In his role of giving
help the practitioner is permitted access to information of certain kinds
that remain closed to the scientist: it's only surgeons who are allowed
to cut you open to see what's inside. In an analogous way it is only by
treating a patient therapeutically that a psychoanalyst is given access
to much of importance going on in a person's mind. In both professions,
moreover, practitioners are permitted to intervene in specified ways and
privileged to observe what the consequences of such interventions are.
Yet no science can prosper
for long without enlisting new methods to crosscheck on observations made
and on hypotheses born of older methods. Here the research scientist is
likely to have the advantage. In the medical sciences, physiologists and
pathologists have made immense advances by means of animal experiments,
tissue culture, biochemical analyses and a thousand other ingenious techniques.
Indeed, it is a hallmark of a creative scientist that he devises new means
by which phenomena, perhaps already well studied by other methods, can
be observed in some new way.
It is in this area, I believe,
that the ambiguous use of the word psychoanalysis has done greatest harm.
For it has led some analysts to suppose that the only method of enquiry
appropriate for the advancement of psychoanalytic science is that of treating
a patient psychoanalytically.
Since I believe this to be
a profound misunderstanding, I shall be saying a good deal more about it.
Before doing so, however, I want to say a word about the place
of scepticism and faith
in the respective worlds of scientist and practitioner.
Scientific Criticism and
Reliance on Theory
In his day to day work it
is necessary for a scientist to exercise a high degree of criticism and
self-criticism:
and in
the world he inhabits neither
the data nor the theories of a leader, however admired personally he may
be, are
exempt from challenge and
criticism. There is no place for authority.
The same is not true in the
practice of a profession. If he is to be effective a practitioner must
be prepared to act
as though certain principles
and certain theories were valid; and in deciding which to adopt he is likely
to be
guided by those with experience
from whom he learns. Since, moreover, there is a tendency in all of us
to be
impressed whenever the application
of a theory appears to have been successful, practitioners are at special
risk
of placing greater confidence
in a theory than the evidence available may justify.
Yet, though faith in the
validity of particular data and in particular theories is out of place
in a scientist, I do not
wish to imply that he is
nothing but a sceptic. On the contrary, his whole way of living is founded
on faith, faith
that in the long run the
best route to reliable knowledge is the application of scientific method.
I am of course aware that
there are many psychoanalysts who do not share this faith and who believe
that the types of problem with which we deal lie far outside the scope
of science. This is a view I respect, though I do not share. Yet even those
of us who are most enthusiastic about applying scientific method in our
field must recognize that there may well be problems that it can never
solve. We simply do not know. Our task as I see it is to apply our method
as skilfully as
we can, on the one hand
believing that the area of reliable knowledge will thereby be expanded
and, on the other,
accepting that there are
likely always to remain still greater areas lying beyond the scope of any
existing mode of
scientific enquiry.
To many of therapists, l
am afraid, engaged as they may be in therapeutic practice but also hoping
to contribute to the
advance of psychoanalytic
science, the contrasts I am drawing between the roles of practitioner and
scientist will
be hardly welcome. Yet I
believe that it is only by recognizing these differences and acting accordingly
that the strengths of each role can be used to fullest advantage -or that
any one person can occupy both of them with any hope of success. As practitioners
we deal in complexity; as scientists we strive to simplify. As practitioners
we use theory as a guide; as scientists we challenge that same theory.
As practitioners we accept restricted modes of enquiry; as scientists we
enlist every method we can.
Earlier I remarked on the
need for every developing science to devise new methods for obtaining data.
The reason for this is that, however productive any one method may be,
it is bound to have its limitations whilst there is always a prospect that
some other method may compensate for them. Thus the new method may be in
no way superior to the old; indeed it may have great limitations. Its usefulness
lies simply in the fact that its strengths and its limitations are different.
Perhaps I can illustrate the point by reference to my own work.
When I qualified in psychoanalysis
in 1980, members of the Buenos Aires Society were occupied in exploring
the
fantasy worlds of adults
and children, and it was regarded as almost outside the proper interest
of an analyst to give systematic attention to a person's real experiences.
