evidence has been published. In a follow-up study of 100 adolescents who had been treated for school phobia it was found that, after an interval averaging three years, about one-third were suffering from serious emotional disturbance, including six (five female and one male) who had developed severe and persistent agoraphobic symptoms (Berg et al. 1976). In another study it was found that, of the children aged 11 to 15 years of a group of agoraphobic women, no less than 14 per cent were reported as suffering from school phobia. The mothers of these school-phobic children were more likely than were other mothers to give a history of having themselves suffered from school phobia as children (Berg 1976). These findings strongly support the view that the two conditions share much of the same psychopathology.
8 This account is a much abbreviated version of a fairly full case report by Lind (1973) in which she draws on material from the referral letter, from brief notes made after each of a total of 19 twice-weekly therapeutic sessions, and from an account, written by the patient after treatment had ended, in which he describes his state of being before and after treatment. The historical material, she notes, ‘was not conveyed in more than fragments until after he had changed’. From a scientific point of view a major deficiency is that all the information regarding the patient’s childhood comes from the patient himself and therefore remains uncorroborated.
9 Discussion of this patient’s psychopathology in terms of the theory sketched in Chapter 4 will be found towards the end of the next chapter.