trauma

Holding the buck: Some thoughts about accountability in the modern marketplace

A couple of weeks ago, I gave a talk to the Institute for Recovery from Childhood Trauma at the House of Lords. I decided it would be too stressful to travel down that morning, so about three weeks in advance I booked an apartment through booking.com. I’ve stayed in apartments and rooms through online sites quite a few times before without incident. Normally they send a code for the door by text or email, or instructions to open a key safe. However, this booking was confirmed with instructions to collect the key from a nearby address by 9pm (I was told if I arrived later there would be a £20 late collection fee). So I caught an earlier train and got a taxi to the pick-up address, which transpired to be an office building, locked up for the night. The security guard on site who came out to see why I was loitering had never heard of this being a collection point for apartment keys. So I spent 45 minutes waiting at the pick-up address and checking the apartment address just down the road, with no ability to check my email or find the phone number of the owner due to the o2 outage. I then found a restaurant which let me use its wifi to contact the apartment owner. He answers the phone as Booking.com and says the pickup address sent to me by email was never given (despite me having it in writing on my screen as I spoke to him) and that I had not confirmed the time. He says he will send a man to meet me with a key. But he isn’t willing to send the man to the restaurant in which I am sitting, I have to go wait across the road outside Patisserie Valerie (which is also closed) for a man in a red jacket.

In about 15 minutes that man arrives. He greets me by name, but does not offer me any apologies or identification. I can’t tell if he is the man I spoke to on the phone or not. He does not provide a key to the apartment, but tells me to follow him and walks off in the opposite direction to the apartment. I ask him where we are going, he says “to the apartment”. I say that it isn’t the right way, and I don’t feel comfortable following a strange man to an unknown address. He is short with me and tells me that he is taking me to an alternative apartment, because a cleaner snapped the key in the apartment door 20 minutes previously. I find this suspicious as a) I’ve been waiting at the apartment and just up the road for 90 minutes and nobody has come or gone from it in this time, and b) why would a cleaner be in an apartment at 10pm that is supposed to have check-in from 3pm to 9pm, and c) why did the man on the phone not notify me of a change of address or email me with a change of booking through the site on which I had booked?

He leads me down less busy streets and alleys across Soho. I start to get anxious that I’m in a part of London that is unfamiliar to me, and have no idea where I am going. I will not be at the address I have booked and nobody will know where I am, its past 11pm and dark, and I’m being led by a total stranger who has shown me no ID. So I call my husband, explain the situation and start reading out street names so he knows where I am. He says that I sound nervous, and that if my gut doesn’t feel like this is safe I should trust it and go somewhere that does.

My mind goes into overdrive. I start worrying I’m being taken to an unknown address, where I might be robbed or attacked or anything. I’m thinking perhaps they gave the fake address as a means to be harder to trace, or perhaps they use the photos of one apartment in a good location to put people in cheaper accommodation in less favourable locations. Perhaps he is nothing to do with Booking.com and is just a confidence trickster. Did he definitely use my name? Was he the man on the phone? I have no way of knowing. I can’t just follow a stranger to an unknown address in the middle of the night with no explanation. I find an open wine bar to run into and hide.

Suddenly, all those feelings are right at the surface and I’m sobbing with fear and hiding behind the counter of the wine bar until the man has gone. Then the man who claims to be from Booking.com (I still can’t tell if he is also the man in the red jacket, or someone different) calls me and asks where I am, and I say “I don’t feel safe dealing with you and being taken to an unknown address, I’m going to find somewhere that feels safe to sleep”. It seems like something I should be able to take for granted, that now seems out of reach.

The staff at the bar are super-nice and patch me up, give me some water and use of their wifi. They offer me wine and fancy olives. I take the latter (and they are the best olives ever, as well as thoroughly nice people, so do check out Antidote if you are ever in Soho). When I calm down a bit, I start searching all the usual websites to find a hotel room. I then find out there is nowhere else to stay. And I mean that literally. Even when I increase my parameters to travel up to an hour from my location, nothing is coming up on any hotel booking site that isn’t fully booked. So I’m sat there in a random wine bar in Soho, 200 miles from home, and there are no longer trains to get back there even if I didn’t have to be in London by 9am the next morning to speak at the House of Lords.

At nearly 11pm I find one, very expensive, hotel with a single room available through LastMinute.com. I book it, pay and then pay £20 to get a taxi there only to find it is overbooked and they’ve already turned away 4 other customers. It is a converted Georgian townhouse with a small number of rooms, so I’m sat in the only chair in a tiny lobby. I’m repeatedly calling LastMinute, and it has gone past midnight so there is no longer even a means to find another hotel (as you can’t search for availability for the previous night), and they tell me they don’t have a room. It takes me four calls and 47 minutes on the line to speak to Last Minute’s customer services, who conclude they can’t find an alternative room for me, and don’t see that as their responsibility. At 1.25am they suggest a room is available at the Taj St James Court hotel and they have reserved it for me. I call them, they have no rooms and have never heard of me. It is now 1.30am, and I am making plans to sleep in the bucket chair I am sitting in, in the hotel lobby, as I have nowhere else to go* and it is raining heavily. Eventually at 2am the hotel say that one guest has not checked in yet, and agree to take the gamble and let me use the room. I get less than four hours sleep for twice-the-price-I’d-normally-set-as-my-upper-limit-for-a-room, before having to head out to speak at the House of Lords.

Having given the talk I decided to complain to both Booking.com and LastMinute.com. The response from the former was “You got a refund for the apartment, so it’s all settled” and the latter offered “€20 as a goodwill gesture due to the 2 hour delay checking in”. No recognition of the fact the experience was traumatic, wasted 5 hours of my evening, cost me 3 extra taxis, and left me 200 miles from home without somewhere safe to sleep. I am faced with the realisation that trauma is subjective, and to many men hearing the tale I might have taken fright for no reason and brought the events that followed upon myself. I am forced to say “imagine if your Mum were in this situation” when explaining it to try to trigger sympathy. But nobody really cares. The apartment owner feels he has done his bit by refunding (and the website has conveniently blocked me from leaving a review). The men in the call centres were in another country, abstracted away from the problem. The customer service teams are seeing the facts in retrospect, not the feelings the experience generated, and are motivated to protect their brand rather than genuinely caring about me as a customer. The night manager of the hotel cared, because he met me in person, and saw I was upset. As a result he tried his best, but he wasn’t in a position that could resolve the problem.

And that’s where I finally reach the point. In a system where you book with a middleman who doesn’t actually provide the product you are paying for, nobody really feels accountable for the service you receive. And, to bring this round to being relevant to a wider point for health and social care, this model is being increasingly replicated in public services, where the NHS or local authority commission the service from another provider, who is assumed to be responsible. That split between online broker and real life provider, or the public sector split between purchaser and provider seems like a good model for each of those parties, as the purchaser delegates responsibility whilst fulfilling their obligations (or making a profit, in the case of online brokerage sites) with much reduced staffing and without having to invest in any tangible assets. The provider gains access to a wider market, rather than becoming obsolete. But somehow inevitably, as in my experience, the recipient of the service misses out in the middle, and finds out there is minimal quality control and an absence of clear lines of accountability when things go wrong or aren’t delivered as planned.

For example, there is a level of risk aversion that has made local authorities anxious about providing residential care placements, because of the prevalence of historic institutional abuse and the increasing awareness of child sexual exploitation and involvement in county lines (and the accompanying risk of compensation lawsuits). The result is a marketplace where private providers (many of them owned by international venture capital groups who pay minimal UK taxes) use unqualified, low-paid staff to care for some of the most complex and vulnerable young people in the UK, and it is hard for recipients or commissioners to distinguish them from provision that has different financial or delivery models. Likewise in health (and public transport) private providers cherry pick off the profitable services, whilst the public purse is left holding the can when they don’t deliver. There is a move to entrench this even further with the push towards Integrated Care Providers, where private organisations can manage the entire health and social care services for a particular region of the UK, in a way that is potentially unaccountable for its decisions and not subject to the rules for public sector organisations (like Freedom of Information requests, public consultation, or being subject to Judicial Enquiries if things go wrong, or even their statutory obligations). I think that might be a recipe for disaster, but then, I’m not a fan of corporations and the super-rich profiting from the suffering of the rest of us.

Update: Booking.com fed me some platitudes and agreed to reimburse my costs in relation to the apartment, but then failed to do so, whilst LastMinute.com have not yet replied, telling me they take 28 working days to respond to customer complaints that don’t accept the initial boilerplate response. I suspect that just like in health and social care, the (explicit or implicit) policy is to respond to those who kick up a fuss and have the potential to create negative publicity if things are not resolved, meaning that those who are devalued most by society have the least redress when things go wrong.

*call me a wuss, but I declined the option of having one bed in a bunk room in a hostel shared with 8-12 strangers

Nature versus nurture revisited

This week I have been reading the Power Threat Meaning Framework published by Lucy Johnstone and colleagues. This document is an attempt to challenge the dominant medical model in adult mental health with a more functional framework for formulation, based on the person’s experiences and circumstances. It is an interesting and challenging read, because it tries to cover the political and philosophical context of challenging the medical model, and input from service recipients about the benefits and challenges of different ways of conceptualising their difficulties. But at the core it rests on a pretty simple and (I’d like to think by now) well-established concept – that the adverse childhood experiences a person has prime them to use survival strategies that make them vulnerable to difficulties later in their life. Those early templates for dysfunctional relationships and the sense of self created by inconsistency and maltreatment also mean that people are more likely than others without those experiences to go on to have other relationships and experiences that are traumatic/harmful as they grow older, which compound the strategies and narratives with which they navigate adult life. The survival strategies which made perfect sense in response to their experiences at the time, have a lasting impact on the brain, body and behaviour. They change the way the person perceives themselves, understands the world and relates to others, and go on to have detrimental effects long after the initial trigger is gone.

