Thursday, July 24, 2014

Thoughts on Attitudes towards the Abuse of Children

This is a huge subject and I am just going to make a few comments about my experience.  Though these experiences may to some extent seem random, I think they are also connected by a theme. My first experience of work with children who had suffered abuse and neglect was in 1985. I was shocked to see how their early lives had so terrorized and deprived them of the experiences essential for healthy development.

As a result of abuse and neglect a 12 year old child, might have the functioning level of an infant and may not even have reached the level of emotional or neural integration normally achieved in the first 1 – 1.5 years.  These children’s development had literally been frozen. Their emotions were also highly dysregulated and they can fall into an overwhelming panic or violent rage in an instant.  At the other extreme - still watchfulness, emotional detachment and withdrawal may be the predominant mode of functioning. One thing that surprised me at the time was the fact that children like this existed, as I had no idea. It was and still may be a human problem that is hidden away. I knew about various disabilities and their consequences, and there was plenty of media coverage – but nothing on these children traumatized by those who were supposed to protect them.

“The single most significant predictor that an individual will end up in the mental health system is a history of childhood trauma, and the more severe and prolonged the trauma, the more severe are the psychological and physical health consequences.” (Kezelman and Stavropoulos, 2012)

It has been said that the dynamics of abuse are secrecy and denial. Kezelman and Stavropoulos (2012) refer to the ‘culture of silence that continues to surround child abuse’. They give an explanation of why this may be so,

“The many constraints which still militate against open discussion of child abuse compound recognition and addressing of violations the scale and magnitude of which, were they to be acknowledged and confronted, would both raise questions of complicity and comprise grounds for deep national shame.”

I recently read that it was published in the 1950s that one in a million women had probably experienced incest as a child. Apparently the text where this was stated was still widely used in the training of psychiatrists in the 1980s.  Some researchers these days put the incidence of child abuse within families as closer to one in four. Why is there such a huge difference in 50 years?  Is child abuse on a huge increase or is it just being reported more, or both?  We also know very well the historical controversies that have existed in the relational sciences, as to whether reports of child abuse by adults in treatment are real or phantasy.

“Professor Middleton comments that `[i]t is hard to find a comparable example in society where something so damaging to so many could exist undisturbed for decades under the gaze of those professional bodies who would be assumed to have qualifications and motivations to bring clarity and to be at the forefront of addressing such a pervasive threat to the mental and physical health of fellow citizens’.” (ibid).

On the one hand it seems that progress is made in the exposure of child abuse. But it doesn’t seem that it is becoming any less common. Some westernized countries, may have been ahead in terms of surfacing the problem. I was in India 7-8 years ago and sexual abuse was just beginning to be talked about in the media. Since then there has also been a big movement to expose the violence towards women in India. I gave a talk to 100 or so social work students at an Indian University. During the talk I referred to a child I worked with who had a severe panic attack when I made a simple request, like asking him to finish his breakfast. It turned out his mother had made a similar request and then hit him so hard on the head with a stick that he needed hospitalization. One of the students stood up and said she didn’t see why being hit caused the boy such problems in the future. She added ‘we’ve all had a good beating’ to which everyone laughed.

I explained that the beating, while some would argue is never good for a child, might also depend on the context to determine how much damage is done. For example, if the culture is one where hitting children is common, at least the child feels this is normal - my friends also get hit. Another factor might be whether the ‘disciplining’ action takes place in what is a generally loving family environment – where the parents are concerned for their child. Or is it part of a more neglectful environment where the parents’ actions are more based on their own difficulties rather than the child’s needs. The severity is another factor – violence that requires medical treatment cannot be right under any circumstances. While physical discipline might be considered by some to be ok within a cultural context, I don’t think that anyone would argue that sexual abuse is.

