Bruno Bettelheim (1950) Love is not enough: the treatment of emotionally disturbed children Glencoe IL: Free Press 0 02 903280 6 (reprint)
Bruno Bettelheim (1903-1990) was an Austrian Jew who, before the Second World War, together with his wife, had fostered a girl whom he later described as autistic. He was one of many Jews rounded up and sent to concentration camps but then released in a public gesture in 1939, after which he emigrated to the US. His accounts of concentration camp life were initially vilified (1968) but he was eventually sufficiently accepted to obtain a post at the University of Chicago where he directed the Orthogenic School. Love is not enough (1950) was in effect his manifesto for the school and A home for a heart (1974) his retrospective on those experiences.
– Seriously disturbed behaviour is caused by a child’s prior experiences.
– Only by using all aspects of a child’s environment can it be successfully treated.
– Individual and group therapy can take place within the context of daily interactions.
– Unconditional acceptance of behaviour is needed until the child has established
a primary relationship with their carer.
– It is necessary to protect seriously disturbed children from their parents.
In the Introduction Bettelheim stresses that parenting is more complicated than just ‘loving’ your children and that the sources of many of the emotional problems in the lives of children lie in the day-to-day interactions between parents and their children in which the adult, not being sure of the appropriate way to behave, communicates this uncertainty to the child. So carers need to be clear where they stand on issues, and children need to be exposed to a range of adults who collectively can cover for each others’ hang-ups. Carers should be prepared to admit their mistakes and apologise where necessary while emotionally disturbed children need open relationships which allow them to develop relationships at their own pace rather than those with people with labels, for example ‘houseparent’, which are tied to a particular role in society.
In Chapter 1 The children, he stresses that children who have experienced abnormal behaviour may regard it as normal and first have to learn what is normal behaviour. This can best be explored in everyday settings; so the Orthogenic School in practice offers environmental therapy.
In Chapter 2 First encounter, he stresses the importance of allowing children to enter the school through engaging in its everyday activities rather than in discussions of their problems or emotions; if they do not wish to engage in particular activities, no pressure should be put on them to do so, not least because these may have been battlegrounds in the past. Ideally the child should be able to enter a functioning group whose last newcomer joined some time ago because children will more quickly trust the reactions of the children around them than any reassurances from adults.
In Chapter 3 Events in sequence, he argues that dealing with children’s concerns within the context of their day-to-day activities is far more effective than asking them to talk about them in therapy sessions, but that this process may take many days and many interactions to complete.
In Chapter 4 From dreams to waking, he discusses the process of waking up, particularly if that has been through a dream which some children may not be able to separate from reality (this was written long before our current understanding of REM sleep and dreams), and the importance of making it a gradual process through which they can deal with any anxieties they may have about daytime.
In Chapter 5 The in-between times, he discusses times and places that have no defined character, such as times between activities and spaces between rooms, in which many significant activities take place. These times and places may be more important to children if they have experienced frustration or disappointment around set times and places which a child may take years to get over.
In Chapter 6 The challenge of learning, he discusses fears not just of school but of the process of learning and how these can be allayed/overcome, noting that it may be a long time before the nature of a particular fear comes to be understood. Learning must be a shared experience in which other children can be involved and it can be intimately connected with a child’s emotional development.
In Chapter 7 Food: the great socializer, Bettelheim argues that making food freely available avoids the distraction of feelings of hunger in children, makes meal times a social rather than a purely physical event and symbolises emotional care for many children. Where food has been a bargaining tool or children have been more generally deprived, they have to experience it as freely given before they can begin to enter into normal relationships with people. Some may need to eat alone with a member of staff at first because they cannot enjoy a shared meal.
In Chapter 8 Rest and play, he discusses the importance of relaxation as a complement to activity; children who are unable to relax are often unable to engage in normal physical activity. Freedom to act is not always valuable but sometimes only by giving a disturbed child that freedom is it possible to learn what sort of help they really need. Sometimes constructive activity only follows a period of hostile or destructive activity; however, play is essential both to developing as a person and to developing a social network.