As I have mentioned in previous blogs, a person exposed to high levels of trauma or adversity, especially if lacking protective relationships, will become more vigilant to signs of threat, less able to focus on the tasks that help us attain educationally and in the workplace. Where their early relationships have been dysfunctional, they are likely to struggle with forming healthy later relationships, and are more likely to express needs indirectly and in ways that cannot be ignored – including in ways that lead to negative societal responses, such as rejection and/or pejorative judgements by others, involvement with mental health services (and being given diagnostic labels), involvement of criminal justice systems. This leads to an increased risk of socioeconomic adversity, lower social connectedness and a greater chance of a range of adverse outcomes.

In short, thinking about adversity in both the person’s childhood experiences and current context, not only gives us insight into the biggest variable in personality disorder, attachment disorder and other specific conditions. It also explains a lot of the risk factors for wider issues with physical and mental health, challenging behaviour, addiction, violence, crime, homelessness, harmful relationship patterns and helps determine our sense of self and our ability to make healthy social connections. Adverse childhood experiences increase the risk of a very wide range of  physical and mental health problems, for a range of reasons including lower self-care and poor lifestyle choices, a lack of self-monitoring and seeking of appropriate care in the early stages of problems, and what seems to be increased propensity for ill-health mediated by the stress messengers in the body.

I’d go so far as to say that getting child protection and parenting right is the biggest task facing humanity, and the area where I believe we can make most difference for the future – hence dedicating my career to working with the kids who have experienced the most adversity and trying to improve their outcomes. But as I have explained above, it doesn’t just stop there, because the ripples of that early adversity continue to spread out into the lifespan for many people, forming a barrier to the protective factors of education and employment, establishing social networks, and the means to access pleasurable activities. This can then be compounded by financial hardship, hostile systems (such as benefits sanctions and fitness for work tests) and lack of access to resources (including finding it hard to identify and navigate access to social care and health services, to know and assert their rights, or appeal against decisions made by organisations). So the same people who experienced chronic developmental trauma and have unresolved psychological consequences from that are often struggling with their personal relationships, as well as practical issues like debt, homelessness and crime. In that context, dysfunctional coping strategies like substance abuse or presenting with challenging behaviour or mental health symptoms make more sense as attempts to obtain escape or safety.

There are also vulnerability factors such as being in a disempowered/minority population group, that also bring compounding adversity such as sexism, racism/xenophobia, homophobia, transphobia, ableism, ageism, religious intolerance, etc. These can impact at all life stages. For example, a child with physical or intellectual disabilities is more likely to be the victim of abuse, to experience bullying, and (perhaps increasingly as they grow up) to struggle to access community resources, financial independence or a supportive social network. For people from cultures outside of the majority in the country where they live, there can be language and cultural barriers, prejudice and political/economic challenges, as well as exposure to poverty, war, terrorism and other threats to survival that are outside the experience of the majority of lifetime residents of developed nations. Certain population groups such as asylum seekers find things particularly challenging in terms of finding safety, housing, financial security, after already experiencing multiple traumas in the country they have left and during their journey to find safety. Each individual is unique and their story, current situation and past experiences are a huge influence on the way that they experience and interact with the world.

As Johann Hari rightly points out in his recent article to promote his new book, everybody knows that our experiences, relationships and living conditions impact on our state of mind. If a loved one such as a partner or child dies, you are likely to be sad (and perhaps angry, or relieved if they were suffering, or many other complex feelings). Likewise, if you are given a warning of impending missile attack most people would feel anxious, and become hypervigilant for signs of threat. Therefore, most people would not think of grief after a bereavement or loss, or anxiety when in an acutely threatening situation as pathological. Which makes it somewhat curious that the medical model has been applied to mental health in the way that it has. Why has it become that depression or anxiety or even addiction is seen as a disease, a neurochemical imbalance that needs to be treated with medication?

Perhaps the advances of modern science studying genes and neurochemicals made us think of ourselves as complex biological machines that could be understood at a physical level. Perhaps there is wishful thinking about biological models leading to potential cures. Perhaps the fact that brain injuries, tumours, dementias and neurodevelopmental conditions can make an impact on our feelings and behaviours made it seem that all feelings and behaviours could be attributed to brain changes. Perhaps the idea of massive numbers of people suffering is too distressing to think about and it is a common defence to depersonalise that, and to other the person suffering. Perhaps the narrative of mental illness has sustained the power and income of the medical profession as experts and gatekeepers to such treatments. Perhaps it was clever marketing propaganda by the pharmaceutical companies to sell more of their products. Perhaps it was so persuasive because it fits with the neoconservative narrative to think of individual failure rather than individuals showing the symptoms of societal problems (and therefore our collective responsibility to solve these problems and look after each other, rather than just thinking of ourselves). Or, more likely, it was a combination of these and many other factors.

Of course, we don’t want to throw the baby out with the bath water. There are certainly people for whom psychiatric medication has made a massive positive difference. People who feel more able to concentrate and gain attainments when on stimulant medication, or who feel less hopeless, anxious or angry when on antidepressants, or people whose distress, confusion or aggression is reduced by neuroleptics. But we can’t work backwards from positive impact to considering that proof of a neurochemical deficit or imbalance. After all, the evidence for analgesics is very strong, but I doubt anybody thinks a headache is a symptom of lack of aspirin! We need good unbiased data to understand what is going on, not the cherry-picked examples that currently make it into the public domain. Alltrials is a good step in the right direction in this regard, but there is still bias in what research gets funded and what gets published, with bias towards the sexier topics of new technology, genetics, scans and hard science, and less towards the sociopolitical aspects affecting individual and population wellbeing.

I’m not saying that nature isn’t important. It seems likely that various medical/biological factors do mediate the impact of experience. For example, some conditions like autism, intellectual disability, and dementia do appear to have predominantly biological causes, whilst having impact on thoughts and feelings. Brain injuries and diseases can affect personality, mood and behaviour, and various hormonal and physical conditions can affect brain function and impact on mental health. There seem to be genetic differences (eg to telomeres) that make some individuals more resilient to adverse experiences than others. And some twin studies show genetic factors influence the incidence of conditions like schizophrenia and bipolar disorder, although again the epigenetic factors seem important, it is not clear whether the biological differences are a cause or a symptom of the condition, and the role of biology is not large enough on its own to explain who gets these conditions without also considering experience. Like most of these debates, the answer isn’t going to be one extreme or the other. I am glad that the pendulum has swung back towards considering nurture and experience more, and not exclusively the high tech science of genes, psychopharmacology and brain scans. It seems likely that who we are and how we feel and function in the world is affected by both our biology, our experiences, our circumstances and our relationships both now and in the past.

So, whilst Christine Courtois and Bessel van der Kolk’s efforts in the adult and child spheres respectively to get the impact of complex and multiple traumas and damaged attachment relationships recognised as a better way to understand attachment disorder and personality disorder than a neurobiological disease model (and their challenges to the DSM) have not yet been successful, I am heartened if this way of understanding the impact of experience is gaining more credibility in the field. I think the power-threat-meaning framework might be helpful for some clients, and the questions that they advise asking are certainly good way of starting a clinical assessment.

“What is your story?” Specifically:

1) What has happened to you? (How is Power operating in your life?)

2) How did it affect you? (What kind of Threats does this pose?)

3) What sense did you make of it? (What is the Meaning of these situations and experiences to you?)

4) What did you have to do to survive? (What kinds of Threat Response are you using?) and are you still doing this?

5) What are your strengths? (What access to Power resources do you have?)

It certainly resonates for me, and I wrote about a lot of this stuff in my book, Attachment in Common Sense and Doodles in relation to children who don’t live with their family of origin. I wanted to make information about attachment and the impact of trauma more accessible to carers, legal professionals and social care staff and other profesionals in the child’s network. It isn’t novel content, as it was based on themes that had been researched, written and spoken about by others before me, but I have tried to present it in an accessible and engaging way.

I am heartened that in the last few weeks the idea of experiences and nurture being important in mental health seems to be reaching the public consciousness. It seems to be being promoted more vocally by a lot more clinical psychologists, and to have reached me in various different ways. I’m glad if it is gaining traction and a wider audience, but it might be that’s wishful thinking on my part, and merely a product of my unrepresentative sampling. In light of how horrible a lot of the news is since the Brexit vote, Tory election win and Trump victory, I’m trying to be more selective about what I read and the social media I engage with, so it could be I’m in more of a bubble of like minded thinkers these days, and that is the explanation for hearing more about models that fit my own thinking!

Sherlock jumped the shark

Warning: Contains plot spoilers for series 3 (and for August Rush)

I think Benedict Cumberbatch and Matin Freeman are great actors, and the BBC have made a very stylish production of Sherlock with complex and nuanced characters. Both Sherlock’s use of drugs and the relationship between the two men has been portrayed in an interesting and convincing way. I particularly enjoyed the hint of Asperger’s in the way that Sherlock can use his visual observation skills and visual memory to reason in a way that seems almost impossible to a layperson, whilst struggling with interpersonal relationships. So it was with high expectations that I watched the latest set of episodes, and found them sorely disappointing.