Maybe because it simply isn’t ok – having a discussion about sexual abuse tends to become difficult. Besides abhorrence towards the abuser, few other views are expressed. Sex offenders are routinely hated and despised, and portrayed as evil. I remember visiting a sex offender in prison. On the way to the prison the taxi driver was keen to know why I was making a prison visit. When I alluded to the reason, the conversation immediately ended. After the visit, I was wondering why the prisoner I visited came into the room, after the other prisoners, sat on his own, wore a colored band and left before the others. I realized it was probably for his own safety. Having anything to do with sex offenders or even children and young people who have been abused, can be uncomfortable and one’s motives might be questioned. This is highlighted by the difficulty that can be involved in having a conversation on the subject with someone who has been abused. Too much interest might be felt to be intrusive and voyeuristic. Too little might feel like turning a blind eye.

Recent sexual abuse scandals in the UK regarding, dead or elderly celebrities have caused an outrage. Some of the most popular family entertainers, it turns out had been abusing children. The outrage has been towards the individual perpetrators, followed by the organizations that failed to be sufficiently protective or even colluded. It is as if the moral outrage about abuse can be vented towards these cases, but we can’t have a rational discussion about what is happening in our own neighborhoods. A few years ago when I was opening a new children’s home in a residential neighborhood we met each neighbor so we could build a positive relationship. One neighbor could not let go of the question, ‘but have these children been sexually abused?’ He was fearful of this, as if the neighborhood would be threatened and at risk by having an abused child living among them.

I focused on the fact that the children we were looking after all had needs due to their difficult childhoods and our job was to meet those needs, so that they could develop and prosper. The neighbor kept persisting with his question.  In the end I said that according to the statistics maybe 1 in 10 of the children in this neighborhood were abused. After that he abruptly dropped the whole issue. 

Thinking about the conversations with the neighbor and taxi driver, I am struck by the fact that I just allowed the conversations to end. I could have asked them their views on what I had said. Maybe the underlying feelings, such as, anxiety, fear and hostility led me to rather not talk and therefore collude in a small way. One of the inferences for anyone who is close to sexual abuse, whether personally or professionally, is that they may be complicit with the abuse. Therefore anyone who talks about it, rather than to just utter disgust towards a perpetrator runs the risk of being judged in a similar way. It is common in working with traumatized children, to be treated as if one is an 'abuser'.

What I am suggesting with the examples above, is that the problem of abuse gets projected in an extreme way and this is part of the denial dynamic. I have come across many worthy organisations who aim to tackle the problem of abuse by focusing on the pedophile, ‘lurking on the street corner’. The emphasis on stranger danger continues, though evidence suggests that the most likely threat to a child is someone who is close to them, especially a parent. We educate young children on how to avoid being lured by a stranger. Do we educate children on what to do if someone in the family is abusive? Maybe this reality just touches upon too many taboos and challenges the idealization of the family that is prevalent in many cultures.

The sociologist Frank Furedi wrote the book ‘Moral Crusades in an Age of Mistrust: The Jimmy Savile Scandal’, in response to the scandal of the deceased UK TV celebrity Jimmy Savile and the retrospective discovery of his serial abuse of children.

My understanding of Furedi’s argument is that the erosion of our trust in authorities leads to a high level of uncertainty, which makes us feel anxious.  We then project some of our anxiety onto children, who are increasingly perceived to be vulnerable and ‘at risk’. Interestingly, numerous countries have gone through the same process in the last few years. Erosion of trust; exposure of corrupt politicians, church, bankers, etc.; media exposure of scandal in relation to child abuse; as the moral panic grows, there are then ‘witch-hunts’; discovery of institutional abuse; national outcry and government inquiry; followed by recommendations on how to better protect children.

These are necessary and appropriate concerns. However, as Furedi argues our difficulty in really thinking about rather than reacting to the issues involved, leads to some very unhelpful and destructive actions.  It also undermines the potential to make real progress. A slight illustration of a moral panic was when a pediatrician in Wales had bricks thrown through his living room window by an angry neighbor.  Someone referred to him as a pediatrician, which was mistaken to mean pedophile!

Wrongful arrests are on the more serious side of things. I know of one service for children that was closed down, due to the wrongful accusation of a link with a pedophile ring. The sensationalized media headlines was followed by the withdrawal of children from the service. Two years later, after the service had closed, children unnecessarily removed, staff wrongly arrested and careers ruined, the Judge concluded the trial by praising the work of the service.

