A Public Lecture by Rick Curnow, 24 July, 2000.
My interest in this area of work has arisen from my work as a psychiatrist and psychoanalyst in private practice treating adult patients. Over the years I have seen a number of patients who have been suffering the long-term sequelae of childhood emotional, physical, or sexual abuse. Also, I visit some of the public hospitals to teach, and have become aware that treatment for patients with a diagnosis of Personality Disorder is poorly funded. And there is mounting evidence to support the view that Borderline Personality Disorder patients have a history of abuse in childhood. Emphatically, I don't wish to say that childhood trauma will make for a diagnosis of Borderline Personality Disorder. That would be an outrageous generalisation.
How is it that trauma can cause personality difficulties? What protects some children from damage? I can't answer these questions definitively. But I'd like to share some of my own thoughts that arise from my reading, and some research that is relevant to these questions. My interest has been in coming to grips with how abuse links with later emotional and behavioural difficulties. And I have a cautious conceit, a secret agenda that, by presenting my understandings, I might be able raise some public enthusiasm for improving treatment conditions for borderline patients. I don't want to raise false expectations either. I'm not a child analyst. I don't treat abused children - but I do see the adults who bring the history of abuse and seek treatment for the damage caused to them in childhood that still resonates through their lives. I've borrowed the title of my talk from a book by Gitta Sereny about a horrific crime - the murder of two little toddlers by an 11-year-old girl, Mary Bell, in 1968. The author, a journalist, was present at the trial of the child, Mary, which was conducted in an adult court. At the time of the trial, the child was demonised: "the subject of widespread fear and a curious mindless revulsion" ""wicked seed" (p.374). The author felt from the outset that there must be more to be known about this child, and she got to meet her thirty years later. Mary Bell by then was a 40-year-old woman in a longterm relationship, with a daughter of her own. Slowly, and with difficulty, Mary allowed the story to emerge of murderous assaults and sexual abuse by her mother. The book was not written until 1998. The author had held on to her conviction for thirty years, until she could complete the investigations to confirm the suspicions that would allow her to write her book. In my view, the author had a capacity for containment (an ability to sustain an interest in the unknowable, and to bear the frustration of not receiving the gratification of immediate answers). This ability is a primary requirement for any therapist working with such traumatised folk, as answers are a long time coming. Apart from anything else,shame at being a victim makes it hard to tell the story. The phrase "Cries Unheard" catches exactly the sense that this girl's behaviour was an unheard cry from a young girl trapped in an impossible traumatic situation. What sort of cry is this? I think that to describe it as "a cry for help" is to risk sentimentality - it's hard tobelieve this girl could have believed that any help existed in the world in which she lived. I think the cry is more a communication - a behaviour that is there to be understood - I hope my talk will explain what I mean by this. (Talking of herself prior to the crime, Mary Bell said "We'd do more and more dangerously naughty things".we kept hoping we'd be arrested and sent away." p.85)
You must forgive me for introducing my lecture with such a dreadful story. I don't wish to imply that trauma necessarily leads to such horrific outcomes. But it was so impressive to read a book on this subject, which was not mere reportage, nor a moral tract, but rather an attempt to understand. The author senses in "that small girl, not evil, but some kind of deep but hidden distress," and she writes that " The court was neither capable nor required to deal with a child who, above all else, had to protect her mother's secrets."(p.374) This is so often the moving dilemma of traumatised children - as a society, we are not equipped, we are often unwilling, and we frequently lack the understanding, to hear their cries.
TRAUMA AND THE INDIVIDUAL
Just a note for tonight concerning the place of trauma in the history of psychoanalytic thinking. At first, as is well known, Freud believed that all neurosis was a result of past traumatic experience ("seduction"), and could be cured by abreaction and catharsis. His view changed. The seduction theory was granted less significance, in favour of an emphasis on the patient's internal fantasies and the excitement they provoked. Later, trauma as a result of separation and loss, rather than sexual seduction, was taken up as the important cause of pathology. Broadly speaking, analysts became divided as to whether they believed the cause of suffering lay within the individual (eg Melanie Klein), or lay in the effects of trauma within the early infant's environment. (eg Winnicott, Bowlby, Fairbairn) The difference is important as it makes for differences in therapeutic technique. My own view is that it is important to keep both aspects in mind, understanding the importance of the past, whilst not colluding with the patient's wish to hold the past responsible for present difficulties, and thus justify a wish for revenge.