I should say that it isn’t the first time I’ve built up my expectations of a film or show only for the reality to not live up to them. I have long identified a pattern I call “the Total Recall effect” whereby films seem to vary in their quality according to my expectations. The first time I watched Total Recall (the 1990 original, starring Arnold Schwarzenegger) I thought it sounded like a weak premise with a wooden actor, but was pleasantly surprised. The second time I watched it, some years later, I remembered it as a good film and was sorely disappointed. The third time I watched it, after several more years,  I nearly turned it off, remembering it to be dire. However, it wasn’t that bad and I enjoyed it enough to stick with it until the end. I learnt that my expectations influenced my subjective experience; hence naming the Total Recall effect.

I also hate films that mix realism with implausibility. I’m fine with suspending belief entirely for a fantastical tale, or for enjoying the interplay of characters in a different time or place (eg I love Firefly’s futuristic western set in space) but I hate it when stories that are designed to seem within a stretch of reality suddenly take a leap into the impossible. In the film August Rush, for example, I had that experience of a semi-plausible plot jumping the shark. It was a stretch I could just about tolerate for the boy to reject family placements and stay in the care system in the hope of finding his real parents, and to then run away in search of them (despite the fact he’d have been adopted as an infant, would never have known anything but the love and belonging of his adoptive family, and wouldn’t have felt quite the same yearning). His relationship with music was beautifully captured and was the highlight of the film. But the grand finale where everything fell into place, and his parents were both seeking him and each other, and were present in the right place at the right time to hear the concert and recognised it calling to them, then recognised each other and him, made it all fall apart.

That accounts for some aspects of my disappointment with Sherlock but not all. To be honest, whilst I applaud the idea of also including female characters and narrative as a general aspiration for all media, I wasn’t a fan of Watson’s wife being an international espionage expert (it felt a bit like the second series of Heroes, where everyone got superpowers). Likewise I didn’t buy Sherlock having a sister. They felt like a step away from the source material that wasn’t in keeping with the rest. I also found it frustrating that each episode spent three quarters of its time laying out a riddle, and then wrapped it up far too quickly and neatly in the final quarter. I also felt cheated that unlike earlier shows, we didn’t see how Sherlock put together the clues to reach his conclusion. It was presented in an abstract way, a bit like magic. Viewers were left to assume that the song combined with some numbers in the graveyard could be rearranged to lead to a sentence that unlocked the location of the well. But why those graves, and how did it unlock the location – we were short-changed in the explanation.

As ever, huge amounts of trauma were included in the plot, without an appropriate scale of emotional response. The repeated prompts to be soldiers wasn’t sufficient to carry the uneven emotional responses (smashing the coffin because he had upset the pathologist, whilst being unmoved by four murders and recovering from feeling responsible for a suicide in less than a minute). Likewise later scenes showed the repair of 221b Baker Street to its former state, indicating that the explosion that would have supposedly killed Mrs Hudson in the flat below, and threw them out of the windows in bursts of flame had not only caused them no injuries, but hadn’t even penetrated the floor boards of the flat.

However, my main grumble was with the character of Eurus and the plot that surrounded her. The actress playing her was good, and the twist of her being several characters was fun, but the story and back story they gave her was appalling. This woman was supposed to have been born a dangerous psychopath, and to have spent her entire life from the age of around seven in solitary confinement as a result. She was supposed to be lonely, anxious and delusional but to express that by doing nothing for two decades and then engineering plots that skipped continents and killed multiple people without emotional response. Well I call bingo on the theme of propagating negative myths about mental health, with zero points for reality.

First, it reinforced the association between mental health problems and risk of committing crime, when people with mental health problems are much more likely to be the victims of crime. Second, it gave the impression that mental health problems are things that you can be born with, and unrelated to your life experience. For example, we didn’t see that Eurus had been emotionally and sexually abused to create her distress and anger. We saw a highly intelligent child in a highly intelligent family that felt a little left out when her brother had a friend, and as a result decided to kill the friend, then burn the house down, and wanted to kill her brother. She was portrayed as a petty and jealous child, whilst presumably nobody in this highly intelligent family was able to show her affection or to help her regulate her emotions. And nobody recognised the risk or tried to intervene in a supportive way.

Eurus was supposedly unable to tell the difference between laughing and screaming, and was portrayed as being entirely without empathy, yet she had the subtle social insight to see (from her minimal observations whilst supposedly secured in a prison island) that her brother was unable to communicate any affection for the woman who was in love with him. Then, despite the lack of normal human interaction for most of her life it transpired that she had developed sufficient mind control to reprogram others within minutes of conversation. She had never done so as a practise, or in a way that was unsuccessful or aroused concern, however. But after 20 years she had suddenly taken over the entire prison/asylum island sufficiently to get people all over the place to transport her to and from the island, to set up her murder scenarios, to dangle three men in front of the window and cut the ropes to make them fall off the cliff to their deaths. No single person in the entire staff of the island failed to fall under her thrall, or had any moral doubts about her plans that were sufficient to breach her conditioning enough to raise an alarm (whilst the prison governor was able to disobey her to commit suicide in his attempt to save his wife). And she was able to set explosives, procure sedative darts and transport Holmes and Watson to an entire set created at her old family home. And this frightened, lonely girl who had supposedly only killed a child once in a failed attempt to play was suddenly killing many as experiments to test her brothers.

Sherlock, despite his intellect and his “mind palace” of perfect visual memories, was supposed to have entirely erased the existence of his best friend being murdered by his sister, or even of having a sister at all. When he spent the evening with the daughter of the famous serial killer, he could notice the drips of water and the line on her dress from her exit from the taxi, but not the fact that she was his own sister in disguise, putting on a false accent. Likewise he could predict that Watson would be at a particular location in two weeks time, but not see anything suspect in his flirtation with the woman on the bus. Meanwhile, despite the whole of MI6 and the intellect of Mycroft being involved in her supervision, Eurus could come and go from her prison island enough to make a therapy practise that both Watson and Holmes thought to be bona fide. And in the finale, Sherlock could believe that the voice of an adult woman he had been interacting with, communicated from an attic in the rain or a prison island, was that of a small girl in a crashing aeroplane.

In short, once you apply any critical thought, this series was a woeful disappointment, despite the stellar cast, impressive budget and stylish delivery.

 

Is empathy finite? Part One: Richard Huckle

There have been two challenging stories in the news this week. In the UK Richard Huckle was given 22 life sentences for sexually abusing around 200 Malaysian children, and in the USA Brock Turner was given 6 months in county jail for sexually assaulting an unconscious woman outside a frat party. Each of them has been hard to read and aspects of each case have brought me to tears. The stories have made me feel grief for the victims and anger at the perpetrators, frustration about the cultural norms that gave them opportunity and in their mind justification for their actions, and vexed at the justice systems that somehow seemed inadequate in the face of each situation. And in each case, it has been really hard to hold on to any empathy for the perpetrator, despite my strongly held belief that people are the product of their experiences and influenced by the context, rather than ‘born evil’.

Because I have read and thought so much about these two cases, and discussed them online, I thought I would write a blog post about each. This is the first of those two blogs, and is about Richard Huckle.

Make no mistake, what he has done is unthinkably awful. Genuinely evil, to the point it is hard to even comprehend. He deliberately targeted vulnerable children and babies in deprived communities for his own gratification, and shared his activities with others for financial gain through the dark web. He even wrote a manual advising other paedophiles how to sexually abuse children in less developed countries. He was clearly without conscience or empathy, or able to override any remaining scraps of either in favour of sexual gratification. The psychiatric assessments were reported to say that he justified his actions and showed no remorse. His ledger and writings on the dark web boasted about his activities. So I can understand why he got such a hefty sentence, and why many people feel he should have been tried in Malaysia where he could have got a death sentence. He has harmed hundreds of children and families, and changed the course of their lives for the worse. No sentence can ever compensate for that.

I found myself thinking that if he committed suicide or was killed by other inmates very few people would be sorry to hear the news. In fact many would argue that the cost of 25+ years in prison is money that will be wasted on an individual that is beyond rehabilitation. Comments on the internet below the breaking news stories said things like:

“Hope he rots in hell he doesn’t deserve to breath air”

“It’s time to bring in capital punishment for paedophiles. Why should we pay for his upkeep? Death is the only appropriate punishment for this creep”.

“How tragic for his father and mother, who were obviously conscientious and committed parents. It just goes to show, you can give your children a good upbringing but you simply can’t control how they turn out. This guy is a slave to his perverted sexuality and his condition is incurable. He really should be locked up for the rest of his life because he will always be a danger to children. What a terrible affliction for any human being to be born with”.

And a woman in the public gallery shouted “a thousand deaths is too good for you” as he was led away from court.

Despite all of my psychology and experience with child protection issues and knowledge that most people who harm children have been harmed themselves, I found myself hating him and feeling no empathy whatsoever. It was as if he had stepped outside of the range that my empathy could stretch. I wanted him to suffer because he had made others suffer. If I’m honest, I’m still very conflicted about it.