How do we know, when denial is appropriate and when it is a cover-up? Conspiracists might argue that Judges, Police, Politicians, Churches have a lot invested in supporting denial. This dilemma and lack of trust is exactly what Furedi suggests makes this such an important and difficult problem.

Ultimately, what we want is less children suffering abuse and the potentially devastating consequences. How will this be achieved unless we become more able to have rational discussions about the problem? How do we become more able to think about this difficult subject and what it means?

Reference

Dr. Kezelman, C. and Dr. Stavropoulos, P. (2012) The Last Frontier: Practice Guidelines for Treatment of Complex Trauma And Trauma Informed Care And Service Delivery, Australia: Adults Surviving Child Abuse (ASCA), This document can be downloaded here, http://goo.gl/t9o3lA

Comments

Sean Ferrer, Director - Strategic Marketing, England

Patrick, you have written a highly thought provoking, and courageous piece here. I use the word courageous, because the fashion these days is to portray all sex offenders as incarnate evil, so abhorrent that the mere mention of the label provokes a raft of negative commentary. The fact that you have not engaged in the standpoint is to be commended. 

Neither you, nor I, condone such offences, but I feel we both recognise that progress in our understanding of the phenomenon of sexual offences, especially against children, is continuously impeded when it is drowned out by a collective wail of disgust. Moreover, anyone who fails to express his or her own disgust when exploring the topic risks being branded in some way complicit, or supportive of such damaging behaviour. 

Jonny Matthew, Consultant Social Worker and Criminologist, Wales

Good stuff, Patrick - very thought-provoking! Your comments about those who help being in some way viewed suspiciously, is very true. After many years working with harmful sexual behaviour in teenagers, I've experienced this many times. Worse still, at times, I've colluded with this suspicion by moderating my own comments in line with what I perceive to be the likely stance of skeptical others. I guess part of this is the desire to avoid "freaking out" the uninitiated! 
Sean's point about the prevalence of sexual interest in children is perhaps the next taboo for society to assimilate. The thorny issue of sex offenders as victims with reactive behaviours is another. Not that this is permissive or excusing in any way. Neither is it remotely suggesting that all victims do or may become perpetrators - that would be ridiculous. But we do have to face the fact that those who commit sexual crimes were very often victims themselves - meta-analytic research is really clear on this.

Tuesday, July 15, 2014

Empathy Part 3 - The Wounded Healer

The concept of the Wounded Healer, was first explained to me by Olya Khaleelee. Olya is a corporate psychologist and organizational consultant, and I had the privilege of working with her on assessing people’s suitability for working with traumatized children. The links between a person’s history and personality, and how this might interact with the work was the key part of the assessment. Her reference to the wounded healer was an acknowledgement that emotional wounds might be a part of what enables a person to become a healer. Our assessments enabled us to make a judgement as to whether this was likely to be the case or not.

The term wounded healer goes back to Greek mythology.  The Greek god Chiron was wounded by a poisonous arrow.  He could not die due to his divine ancestry.  In agony he roamed the earth healing the injured and sickly.  Similar stories and fables can be found in Christian, Jewish, African and Moslem cultures.  In the relational sciences, Carl Jung is attributed to be the first to use the term wounded healer.  In 1951 Jung suggested that sometimes a disease was the best training for a physician. Therefore, only a wounded physician could treat effectively. For a summary on the meaning and history of ‘Wounded Healer’, see Benziman, et al., 2012.

In the case of healing traumatized children, it is one’s childhood wounds that are likely to be most relevant.  I had a striking experience a few years ago that captures the essence of the link between an adult’s childhood and the work with traumatized children. I was providing training for a group of care workers who were about to start work with traumatized children in a residential setting. The aim of the training was: to encourage psychodynamic thinking - to think about the meaning beneath a child’s behavior and from that insight to consider appropriate responses.

I presented the following scenario to the group. One of the children, Luke, had disappeared from his home and a care worker was looking for him. After a while the carer saw him from a distance by a pond. It looked like there was a cat in the pond, attached to a long piece of string that Luke was holding.

