Abstract: It takes much neglect, rejection, humiliation, physical maltreatment and sexual abuse to transform a tiny, trusting, innocent human being into a callous, cruel and vicious youth and adult. This paper will examine some of the factors that contribute to the development of the violent personality. It is suggested that the answer to street violence is not state violence. The answer is conscious parenting supported by social institutions, laws and practices which attend to the needs of pregnant parents, particularly, the disadvantaged.
We all decry the fact that this planet is slowly but inexorably being violated and poisoned by its inhabitants. We rail helplessly against a rising tide of child abuse, wife battering, drug addiction, serial murder, internecine warfare and suicide. We denounce, damn and blame everything and everybody in sight: the politicians, the criminal justice system, multi-nationals, the media, poverty, the decline of moral values; the list is endless. The solution escapes us because we have not looked for it in the right place. We have been blind to our beginnings. Where does a person first experience feelings of love, rejection, anxiety and sadness? Where does a person first learn about interacting with people and the world? Where are basic character traits formed? In the first school we ever attend. - our mother's womb. It is here that we receive our introduction courses in love, neglect, hate, anxiety, trust and empathy. It is here that we need to look for the roots of violence.
I have entitled my paper "Birth and Violence because I wish to focus on factors related to birth and after birth that cause an infant to become cut off from his feelings and filled with rage. Of course, we all know that way before birth, the unborn may be exposed to physical and psychological violence.
Let us consider for a moment the histories of two notorious killers, as told by David Chamberlain (1995).
David Edwin Mason and Robert Alton Harris spent their final years on Death Row before they were gassed by the State of California in 1991 and 1993 respectively for heinous crimes of violence. The dossier on Mason reveals him to have been a sad, lonely child whose mother tried to induce a miscarriage to avoid having him in the first place, and was never allowed to forget that he was unwanted. Older sisters describe a household where hugging or laughter was prohibited, and in which young David was beaten almost daily with his father's belt or his mother's switch or pancake turner.
When only five, the child attempted suicide by swallowing a bottle of pills and set his clothing on fire. At eight, he was taking out his hostility by setting fires at church and at school. His parents started to lock him away in a room they called "the dungeon"--a bedroom with the windows nailed shut. Persistent bed wetting, and worse, were countered by parading David with the soiled clothes wrapped around his head.
At age 23, Mason went on a nine-month killing spree in the neighborhood where he had grown up, strangling four elderly men and women. He later confessed that it was "something I have always wanted to do."
Harris's beginnings were strikingly similar. He was born three months premature after his mother was kicked so brutally in the abdomen by an angry husband, that she began hemorrhaging. As in the Mason family, both parents inflicted frequent beatings--the father with his fists, causing a broken jaw when Robert was not yet two. Sitting at the table, if Robert reached out for something without his father's permission, he would end up with a fork in the back of his hand.
For sport, father would load his gun and tell the children they had 30 minutes to hide outside the house, after which he would hunt them like animals, threatening to shoot anyone he found. The senior Harris was jailed for sexually molesting his daughters, while the mother smoked and drank herself to death.
Like Mason, young Harris soon began showing anger towards animals and people. At twenty-five he shot two San Diego teenagers to death. Prosecutors told the jury that Harris taunted the victims before they died, laughed at them after he pulled the trigger, then calmly ate the hamburgers they had bought for lunch.
In an editorial on the occasion of Mason's execution, former U.S. Congressman Lionel Van Deerlin of San Diego concluded: "Such persons must be put away, of course. But can society feel comfortable when providing the final touch to a pattern of violence, which may literally have begun in the mother's womb?"
Congressman Van Deerlin has good insight. I just wish more scientists and health professionals would share it.
The womb is not always the safe, loving, oceanic bliss that we all, according to popular belief, long to return to. For many, in fact, it is a dangerous and often painful abode. Exiting from it can be quick and relatively easy or quite horrendous. Each physiological event will leave a psychological imprint.
Birth and Life Scripts
A number of studies report findings suggesting the possibility of a relationship between birth complications and violent behavior (Litt 1972). They offer the hypothesis that birth complications result in brain damage that predisposes a child to impulsive and aggressive behavior (Mungas 1983).
In 1960 Mednick (1971) studied the records of violent criminals in the Danish penal system. Fifteen of the sixteen most violent criminals were found to have had an extraordinarily difficult birth and the sixteenth had an epileptic mother.