However, like the awesome film Arlington Road illustrates, there is rarely a lone gunman. As much as it is an attractive narrative that distances us from responsibility, I don’t think that one person in a million is randomly born evil and will inevitably do things like this. I believe there are things we can do to make such events less likely to recur over time, and it is that belief that stops me feeling hopeless and helpless when the news constantly bombards me with all the evil in the world.

When I took a step back from the emotions raised by the awfulness of what this man did and thought about what I have learned from both research and practice, I found that there are in fact lots of pieces of knowledge that can help us to make sense of what happened and what we can do to reduce the chances of it happening again. In other words, I started to think like a psychologist again, and I wanted a formulation that would help me to reach some understanding of how he got to the position of doing such evil things. Such an understanding would let me sidestep my helplessness, anger and desire for retribution, and instead focus on something constructive; doing something positive to prevent similar cases from occurring again in the future.

As I mentioned earlier, I believe that people like Huckle are a product of their experiences as well as their innate character, and their offending happens within a context. Of course I still believe in free will, and that people are culpable for the outcomes of the choices they made, and clearly Huckle made very very bad choices again and again and deserves to face the consequences of that. But we don’t make those choices in isolation. Although he was particularly prolific in his offending, Huckle was far from the only person to perpetrate child sexual abuse in the UK. In fact, there are over 100,000 people in the UK who have committed a sexual offence against a child and around 5000 new convictions are made each year. About a fifth of the population have experienced some form of unwanted sexual contact before they reach adulthood. Police recorded 36,429 sexual offences against children in the UK in 2013-14, and estimates suggest that only one in eight offences are reported. So this is a massive problem. (To put it into context, 1600 children per year are diagnosed with cancer, so sexual abuse is more than 20-180 times as prevalent). I believe that when it comes to any form of antisocial behaviour, violent or sexual crime, particularly on this scale, such actions are also an indication something is wrong in our society. It doesn’t surprise me that numbers on the child protection register are rising during this decade of ideological austerity that is widening the wealth gap in the UK. Just as suicide rates, substance use, homelessness and the incidence of mental health problems are increasing as a result of political decisions, so domestic violence and child maltreatment is rising as people fail to cope with the additional stressors imposed by benefit cuts, sanctions and reductions in public services.

There are several likely risk factors that relate to the abuser. First we know that whilst experiencing sexual abuse is neither necessary nor sufficient to create a perpetrator, the chance of sexually abusing children is increased threefold if he was sexually abused in his own childhood, and that experiencing sadistic emotional or physical abuse can also increase risk. We know little about Huckle’s family, but attachment disorganisation and the absence of any secure attachment figures seems much more prevalent amongst abusers. It is known that many sex offenders have sexual dysfunction. Isolation, low mood, loneliness and lack of social skill seems to also contribute, as do neuropsychological impairments – and Huckle was described as a loner who spent most of his time on the computer, as well as “uncharismatic” and on the periphery of things. Finally, the majority of people who sexually abuse children are religious (studies show 93% of abusers to report a strong religious identity, and around 5% of priests have been named in disclosures of sexual abuse). In between trips to Malaysia to abuse children Huckle was actively involved in the church and described himself as a devout Christian. Was that just an act, designed to gain the language and credibility to access children, or was there another motivation? Was he perhaps conflicted about his actions and trying to compensate or seek forgiveness? Or did he believe he was already going to hell, so he might as well do what he wanted in the meanwhile? Or did he have outwardly strong morals as compensation for lacking an internalised moral code? I suspect we will never know.

The part of this picture that is less often a focus of attention is the contribution of online communities to the normalising and even encouragement of abusive activities. However, we know that using the internet gives people an (often false) sense of anonymity and privacy, that brings out certain traits in their behaviour that might otherwise be inhibited because of the social consequences. On top of that certain communities have developed that collect and exaggerate certain types of behaviour. For example, the notorious bulletin board 4chan has boards within which particular patterns of behaviour from trolling to internet vigilantism (such as the hacker group Anonymous) have become the norm. Likewise certain boards have allowed the gathering of gamergaters, men’s rights activists, furries (people who like to role play anthropomorphised animals), bronies (adult male fans of the children’s cartoon My Little Pony), otaku (Japanese nerds), toonphiles (people who want to have sex with cartoon characters), adult babies, truthers (people who believe in elaborate government conspiracies, such as that 9/11 didn’t happen), those trying to give up masturbating to pornography, and many other quirky groups that would not be able to express themselves within a mainstream community. There are groups that advocate in favour of all kinds of risky behaviour from anorexia to suicide, drink-driving to barebacking (unprotected sex between men, which includes “bug-chasing” – having unprotected sex with men who are HIV positive with the intention of gaining HIV positive status). Online people can present with whatever persona they want to create. Instead of being lonely and powerless they can be charming and popular. In that context, it is not surprising that there are websites that normalise and encourage child pornography, and create demand for more content (including a financial incentive, which Huckle had used to seek crowd-funding for pornographic material he had made related to his abuse of a 3-year-old girl).

However, there is much that is unknown about the relationship between use of the internet, viewing child pornography and sexual abuse of children. Does the availability of “edgy” content pull users of legal pornography towards more extreme material that they would not otherwise access? Does the market create an increase in abuse to provide the materials that can be sold? Does viewing child pornography online become a stepping stone to contact abuse? Or does it allow potential contact abusers to meet their needs without harming additional children? Is it related to the grooming of children online? One in eight people convicted of viewing child pornography on the internet had a known history of offending against children in person but it is still unclear which is chicken and which is egg when it comes to a sexual interest in children and viewing of child pornography. But it is clear that law enforcement resources are totally outnumbered by the prevalence of child pornography online.

Finally, there are factors which make some children more vulnerable to become victims of child sexual abuse than others. These include the lack of a secure attachment figure, shame, isolation, neglect, disability, the presence of other forms of child abuse, socioeconomic deprivation, stressors placed on the family (eg unemployment, bereavement, divorce), cultures in which secrecy is encouraged or permitted, prior sexual abuse in the family (particularly if this was not reported and discussed), alcohol or substance misuse, domestic violence, and settings in which there is sexual language, pornography or exposure to adult sexual activities. These same factors make it harder for children to disclose what has happened to them, and for such a disclosure to lead to suitable protective action. Only one in eight children who experiences abuse receives any professional input to assess or intervene with it.

So there are things that we can do to mitigate the risk of future harm. We can protect future children by addressing inequality, providing more support for parenting and attachment, providing more prosocial opportunities for engagement for disenfranchised young people, being more proactive about responding to child abuse, having more investment in policing the internet so that access to child pornography reduces or is perceived as more risky. We can help victims of abuse to speak up early, to the right people, and to be believed. We can encourage the investigation and prosecution of sexual offences against children, and ensure that conviction rates and sentences are sufficient to act as a deterrent. We can specifically develop international policing solutions to address sex tourism. And most importantly of all, we can also help victims to recover from the abuse they have experienced, to feel safe and protected and develop healthy norms about relationships.

Huckle has done evil and unforgivable things. I still can’t find much empathy for the person he is now. However, if I think back to him being born, and the experiences that must have taken place to take him to the point at which he could abuse children, I am able to feel sad for that baby and angry at those who harmed him and failed to protect him or to intervene much earlier to divert him from his path and recognise their contribution to his development and the harm that he then perpetrated. And if behaviour is learnt, then no matter how unlikely, there may be a future point at which it can change. So maybe in 25 years from now it is worth reconsidering whether he still presents a risk, or whether he has gained insight and empathy that he is currently lacking. Perhaps new treatments will have emerged by then to make it possible. It seems hard to imagine that being the case. I’m usually an optimist, but for Huckle, I can’t foresee a happy ending – and I’m not sure I want to.

But there is a note of optimism in the bigger picture. Despite all the evils of austerity, and the massive burden that is creating on the wellbeing of the world population, and a few horrific cases that have been well-publicised in the media there is some progress. Sexual abuse is being talked about more, and more resources are being targeted at prevention and intervention. And there is fairly solid evidence that although there has been a dramatic spike of reports of abuse in the UK over the last two years, the overall prevalence of sexual abuse in the western world appears to be decreasing over time. Hopefully, that decrease will continue to accelerate over time, until sexual abuse really is the one in a million exception, rather than an all too present reality for a significant proportion of children.

 

Some thoughts on causing offence: 2 Trigger Warnings

The idea of cultural appropriation being offensive (which I discussed in part one of this blog entry) seems to go hand in hand with other recent social movements towards being more aware of the emotional well-being of others. This includes the use of social media to document the pervasiveness of small everyday actions that are a cumulative indication of how pervasive some prejudices are in society. The everyday sexism project has highlighted examples of how women’s daily experiences differ from men’s because of their gender, and there are similar projects to highlight the pervasiveness of racism. These small and often individually minor experiences, particularly in the context of race, are being termed “microaggressions” to denote the harm they cause when considered across a lifetime. I think these projects are helpful because, like the short films ‘Homoworld‘  and ‘Oppressed Majority‘, they humanise concepts that might otherwise be hard to explain, and show the massive quantity of incidents that might each in isolation seem too petty to raise. Without such examples or dramatisations it can be very hard to put ourselves into the perspective of another and to realise that their everyday experience is different to your own. And awareness is the first step towards behaviour change.