The group was asked what they thought was going on and what the carer should do immediately and in the longer term? They did some work in small groups and then gave feedback. The general consensus was that the first thing that should be done was to make the situation safe, ensuring Luke was safe and the cat was rescued.

Possible reasons given by the group for Luke’s behavior were along the lines of,

·       maybe Luke was angry and was taking it out on the cat
·       he might be treating the cat in a cruel and abusive way that was a re-enactment of how he had been treated. Traumatized children tend to re-enact their own experiences of being powerless, towards others who are less powerful than themselves.

In terms of what to do, the responses were,

·       explore Luke's thoughts on what he might be doing
·       make it clear to him that his behavior was inappropriate and help him to understand why
·       help him to put his feelings into words
·       use the situation as an opportunity to talk with Luke about his abuse in an empathic way

These were all thoughtful and plausible suggestions. As the discussion went on, one of the carers Tim, who had been looking increasingly thoughtful, hesitantly suggested that Luke might have been trying to save the cat. The group reacted by laughing a little.

I was surprised by Tim’s comment as I had taken the scenario from a child’s case history and that was exactly what he was trying to do! The child had had a traumatic and tragic experience when he was younger.  He was out playing unsupervised with his younger brother who fell into a pond and drowned. The child felt responsible for his brother’s death and was blamed by his parents.

From then on the child had a history of re-enacting this trauma in different ways as a desperate attempt to resolve it. He put the cat in the pond so he could save it, which he hadn’t been able to do for his brother. I explained this to the group who were clearly surprised by my explanation and how Tim had made such an unexpected and insightful comment.

When the group took a break, I approached Tim who had seemed very preoccupied and asked if he was ok. He said that he made the comment, because when he was a child he had been with his younger brother who fell into a canal and drowned. I empathized with the distress this training scenario may have caused Tim, but also commented on how his own experience had given him the capacity for empathic insight.

Tim then said that he had been physically abused by his mother as a child, and asked me if I thought he would be able to do the work given his own experiences. I suggested that it is very difficult to predict how our own experiences will either help or hinder us in the work.

If we have integrated our experiences into our life history, difficult experiences can help us provide empathy and understanding. On the other hand, the work may raise very painful feelings, some of which we may have repressed or not integrated and things can feel overwhelming. Research has shown that it is not the facts of our history that are necessarily the problem, but whether we have been able to integrate these facts into a coherent narrative of who we are (van der Kolk et al., 2007).

I explained to Tim that the important thing would be to talk about his feelings about the work in supervision and other relevant forums, especially if something was troubling him. Tim actually turned out to be an excellent carer, showing great levels of patience and understanding with the children he worked with over many years.

The key points of learning from this were that

·       A person’s own traumatic experiences can be useful in developing empathy and insight, if those experiences have been integrated into their own history and identity.
·       Luke had not been able, so far, to integrate the trauma of his brother’s death and was compelled to re-enact it.
    ·       Whenever we are working with trauma, talking or thinking about it, our own experiences will be brought closer to the surface. As with this example, what we might learn is unpredictable.
I had not anticipated such an emotive exercise and was moved by the poignancy of it, which had an emotional impact on me. Working with trauma evokes powerful emotions and often when we least expect it. Tim showed how something constructive can come out of such awful experiences. How the capacity for healing can develop out of our own emotional wounds.

This has been adapted from, Barton, S., Gonzalez, R. and Tomlinson, P. (2011) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for PracticeLondon and Philadelphia: Jessica Kingsley Publishers, Also translated into Japanese.


Reference
Benziman, G., Kannai, R., and Ahmad, A. (2012) The Wounded Healer as Cultural Archetype, in CLCWeb: Comparative Literature and Culture, 14.1,
http://docs.lib.purdue.edu/clcweb/vol14/iss1/11/ 

van der Kolk, B.A., Weisaeth, L. and van der Hart, O. (2007)history of trauma in psychiatry, in van der Kolk, B. A., McFarlane, A. C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

Tuesday, July 8, 2014

Empathy part 2 - 'Ghosts in the Nursery’ – A Powerful Example of Empathy in the work with a Mother and Baby

Since writing my last blog on empathy I found a book, which included a paper that had a big impact on my learning in the 1990’s. I had lost the book, and after a while it turned up on Amazon ‘used and new’. The paper was by Selma Fraiberg et al., ‘Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships’.
  
