#94 Child Maltreatment: Healing and Breaking the Cycle

Aditi Desai [0:00] Before we begin, we should note that this episode contains themes that may be upsetting to some listeners with references to sexual and emotional abuse, self harm, violence and substance abuse. Listener discretion is advised.

Zeynep Kahramanoglu [0:17] We would also like to acknowledge that here in Toronto, we are on the traditional territory of many Indigenous nations, including the Mississaugas of the Credit River, the Anishnabeg, the Chippewa, the Haudenosaunee, and here on the Wendat. This meeting place is still home to many First Nations, Inuit, and Metis peoples, and we are grateful for the opportunity to live and work on this land. As we explore the topic of child maltreatment, we would like to take a moment to recognize the history of the residential school system in Canada. This system forcibly removed approximately 30% of all indigenous children in Canada from their families over 100 years. With the stated purpose of erasing Indigenous language and culture through Western assimilation. Many children experience physical and sexual abuse within the schools, and the impacts of this shameful institution continues to affect Indigenous communities today. The last residential school was closed in 1996. With this in mind, we would ask our listeners to learn about and reflect on the complex perceptions of and barriers to health care and research that are still experienced by Indigenous peoples in Canada today.

Aditi Desai [1:23] In this episode, we're discussing a difficult topic: child maltreatment. That is the abuse and neglect that children or youth may experience while in the care of a person they trust or depend on. Child maltreatment impacts both the mental and physical well being of children and their families. It is a global problem that is complex and difficult to study. We're grateful to our guests today for helping us understand and navigate this challenging topic.

Zeynep Kahramanoglu [1:47] I'm Zeynep,

Aditi Desai [1:48] and Aditi.

Zeynep Kahramanoglu [1:49] This is Episode 94 of Raw Talk Podcast.

Dr. Tracie Afifi [2:27] So, when we look at child maltreatment, there can be physical abuse, there can be sexual abuse, there can be emotional maltreatment or psychological abuse, there can also be neglect. So, neglect is included under maltreatment, so you can have physical neglect, you can also have emotional neglect. And then, the fifth type of child maltreatment is exposure to intimate partner violence. So, seeing parents or adults in the home being violent towards each other is also another type of child maltreatment.

Zeynep Kahramanoglu [2:57] What would you say is the size or scope of child maltreatment in Canada?

Dr. Tracie Afifi [3:03] So, in 2014, my group published the first nationally representative study on on child abuse in Canada. The study only had three types of abuse that we were able to include in it. So, that included physical abuse, sexual abuse, and exposure to violence in the home. So, it only had three of the five types of maltreatment that we normally include. With that study, we asked adults, it was a Statistics Canada database, and so, Statistics Canada asked adults to retrospectively report on those experiences: physical abuse, sexual abuse, and exposure to violence in the home. 32% of adults in Canada said that when they were kids, they experienced those types of adversity. So, about one in three Canadians is a conservative estimate that is experienced child abuse. And if we think about it, if we included neglect and emotional maltreatment in that group, we know that that number would go up. So, 32% is probably a conservative estimate of the size and scope of maltreatment in Canada.

Zeynep Kahramanoglu [4:05] How would you say these numbers have changed during the pandemic?

Dr. Tracie Afifi [4:09] So that's a really good question. We don't really have good data on that, because in order to know that, we would have to have either longitudinal data over time, so collecting data on the same people over time to see how these experiences change, or we would need to have really good cross-sectional data, so snapshots in time to see and to try to compare those numbers. So, we don't really know in terms of that. But, we can kind of piece things together from some of the data sources that we do have. There's been lots of surveys in Canada over the last year from many different groups, from universities, from Statistics Canada, that are trying to understand how the pandemic has impacted people. There have been researchers who have looked at reports and injuries for children. So there are different datasets where we can kind of piece this together, and the concern is that the pandemic is is only going to make adversity within the home worse; we expect that this problem will be growing over the last year, and probably we'll see the effects of this for a long time after.

Zeynep Kahramanoglu [5:11] Yeah, unfortunately. So how do we identify child maltreatment? How do we make a child feel safe again?