This change is happening at both the individual and organisational level. There is an increasing perception that organisations such as businesses, universities, public services and broadcasters having some responsibility for the impact of their content on customers, employees, students or their audience. This means being more aware of how the meaning of various content can impact differently on different people according to their experiences. This includes the use of ‘trigger warnings’ to orient readers/viewers/listeners about the aspects of the content that will follow that may resonate for them in negative ways. This could include mention of rape/sexual assault, violence, trauma, child abuse, racism, hate crimes or other forms of prejudice. The intent is to ensure that any person in the audience who has had traumatic experiences in their past is not re-traumatised by unintended exposure similar material without the option to prepare or opt out of that experience.

Although widely mocked, I think trigger warnings are quite sensible in principle. They aren’t there to molly coddle the delicate sensibilities of a whole generation of students (or social justice warriors) that don’t like being challenged, they are there to protect the small percentage of the population that have had traumatic experiences from post-traumatic symptoms. When I hear people on social media bragging about how they intend to trigger others, it seems like they lack either insight into what this means, basic human empathy, or both.

A trigger is a very specific word for what happens in the brain of people who have experienced serious trauma – normally experiences they have perceived as life-threatening – where the brain becomes sensitised to threat. When similar sensory stimuli to those associated with the event are detected, the amygdala goes into overdrive, and will put the person into a state of high physiological arousal (readiness for fight or flight) and make it harder for them to use brain functions apart from those associated with survival. Because the brain does not encode memories in narrative form very effectively during survival situations (due to much reduced activity in the prefrontal cortex) these sensory links often activate sensory memory fragments from the trauma, causing flashbacks and high levels of distress. This means that certain triggers can cause them to re-experience their trauma later on in their lives. Just as a war veteran might get flashbacks or nightmares about their war experiences, so people who have been seriously abused, raped or tortured experience unwanted intrusive images and memories of what they have been through when they see, hear or feel something similar to something they experienced during the trauma.

This isn’t something that has been made up, or reflects certain people being “sensitive flowers” either innately or by choice. It is a scientifically evidenced change to the brain after trauma. Intrusive images or thoughts, including re-experiencing of trauma is one of the diagnostic features of PTSD, and it is well established that certain experiences trigger these flashbacks. MRI scanners show the limbic brain (eg the amygdala) lighting up faster and brighter to threat signals that would not be perceived as threatening by others without the trauma, and the resulting decreased activity in the prefrontal cortex. Neurochemical analysis (eg from swab tests) have shown that this has a significant effect on the person’s neurochemistry and chemical messengers (like adrenalin and cortisol) are released that prepare the body for fight or flight. In short, this is a serious and well-documented physical response to serious trauma that I have blogged about previously. I’ve worked with lots of traumatised and/or abused children and adults and it is a really horrible thing to go though. It seems like a double dose of adversity for those whose abuse/trauma continues to echo through their life months or years later. It is not something to make light of or mock, and only a truly repugnant person would do so.

But being thoughtful about the impact of content on others, and orienting the audience about what is going to be covered, does not have to equal censorship. We should still talk about the tough stuff, study it, make art about it and even sometimes joke about it. It often makes for the most interesting debates, and it is through engagement with these complex and challenging issues that people learn to analyse the motivation of the writer/speaker and to appraise the context as well as the content of what is said.

As uncomfortable as it can be when people use it to say annoying, idiotic and offensive things, I am a believer in free speech. I don’t think being offended is a reason to silence someone. It is a reason to reply so that others are not persuaded by them, to ignore them, or to deny them their audience (because free speech doesn’t entitle you to a platform, and any website, venue or business can decide not to welcome/endorse somebody). But it isn’t a reason to stop them saying their piece, unless it incites violence or racial hatred and is therefore against the law. As hateful and bigoted as Donald Trump is, for example, the answer to the awful things he says is not to ban him from the UK, it is ignore him and deny him the oxygen of publicity, or simply to laugh at him. Mock his ignorance. Share your disgust. Highlight how hateful and harmful his ideas are, and how he has not earned the right to lead by showing any personal qualities that are admirable. Ensure that he faces legal consequences if he oversteps and breaks the law by inciting racial hatred whilst in the UK. But don’t censor him and allow him to take the role of being oppressed, as it would be counter-productive.

Even President Obama has weighed in to say “Anybody who comes to speak to you and you disagree with, you should have an argument with them. But you shouldn’t silence them by saying, ‘You can’t come because I’m too sensitive to hear what you have to say.’ That’s not the way we learn.” I’m inclined to agree. We are all responsible for this conversation, and in the therapy professions, genuine empathy has to include acknowledging the difference between the client’s perspective (or a colleague’s) and your own.

 

Some thoughts on causing offence: 1 Cultural Appropriation

“Cultural appropriation” seems to be something increasingly causing debate, especially in the USA, and reading about all the new terminology and topics of debate, I feel like I’m playing catch up. There are certainly some pretty extreme emotions being raised by some of the incidents (eg a student screaming at an academic whose wife sent an email expressing that the restrictions around halloween costumes recommended by the intercultural affairs committee might be excessive). It seems to have hooked into the fraught racial tensions in the USA, and a broader debate about whether to protect people from offence versus being able to speak freely and discuss any topic.

Cultural appropriation is the term used when people dress up/make up to look as if they are from a different culture or ethnic group. It is particularly controversial when white people impersonate or borrow from minority ethnic cultures. It seems to be an increasingly widely used term. The perception of it being inappropriate to stereotype racial groups by borrowing from their culture has spread much more widely from it being taboo to use ‘black face’ makeup into examples that have until recently been considered to be more acceptable, like a pop star wearing an outfit referencing a particular country or culture. Some people find this highly offensive, and feel it is appropriate to publicly shame anyone involved in doing this. The gist of this viewpoint is that people who have not experienced the oppression of being in the less powerful group should not be able to cherry pick and borrow the superficial bits they like of exotic cultures, especially when these same cultural traits have been disparaged within western cultures by the dominant white narrative.

As a fairly privileged white British woman who hasn’t experienced this first hand (despite being a second generation immigrant and having high levels of prejudice and persecution associated with my cultural heritage), it is sometimes hard to see why the reactions are so extreme. However, I understand from what I have read that for people who have been shamed for their culture and forced to conform with white norms, the adoption of non-white symbols or traits as a mark of difference or rebellion by white people is a reminder of that oppression. It is notable that it has a different meaning to those observers than the positive interpretation that is typically intended by the person involved, or that which is construed by other white people (who may not hold the same negative associations). Sometimes people can be absolutely blind to stereotyped imagery that they do not have personal associations with (see this example regarding racial imagery in a video game).

However, there is now a backlash saying that these complaints are part of a whiny politically correct subculture that enjoys being offended, and takes offence on behalf of others as part of a progressive agenda. More regressive voices like to scathingly label this as a desire for social justice, as if this would be a bad thing. See the comments on any article on this topic published online for plenty of examples.

So let me start by saying that I absolutely see the core legitimate grievance within the wider label of cultural appropriation. I can completely see that having white people ‘black up’ or ‘red face‘ is racist and would be offensive to people of colour, and that using cultural or religious artifacts when stripped of their meaning or commercialised (eg feathered head dresses, or the Hindu bindi) is controversial and could be considered to be in pretty poor taste. I also acknowledge that these appearances often go hand in hand with other elements to the role that make it more racist (such as using stereotyped accents or behaviours). I think it is right that overtly racist caricatures like ‘golliwog’ logos and toys, or racist scenes in early cartoons are relegated to the history books. Similarly, the use of logos and names that stereotype native Americans by sports teams in the USA has persisted for far too long. However, I can’t help but feel that the issue of cultural appropriation isn’t as clear cut as some people make out. It seems to me that the rules being made to restrict the risk of offence over culture (eg in American universities) are becoming as much of a problem as the issues they seek to address, and obscuring the very genuine issues of race inequality that lie underneath.

So are Halloween costumes on campus really oppressing people from minority groups? Is it really of concern if someone morphs her own white face to represent endangered African tribes? Or if white models get braided corn-rows? Are musicians like Madonna, Selina Gomez, Iggy Azalea and Beyonce really being “disrespectful” when dressing with elements of Indian costumes, such as wearing a bindi, sari or facial jewellery, or when Katie Perry wears a Geisha-like outfit, or Lady Gaga references a burqa? Is Miley Cyrus twerking disrespectful to working class black women?

If these examples are offensive, how far do we take this? What of actors who play people with different nationalities, religions or accents within a particular skin-tone? What about able bodied or neurotypical actors taking on roles of characters with physical, developmental or learning disabilities? What about actors who have not experienced mental health problems playing characters experiencing them in films/TV? Can musicians/artists only draw on influences within their own country/ethnicity/experience? Can writers only create characters of their own ethnic background? Can art or media not be provocative or controversial any more? Can I not cook curry or sushi or chow mein? The slippery slope could continue ad absurdum.

Surely, several issues are being confounded here. Firstly that there are many areas in which there is very little diversity of representation. For example, we clearly need more ethnic and gender diversity in business leaders and politicians in this country, as most of them remain white men. We also need more varied faces, accents and perspectives in the media, and as role models across the board. We need more diversity in the people who win awards (all white oscar nominations two years running is ridiculous, for example) and we need more diversity in those making decisions. Secondly, we can’t compensate for this lack of diversity by putting yet more of the same group into costume to represent others, and doing so would disrespect the lived experience of those being represented. There is a real need for representation and not just for increased mindfulness from those in power.