In a recent Danish study (Kandel and Mednick 1991) 15 violent criminals and 24 property criminals were compared with 177 non-offenders on pregnancy and delivery events. Delivery complications such as ruptured uterus, umbilical cord prolapse, difficult labor, etc., predicted violent offending, especially in subjects whose parents were psychiatrically disturbed.
Psychologist Adrian Raine and co-workers at the University of Southern California, Los Angeles, report a significant association between birth complications and early matemal rejection and violent crime at age 18. While only 4.5% of the subjects had both risk factors, this small group accounted for 18% of all violent crimes. The effect was specific to violence and was not observed for non-violent criminal acts (Raine et al. 1990).
These and other studies very clearly show that personality is shaped, for better or worse, by a chain of events or risk factors that start often before conception and continue through the life span. Because every biological process has a psychological correlate everything that happens to us, especially at the beginning of life, permanently affects us. Whether your mother was awake or asleep when you were born, whether you were delivered vaginally or by C-section, whether you roomed in with your mother or spent four weeks in an incubator--these things matter enormously.
Both children and adults report having memories of birth. What we observe in birth memories is consistent with what we find in modern research: the newborn's brain, nervous system, and physical senses are active and coordinated; a normal range of human emotions is felt and expressed while the infant's mind is alert, perceptive, exploring, and busy incorporating each new experience.
How do we welcome into the family of humankind these new, highly aware and discerning beings? From the darkness and silence of the womb we bring them out into a blaze of blinding lights, a cacophony of noise and harsh voices. Vulnerable spines which have always been curved are whiplashed as we grab newcomers by the ankles (thank goodness a diminishing practice). We further terrify children by suctioning mucous out of their mouths and placing antibiotic drops into their eyes which not only sting but also cloud vision so that everything around becomes a blur. If the babies show any signs of jaundice, their heels are lanced to obtain blood for lab work. After a few minutes of recovery on their mothers breast (if the woman is not unconscious from the anesthetics and painkillers), the babies, whose skin at this point is extraordinarily sensitive, are wrapped tightly in cloth that to them feels like sandpaper. Finally, they are banished to the nursery to recuperate from their ordeal in the midst of twenty or thirty screaming newborns. And this is "a good birth!
If babies are premature, born with a congenital defect, or otherwise ill, they are taken to the Neonatal Intensive Care Unit (NICU). And God help them there!
What is the effect of this painful, sensory overload on babies? Firstly, they don't thrive as well as they should. Secondly, they become psychologically traumatized. The helplessness, the grief of separation from mother, the absence of touching, the constant fear of being hurt, the rage, the anger--these are feelings permanently recorded in their memory banks. These memories do not evaporate, they do not disappear. If subsequently, the child is loved and nurtured the negative charge attached to these memories can be gradually diminished. If, on the other hand, the child is further traumatized by rejection, abuse or neglect, these early experiences will be reinforced and they will come to act like pacemakers in his mind driving him towards increasingly destructive modes of behavior.
Early Parenting and Attachment
Louise Kaplan (1996), an American psychoanalyst, when discussing the importance of mother-infant bonding, says the following:
Were it for not this dialogue, the chaotic excitements and crude appetites of the infant could not be transformed into the desires and longings that enable him to live a fully human life.
And then again:
In her moments of tension and need, a helpless baby can be ruthless. She possesses and destroys the breast that feeds her. She devours the arms that hold her. She rids herself of her body products without any concern. A mother's presence in a baby's life absorbs, contains, and tolerates the baby's unruly lusts and thereby tames and humanizes them. The mother's attunement to her baby's crude and inchoate excitements transforms them into socialized human emotions and affects.
This view of the newborn as an aggressive destructive, cannibalistic creature is fairly representative of orthodox psychoanalysis in general and Melanie Klein (1952) in particular. It is based on the analyses of highly neurotic adults and severely traumatized children. It is like saying that all human livers are scarred and non-functioning on the basis of autopsies of the livers of alcoholics only.
I firmly believe that all mammalian infants including the human infant are hard-wired to develop loving relationships with their fellow species. Whether or not they do so depends entirely on how they are treated. Such an argument is strengthened by findings which show that neural pathways for altruism and aggression may be reciprocally related, so that aggression reflects a deficit in endogenous opiates, whereas their secretion reduces aggressiveness by promoting social comfort and play.
