Fifty Years of Psychotherapy, But What about Infant Mental Health and Early Childcare? 1998. Dr. Cook P.S.

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Forum, J New Zealand Association Psychotherapy 1998, 4:97-114.
(The Journal of the New Zealand Association of Psychotherapists).
Based on paper to 50th Anniversary Conference of NZ Association of Psychotherapy, 1998.

Abstract

In addition to quality psychotherapeutic treatment, primary prevention was, from the beginning, a parallel concern of those who founded the New Zealand Association of Psychotherapists in 1947. This arose both from theory and the experience that many emotional problems were essentially preventable. They sought to apply insights gained during psychotherapy to prevent emotional trauma and promote mental health, especially in infancy and early childhood.

Empirical confirmation came with Bowlby's 1951 Monograph, published by the WHO [8]. Like Suttie and Every, Bowlby was led to adopt an evolutionary perspective, which can illuminate the diagnosis, treatment and prevention of emotional disturbance in infants, young children and their families, with implications for healthy childrearing. This approach also led to critiques of Freudian theory, with calls for it to be reformulated.

Some preventive achievements are outlined, but it is suggested that the most significant failure has been the widespread denial of the emotional consequences for the infant of prolonged early non-parental childcare, underpinned by the now discredited ideology of cultural determinism.

Introduction

I am delighted to join in celebrating the 50th Anniversary of the founding of the New Zealand Association of Psychotherapists. I was present as a fourth year medical student when the NZAP was formed at a conference in December 1947. It was partly held in the Cranmer House Clinic, which was also our family home. The people involved and the ideas they shared have influenced my personal life and professional activities, and the importance of good early nurture was one of their central concerns. Their ideas were at variance with accepted customs in many ways, and they worked for a healthier society. Over the last 50 years there have been dramatic changes in professional and community attitudes to pregnancy, childbirth, breast-feeding, sex education, and child-rearing practice, mostly in directions urged by the founders of the NZAP, but the most conspicuous exception has been the move to early non-parental childcare.

The Founders

If Dr Maurice Bevan-Brown, or B-B as he was universally known, were here today, he would be astonished and deeply gratified. He had a lovely smile [6], a merry laugh, and I remember him with gratitude. I have outlined elsewhere his background in natural sciences and medicine; his return to Christchurch in 1940, after being a consultant physician/psychotherapist at the Tavistock Clinic in London from 1923 to 1939; the situation he found on his return to new Zealand, and his teaching activities and concern for primary prevention [15]. (Since that paper was circulated with the conference papers this material is not repeated here.)

My parents were early disciples, and with others they welcomed the opportunity to learn what he was glad to teach. My father, Frank Cook, left the Anglican ministry in 1945 to practise psychotherapy, and my parents bought a large house at 58 Armagh Street, overlooking Cranmer Square. Some rooms were sound-proofed for consulting rooms, and we lived in other parts of the house. Here, the Cranmer House Clinic was established as a centre for clinical service and training in psychotherapy. With Bevan-Brown, my parents were involved in convening the conference at which the NZAP was formed, and those who attended, coming from many parts of New Zealand, are shown in the photograph in the paper referred to above [15].

My parents and Bevan-Brown set about producing educational pamphlets. Though their lives were overshadowed by World War II until August 1945, they wasted no time, and during that year five educational pamphlets were published, some reflecting concerns about returning servicemen. Two each were by Bevan- Brown and my mother, Dr Enid Cook, and the fifth by Frank Cook. They were called The Lighthouse Series, with the cover showing a lighthouse beaming into the darkness, and they sold for nine pence each [29].

By 1948 eleven pamphlets had been published, and some found their way to Mrs. Gayle Aiken, of New Orleans. She asked for a book, and by December 1948 The Sources of Love and Fear was written [5]. Bevan-Brown was the principal author, with Enid Cook contributing sections on sex education, childbirth and breastfeeding. He recorded his "indebtedness to his colleagues at the Cranmer House Clinic without whose encouragement this book would not have been written". This was literally true, as my mother used to go with him to Kowhai Bush, where he worked to protect his precious remnant reserve of native forest. In his hut, after dinner, he would light his cigarette, sit back and dictate. By the light of a kerosene lamp she wrote down his words. It was a small book but it was unique and met a great need. By 1950 it was published in Christchurch, New York and Toronto, and there was a third edition in 1960.