I’ve sat on a committee in which we have tried to ‘hold in mind issues of race, age, gender, religion, culture, sexuality, disability and other aspects of diversity’ but I don’t think it was possible when very few of those characteristics varied much within the group, and those which did vary were not much spoken about. The focus tends to be on what the group have in common, and each individual might feel unworthy of their status (particularly if they feel they don’t fit in as well, or are there because of a particular minority status), and that makes it much harder to highlight times when a devalued characteristic of an individual might be relevant. For example, in a mostly male boardroom, women tend to take on more traditionally masculine forms of discourse, and to feel less able to express emotions or feminine characteristics or needs. So, it seems likely that it is even harder to speak up about other aspects of diversity. It felt brave yet somehow risky for Crispin Blunt MP to talk about his use of poppers and how banning this would be criminalising a substance used widely by gay men. However, this is more the exception than the rule. Diverse voices tend to be marginalised and to find it hard to reach a platform, and this is something that needs to change. And that change needs to start right from the top. Having a minister for equality who voted against gay marriage is patently ridiculous, for example, yet we have had two in a row, neither of whom have any more experience of inequality than their privileged example of being female.

To go back to cultural appropriation more specifically, I’m not sure it is the action or costume in isolation that is the problem. I suspect that the context has a lot to do with the derived meaning. If actors and public figures were more varied and included people with physical disabilities, learning difficulties and mental health problems, a variety of religions and cultures, diverse ethnicities, all sexualities, genders, ages and body shapes, then everybody would feel represented and emotions would not be so heightened. If musicians, celebrities and scholars gaining funding and media coverage were more diverse, then the cliched references to other cultures would have much less power. Similarly, if the fashion industry routinely used models with a variety of skin tones for all campaigns, and treated their sources of inspiration more respectfully, then the hairstyles of models used to showcase collections with international influences would be much less problematic. If people from different perspectives had similar levels of power, then speaking up to criticise someone from a majority group would not be so difficult do or as easy for critics to attribute to sour grapes. But attitudes and power structures take a long time to change, and can be very resistant to progress, particularly where this threatens the status quo. The difficulty is therefore twofold – how we move towards the bigger goal, and what we do to manage the problems that will continue to appear until we get there.

Broadly I think we should allow people to express themselves, but also encourage thoughtfulness and conversations that challenge people’s preconceived ideas. Dressing up is usually playful, and done for fun rather than to make a statement. Sometimes, being a little ‘edgy’ is part of that fun. I would hope that a certain degree of role play allows us both flights of imagination and greater empathy. It would be a great shame if children couldn’t dress up as anyone outside of their own cultural group in play, for example, or if fancy dress costumes were similarly restricted. However, we should also be open to learning from other’s experience. So if a costume is culturally insensitive or causes offence, people need to speak up to say so.

However, there are two very important provisos to this. Firstly, it isn’t the responsibility of disempowered minorities to challenge the actions of the majority group, it is everybody’s responsibility. And second, highlighting a different perspective should, as far as possible, be done without publicly shaming the person involved, unless they continue to repeat the same actions which are causing offense. We can all have times when we accidentally do or say something thoughtless, and that shouldn’t be an irreparable error. It is what we do when that is drawn to our attention that is the measure of the person. Publicly shaming a person who makes a mistake or poor judgement is the kind of black and white thinking (if you excuse the pun) that polarises opinion and drives a wedge between different population groups.

I would also note that there are times that it is perfectly appropriate to join in with traditions and wear costumes as an outsider, and would be disrespectful not to. For example, for female western tourists to cover up exposed skin and perhaps their hair when visiting various religious sites, such as mosques and temples, or for guests to festivals and weddings to be dressed and decorated in the local style as part of the ritual preparations. Similarly it is sometimes helpful for somebody independent of a particular culture to study and document aspects of it that those within the culture might take for granted. It doesn’t replace the voices from within that culture (which we need to facilitate and amplify), but can be a helpful supplement. Similarly, I can’t see that use of influences from other culture as inspiration for art can’t be done respectfully or that having different perspectives isn’t generally a way to drive progress in any area of study. We wouldn’t have mathematics, a calendar, politics, written language or many sports if we relied solely on our indigenous and anglo saxon heritage.

Overall, I think nowadays we are in a melting pot whether we want to be or not. Our culture isn’t static, it is fluid and constantly evolving. There is increasing globalisation, and our history has gained from many different cultural roots. We travel internationally more than ever and we all have heritage in our DNA that we can track across continents. Our fashions, arts and sciences are enriched with knowledge and influences from all over the world. I’d see that as a positive thing, and an opportunity for ongoing dialogue and learning. To me, the key to drawing on other cultures is the context and respect with which we do so. There are some good examples of cultural appropriation. If we want to be sensible about culture, then giving credit to our sources, being open to feedback, and doing it with respect and admiration seems like a good place to start.

Happily ever after: Some thoughts on trauma in the movies

I watched a romantic drama this evening in which a man and a woman who has a child from her past relationship fall in love. The ex-boyfriend is controlling, threatening and manipulative and tries to sabotage the relationship. He is shown getting drunk and grabbing the woman’s arm tightly to stop her leaving twice, and at another point he threatens the man with a weapon. Towards the end of the film the ex-boyfriend is drunk and upset. He threatens to take the child, who runs away and falls into a river. The ex-boyfriend rescues the child at the cost of his own life, and the mother and child witness him meeting a sudden grizzly death. Then the couple get together, become a family with the child and the film ends, leaving them to live happily ever after.

Having watched a set of characters for an hour and a half that were portrayed sympathetically and realistically enough to feel invested in, this seemed like a weird ending. I was left with this really disconcerting feeling that the writers, producers and large numbers of reviewers of this film (who gave it respectable scores on Amazon and IMDB) thought that this climactic scene tied up the ends neatly and left us with the uplifting moral righteousness of the baddie getting his just deserts, the couple unimpeded in their romance and a perfect nuclear family.

But how could a child who just witnessed his father’s death (and probably felt responsible for it) not have any emotional reaction to that? Would it not be yet another loss of a close male relationship for this young child, who had already lost others as part of the back-story? How could the mother not have complex feelings about the death of a guy who has been emotionally and potentially physically abusing her for five years? Would her relief perhaps be tinged with guilt that her new romance triggered these events, or at being relieved to see the back of him? Would a mother not feel sadness in empathy for her child’s experience of trauma and loss? Would she not feel echoes of the loss of her own father in childhood, or her brother the previous year? Perhaps their different ways of dealing with grief and loss would challenge the romantic relationship? How about our leading man, who was mourning lost friends and showing signs of PTSD at the beginning of the film. Would it not re-awaken all the unresolved grief he is repressing? And what of the ex-boyfriend’s parents and their stoical thanks to those that tried to rescue him? Does nobody cry for this man, who gave his life up to save his child? Was his inept handling of the relationship that resulted from an unplanned pregnancy in his teens so bad that he deserved to die?

Why couldn’t the film have been one that illustrated the reality and complexity of modern family relationships? Surely the alternative was for the father to have shown his priority was the wellbeing of the child, during the rescue scene, but to have survived and been part of a renegotiated family configuration in which the child was able to have both a positive experience of contact with him and to live in the new family unit with Mum and step-Dad? As I often tell children who feel that any affection to foster or adoptive carers is disloyal to their birth family, love is not like a cake where you have a finite amount to share out between all your relationships, love is like candles where using your fire to light others just creates more brightness for everyone. But if the father had to die, then they needed to show the emotional fallout of that. They can’t have one without the other, any more than they could show a person standing in sunshine without showing their shadow.

As it stood, the film profoundly failed to acknowledge the impact of trauma on the different characters. And this film was far from alone in that. So many traumas occur in films and TV shows that it seems they are very much part of the expectation nowadays. In every vampire franchise I’ve seen the head counts of characters close to the main protagonists who die are extraordinary, and yet they briefly mourn and then move on. In Vampire Diaries, an average of 19 characters shown on screen die per episode, and the main character, Elena, has lost almost every living relative and most of her friends, as well as dying herself, twice! Many other shows track medical emergencies, murderers, serious crimes, drug dealing and power battles, yet they are dealt with in an entirely sanitised, emotion-free way. Sure, a pathologist would be well-used to the physical nature of human corpses, but even in the most hardened professionals some cases creep through the cracks into your psyche. The person that looks a little like someone you know, or reminds you of something in your past. The tragic story that becomes apparent from the cause of death, or the untimely demise of a child. We are not robots analysing data, surely we recognise that people are like us and the people we care about?

The latest Star Wars film showed planet-scale genocide without that even being acknowledged by the cast. It’s a really good film otherwise, and I really enjoyed it, but the scriptwriters chose to show genocide as shorthand to make the baddies bad. It could equally have done so through less wide-scale slaughter, or by showing the snatching of children to indoctrinate as stormtroopers or many other plot devices. Including the slaughter of millions of people was a plot choice, and given that the film is part of a historical franchise that is pitched to the whole family and used to market toys to children, that is a pretty weird choice of plot. To then skim over making light of it makes that more disturbing, rather than less, once you think about it. I’m not saying the main characters should have processed the emotional impact there and then; I’m sure if you are busy fighting for your life or have 20 minutes to save the world and see some planets blow up, that isn’t the moment you down tools, lie down and cry. But even an extra second of footage showing sad faces, one person humanising the loss by mention of having lost individuals there, or an additional comment about how awful that loss was, would have given some hint of the emotional connections of all the people whose lives were extinguished in an instant. In the original trilogy when Alderaan was destroyed they used the change in the force to acknowledge how monstrous it was. I still remember the scale and momentousness given by the line “I felt a great disturbance in the Force, as if millions of voices suddenly cried out in terror, and were suddenly silenced. I fear something terrible has happened.” And this is what was missing in The Force Awakens.

