Book
Maternal Care and Mental Health
Maternal Care and Mental Health is the report John Bowlby wrote for the World Health Organization in 1950–51 as its contribution to a United Nations study of homeless children: children orphaned or separated from their families and cared for in institutions, foster homes or other group care within their own countries. Drawing on visits to France, the Netherlands, Sweden, Switzerland, the United Kingdom and the United States, and on the clinical and research literature of child psychiatry and child guidance, Bowlby argues that what the infant and young child needs for mental health is "a warm, intimate, and continuous relationship" with the mother or a permanent mother-substitute, one in which both find satisfaction. The lack of such a relationship he calls maternal deprivation. It is partial when a child lives with a mother unable to give loving care, or is looked after by someone other than the mother; it is almost complete when, as in many institutions, residential nurseries and hospitals, no one person cares for the child in a personal way. Part I reviews three kinds of evidence. The first is direct observation of children in institutions, hospitals and foster homes (Spitz and Wolf, Goldfarb, Burlingham and Anna Freud, Roudinesco and Appell, and others). The second is retrospective study of disturbed and delinquent adolescents and adults, including Bowlby's own study of juvenile thieves with an "affectionless" character. The third is follow-up studies. Bowlby grants that few of these studies are conclusive alone, but finds that together they agree well enough to establish that prolonged deprivation in early childhood can do grave and lasting harm to character. He explains this by analogy with the critical periods of embryology, and in the terms of psychoanalytic ego psychology: until the child internalizes the functions of ego and superego, the mother performs them, so deprivation during the phases in which a relationship is formed and sustained arrests their growth. Part II turns to prevention. Children tend to fare better even in poor homes than in good institutions, and deprived children tend to become parents who deprive their own children. The first aim must therefore be to keep families together with economic, social and psychiatric help. After that the report recommends early adoption for the children of unmarried mothers, supervised foster care, and small family-like group homes rather than large institutions. It also asks for humane hospital practices, such as admitting mothers with young children and encouraging frequent visits. The report closes by urging governments to accept that mother-love matters as much to mental health as vitamins and proteins do to physical health, and to act without waiting for complete evidence.
Main ideas
- Mental health in infancy and early childhood depends on "a warm, intimate, and continuous relationship" with the mother or a permanent mother-substitute, in which both partners find satisfaction. In this account the father matters chiefly as the mother's economic and emotional support.
- "Maternal deprivation" replaces the vague statistical category of the "broken home". It names the lack of that relationship, whether the child is separated from the mother or lives with a mother unable to give loving care. Partial deprivation breeds anxiety, an excessive need for love, vengefulness, guilt and depression. Near-complete deprivation, common in institutions, can cripple the capacity to form relationships altogether.
- Direct observations, retrospective histories and follow-up studies from many countries are each weak alone, but they agree so consistently that the general proposition can be taken as established. Prolonged deprivation of maternal care in early childhood may gravely and lastingly damage character, as rubella damages the foetus or a lack of vitamin D causes rickets.
- The "affectionless" or psychopathic character shows superficial relations, lack of feeling, deceit and persistent stealing. It follows three kinds of early experience: no chance to attach to a mother-figure in the first three years, a separation of several months in the first three or four years, or repeated changes of mother-figure. Such children respond poorly to psychotherapy, so prevention is far cheaper than cure.
- Vulnerability depends on developmental phase. The child forms a relation with a clearly identified mother by about six months and needs her as an ever-present companion until about three. Only gradually does the child become able to keep the relationship alive in her absence. All agree that deprivation in the second half of the first year is very harmful. Good mothering can repair early damage only if it comes in time: delayed beyond about two and a half years it is of little use, and for many infants the limit comes much earlier.
- In theory, the mother serves as the young child's ego and superego, orienting the child in time and space and regulating impulses, until the child internalizes these functions. Borrowing the embryological idea of an organizer that acts in critical periods, Bowlby calls her the "psychic organizer". Deprivation therefore impairs abstract thinking, identification and introjection, and leaves children impulsive and unable to pursue long-term aims.
- A separated child often turns hostile toward the parents who seem to have deserted it, or withdraws from relationships altogether to avoid further loss. The young child's meagre sense of time makes a separation feel like an indeterminate sentence, and it may be taken as punishment.
- Children generally do better in bad homes than in good institutions. They remain attached even to neglectful parents, who still give them continuity of care. Deprived children tend to grow into parents unable to care for their own children, a self-perpetuating cycle that Bowlby likens to the spread of infectious disease.
- Prevention starts with keeping families together. Western industrial society has lost the ready substitutes that the extended family once supplied. It should therefore give the home direct economic, social and psychiatric help rather than pay more for residential care, through social workers trained to understand unconscious motivation.
- When a child must live away from home, the report ranks the options. First comes adoption soon after birth for the children of unmarried mothers. Next come carefully chosen and supervised foster (boarding) homes that keep the child in touch with its own family. For older children, adolescents and the maladjusted it accepts small residential homes, divided into mixed family groups that keep siblings together. It condemns large institutions.
- The same principles apply to sick children. They should be nursed at home where possible. Mothers of children under three should be admitted to hospital with them, and older children should be visited often.
- Research should no longer re-prove the general proposition. It should study the variables: age, the duration and degree of deprivation, and the child's relationships before and after it. Meanwhile governments should act now, since "to await certainty is to await eternity".
What it shows
René Spitz influenced John Bowlby
Spitz and Wolf's work on hospitalism fed into Bowlby's theory of maternal deprivation; Bowlby cited it in his 1951 report for the World Health Organization.
Maternal deprivation derives from Hospitalism
Spitz and Wolf's interpretation of hospitalism fed into Bowlby's post-war theory of maternal deprivation, and the notion of hospitalism was later widened to severe and lasting maternal deprivation in general.