Attachment and attunement occur at a psychological as well as at a physiological level right from the beginning of the mother-infant relationship.
Studies on the importance of the maternal-infant bond (and lately--paternal bond) are relatively recent. In 1945 Rene Spitz (Garnezy 1985) studied two groups of infants who received vastly different kinds of mothering (Kaplan 1996).
In one group, the mothers were imprisoned delinquent girls, who were encouraged to care for their babies every day in the prison nursery. Most of these girls were not very intelligent and had never mothered a baby before. Yet in their easygoing, spontaneous way, they gave their babies the kind of one-to-one attention and care that human babies thrive on. In the other group, for one reason or another--the mother's death, an illness in the family, financial stress--infants had been deposited for various periods of time, ranging from a few months to several years, in a foundling home. These infants were cared for by intelligent, experienced, highly trained nurses, who efficiently dispensed the food, clothing, and physical care that human children require. But there was only one head nurse and five assistant nurses for forty-five babies. No time. was wasted on play or talk.
Whereas the infants in the prison nursery were emotionally responsive and animated, and physically flourishing, the foundlings would lie in their cribs in a stupor, staring at nothing, until many of them simply withered away and died. Those who had more physical resilience did not die. They would, however, make their desperate hunger for human contact evident by spending their waking hours weaving their fingers in front of their eyes, as though eyes and hands were engaged in a meaningful dialogue.
Most of the infants who had been foundlings since birth and never experienced a human attachment, could not recover even after Spitz arranged to provide them with intimate, one-to-one attention and care. Remarkably, some of the bonding-deprived infants were still able to respond to the invitation to engage in dialogue. But their initial contacts with an animated, responsive caregiver aroused an intense and unmanageable anxiety in the bonding-deprived infants, who reacted with a violence rarely seen in children. They would tear their clothing and bedsheets into shreds. They would bite the other children in the nursery and tear their own hair out by the fistful (Kaplan 1996).
Scientists began to wonder why and how infants were affected by the loss of a mother. In the 70's Harry and Margaret Harlow (Harlow and Mears 1979) began to research these and related topics in their primate laboratories at the University of Wisconsin.
In Harlow's study, eight rhesus monkeys were separated from their biological mothers immediately after birth. Each infant was placed in its own private cage containing two surrogate mothers, neither of them alive. One was a "terry cloth mother," a block of wood layered with spongy rubber and covered with terry cloth. The other was a "wire mother," a wire mesh construction of the same size and shape as the terry cloth mother. For four of the infants, only the terry cloth mother was fitted with a feeding nipple, while for the other four, only the wire mother had the feeding nipple.
In a few months, all eight rhesus infants were firmly attached to their terry cloth mothers. When, in another series of experiments with a different group of rhesus infants, Harlow added heat and a rocking motion to the terry cloth mother, she became a magnet of love. The attachment of the rhesus babies became resolute. They would cling to her for sixteen to eighteen hours a day. When Harlow's infant rhesus monkeys grew up, their repertoire of emotional responses was limited to clinging attachment and destructive aggression. Aside from an urgent and almost continual need to hold onto familiar, soft, furry-like objects, they bit and tore at paper, cloth, their own bodies, and the bodies of other rhesus monkeys as though they had no way of discriminating animate from inanimate. Some carried around shredded remnants of their original terry cloth mothers, some hugged and cuddled with their siblings, but they could not tolerate any sort of reciprocal interactive relationship (Kaplan 1996).
The majority of monkeys who survived early maternal deprivation were unable to mate as adults. Those that did or were artificially impregnated were unable to take care of their young. In fact, more often than not, they attacked them viciously.
Gradually, through the pioneering works of Bowlby, and Klaus and Kennell, we have gained a deeper understanding of the sensitive period after birth during which the baby and parents learn to know and love each other. If this period is interfered with by sickness or absence of one of the participants, or if the mother or father reject the newborn child, then the child will begin to withdraw. This does not mean, for example, that every preemie who is sent to a Neonatal Intensive Care Unit (NICU), will automatically be scarred for life, but it does mean that parents need to try harder to connect with babies in the NICU and thereafter.