But I think this lack of acknowledgement of millions of deaths was also illustrating something very poignant about human processing of events; we identify much more emotionally with death or distress at the individual scale than we do at a population level. Think of how the discovery of the body of young Aylan Kurdi humanised the treatment of Syrian refugees in the news narratives, for example. Prior to that point, they were treated like an invading army of ants, but in the weeks immediately afterwards some individual stories were told and people felt more sympathetic and we were shown footage of refugees being welcomed into various European countries. I think that change in response according to the scale of deaths is part of human nature, as is our ability to shut off from suffering and get on with life, if that is necessary to our survival. At the extreme end, people living through wars or in areas of high risk or conflict are probably coping by living in “survival mode” and using more primitive parts of the brain in favour of the prefrontal cortex, which has reduced activity under threat. It makes sense, logically, as we do have to compartmentalise awful stuff to just keep on going sometimes. I think back to all the life events that happened whilst I was pregnant (including a car accident, my granddad dying, a close colleague dying unexpectedly, my job being placed at risk, my babies being born very prematurely) and think I only coped with everything I couldn’t avoid by going into a psychological bubble and putting all that bad news aside to deal with later.

Maybe these fictional narratives of unacknowledged loss that have become so prevalent in TV and film are using this tendency – our ability to put emotional distance between ourselves and tragedy through various forms of displacement. If something awful happens far away, or it happened in the past, or in a different cultural context, or in fiction, then we are able to distance ourselves from it and deal with it at a purely cognitive level. We think about it but don’t feel it. The shame is that this seems to be how many politicians and decision makers deal with the problems affecting people in our day to day lives. Although it is ‘psychologically expensive’ to allow emotions in, it is only with empathy that we can really make informed decisions. So in real life as well as in fiction, I think a bit more feeling would be a good thing.

Slow burn: Reflecting on the emotional impact of working with chronic trauma*

*This post contains vignettes of harrowing material which may upset some readers. Case examples are all anonymised.

When I decided to do work in child protection, people warned me it was the fast road to burnout. Twenty years later I think they are right about the direction, if not about the speed.

Burnout is an insidious thing. It sneaks up on you as a chronic accumulation of many tiny things, rather than having an obvious trigger, like a single life threatening event that causes PTSD. A thousand small examples of vicarious traumatisation. Experiences that I shouldn’t complain about as I’ve chosen a career that inevitably brings exposure to distress and tragedy. It feels like I’ve chosen to wade through the grottiest parts of life, until I’m normed on that 1% of stories that cause the most concern. It saturates me. Pollutes my perceptions of life. It has been building up for a long time.

Fifteen years ago my two specialist placements included post abuse work with survivors of sexual abuse, a group for non-abusing parents of children who had been sexually abused and work with “complex” children and families, such as those on the child protection register. I knew it was emotionally harrowing work then. I talked about it with a good friend, and concluded that my drive was to go where I was most needed, to grapple with the most complex cases, and that I’d worry about burnout when I got there. I graduated onto a clinic for children who were “failing to thrive” and most of my clinical time being with Looked After Children and therapeutic work with those who had experienced trauma or maltreatment. Right from the start, it was an induction of fire, salved only by the fact that it was important work that needed to be done.

It started with individual stories.

The sad silent child who ate 7 digestive biscuits and carefully stowed extras in his pockets during clinic, but whose parents claimed he had a digestive disorder that meant he wasn’t gaining weight despite eating plenty.

The young woman with learning disabilities who repeatedly played out how the daddy bear lay on top of the baby bear and thrust, but said baby bear was a liar and nobody believed her when she told.

The adult relatives who revealed at the last moment the sadistic physical and sexual abuse that their step-father inflicted, after he had charmed the professionals enough to get residence of his grand children, when their mother was unable to cope and had reverted to chronic drug use.

The maps of children’s bodies in medical notes, used for annotating injuries, including one for babies. The paediatricians sharing photographs of torn orifices, injuries, malnourishment and legs with rickets. “This one has burns on their hands up to a straight line on their arms, showing they were held in boiling water as a punishment”. No, I don’t want to see, thanks.

The little girl in a religious cult who couldn’t disclose her abuser as she had been taught it was as bad to think or speak badly of others as what they had done, and shown pictures of people rotting in the ground or burning in hell for their sins.

The boy who was conceived through rape, whose mother couldn’t look at him, and whose grandmother thought any challenging behaviour showed he was “living up to his genes”.

A girl asking how she got the zigzag scar on her stomach. The family didn’t want to tell her about how her mother tried to cut her open to let the devil out during a puerperal psychosis. They don’t want to spoil the relationship as she goes to Mum for alternate weekends. When I meet Mum she talked incoherently about spirits and auras, telling me she likes climbing on the roof to be nearer to God. She has no need of adult mental health services, thanks.

The young woman who always claims to be pregnant. Partners are less likely to harm her that way. She is couch surfing at the moment, which is the new name for homeless. Her only possession is a photograph of her son who was removed at birth and adopted. After physical and sexual abuse at home, and attempts to stay with numerous relatives, she grew up in care. She had a sexual relationship with her male carer at 14 which she views as consensual.

Since 2000 I have done expert witness work for the family courts. That means reading bundles of documents about trauma, child abuse, neglect, loss, violence, family breakdowns and mental health problems. It means speaking to parents who have been maltreated in their own lives, lack coping resources and instead of being able to create healthy relationships and flourish have limped from one bad experience to another. It involves speaking to children who have seen too much, had to cope with awful things and missed out on the love and nurture that you’d want every child to take for granted. I read about and sometimes see the state of the home, with rubbish heaped up and rotting, flies circling, dirty nappies on the floor, no clean clothing, nowhere to store possessions and no space that isn’t filled with clutter. I hear about broken bones, bruises, burns, rapes and assaults. Sometimes there are x-rays, photographs or medical records. I see sadness and anger accumulated over many years of getting a raw deal. I measure problems with learning, attention, behaviour, life skills, self-esteem and mental health. I observe who denies the problems, who spills over with them, and who recognises themselves doing as they were done by despite all their best intentions otherwise.

I read, and I listen. I measure and observe. I pull the pieces together to see what fits and what conflicts. It is an active process, trying to understand what happened, how and why. Evaluating insight and future risks. A computer couldn’t be programmed to do this. It takes empathy, curiosity, critical thinking and detective skills. I am the barometer of relationships, of what would feel okay, of what is causing harm. If I felt nothing, I couldn’t do the job. But there is so much pain to feel. So many sad stories.

A little girl with curly dark blond hair who the foster carer told me “shook with excitement to get her own dolly for the first time and promised to keep it pristine so that when mummy gives it to her little sister she will still think it is new”. I nod politely. Take verbatim notes. I have to stop the car on the way home for a cry.

A teenage boy tells me how his father often pinned him up against the wall by his neck or beat him with a belt. He wonders why he dissociates when he perceives threat or criticism now and worries that he is going mad. I try to explain his brain learnt to protect him when nothing else could.

I observe the baby that was rescued from the fire. Her scars are healing slowly, and the medical treatments are painful. She can’t bear to be touched. There is too much pain for someone so young.

A mother tells me how it hurts her watching the foster carer do a better job than she was able to at caring for her children. “I always swore I’d be different to my mum, make better choices of partner than she did, keep my kids safe from harm. I look at where we are now and see it has happened all over again and I can’t bear it”. And neither can I.

A teenage girl tells me she took the overdose because her step-dad broke the door down and overturned the bed to reach where she and her mother were hiding, and hit her mother repeatedly with the broken bed leg. She shrugs and smiles, and says “its just how it is, you know”. I don’t know. But trying to imagine it makes my guts curl and my eyes leak involuntarily.

A mother tells me about the culture she grew up in, and how grateful she is to be here, even though the whole family live in a single room in slum conditions, and it is hard to find work as an illegal immigrant. If her son is hungry, developmentally delayed, and being beaten for misbehaviour at least he is safe. I think that isn’t safe. It is all relative.

A father tells me that his uncle sexually abused him as a young boy, but there was too much stigma to tell anyone and he was afraid to lose this special relationship. He still spends time with his uncle now, and trusts him implicitly with his own children. A few sentences later he says he is baffled why the children are showing sexualised behaviour. I am baffled that other people can’t see how obviously the pieces fit together.

I assess a couple that smell so bad I struggle not to gag. I open the windows but it is not enough. I go out for air every hour. A social worker sprays perfume on my sleeve so I can raise it to my face to mask the smell. I learn the phrase “body odour to an extent causing discomfort to anyone in the proximity”. They don’t own toothbrushes and show me teeth rotting in swollen gums.

A woman tells me she has put on 9 stone as she needs to have fat deeper than the knife blade is long, since she was stabbed by her ex-partner. She wheezes for a long time after climbing the stairs at the contact centre, and she struggles to get down on the floor to play with the baby. I worry when she is slower than expected to return from the toilet, do I need to check if she is okay?