So what is the effect of trauma? I'll give a brief overview of current psychoanalytic theory as it deals with trauma, so you know where I'm coming from. In this section of my talk I want to give an overview of theory as it applies to both adult and child. Literally trauma refers to tissue damage. Freud (1920) and later authors(Garland, 1998) use the skin metaphor to describe how, in health, we have a similar 'skin', a protective barrier, in our mind, to protect us from harmful and painful excessive stimulation. Trauma occurs when the protective shield is breached. In young children this filtering, protective function is largely served by the mother,through her sensitivity in knowing what her child is able to manage at any one time. (As we get older we take over this filtering function ourselves, of course, with varying degrees of success.)
After a traumatic event, there may be two distinct phases. There is an initial breakdown when the protective shield is breached by trauma, and there may be a catastrophic disruption of functioning. There is a sense that death is imminent, or that one is threatened by total annihilation of the self. The victim is often shocked and confused, perhaps unable to take in what has happened. He may be silent and withdrawn, or talkative and excited. Sometimes we describe people in this state as "dissociated".
The second stage is more insidious. The victim/survivor may appear to return to normal functioning. But two powerful processes may take place in the mind. The first relates to the tendency we all have to attach any experience to an agent. We seek to attribute cause or blame to an agency either external to us ("It was theother driver's fault."), or internal ("If you hadn't made me feel so bad".") that is felt to be responsible for our predicament. In the wake of a catastrophe, we are likely to feel intensely persecuted, and we may link this with deep suspicions we harbour (sometimes unknowingly) about the hateful nature of those whom we usuallytrust to care for us. There is a loss of belief in the fundamental goodness of loved ones - how could they let this happen? The second of these powerful processes is the wish to make sense of the experience by searching for meaning. A trauma in the present may be linked up with troubled relationships and disturbing events fromthe past which have previously been more or less manageable. And the sense of meaning that is discovered is held on to in an entrenched way that may damage current social relations.
I'll give an example to illustrate these last points. A single woman in her thirties survived a life-threatening cliff-climbing accident. She was both depressed and afraid of losing control of anger. The significance of the accident to her illness only emerged incidentally. She was a fit athletic woman who enjoyed risky sports, proud of her ability to survive on strength and careful knowledge of the risks involved. However, in the climbing accident, outside circumstances overcame her careful planning. Since the accident, she had "lost her cool", and was alarmed that she now reacted with contemptuous rage to any male colleagues whom she perceived asweak and unsure of themselves. She sought treatment after she had unhappily felt compelled to end a stable relationship with a man she had known for several years. She was an only child. When she was 3 years old her mother developed a depressive illness, and her father left home to study overseas. He was supposed to be away for one year, but only revisited the family sporadically after his departure. He was very successful, and was seen as an ideal achiever by his daughter, whereas she had a rather dismissive attitude to her mother. Relating this to what I said above, I might think that she was a woman who had lived reasonably successfully by identifying herself with her successful father, valuing her strength and independence. The accident undid that. One could think that her fear had overwhelmed her defences. Suspended on the cliff-face she felt weak and completely dependent on her rescuers. We could make some sense of this when we learned of the circumstances of her parent's marriage breakdown. One could think that in 'attributing blame to an agent' (see above) she may have felt that the idealised strong father figure she had identified herself with had let her down. In therapy it became apparent that the time of her father's departure was very important to her. She recalled the fearful sense of loneliness when she was left alone with her depressed and despairing mother. She became a little girl who washypervigilant, ever alert to mother's every need - keeping mother going in order to insure her own survival. The 'sense of meaning' (the second point above) she found was that as a woman she felt helpless and abandoned and depressed in a world where men were not trustworthy.
This is an important plank of the theory that underpins the psychoanalytic method of therapy. One seeks to understand the way in which the survivor links the external event with the frightening phantasies of their internal world.
Two other results of trauma are important. An important sequel is the loss of a capacity for symbolic thinking about the event. For example, it may be as though the mind no longer has a capacity to sort out incoming signals - if the feared sound, sight, smell, etc. is re-experienced, the mind responds with an immediate flood ofanxiety. (The experience known as flashbacks.) I'll refer back to this loss of a capacity for thought later. Another important aspect to understand is the occurrence of the compulsion to repeat the event, either in a directly recognisable form, or symbolically. (cf the story of Mary Bell) This repetition is, at the very least, a sign thatsomething is stuck and has not been worked through, not digested into the mind.