The Unwanted Child
Studies of mothers who petitioned but were denied a legal medical abortion tell us a lot about the effects of prenatal rejection on children. Research from Finland, Sweden and Czechoslovakia is instructive in this respect. Blomberg (1980) observed that all the differences in the Swedish study were uniformly to the disadvantage of the unwanted children. In the Finnish study, which is still continuing, the incidence of infant mortality, cerebral palsy and mental retardation was significantly higher among the unwanted children than the controls (Myhrman 1986).
The Prague cohort (David, Dytrych, Matejcek, and Schuller 1988) follows the development of 2,290 children born in 1961-1963 to women twice denied abortion for the same pregnancy and pair-matched controls from age 9 through ages 21-23. All the differences noted were consistently in disfavor of the unwanted children. Over the years, these differences widened and many differences that had not been statistically significant at age 9 became so at age 16 or 21. The findings of the Prague study and also of the Scandinavian research support the hypothesis that children rejected prenatally will, more likely than controls, show developmental, psychological and social handicaps.
In a recently published paper (Bustan and Coker 1994), Ann Coker, epidemiologist from the University of South Carolina found that infants born of unwanted pregnancies are more than twice as likely to die within a month of being born than wanted children. The group studied were married, largely middle income women who were all receiving prenatal care.
A less extreme case of being born unwanted is the plight of children given up for adoption. Every study on adoptees shows that they are over-represented among children with behavior problems, and adult criminals and murderers. In fact, I have yet to find a serial killer or violent rapist who was a wanted child reared in a normal, loving family.
Across the land and all over the world too many children are dying after being beaten, tortured or shaken to death. The unspeakable horrors that are being inflicted on children of every age every hour of every day is barbaric. Those who are not killed are often crippled for life by neglect and physical, sexual and emotional abuse. The children who survive this process of abuse will repay the world and its inhabitants with rage and destruction.
The U.S. Advisory Board on Child Abuse and Neglect (Rivera 1995), after a two and a half year nationwide study that included hearings in ten states, found a level of deadly abuse and neglect that is far greater than experts in the field had previously estimated.
The number of violent acts against young children in the U.S. constitutes a public health crisis, annually claiming the lives of at least 2,000 children and seriously injuring upwards of 140,000 others. Abuse and neglect in the home is a leading cause of death for young children in the U.S. outstripping deaths caused by accidental falls, choking on food, suffocation, drowning or residential fires. The vast majority of abused and neglected children are under four years old. In fact, the homicide rate among children in this age group has hit a 40-year high, a chilling trend similar in scope to the violence directed at teenagers from street gunfire.
The enumeration of violent acts is grim. What is even more disturbing is the failure of the child protective system. The report describes an alarming national environment of under-reported child abuse fatalities; inadequately trained social workers and medical professionals; inconsistent autopsy practices; and an American public that continues to regard child deaths as "rare curiosities." "When it comes to deaths of infants and small children at the hands of parents or caretakers, society has responded in a strangely muffled, seemingly disinterested way," states the panel.
It was only thirty years ago that a paper by Curtis (1963) first expressed the concern that abused or neglected children would become tomorrow's violent criminals and murders. Since then the notion of an intergenerational transmission of violence has become the premier developmental hypothesis in the field of abuse and neglect.
The scholarly literature on family violence has grown enormously. There is a consensus of opinion that the rate of abuse among individuals with a history of abuse is 30% which is approximately six times higher than the base rate for abuse in the general population (5%) (Parke and Collmer 1975). These studies also suggest the need to consider neglect as distinct from abuse, because in some reports (Rohrbect and Twentyman 1986) neglected children appear more dysfunctional than those abused.
In addition to studies of children directly victimized, the indirect effects on children observing family violence have also been investigated. Large-scale self-report surveys have found a modest, although fairly consistent, association between exposure to family violence and approval of violence or marital violence as an adult.
Owens and Strauss 1975; Kalmus 1984; Kratwski 1985). Studies of the children of battered women suggest that observing abuse or extreme marital discord may be as harmful to the development of the child as physical abuse (Wolfe et al. 1985; Jaffe et al. 1986).
There is no doubt that early child abuse and neglect place one at increased risk for delinquency, adult criminality and violent criminal behavior. However, a large portion of abused or neglected children do not succumb. In one study at Indiana University (Gamezy 1985) 26% of child abuse and neglect victims became juvenile offenders; 74% did not. Eleven percent had an arrest for a violent criminal act, 89% did not.