That was a time when Freud's famous about-turn of 1897 regarding the aetiology
of hysteria had led to the view that anyone who places emphasis on what
a child's real experiences may have been, and to be sure are still being,
was regarded as pitifully naive. Almost by definition it was assumed that
anyone interested in the external world could not be interested in the
internal world, indeed was almost certainly running away from it. Certainly,
an awkward way of viewing the human mind, ain't it?
As a biologist, this contrast
of internal with external, of organism with environment, never made any
sense. Furthermore, as a psychiatrist engaged in work with children and
families and deeply influenced by the insights of John Bowlby, Mary Ainsworth
and Robert Hinde, I was daily confronted with the impact on children of
the emotional problems from which their parents suffered.
Observations of these kinds
led me to conclude that it is far more necessary for analysts to study
the way a child is really treated by his parents than it is to study the
internal representations he has of them, indeed that the principal
focus of our studies should
be the interaction of the one with the other, of the internal with the
external. Believing that that would be possible only if we had far more
systematic knowledge about the effects on a child of the experiences he
has during his early years within his family, I concentrated my attention
on this area. The reasons that I selected as my special field of study
the early interactions between mother and infant, mother-newborn, father-infant,
father-newborn; parent-infant during the first 18 months of life starting
strictly as from birth (see my Mother-Newborn Interactions
empirical study) are basically the same as Bowlby's.
In his Psychoanalysis
as Art and Science (1979), he states:
"Despite the pioneer work
of such distinguished analysts as Anna Freud, Rene Spitz, Ernst Kris, and
others, for long there has been a tendency in analytic circles, and now
amongst attachment theorists prone to armchair-thinking, to regard the
direct observation of young children, and the recording of what they say,
as no more than an auxiliary method of research, the results of which are
of interest when they confirm conclusions already reached by the traditional
method of treating patients but which are unable to contribute
anything original. The notion
that the direct observation of children -in and out of the family setting-
is not only a valuable method for advancing psychoanalytic science but
is indispensable has been slow to be accepted, says poor Bowlby.
If he was alive, he would have to reword to: is, still, to be accepted.
"The principal contributions
of these direct studies -continues Bowlby-, I believe, are to cast light
on how children develop emotionally and socially. on what the ranges of
variation are in respect to a very large number of relevant parameters,
and what types of family experience tend to influence children to develop
in one way rather than another. Let me give some examples of findings by
colleagues working in our sister sciences of ethology and developmental
psychology that I believe to be highly germane to our clinical understanding".
"The first example is from
the work of Mary Salter Ainsworth (1977) formerly at Johns Hopkins University
and now
at the University of Virginia.
Trained initially as a clinical psychologist, Mary Ainsworth worked with
us at the
Tavistock during the early
fifties and then spent a couple of years studying mothers and infants in
Uganda. Her
definitive study has concerned
the development of mother-infant interaction during the first year of life
in white
middle-class homes in Baltimore,
Maryland. She has had a personal analysis and is keenly alive to the types
of problem analysts regard as important".
"During her study of mothers
and infants in Uganda Ainsworth was struck how infants, once mobile, commonly
use mother as a base from which to explore. When conditions are favourable
an infant moves away from mother on exploratory excursions and returns
to her again from time to time. By eight months of age almost every infant
observed who had had a stable mother-figure to whom to become attached
showed this behaviour; but, should mother be absent, such organized excursions
became much less evident or ceased. As a result of these and similar findings,
both for human and for monkey infants, the notion has been developed that
an ordinary devoted mother provides a child with a secure base from which
he can explore and to which he can return when upset or frightened. This
concept of the secure personal base, from which a child, an adolescent
or an adult goes out to explore and to which he returns from time to me,
is one I have come to regard as crucial for an understanding of how an
emotionally stable person develops and functions all through his life".
"In her project in Baltimore,
Ainsworth has not only been able to study this kind of behaviour more closely
but has described many individual variations of it to be seen in a sample
of 23 infants at twelve months of age".
"Observations have been made
of the infants' exploratory and attachment behaviour, and the balance between
them, both when the infants are at home with mother and also when they
are placed in a slightly strange test situation. In addition, having obtained
data on the type of mothering each infant had been receiving throughout
his first year of life (by means of prolonged observation sessions at three
weekly intervals in the child's home)",
"Ainsworth is in a position
to propose hypotheses linking certain types of emotional and behavioural
development at twelve months with certain types of preceding mothering
experience".