CONTAINMENT
I want to talk more about this loss of a capacity for thinking about the event. In order to do so it will help if I explain more of what I mean by the function of containment, which I've already referred to as being in the author of the book on Mary Bell. When all is going well, the quality of containment is fundamental in the relationship between mother and infant. It means that the mother can grasp and take into herself, as a container, something of the baby's earliest anxieties. We conceptualise these early anxieties as being a fear about such terrors as being dropped, of falling forever, of annihilation, of ceasing to exist, of death. (My homely example) The mother can think about these things in her own way, without being overwhelmed by them. She can take the panic out of the anxiety. Eventually the infant can begin to take into itself something of mother's ability to handle anxiety. A psychoanalyst might say that the infant has begun to internalise the containing function, and will eventually be able to handle anxiety itself. The child is now developing the capacity to think about an event, rather than just reacting emotionally to it. We might say that the child has been able to transform the unbearable experience into something that can be thought about. This is a function that mother has been able to do for the child - and that the therapist may do for the patient.
A successful businesswoman in her 40s sought treatment for severe anxiety attacks in which she became convinced that colleagues were plotting her destruction. It was possible to reconstruct, with some collateral information from the family, that her mother had been profoundly depressed post-natally, and that the infant hadrequired several admissions to a hospital with a diagnosis of failure to thrive. One of the tasks of therapy was to reflect on the anxiety of an infant with a sensation of starving to death, in a dependent relationship with a mother who is unable to respond emotionally to her child because she is depressed. She was a mother who was unable to fulfil her containing function. This process of containment links with the phenomenon of flashbacks that occur in survivors of trauma. This refers to the sense that you are not just thinking about something that happened in the past but reliving it in the present. It is as though that containing function has suddenly disappeared. The internal space or place in the mind in which one could think about events has been lost, and the past becomes real in the present and is accompanied with a flood of anxiety.
In the Cries Unheard book, we learn enough of Mary Bell's life to expect that her mother would have had no ability to act in a containing role with Mary - and father was mainly absent. I think Mary's actions in the murder of the boys was an example of how the unbearable could not be thought about because there was nocontaining function present in Mary or her mother. When this is so, the unbearable is exploded out in action ("evacuated", say some analysts graphically). The psyche rids itself of the unbearable in this process, and the action becomes the cries that are usually unheard.
THE RECOVERED MEMORIES CONTROVERSY
It's relevant, now that we've spoken of flashbacks, to digress for a brief discussion of the issue of memories recovered in therapies. This has blown up in recent years, particularly in the United States, where 'recovered memory therapists' work. Psychoanalysis cops it from both sides in this controversy. On one side it is claimed that all such memories are false, and gullible therapists (such as psychoanalysts) are responsible for stirring up a hornet's nest. On the other side of the argument, there is anger that a surviving victim's valid memories are invalidated as mere fantasies by unsympathetic therapists (such as psychoanalysts). It is then argued that such therapists repeat the trauma by denying the reality and bitter betrayal of childhood sexual abuse.
There has been recent research on memory functions (Target 1998) which shows amongst other things that significant trauma may actually cause damage to the brain in the areas where memories are encoded, thus impairing memory function. (ie. the memory may simply not be there - not everything is encoded in memory) And after the age of 4 years significant trauma is usually retained to some extent as continuous narrative memory.
These and other facts fit with clinical experience that memories of abuse almost always occur in people when it is entirely consistent with everything else in the history of their relationships. If a therapist relentlessly pursues sexual abuse as a causative agent for all the patient's ills then the patient might feel compelled to bring forth memories, as it were, to please the therapist. It may be that the current therapy is experienced by the patient as an abusive relationship, but that can't be discussed with the therapist and the abuse is spoken of as occurring "back then". This brings up the golden rule for dealing with such recovered memories: that the therapist consider the memory in the light of current knowledge of memory function, and to look at the significance of the memory in terms of the present relationship.
ATTACHMENT THEORY
The work on trauma that I've spoken about derives from "pure" psychoanalysis - the ideas about containment are a vast oversimplification of Bion's (1962) work. I find it consoling that there is another body of work that reaches somewhat similar conclusions, coming from a more "pragmatic" starting place.
