by Patrick Tomlinson
Patrick’s experience working with traumatized children spans from 1985. He has held many roles during this time in, care, clinical, management and leadership positions. He has also published widely on the subject of work with traumatized children.
He mainly works now as a development specialist to professionals and organizations providing services for children, young people and their families. He works with professionals and organizations in many countries.
This article is adapted here from Patrick Tomlinson’s informative, insightful and treasure chest of a blog concerning the therapeutic care of troubled and traumatised children. It can be found at http://patricktomlinson.blogspot.co.uk
It is also a short adaptation of Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice by Barton, S., Gonzalez, R. and Tomlinson, P. published in 2011 by Jessica Kingsley Publishers
by Patrick Tomlinson
Is the Capacity for Empathy the Key Quality in our Work with Traumatized Children?
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. 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 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. Brené Brown talks about Empathy and Shame being on a spectrum with both being at the opposite ends (see 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!
Ghosts in the nursery
The book Clinical Studies in Infant Mental Health: The First Year of Life, edited by Selma Fraiberg, includes a paper that had a big impact on my learning in the 1990s. The paper, ‘Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships’ was written by Fraiberg, Adelson and Shapiro. I had lost my copy of the book, but was very pleased to find a copy recently. It fits very well with the subject of empathy.
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
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.
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 wordsuse 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 article 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 Practice, London and Philadelphia: Jessica Kingsley Publishers
Cameron, R.J. and Maginn, C. (2008) “The Authentic Warmth Dimension of Professional Childcare” in 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 (1993) London: Free Association Books
Dockar-Drysdale, B. (1970) “Need Assessment – Making an Assessment”, in Therapy and Consultation in Child Care (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,
Brandt, K., Perry, C.,Seligman, S..and Tronick, E. (eds) Infant and Early Childhood Mental Health: Core Concepts and Clinical Practice, Arlington VA : American Psychiatric Publishing
Worldwide Alternatives to Violence (2005) The WAVE Report 2005: Violence and What to Do About It, accessed at http://www.wavetrust.org/
Fraiberg,S., Adelson,A., and Shapiro, V. (1980) “Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships” in Selma Fraiberg (ed.), Clinical Studies in Infant Mental Health: The First Year of Life New York: Basic Books
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
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 © Patrick Tomlinson2015
© Patrick Tomlinson June, 2015
John Fallowfield writes : I enjoyed your piece on empathy, Patrick – a key topic in my work with foster carers. We currently teach Dan Hughes PACE model.
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