The paper is about work with mothers and their babies (sometimes fathers too). The babies were in major peril, bordering on them needing to be removed for their safety. The main thrust of the paper is that unresolved issues from the mothers conflicted pasts were preventing them from parenting their own babies. The way forward was to work with the mother’s unconscious pain, through empathic understanding – to enable her to be in touch with her own feelings. This would then reduce the risk of the mother’s history being re-enacted with her infant. It is a great example of why early intervention is so important. Here are a few excerpts that beautifully illustrate the quality of work, with my own comments in-between,

“In every nursery there are ghosts. They are the visitors from the unremembered past of the parents, the uninvited guests at the christening. Under all favorable circumstances the unfriendly and unbidden spirits are banished from the nursery and return to their subterranean dwelling place. The baby makes his own imperative claim upon parental love and, in strict analogy with the fairy tales, the bonds of love protect the child and his parents against the intruders, the malevolent ghosts.”

Interestingly the use of fairy tales as a way of dealing with potential threats to the parent-child relationship is mentioned. Angus Burnett commented on a previous blog, where I also referred to fairy tales - that sometimes it takes a long time for something that is read to permeate and be understood. I think he is right!

“The methods of treatment which we developed brought together psychoanalysis, developmental psychology, and social work in ways that will be illustrated. The rewards for the babies, for the families, and for us have been very large.”

I think the integration of different disciplines can be very helpful. The paper goes onto discuss one of their cases. At the initial assessment meeting with a four month old baby (Mary) and her mother (Mrs. March), Mary became very distressed,

"What do you do to comfort Mary when she cries like this?" Mrs. March murmurs something inaudible. Mrs. Adelson (psychologist) and Mrs. Atreya (assessor) are struggling with their own feelings. They are restraining their own wishes to pick up the baby and hold her, to murmur comforting things to her. If they should yield to their own wish, they would do the one thing they feel must not be done. For Mrs. March would then see that another woman could comfort the baby, and she would be confirmed in her own conviction that she was a bad mother.”

The intuitive thing for the ‘professionals’ might have been to pick up the baby, but as they point out interventions like that can be counter-productive. I think this can be what happens, when we think that parents need training. The training might help, but it is less likely to, if there isn’t an understanding of why parenting is difficult for the parent. However, if there aren’t major underlying issues an educational focus may be effective.

“The Mother’s Story (Mrs. March)
It was a story of bleak rural poverty, sinister family secrets, psychosis, crime, a tradition of promiscuity in the women, of filth and disorder in the home, and of police and protective agencies in the background making futile uplifting gestures. Mrs. March was the cast-out child of a cast-out family.”

“This led us to our first clinical hypothesis: "When this mother's own cries are heard, she will hear her child's cries."

I find that hypothesis poignant – rather than show or teach the mother how to parent, the emphasis was on showing her empathy. The first few weeks of work, were focused on the aim of hearing Mrs. March’s unresolved distress.

“But now, as Mrs. March began to take the permission to remember her feelings, to cry, and to feel the comfort and sympathy of Mrs. Adelson, we saw her make approaches to her baby in the midst of her own outpourings. She would pick up Mary and hold her, at first distant and self-absorbed, but holding her. And then, one day, still within the first month of treatment, Mrs. March in the midst of an outpouring of grief, picked up Mary, held her very close, and crooned to her in a heart-broken voice. And then it happened again, and several times in the next sessions. An outpouring of old griefs and a gathering of the baby into her arms. The ghosts in the baby's nursery were beginning to leave.”

That sounds like an amazing moment, when an intervention that has been so challenging, begins to show a sign of working.

“Within four months Mary became a healthy, more responsive, often joyful baby. At our 10-month testing, objective assessment showed her to be age-appropriate in her focused attachment to her mother, in her preferential smiling and vocalization to mother and father, in her seeking of her mother for comfort and safety. She was at age level on the Bayley mental scale. She was still slow in motor performance, but within the normal range. Mrs. March had become a responsive and a proud mother.”