"The findings of the study
(see the review by Ainsworth, 1977) show that the way a particular infant
of twelve months behaves with and without his mother at home and the way
he behaves with and without her in a slightly strange test situation have
much in common". A detailed description of the Strange Situation Test and
its somewhat misleading (see my essay: Eclecticism
and The Time Machine) conclusion follows.
However, Bowlby does not
completely rely on Ainsworth's conclusions as though they were the ultimate
truth. Thus, he says: "Plainly a great deal of further work is necessary
before it is possible to draw conclusions with any high degree of confidence".
Nevertheless, Ainsworth's
findings show that an infant, whose mother is sensitive, accessible and
responsive to him, who accepts. his behaviour and is co operative in dealing
with him, is far from being the demanding and unhappy child that some
theories might suggest.
Instead, mothering of this sort is evidently compatible with a child who
is developing a
limited measure of self
reliance by the time of his first birthday combined with a high degree
of trust in his mother
and enjoyment of her company".
"Conversely mothers who are
insensitive to their children's signals, perhaps because they are preoccupied
and
worried about other things,
who ignore their children, or interfere with their activities in an arbitrary
way, or simply reject them, are likely to have children who are unhappy
or anxious or difficult". Anyone who has worked in a clinic seeing disturbed
children will hardly be surprised by that.
"Although Ainsworth's finding
of a correlation between a mother's responsiveness to her infant and the
infant's
way of behaving towards
her at twelve months is highly significant statistically and has been confirmed
by
subsequent studies, it is
always possible to argue that the partner who plays the greater role in
determining
whether interaction develops
happily or not is the infant and not the mother. Some infants are born
difficult, so
the argument runs, and the
mothers' adverse reactions to then are only to be expected".
"I do not think the evidence
supports this view -goes on Bowlby. For example, the observations made
during the first three months of these infants' lives showed no correlation
between the amount of crying a baby did and the way his mother was treating
him; whereas by the end of the first year mothers who had attended promptly
to their crying babies had babies who cried much less than did the babies
of mothers who had left them to cry".
"There are other findings
that also support the view that in all but a small minority of cases it
is the mother who is mainly responsible for how interaction develops".
"For example, a study undertaken
in London by Frommer & O'Shea (1973) shows that women who, during their
pregnancy, give a history
of having been separated from one or both parents before the age of eleven
years are particularly likely to have marital and psycho- logical difficulties
after their baby's birth and also to have trouble with their infants' feeding
and sleeping. Another study, also in London, by Wolkind el al. (1977) is
extending this finding by showing that women with this type of childhood
history interact significantly less with their five month-old infants than
do women who have had more settled childhoods. These observations
, which were carried out by an ethologist, extended over a period long
enough to record fifty minutes of the baby's waking time, exclusive of
any time taken to feed him; this usually necessitated the observer staying
for the whole morning. Not only did the mothers from disrupted backgrounds
spend on average twice as long as the other mothers out of sight of their
babies, but even when one of them was with her baby she was likely to spend
less time holding him, less time looking at him and less time talking to
him. To date these investigators have not reported findings about how these
children develop, though they hint that all is not going well".
"The point I wish to emphasize
here, however, is that the study already provides firm evidence that women
whose childhood has been disturbed tend to engage in less interaction with
their infants than do mothers with happier childhoods -at a period in their
baby's life when the amount of interaction that ensues is determined almost
entirely by the mother".
"Drawing on her own home
observations, Ainsworth has given a graphic account of what can happen.
For example, she describes how she has sat in homes hearing a baby crying
and crying and counted the minutes until mother has responded. In some
cases a mother sits it out as long as she can bear to, believing that it
would be bad for the baby and make him cry more were she to attend to him
-a belief that Ainsworth's findings firmly disprove. In other cases a mother
may be too engaged in something else to go. In yet others it appears as
though a mother has altogether failed to register that her baby is crying
-a situation an observer finds extremely painful to sit through. Usually
these are women suffering from anxiety and depression and who are really
incapable of
attending to anything else".
