Anna Freud – advocate of the child

In the late 1970s, a survey was conducted among child psychiatrists in the USA, asking who was the most influential figure in child psychology and psychiatry of the 20th century. The person who received the most votes was Anna Freud. But 40 years after her death in 1982, much of her work is out of print and few courses in child psychology or psychiatry in the UK teach her work. So who was Anna Freud, and what is her true legacy today?

Born in 1895 in Vienna, the sixth and youngest child of Sigmund and Martha Freud, Anna Freud's life was caught up with the history of psychoanalysis. Growing up as a Jewish woman in a conservative and authoritarian society, she faced discrimination and had limited opportunities. She was not allowed to study at university, but by her mid-20s she was a trained nursery teacher, a practising psychoanalyst and the only one of Freud's children to follow into his profession.

During the 1920s, Anna Freud was part of a progressive group of young analysts who wanted to use the insights of psychoanalysis to build a new world; in particular, by shaping the way that children were thought about and cared for. During this time she did important work to support war orphans, working with so-called 'wayward youth' and helping parents and teachers use the insights of psychoanalysis to support their role in the care of children. This important world was increasingly stifled by the rise of fascism in the 1930s. After Anna Freud was briefly arrested by the Gestapo in 1938, her family escaped Vienna and came to London.

A year after arriving as a refugee and immigrant in the UK, Sigmund Freud was dead, and World War Two had broken out. Instead of withdrawing, Anna Freud instead looked to what she could do to help with regard to the difficulties children and families were facing. With the 1941 bombings of London, the Blitz, she asked how the lives of children were being impacted by the war, and what could be done to help.

The Hampstead War Nurseries

Miss Freud (as she was usually called after moving to the UK) set up the Hampstead War Nurseries in 1941 to support children, largely from the East End of London, who had been most affected by war. They provided nursery services for children focused on emotional wellbeing of children, as well as physical care. Originally based in London, the children were moved out to a residential nursery in Essex once the bombing became more intense. Children had experienced losses and destruction of their homes – and the Hampstead War Nurseries looked to repair that damage and play a preventative role to ensure no further harm.

The Anna Freud Centre today hosts and supports the UK Trauma Council, which aims to empower professionals and local communities in supporting children and young people following traumatic events and experiences.

It was also seen as an opportunity to learn – about the needs of children, the impact of war – and to discover what kind of support and training the young staff (mostly Jewish refugees themselves) needed to best meet the needs of the children in their care. The impact of violence, war and disruption on the lives of children continues, and making sure support services are informed by the best available evidence remains essential. The Anna Freud Centre today hosts and supports the UK Trauma Council, which aims to empower professionals and local communities in supporting children and young people following traumatic events and experiences.

Miss Freud and her colleagues quickly realised that separation from families, and the impact of these separations on children, posed a great risk factor for children's mental health – over and beyond the impact of war itself. In the Nurseries they did everything to maintain the attachment relationships and parental contact, arranging flexible visiting hours for mothers, and striving to maintain attachment relationships to fathers too, many of whom were fighting abroad, via regular letters sent to them about their child and their development.

But Miss Freud and her colleagues soon also realised that supporting contact with the family was not enough in itself. Although residential care seemed to have quite positive impacts on the children's physical health and cognitive development, their emotional wellbeing was suffering. Instead of offering group care, as was standard in most residential nurseries at the time, the Nurseries decided to allow 'artificial families' to form where small groups of children selected one nurse as their primary carer. In many ways, this made life more complicated. The children cried when their nurse left their room, they were jealous when they attended to someone else in their 'family'; but the positive impact on their emotional development was striking. Miss Freud said:

'When choosing between the two evils of broken and interrupted attachments and an existence of emotional barrenness, the latter is the more harmful solution… In reality, it is not the absence of irrational emotional attachments which helps a child to grow up normally, but the painful and often disturbing process of learning how to deal with such emotions.'

This approach helped children, not to avoid emotional experiences and relationships, but to ensure they had essential attachment relationships in their early years and were able to negotiate the experience of connection and loss for their emotional development. This emphasis on the centrality of relationships to the wellbeing of children remains at the heart of the Anna Freud Centre's work today.

The Hampstead Clinic – later the Anna Freud Centre

After the war, Miss Freud set up the Hampstead Clinic, which offered child psychotherapy and treatment to children in need of clinical services. But building on what had been learned in the War Nurseries, the clinic also provided preventative support and advice to help families prevent problems and offered consultations to thousands of teachers and healthcare professionals. There was still the need for research, and to train child psychotherapists based on what they had learnt from their research and treatment. When she died, the Hampstead Clinic was renamed the Anna Freud Centre.

Miss Freud's work in the post-war years in London went beyond the setting up of the Hampstead Clinic. She was one of the founders of developmental psychopathology – the idea that we cannot understand psychopathology unless we understand it from a developmental perspective. In her essays and books she argued that, to support children's mental health, we must understand the interaction of their various 'developmental lines' – that a child doesn't grow out of their problems, but they grow with and through them.

Anna Freud also challenged psychiatric models which saw children as just 'miniature adults'. She challenged diagnostic systems based purely on a checklist of symptoms. She looked to the underlying meaning or causes of problems – and argued that we could only meaningfully understand a diagnosis when we comprehend the underlying causes and meaning of the behaviour, in the context of a child's development.