In Chapter 9 Alone and in the group, he says that, depending of the child’s needs, individual work may be with the person who cares for them on a day-to-day basis or with someone else in the establishment; group work is conducted within the children’s daily living groups who are often able to interpret behaviour and provide more acceptable control than if it came from an adult.
In Chapter 10 The world outside, he describes children’s reactions to the world outside the school and how these are managed.
In Chapter 11 In the bathroom, he discusses the anxieties and behaviour of children who have difficulties over being clean or dirty or who have been distressed about intimate behaviour or abused in intimate situations.
In Chapter 12 Bedtime, he describes the anxieties children may have about bedtime and how these can be managed through preparatory activities such as bedtime stories and individual work. In particular he considers some children’s sexual fears and fantasies and responding throughout the night including to bed-wetting.
Though Bettelheim draws heavily on Freudian ideas, many of his ideas about the interactions between parents and their children would not be out of place in a behaviourist or interactionist textbook. His argument that therapy is best offered in everyday settings rather than in formal interviews or groups is taken up in The Other 23 Hours (Trieschman et al., 1969).
Love is not enough is not a manifesto for good parenting and, unlike Neill (1962), Bettelheim never tries to draw conclusions about good parenting from his work. He is not concerned with children who have a secure attachment, to use modern parlance, nor with most of those who have an anxious/avoidant or insecure attachment but with a tiny minority whose relationships with adults have become so skewed that they do not know what a normal attachment might be. For these children, because they have no concept of a normal relationship within which the therapy can take place, individual therapy needs to take place as part of individual relationships within a functioning group in which the relationships between their peers will also give them an understanding of what a normal relationship might be like. The idea that children need to develop both individual and group relationships reflects our modern understanding of children’s needs (Ladd, 2005) but it was not so in Bettelheim’s time, which may be why he makes no claims about its application beyond disturbed children.
In the half century since he wrote, there has been a strong reaction against using group care for such work but the recent evidence that those damaged by abuse may benefit from group work (Sgroi and Sargent, 1993) suggests that this idea may be worth revisiting.
At times his account is burdened by the particular interpretations that he places on what he describes but none of the points he highlights are insignificant in caring for children and he shares with O’Neill (1981) the view that those working with a child can be baffled by a child’s behaviour but still have to continue working with the child in the belief that one day it will change in ways as yet unknown and often unexpected. He also argues that trying to explain a child’s behaviour to a child is normally counter-productive because we don’t really understand it anyway.
In that context unconditional acceptance serves the two purposes of avoiding replicating actions which the child may see as rejections and allowing the display of the behaviour which may eventually lead to the understanding that workers need in order to help the child more effectively.
In advocating separating children from their parents, though parents are allowed to write, he goes against what would now be regarded as good practice for most children, but his argument that this is necessary when children do not have normal relationships with their parents and need to develop normal relationships before resuming any form of relationship with them may be worth reconsidering in the light of Wiener and Wiener’s finding (1990) that the parents who had most harmed their children were often the most resistant to their children receiving appropriate care.
Bettelheim, B (1950) Love is not enough: the treatment of emotionally disturbed children Glencoe IL: Free Press
Bettelheim, B (1968) The ultimate limit Midway 9, 3-25 Autumn Reprinted in B Bettelheim (1979) Surviving and other essays London: Thames & Hudson
Bettelheim, B (1974) A home for the heart London: Thames & Hudson
Ladd, G W (2005) Children’s peer relations and social competence: a century of progress London: Yale University Press
Neill, A S (1962) Summerhill: a radical approach to education London: Victor Gollancz See also Children Webmag June 2009.
O’Neill, T (1981) A place called Hope: caring for children in distress Oxford: Blackwell See also Children Webmag May 2009.
Sgroi, S M & Sargent, N M (1993) Impact and treatment issues for the victims of childhood sexual abuse by female perpetrators In M Elliott (Ed.) Female sexual abuse of children: the ultimate taboo Chapter 2, pp. 15-38 Harlow: Longman
Trieschman, A, Whittaker, J & Brendtro, L (1969) The other 23 hours: child care work with emotionally disturbed children in a therapeutic milieu Chicago: Aldine
Wiener, A & Wiener, E (1990) Expanding the options in child placement Lanham MD: University Press of America