Theoretical Perspectives

Bevan-Brown belonged to the pre-war, eclectic, analytic tradition at the Tavistock Clinic, which included Drs. J.A. Hadfield [22] and Ian Suttie. This tradition dissented from some Freudian teachings, and it held that much emotional disturbance, neurosis and personality disorder, need never occur if infants and young children were given good early nurture.

In The Origins of Love and Hate, Ian Suttie, who died on the day it was published in 1935, adopted an evolutionary and cross-cultural perspective. While valuing psychoanalytic treatment, he said its results were not adequately explained by Freud's theories, of which he offered a detailed critique [38]. He entitled one chapter "The Taboo on Tenderness" and another "Freudian Theory is itself a Disease". He argued that "… all the errors and shortcomings have one general tendency. … in all these cases the failure of theory seems to be due to its denial of the existence of love and to its depreciation of the social significance of the mother." (p.175). He argued that Freud had "a grudge against mothers and a mind-blindness for love, equal and opposite to the mind-blindness and repugnance that many of his opponents had for sex". He asked "Why should we not as analysts ask ourselves what was the reason for the original oversight (i.e. whether we ourselves were biased), and why, as scientists, not overhaul the whole theory so as to make the correction systematic?" (p.179). This call went largely unheeded, but it is remarkably similar to the challenge which Dr John Bowlby, as a psychoanalyst, was to make 38 years later in 1973 (see below).

The Times Literary Supplement [38] said that Suttie's book, "offered the first really comprehensive and constructive criticism of Freudian psychology in its social application … It shows how all the admitted errors of Freud, the contradictions and dissensions within psychoanalysis, and the problems that have defied solution, are not just the accidental mistakes and oversights inevitable in a new science. On the contrary, they proceed from one definite and consistent bias affecting Freud's theories far more than his practice. His fallacies and failures, therefore, form one coherent system; his positive achievements another. …This book offers a biological and psychological conception of Infancy, Sociability, Love and Interest."

Hadfield, in his preface to the 1960 edition of Suttie's book, said:

"His [Suttie's] system may be styled as essentially Matriarchal, as distinct from Freud's obviously Patriarchal system. … He concentrated on the concept of love, rather than of sex. This in itself was not new; for, in my lectures both in the University and at the Tavistock Clinic, I had maintained, as against the Freudian view, that the fundamental need of the child was for protective love, and further, that the psychoneuroses were not primarily the result of sex complexes, but were due to insecurity resulting from the feeling of deprivation of love."

From this eclectic Tavistock milieu, Bevan-Brown's psychotherapeutic technique and experiences also led to his emphasising the importance of the first year of life, with a loving and mutually gratifying breast-feeding relationship being of fundamental value. A small book which he often said was worth its weight in gold was Baby's Point of View by Dr Joyce Partridge, published by Oxford University Press in 1935. It was out of print in 1948 so he quoted from it in The Sources of Love and Fear. At the end of his book he wrote a conclusion which seems as relevant today as 50 years ago. He wrote :