When having to emotionally contain so much anxiety, there can be little more rewarding than seeing these kind of outcomes. And being able to intervene so early, is valuable beyond words.

“For us the story must end here. The family has moved on. Mr. March begins a new career with very good prospects in a new community that provides comfortable housing and a warm welcome. The external circumstances look promising. More important, the family has grown closer; abandonment is not a central concern. One of the most hopeful signs was Mrs. March's steady ability to handle the stress of the uncertainty that preceded the job choice. And, as termination approached, she could openly acknowledge her sadness. Looking ahead, she expressed her wish for Mary: "I hope that she'll grow up to be happier than me. I hope that she will have a better marriage and children who she'll love." For herself, she asked that we remember her as "someone who had changed."

The paper, which also includes other case studies, concludes with this sentence,

“In each case, when our therapy has brought the parent to remember and re-experience his childhood anxiety and suffering, the ghosts depart, and the afflicted parents become the protectors of their children against the repetition of their own conflicted past.”

Also using the metaphor of ghosts, Bessel van der Kolk et al. (2007) emphasize the importance of integrating a personal narrative of the trauma,

“Many trauma­tized people continue to be haunted by "them" (unintegrated traumatic memo­ries), without an "I" to put these feelings and perceptions in perspective. Treat­ment at this stage consists of translating the nonverbal dissociated realm of traumatic memory into secondary mental processes in which words can pro­vide meaning and form, thereby facilitating the transformation of traumatic memory into narrative memory. In other words, what is currently implicit memory needs to be made explicit, autobiographical memory.”

In many ways the same principle applies in work with traumatized children.  They need to integrate their experiences, including the feelings involved, as part of their history. As well as enabling the child to move on from the past and live positively in the present, it also greatly improves the possibility that the cycle of trauma will be not passed on to future generations.

Having read ‘Ghosts from the Nursery’ again after so long, I am reassured to discover that it is just as impactful as it was the first time. It is a very moving and excellent example of the use of empathy. As well as finding the book, I have also discovered that the paper can be downloaded here, http://goo.gl/64qwRG

Sadly Selma Fraiberg died just a year after this book was published. A few comments about her by Constance Brown, http://goo.gl/GJ3M3g

Selma Fraiberg was a psychoanalyst, author, and pioneer in the field of infant psychiatry. A woman and a social worker in a profession dominated by male physicians, Fraiberg rose to prominence because of her brilliance, originality, and dedication. She devoted her life to understanding the developmental needs of infants, to creating programs that promote infant mental health, and to reaching parents and policymakers through clear, persuasive prose…………Fraiberg accomplished enough in her life to fill three careers………During this last phase of her career, Fraiberg started the Child Development Project at the University of Michigan, which served troubled families, trained clinicians, and developed a treatment model that has been widely replicated……..…..Selma was feisty, shy, and intellectual……………She was known to colleagues and students as brilliant, demanding, fiercely principled, difficult, and inspiring. Those close to her knew that she was shy and self-conscious, and that public exposure caused her strain............In 1981, she received the Dolley Madison Award in recognition of her critical role in the field of infant mental health.

Reference

Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships, by Selma Fraiberg, Edna Adelson, and Vivian Shapiro, in, Clinical Studies in Infant Mental Health: The First Year of Life, Friaberg, S. (Ed.) (1980), New York: Basic Books, Inc.

van der Kolk, B. A., McFarlane, A.C. and van der Hart, O. (2007) A General Approach to Treatment of Posttraumatic Stress Disorder, in van der Kolk, B. A., McFarlane, A. C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

Tuesday, July 1, 2014

Is the Capacity for Empathy the Key Quality in our Work?

One of the first things I learnt in work with traumatized children, is that the Capacity to Empathize marks a critical stage in a child’s development. The children and young people, who were placed with us often had no capacity for empathy or very little. However, this didn't mean they didn't have the potential to develop it. The development of empathy was one of the key aims of our therapeutic work, as it is for many of us that work with and look after children.