The child was born with HIV. His mother died of it. He lives with his grandmother. She doubts the diagnosis. “He doesn’t look ill, the English doctors don’t know about us”, she says when I ask why his prescriptions have not been collected.

A lady tells me that she must have had post natal depression. If she wasn’t ill she would keep the house clean, but when she is ill she can hardly get out of bed, and gets ideas that the world is very unsafe. That is why she kept the children in her bed with her, rather than sending them to school, until they were no longer able to walk. She’s on antidepressants now, and saw a counsellor for six sessions, so everything will be fine. The social workers are making a fuss about nothing.

A man tells me he has exercised to pass the time whilst in prison. He is proud that he is bigger and tougher than his father now. He says the robbery was the fault of the friends who bought him the beer and suggested the idea, and much exaggerated by the victim. I am glad I brought with a student to observe, as the room is quite isolated and his body language makes me tense.

This couple have managed to sustain the acrimony of their separation for five years. She says he was controlling, violent and obsessive about having every last penny accounted for. She tolerated his promiscuity for far too long. He says she was moody and manipulative, and it is probably her mental health that’s the problem, and her jealousy that he moved onto another relationship. It makes me cross that both of them seem to have forgotten the kids in the middle of their conflict.

A little boy tells me what it felt like to be buggered. I try not to think about it that night in bed. I play tetris on my phone until I fall asleep at 4am.

A woman tells me that all of her relationships have been with men who present a sexual risk with children. They are all so different, she says, that whenever she learns what to avoid the next one is nothing like it. And why wouldn’t you move in with someone you’ve just met? How else do you get somewhere to live after the last relationship has turned sour?

The story stems of a girl of eight show the family repeatedly pushing the girl off a cliff and laughing at her. For variation they poison her and laugh as she vomits. She repeats the loop for 90 minutes, then returns to lying foetal under the table as I leave, just as she was when I arrived.

“I had a cold, mum caught it, and it made her sick so she fell down the stairs” says the boy with autism. “That is why she had to go to hospital”. It wasn’t the head injuries her partner caused, it was his fault. But later in the conversation “Daddy gets out of prison soon. When he finds us he will kill us this time”. It is deadpan. An emotionless fact of life.

The girl in the children’s ward tells me “I didn’t want to go home. I jumped off the bridge because it would be better to be dead. They say I will need to be in hospital at least six weeks whilst my leg heals”. She smiles showing me the metal cage and all the pins reassembling her bones, and counts the pieces in the x-ray. She won’t say what is wrong at home.

“He spat right in my face and pushed me over. I was so angry then. I hit him with the lamp until it broke, then I whipped him with the cable. I could see the shape of the switch in the bruises when I was done. They might have seen it, but that’s not the same. I’d never hurt the children.”

A boy tells me what is different in foster care. “It was the best day ever. We went to the garden centre. I got to look at the fish, and we had a drink and a slice of cake at the cafe. We eat at the table with the grown ups here. I got my own coat too, nobody wore it before me! And my skin is better”. The carers tell me that they had to wash the grime off the bath after he arrived, replace all his clothes and do twice daily treatments of his infected eczema. They had to get a court order to shave off his matted hair as his parents would not give consent.

A five year old girl tells me about the day she came into care. “I could hear they had fish and chips in the front room. I could smell it. I tried to walk there, but my legs weren’t working and I kept falling over”. The medical records show that a visitor called an ambulance when they saw her unconscious and malnourished. Her blood test results are marked with blue biro. Haemoglobin is captioned “how is she alive?”. She dances when she shows me the foster carers have a rabbit run in the garden.

In each family I hear many of these stories from each individual, and I see several families each month for assessment. I’ve been doing this for over a decade now. I have banked hundreds of such narratives, maybe a thousand. All involve a child or children being harmed. The stories are each unique, but the themes recur. James blurs into Joshua and Jared and Jacob. Samira merges with Samantha and Saskia and Sasha. Depression and anxiety, broken bones and bruises, filth and mayhem, conflict and violence, cancer, obesity and sensory impairment, neglect and abuse heap up in my repertoire of human experience and leak out into my life. I see those stories lurking at the edge of my vision, in the arguments partially overheard in the shops, or behind the headlines in the news. I see their echoes amongst people that I know; my neighbours and colleagues and friends.

I set myself impossible standards. I worry if my child has messy hair when she gets back from school, or I notice mud under her fingernails. Will people think we aren’t taking proper care of them? Are we not taking proper care of them? We go to A&E after my daughter burns her hand. I ask her to tell the story before I speak and she says “it was your fault mummy, it was your drink that tipped over”. I feel like a failure and a hypocrite. My cat has a jaw infection and needs teeth removed and antibiotics. I should have known. He smells like the couple I assessed at the social work centre last year.

I say we need to leave the restaurant. I can hear a mother saying “ungrateful brat, I should never have had you” to her son. Outside the school a mother pushing a baby in a pram says to her friend “look at him giving me evils, he’s going to be just like his father”. I walk away. The couple outside the pub argue incoherently and their voices get louder and shriller as we walk back to our car after a night out. The child in the park approaches me and asks me to push him on the swings. People on the internet disclose abuse. In the supermarket I hear a slap and the child is crying. The woman walks past on the street with a fading black eye. They are anonymous and legion. The scale of the problem is overwhelming. I can do nothing.

Friends of friends ask for advice as they have heard I am a psychologist. Its important to try to point people in the right direction, but I am depleted. Another 2 lever arch files arrive at work. Its an incest case and mother is terminally ill. Surely there can be no more stories this bad, but there is a queue awaiting my attention. The next one has police transcripts of the interviews of all of Dad’s victims. He might be a paedophile but his daughter wants to see him anyway. The one after that they want me to see Dad whilst he is in prison for abducting the children to a different country. He believes it is his right; fathers own children in his culture. Then back to the bread and butter of court work, another family where neglect and maltreatment has been the norm through many generations. One of the children is the same age and gender as one of mine. Don’t make comparisons. Don’t go there. Change the subject.

A letter from a solicitor tells me that my invoice has been reduced by the Legal Aid Agency on appraisal. I will get £400 less than the total billed, despite not billing for 6 hours work already because of the fee caps. The hours were “not proportionate”. Do I explain again that it takes longer to do assessments via a translator? I don’t have the energy. Another one is querying the hourly rate. I should work for £7 less if I only see the adults as I won’t be a child psychologist. I ask if a psychiatrist gets paid the rate for a psychotherapist if they don’t diagnose or prescribe. The solicitor is sympathetic but says there is nothing they can do. A father doesn’t attend an appointment that is booked to fill a whole day. I have driven 2 hours to get here, and I wait for an hour whilst phone calls are made, then drive 2 hours home, exhausted. I can do nothing else with my day. Legal Aid say a psychologist can fill their time productively with other activities and refuse to pay anything over travel costs, even though the contract says that they will pay for any appointment cancelled with less than 72 hours notice. I can’t bill for materials, venues or typing. The questionnaires cost an average of £5.31 each. I used 6 per child and there were 7 children in the family. Does it add enough to my report to justify £220 of lost income? The LAA ask what ‘capacity’ is and why it took me 4 hours to assess it. Is it not embarrassing to work for the family court system and not to know this or to have the sense to Google? The self-funding father who was supposed to have lodged the cost of the report with his solicitor hasn’t. He now wants to pay in monthly instalments, but my staff get paid next week. I have to turn away two cases a day after reading about the plight of the children, because I am booked up too far ahead. The wealthy mother from abroad hasn’t paid her share of the bill from 4 months ago, but the court wants me to do more work for her case. There are 16 follow-up questions from the report I filed last week. Why do I do this again?

Tomorrow is the appointment to assess the teenage mother in the mother and baby unit. Yesterday her boyfriend told me about how they met online, and gave me their usernames. Google shows me his dating site entries seeking single mothers, Facebook posts about the violence in their relationship and a video of the baby’s “sexy dance”. A solicitor phones. Can I squeeze in one extra case this month? Mother has been evicted. She doesn’t want to see her child and is too anxious to talk to her lawyers. Could I fit the capacity assessment in this week? I get an email to my personal account. My builder’s sister’s son is feeling suicidal. I reply with the phone numbers for the Samaritans and the local crisis service. I watch the news story about the children in the refugee camp and am horrified to find I feel nothing. I have reached compassion fatigue. I turn off my phone and computer and go back to bed.

I am empty. My emotional resources have run out. Is this constant aching tiredness what they call burnout? I run on clockwork. I am a robot Mum and a robot wife. I fall asleep on the sofa. I am exhausted. At night when I finally fall to sleep I dream about children with their eyes sewn shut. I can’t save them all. When I wake I go to work and do it all over again. I’m good at this. It is important. It is needed. It is never ending.

Then I pause and take a few weeks off for a family holiday. Soon after we arrive the bubble of numbness bursts. I cry watching a video on Youtube. It segues into crying for all the children I’ve met, and all the children someone like me never met or didn’t reach in time, including the parents I speak to so often. I cry with frustration at my own limited reach. I cry for the selfishness of politicians, the broken systems and missing safety nets. I despair at how you increasingly need money to buy justice, and how hopeless and disengaged wide tranches of society are becoming. I click to sign petitions. I donate to campaigns. I counsel compassion in online debates. But I am tired. Achingly tired. Tired in my bones and my guts and my heart. I know how much this needs to be done. And I don’t know what else I can do. But I can’t do this any more.