It is essential that we learn to understand and distinguish between factors that increase destructive and self-destructive behavior and factors that build strength and competence. What are the dispositional attributes and the mediating variables that act to buffer or protect children from misfortune? I shall address that question in a future paper.
Build Babies, Not Jails
Violence does not occur in a social or cultural vacuum. Violence is endemic to our society. Our institutions, values, beliefs and rituals are a function of who we are as human beings. And who are we? There is not one of us who has not felt anxious, helpless, dejected, rejected, angry, criticised or shamed by the time we were two years old. Most of us, in addition, have suffered some form of emotional, sexual or physical mistreatment. We are the walking wounded. Considering the hurts, the injuries to body and soul that we have all experienced in our own personal histories and the history of our species, it is a testimony to the strength of the human spirit and the power of human love that we are as civilized as we are. Our only hope for a better world lies in heightening and deepening this innate capacity to care, to nurture and to feel for others.
To achieve that, we urgently require government policies that will reduce poverty, eliminate income inequalities, eradicate homelessness, and ensure status enhancing work (if possible in paid employment) for all.
Abolishing the sexual and economic exploitation of children should be a high priority on any governments' legislative agenda. Censoring videos and television programs featuring gratuitous violence, could be expected to have a small but measurable effect.
"What is not needed is to fight street violence with state violence. We don't need more police, more courts and more jails. We need more conscious parenting. Conscious parenting leads to positive psychogenesis and is based, I suggest, on understanding and practicing the following simple rules.
Guidelines for Conscious Parenting and Positive Psychogenesis
Future parents must receive information about what physical and chemical toxins to avoid prior to conception and during pregnancy.
Their readiness for pregnancy and raising a child needs to be assessed.
If problems, be they psychological, financial or other surface, personal counseling or therapy should be available to them.
Every child, ideally, should be a wanted child.
Every child should be created as an expression of the love the parents feel for each other.
Mothers and fathers must explore their:
Relationships to their parents.
Relationships with their partner and be willing to engage in open and honest dialogue.
Mothers and fathers need to learn:
To appreciate the fundamental humanity of their unborn child, their need for love and communication and how to give it.
How to bond with their unborn child prenatally and postnatally through talking, singing, dancing, playing with and visualizing him.
The pregnant mother should make every effort:
To have a stress free pregnancy. If there is the threat of or actual violence, she must remove herself from it.
To attend prenatal classes, if possible, with her partner.
To obtain the services of a midwife.
To resist the unnecessary use of gyne-gadgetry (amniocentesis, ultrasound, chorionic villi sampling, etc.).
To totally abstain from alcohol, tobacco, soft or hard drugs.
4. Labor and Delivery
If at all possible, the mother's partner as well as a professional support person such as a midwife or doula should be present.
Unless there is a medical problem, the birth should be as natural as possible. That means no fetal heart monitors, no anesthetics or analgesics, no episiotomies and no forceps.
Only people that the parents know and trust should be present during labor and delivery.
Only professionals who love and respect babies should assist at birth.
5. After Birth
Say only complimentary things about your newborn.
Insist on holding your newborn and rooming in with her.
Resist the installation of silver nitrate eye drops and other unnecessary medicines and tests on your unborn.
Oppose circumcision or genital mutilation of any kind.
Leave the hospital as soon as possible.
Breast feed your baby if you can.
6. First Few Months
If you are isolated, vulnerable or depressed, ask for help. Visits by nurses or social workers have a demonstrable positive impact.
If the baby develops physical problems don't wait until tomorrow; take her to a doctor now.
Don't feel that it's your fault or that you are an incompetent mother if the baby develops colic or cries a lot or does not sleep much.
If you are a single mother and you are beginning to lose your patience with the baby, get help. Call a friend, family, women's support group, or social agency. Whatever you do, don't yell, shake, or hit the baby.
Babies need a lot of attention. They cannot take care of themselves but they are a source of great joy. Have fun with your baby.
Babies can teach us many important lessons. Be prepared to learn.
I hope you will agree with me that to transform the violent world of today into the peaceful world of tomorrow, we need to change the way we treat our children from the very beginning of their lives. I think we could learn a lot in that respect from a tribe in East Africa (Kornfield, 1996).