John Bowlby was an analyst who was concerned about the effect of attachment, separation and loss on the emotional development of children. In the 1950s he made films about kids in hospital, and this is the only analytic work I know that has directly wrought social change. His films of everyday kids separated from parents by admission to hospital or institutions, showed the distress of children so clearly, that now hospital visiting hours have been liberalised to benefit families, not hospital routines. At the heart of attachment theory lies Bowlby's belief that the infant's need to be physically close to the caregiver is an evolutionary necessity, and all attachment behaviour follows from this premise. The nature of the relationship that the caregiver can provide will dictate the pattern of attachment behaviour seen in the child. Tests have been devised which allow for observation of, and classification of the different attachment patterns of behaviour.
PATTERNS OF ATTACHMENT BEHAVIOUR IN INFANCY
1. SECURE 55-65%
Child is distressed by separation but is comforted on reunion, resumes contented play.
2. INSECURE
a. Insecure-avoidant 20-25%
Child shows little overt distress, ignores mother on reunion, then inhibited in play.
b. Insecure/ambivalent 10-15%
Child highly distressed on separation, not pacified on reunion, remains alternately angry and clinging, play inhibited.
3. DISORGANISED - low numbers
Diverse confused behaviours, eg. "freezing" or stereotyped movements. Often traumatised, abused children.
These studies allow attachment behaviours to be classified statistically. And it has been found repeatedly that these attachment patterns of behaviour carry forward into subsequent development. And they are reasonably consistent across cultures. But of course what the tests are really assessing is feelings. How does the child react when mum leaves the room? And when she returns does he scream, or ignore her, or beat up on her? We have a tool for testing emotional responses within an important relationship. For the securely attached infant things work fine - these are the kids who do better in contact at school and socially. But for the insecurely attached some form of defensive compromise is used, in the sense that the child sacrifices something in order to fit in with the parent's psychological state, and to maintain proximity to the caregiver. For the avoidant child, intimacy is sacrificed in order to maintain attachment, and these may be children who become hostile and distant in social relationships. For the ambivalent child a sense of autonomy is sacrificed and the child adopts clinging angry behaviour and may be somewhat inept and dependent socially. To put it simply, a child will take on board that Mum has an aversion to close contact, and adjusts its behaviour to fit in with her in order to keep its close attachment intact.
.In order to make the jump from the quality of relationship with the caregiver, to the style of relatedness the child exhibits later, say at school, I am assuming that infants develop internal working models - an internal set of models of the self and others, and how they interact. This is the way of describing how the child comes to have an inner representation of relationships with significant others, and how it comes to build expectations about other relationships. Just as we have studied children, so we can study the attachment patterns of adults, and their emotional memories of their own parents. And an instrument has been developed to assess adults' attachment patterns.
ADULT ATTACHMENT CLASSIFICATIONS
1. SECURE/AUTONOMOUS 45-55%
2. DISMISSING (cf. AVOIDANT) 20-35%
3. PREOCCUPIED (cf. AMBIVALENT) 10-15%
4. UNRESOLVED/DISORGANISED 15-20%
There is strong evidence (Fonagy 1995) that emotional states are transmitted across generations. Give pregnant mums the AAI and you find a reasonable correlation with the attachment behaviours of her child when it is tested at the end of its first year of life. I don't think there is any other test that reliably predicts the quality of a child's emotional relationships. (I find this very interesting because it confirms an observation made by an analyst years previously. Fraiberg (1982) suggested that a mother may internalise a representation of her own mother's mothering, and recreate this unconsciously in the early months of her relationship with her own infant. She coined the evocative phrase "Ghosts in the Nursery" to describe this phenomenon.) There is also research into what factors protect a child from developing personality problems, and what is associated in development with later damage. It's hardly surprising to hear that a secure attachment relationship is a good start. The other factor that they found to be important was Reflective Functioning in the caregiver.
"Reflective functioning" refers to the ability of the caregiver to reflect upon his or her own thinking - "to think of ourselves as thinkers". In turn, the child in relationship with this caregiver with a high reflective ability will develop a robust reflective capacity. It's found that even in a highly-stressed, deprived family environment (where there is likely to be an increased risk of insecure attachment) the child of a mother with this reflective capacity will have a secure attachment. So Fonagy is working his way towards suggesting that what is of greatest importance in the child is the development of a capacity to think about its own experience. This sounds very like the idea we arrived at above in speaking of the importance of containment.
THE EXPERIENCE OF TRAUMA
Now I'd like to think about what might happen to the child who experiences trauma. First we could consider the effect of trauma on a child who has a secure attachment, or has the experience of a containing relationship with its caregiver. Then consider what happens when the trauma is experienced within the relationship one hopes would provide the containing function ie in some way the containing figure/ the parent has become noxious.