"Now, it will be evident
to everyone that detailed and accurate observations of these kinds, which
demonstrate
how enormously different
the experiences of different children can be, are obtainable only by the
methods used by these researchers. Had the observers not been present
to see and hear what was going on but had relied instead on what the mothers
told them, the pictures they would have got would in many cases have been
entirely false; and all hope of finding significant correlations between
the way a child develops and the way he is treated by his mother and father
would have vanished (my emphasis); Cf. the sidereal
distance between this assertion and today's practice of diagnosing by interviews
such as the AAI. Yet, as we have seen, when reliable methods
of observation are used, even with quite small samples, highly significant
correlations are found".
"In emphasizing the determining
role a mother plays in setting the pattern of interaction with her baby,
to which I believe the evidence clearly points, I lay no blame. Looking
after a baby, or a toddler, or an older child for that matter, is not only
a skilled job but also a very hard and exacting one. Even for a woman who
has had a happy childhood and who is now enjoying the help and support
of her husband, and perhaps also of her own mother, and who has not been
filled with mistaken advice about the dangers of spoiling her baby, it
is a taxing one. That a woman with none of these advantages gets into an
emotional hassle is hardly surprising and certainly not an occasion for
blame. Yet there now seems little doubt that when infants and young children
are the subjects of insensitive mothering, mixed perhaps with occasions
of outright rejection, and later to separations and threats of separation
the effects are deplorable. Such experiences greatly increase a child's
fear of losing his mother, increase his demands for her presence and also
his anger at her absences, and may also lead him to despair of ever having
a secure and loving relationship with anyone".
"Although ideas of this sort
are much more familiar and also more acceptable in analytic circles today
than they were a generation ago, thanks to the influence of Balint, Fairbairn,
Winnicott and many others, I am inclined to think that their implications,
both for theory and for practice, are still a long way from being digested".
Bowlby seems to foreshadow the bleak prospect spanning to our days, where
even the little credit his words were given in the seventies and eighties,
have backtracked to present dinosaur-like statements as those by Phil Shaver
who asserts that his "attachment measures" lead to predicting how a child
will develop socio-emotionally if he is born to a determined mother (he
has studied with his clever methods).
"Let me illustrate the point
by considering the aetiological and therapeutic problems presented by the
type of patient who in the United Kingdom is likely to be described as
a schizoid personality (Fairbairn, 1940) or as having a false self (Winnicott,
1960) and in North America as being a borderline personality or suffering
from pathological narcissism (e.g. Kohut, 1971; Kernberg, 1975)".
"The picture such a person
presents is one of assertive independence and emotional self- sufficiency.
On no account is he going to be beholden to anyone and, in so far as he
enters into relationships at all, he makes sure he retains control. For
much of the time he may appear to manage wonderfully well, but there may
be times when he becomes depressed or develops psychosomatic symptoms,
often for no reason he knows of. Only should symptoms or a bout of depression
become severe is there any
possibility of his seeking treatment, and then more likely than not he
will prefer drugs
to analysts".
"When such a person does
come for analysis he is careful to keep the analyst at arm's length and
to control what happens. What he tells us is lucid, but he avoids any reference
to feeling, except perhaps to say how bored he gets. Holidays or other
interruptions he welcomes as saving his time. Perhaps he finds the analysis
an 'interesting exercise'; although he is not convinced it is much use.
And in any case he could probably do a better job by analysing himself!"
"There is, of course, a large
literature discussing the psychopathology of these conditions and the therapeutic
problems they present; but
on whatever issues there may be agreement there is none on aetiology. To
take two
contrasting viewpoints:
whereas Winnicott (1960, 1974) attributes the condition squarely to early
environmental
failure in the form of 'not
good enough mothering', Kernberg (1975) in his systematic treatise gives
no more than a
couple of easily missed
paragraphs to the possible role that mothering plays in influencing development,
and only a few passing references to the inadequate mothering certain of
his patients may have received. That early experience may play the key
role in determining these conditions is not seriously examined by him".
"Plainly it is of the greatest
importance that in due course we should reach some consensus about this
matter; and in debating the issues I believe we should be foolish not to
take account of data from as many sources as we can tap. For some conditions
epidemiological surveys are now proving informative but I doubt whether
they have anything yet to tell us about this one. At present therefore
we have to make do with data from our two familiar sources: (a) the analytic
treatment of patients, (b) the direct observation of young children with
their mothers".