There is a tribe in East Africa in which the art of true intimacy (I would call it bonding) is fostered even before birth. In this tribe, the birth date of a child is not counted from the day of its physical birth nor even the day of conception, as in other village cultures. For this tribe the birth date comes the first time the child is a thought in its mother's mind. Aware of her intention to conceive a child with a particular father, the mother then goes off to sit alone under a tree. There she sits and listens until she can hear the song of the child that she hopes to conceive. Once she has heard it, she returns to her village and teaches it to the father so that they can sing it together as they make love, inviting the child to join them. After the child is conceived, she sings it to the baby in her womb. Then she teaches it to the old women and midwives of the village, so that throughout the labor and at the miraculous moment of birth itself, the child is greeted with its song. After the birth, all the villagers learn the song of their new member and sing it to the child when it falls or hurts itself. It is sung in times of triumph, or in rituals and initiations. The song becomes a part of the marriage ceremony when the child is grown, and at the end of life, his or her loved ones will gather around the deathbed and sing this song for the last time.
Blomberg S. (1980), Influence of Maternal Distress During Pregnancy on Postnatal Development. Acta Psychiatrica Scandinavica 62:405-417.
Bustan, M. N. and Coker, A.L (1994), Maternal Attitude toward Pregnancy and the Risk of Neonatal Death. American J. Public Health 4(3):411-414
Chamberlain, D. (1995), The Primal Roots of Violence: A Tale of Two Criminals. APPPAH Headquarter's Report, Winter/Spring (p. 3)
Curtis, C.G. (1963), Violence Breeds Violence--Perhaps? Amer. J. Psychiatry 120:386.
David, H.P., Dytrych, Z., Matejcek, Z., Schuller, V. (1988), Born Unwanted: Developmental Effects of Denied Abortion. Springer Publishing Co., New York.
Garnezy, W. (1985), Stress Resistant Children: The Search for Protective Factors. In: Stevenson, J.E. (Ed.) Recent Research in Developmental Psychopathology. Pergamon Press, Oxford.
Harlow, H.F. and Mears, C. (1979), Primate Perspectives. John Wiley & Sons, New York.
Jaffe, P., Wolfe, D.A. et al. (1986), American J. Orthopsychiatry 56:142.
Kalmus, D. (1984), J. Marriage and Family 46:11.
Kandel, E., Mednick, S.A. (1991), Perinatal Complications Predict Violent Offending. Criminology 29(3):519-527.
Kaplan, L.J. (1996), No Voice Is Ever Wholly Lost. Touchstone, New York.
Klein, M. (1952), Developments in Psychoanalysis. In: Rivere, J. (Ed.), Hogarth Press, London.
Kornfield, Jack (1996), A Path with Heart: A Guide Through the Perils and Promises of Spiritual Life (Bantam, New York).
Kratwski, P.C. (1985), Journal of Adolescence 8:145
Litt, S. (1972), Perinatal Complications and Criminality. Proceedings, 80th Annual Convention, Amer. Psychological Association, Washington, D.C.
Mednick, S.A . (1971), Birth Defects and Schizophrenia. Psychology Today 4(11):48-50.
Mungas, D. (1983), An Empirical Analysis of Specific Syndromes of Violent Behavior. Journal of Nervous and Mental Disorders 171(6):354-361.
Myhrman, A. (1986), Longitudinal Studies on Unwanted Children. Scandinavian Journal of Social Medicine 14:57-59
Owens, D.J., and Strauss, M.A. (1975), Aggressive Behavior 1:193
Parke, R., and Collmer, C. (1975), Child Abuse: An Interdisciplinary Review. In: Hetherington, E.M. (Ed.), Review of Child Development Research, Vol. 5. Univ. of Chicago Press.
Raine, A. et al. (1990), Relationships Between Central and Autonomic Measures of Arousal at Age 15 Years and Criminality at Age 24 Years.
Archives of General Psychiatry 47:1003-1007 Rivera, C. (1995), Report to the U.S. Congress. The Advisory Board of Child Abuse and Neglect. Los Angeles Times, Apr. 26
Rohrbect, C.A. and Twentyman, C.T. (1986), Neglect and Abuse. J. Consulting and Clinical Psychology 54:231.
Wolfe, D.A., Jaffe, P. et al. (1985), J. Consulting and Clinical Psychology 53:657.