"What, then, is the conclusion of this matter? For unless this book contributes to a better understanding and practice of child nurture it is of little value. The main conclusion is that we must try to produce a better race of parents than now exists, and better parents than we have been ourselves. 'Good' parents do exist in our generation but they are in a minority. The first requirement for a 'good' parent is to be emotionally mature. The majority of parents are emotionally immature - that is, they still retain in some respects the emotional attitudes characteristic of children. Therefore their children, lacking real parental affection themselves also remain emotionally immature when they become adult. We must try to break this vicious circle at as many points as possible by educative measures applied to: (1) Parents with young children, (2) Prospective parents, (3) Adolescents, (4) Educationists and (5) Doctors.
"The whole matter cannot be condensed into rules, but rules are not without their value. We have contended that the first year of any individual's life is the most critical for mental health. Concerning the first year, I know of no code of rules as good as that given by Joyce Partridge in her little book, Baby's Point of View. I understand that unfortunately this is out of print: otherwise I would recommend everyone interested in the care of children to buy a copy and keep it. Here are Joyce Partridge's rules (quoted by her permission):
(1)."Try to recognise before your baby is born that in the matter of sex the chances are even.
(2). Don't be afraid to follow the maternal instinct and intuition: in other words, give scope to your love for your baby and don't bring him up by rule of thumb.
(3). Breast -feed your baby.
(4). Never leave a baby alone to cry.
(5). Be as much as possible within earshot of your baby in the early weeks and months of life.
(6). Never in any circumstances scold a baby of whatever age, and never allow anyone else to scold him for wetting or soiling napkins or for wetting or soiling any other place whatsoever."
. "Joyce Partridge is a first-class psychiatrist, a Fellow of the Royal College of Surgeons (England), and a mother. I commend her rules to you.
"It is the daily lot of the psychiatrist to meet and endeavour to relieve people who have experienced years of disability, ill-health, distress, and often of utter misery, all, or nearly all, of which need not have happened if they themselves and their parents had had more understanding.
"There are two highly emotionally-toned words in this connection -- 'IF ONLY.' 'If only I had come to you ten or twenty years ago….' 'If only my mother and father had understood these things……If only I had understood these things when my children were younger.'
"If this little book is able to mitigate in any degree some of this widespread distress it will have fulfilled its purpose."

Though infancy was a central concern, The Sources of Love and Fear covered a much wider scope. Bevan-Brown's papers, collected in Mental Health and Personality Disorder [6], included his 1936 Presidential Address to The Medical Society of Psychology in London, called A plea for correlation between the different schools of psychodynamic thought [7].

Initiatives in Primary Prevention

The importance of early childhood experiences, let alone the idea that breast-feeding should involve a mutually enjoyable relationship, was not echoed in anything I heard in medical training at Otago University - nor was there any guidance in diagnosing or treating emotional disorders. So a number of doctors and medical students welcomed the training courses, organised at the Cranmer House Clinic. The ideas about natural childbirth led to the formation of the Parents' Centres movement [35; 29,9; 29,10)].

In 1951 I read Bowlby's classic Monograph Maternal Care and Mental Health [8] which presented empirical evidence that early experiences were important, and maternal deprivation in institutions could be damaging. In 1952 there was a world-wide shortage of child psychiatrists, and I went to London, to get on with training before I might get caught up in the Korean war. I was able to hear such luminaries as Anna Freud and Margaret Mead, but I heard little about primary prevention. I got to know Hadfield, who had been Director of Studies at the Tavistock Clinic, and his continuing concern for primary prevention through healthy child rearing was spelled out as late as 1962 in his Pelican publication Childhood and Adolescence [23]. However, the schools of psychodynamic thought which had become dominant were generally remarkably inert, and even pessimistic, about the possibilities of preventing emotional disorder through any educational or environmental measures affecting infancy and early childhood.

I was back in New Zealand from 1957 and, with others, was concerned to counter official proposals to institutionalise all moderately retarded children for life [10]. Later, I became aware of the distress and sometimes gross separation reactions presented by toddlers when their mothers' went to maternity hospital to have another baby. The stay was routinely two weeks, and children under twelve were the only ones not allowed to visit. The toddlers might go to stay with a relative or stranger, and two weeks was long enough to develop a major grief reaction. I suspected that much of what was regarded as natural sibling jealousy might be culturally induced by this practice. The policy had no scientific justification, since the toddler was unlikely to carry any infective organisms which mother did not already share. So in 1962 I wrote A Two-Year-Old's Mother Goes to the Maternity Hospital which was widely quoted, and soon this misconceived custom died out [11].

Like Bevan-Brown I wished to make available to ordinary parents the knowledge gained by treating disturbed children that could help them avoid such problems with their own children. Classes such as those run by the Parents' Centres to prepare mothers for more natural childbirth might also offer education for parenthood. As there was almost nothing in the literature about what might be covered, I offered curriculum suggestions in a paper Antenatal education for parenthood as an aspect of preventive psychiatry: some suggestions for program content and objectives [12]. This placed in a medical journal many of the ideas in The Sources of Love and Fear .

The 1971 Position Statement of the Australian and New Zealand College of Psychiatrists, Admission of mothers to hospital with their young children [2,32] expressed similar concerns, suggesting that "the psychological and emotional damage caused in one year through lack of application of available knowledge about the care of children in hospital greatly exceeds that which all available child psychiatrists can undo in several years".