We carried out a needs assessment on each child to determine his stage of development, how it had been disrupted by trauma, and how his developmental needs could be met. Dockar-Drysdale’s (1970) Need Assessment, described empathy “as being the capacity to imagine what it must feel like to be in someone else’s shoes, while remaining in one’s own.”

The consequence of not being able to recognize another person, as a separate being with their own emotions, thoughts and needs causes havoc in daily living. It can also be dangerous as the child has no conscious sense of the hurt they are potentially able to cause, and therefore also, little if any remorse.

More recently, Cameron and Maginn (2008) claimed,

“Increasingly, too, it is the development of empathy which is now being viewed as the antidote to both childhood and adult violence—an argument which is well evidenced in the ‘Worldwide Alternatives to Violence’ report (2005).  Children who do not experience attunement with a caregiver may fail to develop empathy altogether. Secure attachment is therefore fundamental to children’s socialisation and wellbeing.”

To develop empathy a child needs to experience empathy. That sounds straightforward on paper, but can be extremely difficult to achieve, when working with children and young people who have long passed the age at which empathy would normally develop. For example, it is not easy to ‘empathize’ with a 10 year old’s ruthless lack of concern towards others, especially when this has to be lived with 24 hours a day. On top of this, a traumatized child often actively rejects any attempts to show empathy towards him/her. This is partly because empathy might connect him with his traumatic experiences, which he is desperate to keep out of mind. It might also cause him to feel vulnerable as empathy normally connects people, and children who are mistrustful are resistant to being connected.

As well as showing empathy, another key factor in helping a child develop empathy is creating a safe, reliable and nurturing relationship where the child may begin to feel attached. Attachment usually leads a young child to develop the capacity for feeling concern towards the attachment figure. This makes sense from an evolutionary survival point of view - the vulnerable dependent infant, benefits from being able to understand the protective carer. If the infant is completely dependent on the carer it is necessary for her to develop a level of understanding that helps reciprocate and grow the attachment relationship, which is critical for survival.

Young infants can be seen to make efforts of contributing something positive towards their attachment figure. For this to work well the infant needs to understand something about how the other feels. Normally by the end of the first year an infant has some ability for understanding what thoughts and feelings are in another’s mind. When empathy begins to develop it may be rudimentary but it is very important. It may be a gesture like an infant, wanting to feed the parent a spoon of her food. Though she hasn't quite worked out that the parent might not like baby food, she is moving in the direction of wanting to give something good to the other. By 18 months an infant might be able to show sympathy to another infant who is distressed. A securely attached infant, who has had more attuned experiences with his caregivers, is more likely than an insecurely attached infant to show empathy.

Graham Music, in his excellent book ‘Nurturing Natures: Attachment and Children's Emotional, Sociocultural and Brain Development’ states, “Children who suffer neglect and receive little attuned attention can be less able to make sense of another's mental states. Others who experience more abusive rather than neglectful parenting can develop a skewed understanding of others.”

Empathy is different to sympathy, which can be shown without necessarily understanding much about how the other feels. It is also different to projection, where one’s own feelings are projected onto the other. Various clinicians have emphasized how empathic understanding is therapeutically helpful in the process of therapy. According to Nelson et al. (2014, p.140),

“Research has shown that therapists trained in mindfulness have better patient outcomes, and even a patient’s visit to a physician for a common cold can be made more effective when the clinician is open and empathic.”

Shame is often a theme involved with trauma, and especially that caused by abuse. Dr. BrenĂ© Brown talks about Empathy and Shame being on a spectrum with both being at the opposite ends.  https://goo.gl/DTVyKw

If children need to experience being empathically understood to develop empathy, those working with and caring for them will also benefit from receiving empathic support. This can help make what feels intolerable, tolerable. The capacity to feel empathy towards another isn't static, it changes according to circumstances. For example, if someone is feeling anxious, it isn't so easy to feel empathy.

If care workers are expected to show qualities such as, empathy, reliability and dependability in their work then these qualities also need to be reflected in all aspects of the organisation’s culture and the way it operates. The same could be said of the support provided by the extended family and community, in the case of parenting.