She was also interested in the parent-infant relationship and the role the parent has in working hard to 'get' the child and understand their experiences. She then took this to the therapeutic relationship and showed how this could be transformative because the adult is showing interest, openness and understanding of the psychological experience of the child, what the world looks like and feels like from the child's perspective. For children with early trauma, what was needed, she suggested, was a 'developmental therapy'.

These ideas helped to form the basis of what we today call 'mentalizing'. Mentalizing is the process of making sense of self and others in terms of underlying mental states. It is what we do when we are imagining what might be going on in the mind of someone, underneath the behaviour that we see on the outside. This forms the basis of Mentalization Based Treatment, which is now an evidence-based model of help which the Anna Freud Centre is best known for.

Pioneer, teacher and innovator

Anna Freud had a profound impact in creating the field of psychoanalysis and psychotherapy for children and young people. That children's emotional and behavioural problems could be understood psychologically is an idea that is taken for granted today but didn't exist at the time she was first developing her ideas, in the 1920s.

Along with other pioneers of child analysis, such as Melanie Klein and Hermine Hug-Hellmuth, she made an essential contribution that children could communicate about their psychological world not only through talk but also through play. The language of childhood is play, and this was a way for children to share their internal worlds. It was revolutionary at the time, that children's minds were to be explored in the context of a relationship with an adult, listening and trying to understand the child's mind, which could be a therapeutic process.

Before becoming an analyst, Miss Freud trained as a nursery school teacher and was influenced by the work of Maria Montessori. She was involved in education throughout her life and in the 1920s she even set up her own experimental school in Vienna, called 'The Matchbox School'. At a time when education was still very focused on discipline and learning of facts, she challenged what education could be. Instead of asking 'How can we make children learn?', her question was rather 'How can we inspire children to want to learn?' About one of her mentors, August Aichhorn, she said:

'So often teachers are in a hurry to get their students to know something, to have the right answers: a possession. Aichhorn knew how to scratch his head and say: Well, we can look at this boy in this way, but we can also look at him in this way, and there may be other ways, too. He was challenging us: can you do the same – focus and refocus, shift your angle of vision, adjust your point of view?'

What was true of Aichhorn is surely true of Anna Freud herself. She was not only a teacher in the literal sense, but was deeply interested in learning and how to pass this on so that she could help others to learn too. By looking at problems from different perspectives and views, our minds can be changed; and if we don't do this, then we will not get the full picture and a deep understanding of childhood and child mental health.

This interest in exploring how psychological thinking can inform education continues today. The Anna Freud Centre does a significant amount of work with schools and has founded its own school – the Pears Family School – which is an alternative provision for children and their families with emotional and behavioural difficulties.

From the child's perspective

From the accounts of those who knew her, it seems that Miss Freud was quite shy and not socially comfortable; but where she was most at ease was in the nursery talking to children. She was interested in and listened to children, and she wanted to know what the world looked like from a child's perspective.

Towards the end of her life, it was in the sphere of family law that Anna Freud made one final contribution. She was a visiting professor at Yale in her 70s, not in psychology but in the law department. She invited her colleagues there to look at what a child-centred law system would look like – how to redesign family law, and the system, around the needs of children and not the needs of parents or society.

After her death, her niece, Sophie Freud, who was herself a social worker and academic, said this about her aunt: 'She wanted children to have lives that would not be oppressed and exploited, restricted, impoverished, or damaged by an uncaring adult world. It was her hope that by spreading the wisdom of psychoanalytic insight she could improve children's lives in their families, clinics, schools, hospitals, and courts. It was in this role of mother/educator and advocate of children that she spoke most clearly in her own voice and that we can celebrate her wholeheartedly.'

The Anna Freud Centre today

This year marks the 70th anniversary of the Anna Freud Centre, and in certain respects the Centre has moved away from Anna Freud's ideas, especially her commitment to Freudian psychoanalysis. Yet her thinking and pioneering work has profoundly shaped the organisation that carries her name.

As well as the work in education, and on the impact of trauma, the Anna Freud Centre's participation work today takes on board the perspectives and lived experiences of children and young people so that this can be at the heart of our training, clinical services and research. Miss Freud suggested that the child's perspective and experiences are often not kept in mind when decisions are made by adults, but need to be explored and argued for. She recognised that society suffers from what her biographer, Elisabeth Young-Bruehl, called 'childism' – a form of systematic prejudice that impacts on children in all spheres of life – family, education, and the law.

Anna Freud showed a commitment to prevention, research and treatment, and how these can all inform one another. She was passionate about how we train, share and disseminate ideas, not just in mental health services but through all settings around a child – including education, hospitals and the legal system. This is an overarching vision that motivates our work today and will do so in the years to come.

- Professor Nick Midgley is Co-Director of the Child Attachment and Psychological Therapies Research Unit, and Academic Programme Director for the Doctorate in Child and Adolescent Psychotherapy at the Anna Freud Centre and UCL. He wrote Reading Anna Freud (Routledge, 2012), as well as several papers about Anna Freud's work in Vienna and the War Nurseries.