There was also in 1971 a Memorandum on some aspects of the welfare of children under three years, whose mothers are in full-time employment [33]. This concluded that "full-time work of mothers of children is undesirable" and said "it is doubtful whether there are any circumstances in which mothers of children under three might be encouraged to go to work for national reasons".

Evolutionary Perspectives

The idea that there might be cultures which were more conducive to emotional health, was touched on in The Sources of Love and Fear. The example of the indigenous society described by Jean Liedloff in The Continuum Concept has become well known [28], but the American military psychiatrist Dr J.C. Moloney had much earlier linked to their early nurture the emotional stability of the indigenous Okinawans, whose culture he contrasted with that of the Japanese [30].

The doctrine of cultural relativism, developed by anthropologists to counter ethnocentrism, taught that whatever customs prevail in a given society are to be accepted as appropriate for those people, and one should not make value judgements about them. On this basis, the customs which prevail in New Zealand are ideal for New Zealanders. But are there any basic biological "givens" which form a basis for evaluating customs in matters relating to physical or mental health - for example with respect to childbirth, early nurture and childrearing?
Bowlby came to see that his explorations of the nature of a child's tie to its mother could only be understood by adopting an evolutionary perspective. In fact, tucked away in an Appendix to Volume 2 of Attachment and Loss, in 1973 Bowlby [9] wrote these challenging words:

"On reflection it becomes clear that Freud's increasingly deep commitment to a Lamarckian perspective, to the exclusion of Darwinian ideas about differential survival rates and the distinction between causation and function, has suffused the whole structure of psychoanalytic thought and theory. With the remainder of biology resting firmly on a developed version of Darwinian principles and psychoanalysis continuing Lamarckian, the gulf between the two has steadily and inevitably grown wider. There are thus only three conceivable outcomes. The first, which is barely imaginable, is for biology to renounce its Darwinian perspective. The second, advocated here, is for psychoanalysis to be recast in terms of modern evolution theory. The third is for the present divorce to continue indefinitely with psychoanalysis remaining permanently beyond the fringe of the scientific world".

As a psychoanalyst, Bowlby was subject to much alienation from his colleagues for his stand. When asked how he had withstood such attacks he replied "I had the evidence!" He died in 1990, but that evidence continues to accumulate. On 21st October 1980, as Freud Memorial Visiting Professor at the University of London, he gave the Freud Memorial and Inaugural Lecture Psychoanalysis as a Science [9], and said:

"I believe that all the developmental concepts of psychoanalysis will have to be re-examined and that most of them will in due course be replaced by concepts now current among those who are studying the development of affectional bonds in infants and young children by means of direct observation. … Put briefly, I believe our task as psychoanalysts is, when researchers, to render unto science the things that are scientific and, when clinicians, to render unto persons the things that are personal".

Derek Freeman, a New Zealander, who is Emeritus Professor of Anthropology at The Australian National University, points to the same problem today in the social sciences. He documented as false, the account (based on a hoax) which Margaret Mead published as research into adolescent behaviour in her 1927 "classic" text Coming of Age in Samoa. She was eager to please her supervisor, Franz Boas. He was an ardent believer in the ideology of cultural determinism, and wanted Mead to find support for his denial of significant genetic and evolutionary factors in human behaviour. Thus, says Freeman, Margaret Mead, the world's most eminent anthropologist, misled generations of anthropologists into denying genetic influences in human societies and the value of an evolutionary perspective in studying human behaviour, perhaps the most serious scientific misinformation of this century [18]. I think this denial of an evolutionary perspective in the social sciences has contributed to the serious social problems with early childcare today.

Dr R.G. Every, Thegotics and Evolution

An evolutionary and cross-cultural perspective is implicit in The Sources of Love and Fear. However, my own realisation of its fundamental importance came through Dr Ronald Every, a Christchurch dentist, who died in 1996 - a family friend to whom I pay tribute. He was in Bevan-Brown's training groups and is in the NZAP founding photograph [15]. He showed how dental and medical trauma could be caused by extreme movements of the jaw, which presumably occurred during sleep, since his patients were completely unaware of them.

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