Not long into my own career and after a period or relentless testing out by the young people I worked with, I felt exhausted and demoralized. There were many times when I felt like I’d had enough. One day I was telling our consultant Barbara Dockar-Drysdale how I felt. She told me that sometimes the most important thing you can do, is just survive and be there the next morning. This seemed manageable to me and by saying this she was empathizing with exactly how difficult it was for me. I found this very helpful and I did survive!

I try to share a few useful links in my blogs.

This book by Maia Szalavitz and Bruce Perry is a fascinating and very accessible read on the subject of empathy – exploring it from many different perspectives.


A couple of good blogs on empathy from the Daily Good,

“If you think you’re hearing the word “empathy” everywhere, you’re right. It’s now on the lips of scientists and business leaders, education experts and political activists. But there is a vital question that few people ask: How can I expand my own empathic potential? Empathy is not just a way to extend the boundaries of your moral universe. According to new research, it’s a habit we can cultivate to improve the quality of our own lives.” - Six Habits of Highly Empathic People, Roman Krznaric, http://goo.gl/wZh35s

What Is Empathy?  http://goo.gl/0T4jQP

References
Cameron, R.J. and Maginn, C. (2008) The Authentic Warmth Dimension of Professional Childcare, British Journal of Social Work, Vol. 38 No. 6 p.1151-1172

Dockar-Drysdale, B. (1953) Some Aspects of Damage and Restitution, in Therapy and Consultation in Child Care Problem (1993) London: Free Association Books

Dockar-Drysdale, B. (1970) Need Assessment – 11 Making an Assessment, in Therapy and Consultation in Child Care Problem (1993) London: Free Association Books

Music, G. (2010) Nurturing Natures: Attachment and Children's Emotional, Sociocultural and Brain Development, Hove and New York: Psychology Press

Nelson, B.W., Parker, S.C. and Siegel, D.J. (2014) Interpersonal Neurobiology, Mindsight, and Integration: The Mind Relationships, and the Brain, in Brandt, K., Perry, B.D., Seligman, S. and Tronick, E. (Eds) Infant and Early Childhood Mental Health: Core Concepts and Clinical Practice, Washington DC, London: American Psychiatric Publishing

Worldwide Alternatives to Violence (2005) The WAVE Report 2005: Violence and What to Do About It, www.wavetrust.org/

Comment

Joanne Prendergast - Social Care Worker at St Bernard Group Homes, Ireland

Such a great article Patrick. When infants are "held" by their mother’s arms and psyche for the really important first year and beyond, they develop the neurological functioning that is biologically mapped out. Deficits in this magical process, impact on young person’s view of the world and capacity to interact with others, amongst many other aspects of their well-being. Empathy is such an important aspect to this and this article has summarised the importance of this. In addition if the organisational culture is non-congruent to the overall task of the therapeutic work, the environment can become chaotic for all, and this in turn can be detrimental rather than healing.

Gulchekhra Nigmadjanova - Advocacy Advisor at SOS Children's Villages, Uzbekistan

Many thanks for sharing this enhancing article indeed. All true to me and I think empathy is key quality of a social worker, actually it is a quality which makes us human of high conscious. Bravo!

Janet Eades - Teacher at Capitol area community action agency, USA

Just survive and be there the next morning. Sounds like our organization every start of a new school term. Never know where you are going to be placed or what your hours may be. Whew, I will remember that comment.

Marlaine Cover - Transforming the Life Skills educational process for the benefit of humanity present and future, USA

Empathy is teachable and core to humans' mandatory curriculum of communing with others. Imagine how every avenue of human interaction will improve when we embrace proactive education for emotional literacy as passionately as we do for academics, sports and music. Much appreciate your advocacy Patrick!

Patrick Tomlinson 

Thanks Marlaine - I tend to think of empathy as something that can be facilitated and develops through experience.

Lynda Noble - Senior Recovery Practitioner FDA at SACCS, England


I remember feeling worthless, angry, emotional and then finally understanding that they were not my feelings at all, but the feelings of my key child. It takes time and understanding to be able to recognize this and lots of good supervision, which is extremely important in child care organisations.