"As regards data obtained
during treatment, I suspect it would be fruitful for some open minded person
to survey
the psychoanalytic literature
and draw together all the case reports which record information about the
childhood experiences of these patients. My guess is that, in so far as
any information is given, it would strongly support Winnicott's view that
these patients have had disturbed childhoods in which inadequate mothering
in one form or another- and it
can take many- bulks large.
Since I have made no such survey, I can do no more than illustrate the
kind of findings that I would confidently expect. The following details
come from case reports published by three analysts each much influenced
by Winnicott's views".
"One report is by Donald
Winnicott's widow, Clare Winnicott (in preparation). The patient, a professional
woman of 41, presented a classical picture of the emotionally self- sufficient
personality who recently had developed a variety of psychosomatic symptoms.
Only after a good deal of analysis did she divulge the events of her childhood.
Since her mother was in full time work, she was looked after by a German
girl who left suddenly when the patient was two-and-a-half. Then, after
six months of uncertainty, she was taken by her mother to have tea with
a friend and later found her mother had disappeared and she was alone in
a strange bed. Next day she was taken to the boarding school where her
mother's friend worked as matron, and she stayed there till she was nine,
usually spending the holidays
there also. She appears to have settled in well (ominous words!) and coped
very successfully; but from that time forward her emotional life had dried
up".
"A second report, by Jonathan
Pedder (1976), is of a young teacher in her mid-twenties whose personality
and
symptomatology bear a strong
resemblance to Clare Winnicott's patient. Although at the initial interview
she had
given an idealized picture
of her childhood, it soon emerged that at the age of eighteen months she
had been sent
to stay with an aunt during
her mother's next pregnancy. After six months there she had come to feel
that her aunt
was more of a mother to
her than was her real mother and she had found returning home a painful
experience.
Thereafter, until she was
ten, she had been terrified of another separation; but then she had 'switched
off' her anxiety 'like a tap', as she put it, and with the anxiety had
disappeared most of her emotional life as well".
"The third report, by Elizabeth
Lind (1973), concerns a young graduate of 23 who, though severely depressed
and
planning suicide, main tained
that his state of mind was less an illness than' a philosophy of life'.
He was the eldest of a large 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 un predictable.
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 behind".
"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.
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, he fully expected her to be offended and perhaps lock
herself in her room".
"In all three cases the patient's
recent breakdown had followed the collapse of a significant but fragile
relationship about which each member of the pair had had reservations and
to the ending of which each of the patients had,
him or herself obviously contributed".
"In treating these patients
all three analysts adopted Winnicott's technique of permitting the free
expression of what are traditionally termed dependency
feelings ', with the result that each patient in due course developed an
intense and anxious attachment to his or her analyst (to use the
terminology I prefer, Bowiby, 1969, 1973). This enabled each patient to
recover the emotional life he or she had
lost during childhood and
with it to recover a sense of' real self'. Therapeutically the results
were good".
"Admittedly, the findings
from these three cases prove nothing. Nevertheless, they are suggestive
and, so far as
they go, support Winnicott's
theory of aetiology. Even so, it is
always open to critics to
cast doubt on the validity of what a patient recalls about his childhood
and to question whether the sequence of events recounted had the effect
on his feeling life that he so explicitly claims. (It is worth noting that
the events that each of these three patients held to be a turning point
had occurred after their second birthdays)".
"Now
it seems clear that the controversies about aetiology are
never
going to be settled as long as we rely solely on the retrospective and
perhaps biased evidence derived from the analyses of patients, whether
they be adults or children. What is needed
is evidence of a different kind to provide some sort of cross-check. This
is where I believe the direct observations of young children and their
mothers are potentially so useful. Is there any evidence from that
source that suggests that a child's feeling life can become numbed by the
types of experience described? The answer, of course. is that there is
a great deal".
"Here naturally I point first
to the observations made by James
Robertson (1953) and confirmed
later by Christoph
Heinicke and Ilse Westheimer
(1965) on how children between the ages of twelve and thirty-six months
behave
when removed from home to
the care of strange people in a
strange place, such as a
residential nurseries or hospital. with no one person to act as a mother-substitute.
In such conditions a child comes in time to act as if neither mothering
nor contact with humans has much significance for him. As his caretakers
come and go he ceases to attach himself to anyone and
after his return home stays
remote from his parents for days, and perhaps for much longer if he is
treated unsympathetically".