CONTAINER PRESENT AND INTACT
A personal anecdote: - Anecdote removed for reasons of confidentiality. It concerned a woman who stated she had been abused in late childhood by a family friend, but had experienced no harm. In fact she perceived it as an introduction to the pleasures of mature sexuality. My point was that the woman very likely had a secure and reflective family structure, which was helpful to her sense of resilience.
I don't mean to trivialise this issue. Awful events still happen to children from the most secure homes. But, I think they will have a resilience lacking in children with less secure, or more disrupted, attachments. It may be that, if they seek therapy, they will have a better chance of making contact with the secure relationship offered by the therapist. My anecdote makes my point that these strong attachment patterns, and parental relationships may provide protection for the child in the event of trauma that arrives from outside the family. But what of the situation where the caregiver is cruel and unloving, or if the child is met with the vacuous mind of a deeply depressed caregiver.
CONTAINING FUNCTION DISRUPTED
This seems to me to be just awful - a doleful mess. Of course this is where we would find Mary Bell, and I'll talk a bit more about that situation, but I don't want to give the impression that I am only talking about sexual abuse. Of course it is important, but it is equally important to be aware that other situations produce trauma for the child as well. An especially significant factor is depression in the mother. (Refer back to my businesswoman client with a depressed mother and anxiety.) We all know how hard it is to be responsive when we're depressed. Imagine the situation for a depressed mother with all the anxieties of a new child making demands for contact with her, and she frozen into a painful isolation. Nowadays there is much good work done studying the mother-infant relationship, and we know the importance of the interplay between caregiver and infant. It's not appropriate now to go into detail, but broadly speaking, we know that the everyday interchange that goes on between mother and infant has a great deal to do with the child developing a coherent sense of self, and a good knowledge and understanding of its own feelings. We even know now that, in the first year of life, anatomical nerve pathways in the frontal lobe of the brain (where emotions are regulated) are laid down when this mother-infant interchange goes on. If the mother is depressed, and unable to bear the child's expression of feeling, and unable to respond spontaneously, then these processes in the infant are impeded. I don't wish to stigmatise depressed mothers, but to give a sense of the delicacy of these processes in the caregiver-infant relationship. Traumas can be caused by subtle and complicated interactions between parent and child, which may not register in the conscious awareness of the developing infant. Emotional play within the infant-caregiver couple is vitally important.
Returning to situations in which children suffer actual abuse, a recent review (Oliver quoted in Fonagy, p.262) suggests that one third of child abuse victims grow up to continue a pattern of neglectful or abusive child rearing as parents. One third are at risk of becoming abusive under severe stress. And one third are resilient and escape the repetition. (One thinks sympathetically of the stolen generation of Aboriginal people - with totally disrupted parenting. What a struggle to establish themselves as parents in the next generation!) Fonagy proposes a model to explain why abuse might occur at such a high rate across generations. He refers back to the importance of the capacity to think about our experience, which is developed in concert with the parent. If the parent is abusive this process is undermined. If you remember, I suggested that containment involved the mother thinking about the child's painful experience, and taking the panic out of the anxiety. But what if the caregiver is the cause of the painful anxiety?
Then surely it becomes unsafe to take in the thoughts and wishes of the parent who actively wishes to harm the child, because that implies taking in and contemplating the real wish of the parent to harm the child. Because of this the child's development of the ability to think about his experience is inhibited. This has the advantage in the short-term that the child does not have to think about an unbearably painful psychic situation. But the terrible long-term consequence of this short-term advantage is that the developing child sacrifices the ability to think about its experience. (In fact, the child may learn to "evacuate' his thinking and feeling. One suspects this is what happened to Mary Bell. When she was unable to bear the psychic pain of the real abuse done to her, she was compelled to enact the abuse with the toddler victims, doing to them what had been done to her.)
The child is now in an intolerable position. In the real world, and in the inside world in his mind, he is beset by aggressors. He may seek "rescue" by looking to an idealised image of his parent and joining in a sort of compliant "eager-to-please" relationship with the parent, who is in reality the instigator of his torment. Now there is a mess, and thinking is abandoned. This is a worst-case scenario, which is like a pathway to incipient personality disorder. One further gloomy thought. A dangerous development may take place in the post-traumatic situation, and in the treatment situation. The patient may begin to mobilise some anger, which may be murderous in nature. But it may not be immediately possible to express this outwardly, to people in the real world. The anger may get linked up with internal representations of the cruel parental figures, and the anger is then directed at the self. A suicide script may then be in place, ready to be acted on.
TREATMENT
Having reached the darkest moment of my talk, let me conclude with a brief overview of treatment possibilities. I hope to finish on a more optimistic note. I offer therapy that comes from a psychoanalytic perspective, but I think there would be many common features in therapies from many perspectives. (Cognitive therapy, family therapy, group therapy, narrative therapy, counselling, etc, etc) The basic ingredient is to listen. But the listening can be difficult, because one is hearing powerful distress and pain. The therapist is engaged in a kind of balancing act all the time - entering into the painful experience, yet struggling not to be knocked off balance at the same time. At the same time one must be able to make an imaginative identification with the patient, to enter into the world of their distress. The theory I've elucidated tonight is in fact helpful in the listening - it helps one to maintain a balance.
I'll return, for the last time this evening, to the idea of containment. What one hopes to offer to one's patient or client, ultimately, is an experience in which containment of his distress is a possibility. The therapist undertakes to attempt to understand and take the panic out of the patient's most painful anxieties. . This can prove to be very hard work. It involves reworking all the traumatic experience with all the emotional impact that entails. Over a length of time, the therapy compels the patient to attend to the mental state of the therapist, who is present in a benevolent role. They are both, therapist and patient, engaged in the task of attempting to think about their thinking. Hopefully, the patient will be able to make use of this in order to begin to think about his own painful experiences, rather than expelling them as Cries Unheard. As well, theory acts as a container for the therapist. In turn, the therapist offers a containing relationship to the patient. The therapist has need of his theory to "hold on to".
Finally, there are some patients too traumatised to be able to benefit from individual psychotherapy. These are the folk who end up in the currently woefully underfunded public mental health services. These people also need a holding, containing relationship to allow them time to settle and begin to be able to think about their parlous state. But current policies dictate a quick discharge and this allows no relationship to develop. These are the people I'd like to see admitted to a special unit. There they could relate to a consistent coherent group of staff members who are united in treatment goals. Some traumatised people are so damaged that they need help at this institutional level, rather than at the level of personal therapy, which can not contain their distress. With this in mind, I'll conclude by returning to Mary Bell. Quite fortuitously (the court merely wanted to dispose of her) she was placed in a helpful institution after the trial. It was an institution for delinquent boys, run by a stern but understanding ex-navy man, " the first honourable adult she could respect and love." Subsequently things did not go smoothly for her, but this beginning was probably all-important to her, and could only happen in an institution.
Lastly, I think it is important to say that if things go well in treatment, the patient will come to an attitude of acceptance of what has happened to them. Of course, it's likely that during therapy the patient will access a great amount of anger, rage, and hatred. But the outcome may be to reach a position of understanding. It may be understood that even the abuser had no control over his or her actions, which were, in their own right, in the nature of cries unheard. I don't want to be too sententious about this - some sadistic acts may be unforgivable. But I think it is helpful if ultimately we can accept responsibility for our own feelings, rather than heaping blame on another.
Suggestions for Further Reading
Bion, W. (1962) Learning from Experience, London: Maresfield Reprints
Fonagy, P. (1995) Attachment, the Reflective Self, and Borderline States, in Attachment Theories: Social, Developmental, and Clinical Perspectives, New York: The
Analytic Press.
Fraiberg, S. (1982) Clinical Studies in Infant Mental Health, New York: Basic Books.
Freud, S. (1920) 'Beyond the Pleasure Principle', S.E. 18: 1-64.
*Garland, C. (1998) Understanding Trauma: A Psychoanalytic Approach, London: Duckworth
*Holmes, J. (1993) John Bowlby and Attachment Theory, London: Routledge.
Klein, M. (1952) 'Some theoretical Conclusions Regarding the Emotional Life of the Infant', in Envy and Gratitude, Vol. 3 The Writings of Melanie Klein (1975),
London, Hogarth Press.
*Sereny, G. (1998) Cries Unheard: the Story of Mary Bell, London: MacMillan; repr.
Papermac (1999).
Target, M. (1998) Book Review Essay: The Recovered Memories Controversy, International Journal of Psychoanalysis, 79: 1015-1028.
Winnicott, D. (1982) The Maturational Processes and the Facilitating Environment, London: Hogarth Press