Dr. Tracie Afifi [5:18] That can be a challenge, and the pandemic is making this even more challenging, because for a child to be identified as experiencing child maltreatment, someone needs to sort of raise their hand and say, "I think something bad is happening to this child, and we need to help." That might be a teacher, that might be a doctor or a healthcare professional, it might be a neighbor, it might be a family member, it could be many different people that can put their hands up. But, those people who are identifying and noticing that abuses are occurring have to be able to see it. So, when when we're in this pandemic, and lots of kids are not going to school, or we're in these lockdown phases, and you pair that with parents who are experiencing more stress themselves, and maybe more substance use, all of this is a perfect storm for for more violence against children. So, identifying it is a challenge in of itself. When a child is reported for experiencing these types of maltreatment, we need to make sure we're responding appropriately. So, that the child welfare system has to have the resources in place to be able to respond to all the calls of individuals. So, we need to make sure that we're really investing in our child welfare system and supporting the whole system, because that's a really important thing. Then, the next thing is we need to make sure the child is safe. So, we need to support the child and the family so that the abuse doesn't keep reoccurring. And so, that's really important. So, we need to support the family. It's best to keep families intact whenever possible and not separate families; that should always be thought of as a last resort. But, the reality is, we need to then keep the child safe. And so, if we can do all those things, if we can identify when abuse is happening, we can respond to it. And then, we can keep that child safe from experiencing again. That's when the child can start the road to recovery. You know, depending on what specifically that child has experienced would determine what kind of interventions would be the best for that child. But, there's lots of ways that people can heal from child maltreatment. And, there's lots of good evidence-based interventions, lots of ways we can support these kids. So, the sooner we can do it, the better. So, early intervention for almost anything is always the best, so, the sooner we can intervene and help these kids. And, we need to be investing in this not only in research but also in treatment, you know, at a at a national level and also internationally, so that we can have resources to help these kids and help these families.

Zeynep Kahramanoglu [7:54] What are some of the risk factors associated with child maltreatment?

Dr. Tracie Afifi [7:58] There's a lot of stressors that can lead to it; it could be financial stress, it can be poor relationships, so having poor intimate partner relationships can lead to child maltreatment, substance abuse is associated with increased likelihood of child maltreatment. So, there's lots of risk factors, you know, but, like I said, there's not one path that just leads to child maltreatment. Our work now is really trying to look at protective factors: So, protective factors at two levels. One level is how can we prevent the child maltreatment from happening in the first place? That's the ideal. We don't want children and families to experience this. So that's, that would be the ideal if we could just prevent the child maltreatment from happening in the first place. And, we actually did research several years ago using data from the United States that showed that if, in theory, we could eliminate child maltreatment within families, we might be able to reduce mental health problems in individuals by anywhere from 20 to 30%. So, it does contribute to a lot of mental health problems. So, we've sort of established, you know, the size and scope and why it's important to prevent child maltreatment in our earlier work. And, as I mentioned, now, we're trying to do two things. We're trying to prevent child abuse from occurring. I tried to understand what are the protective factors and how can we support families. And then, we're also realizing that, even though maltreatment is an awful experience, the response to trauma is not the same for individuals. So, some people will have many, many poor outcomes related to it in many parts of their lives, and that will be throughout their lifespan even into old age, and some people don't have as severe of reaction to maltreatment or that they are able to cope, and they don't have as many poor outcomes related to it. So, we're really interested as to why some people might see more resilient following child maltreatment and why some people won't. So, that's what our research is really focusing on right now: understanding in what is related to better outcomes or resilience following child maltreatment. And so, some of the things we're looking at are things at the individual level, so things such as do the individuals feel excited and hopeful for their future? What are their own personal coping skills? Do they have positive coping skills instead of negative coping skills? We're also looking at relationship and family level variables, so, do they have a supportive relationship within their family? How connected are they to their family? Do they have someone that they can talk to? Also, looking at school level factors, so in terms of education, grades, and attendance, do they feel safe at school? Do they have a teacher that they have connection with? Do they do activities at school, whether it's sports or non sports? And, also community level factors as well, so looking at things like volunteering in the community and and being involved in your community. So we're looking across all parts of their life to see what is related to better resilience following maltreatment and how can we foster that in individuals.

Zeynep Kahramanoglu [11:07] You just mentioned resilience. What does it mean in this context?

Dr. Tracie Afifi [11:12] Resilience can be defined in different ways. That's the thing with resilience is that we don't really have one definition of what resilience is. And, in research, we have to measure things in order to determine whether or not things are related. So, how we define something conceptually and then how we measure it in research can be a challenge. So, we've looked at resilience in different ways. In some of our work, we've defined resilience as people who do not have a mental disorder, who have not thought about suicide, suicidal ideation, but also have really good psychological well being, because there's a difference between psychological well being and mental disorders. And so we've tried to look at a broad definition of what resilience might be. And so, that's one example of how we looked at it in some of our studies.

Zeynep Kahramanoglu [12:00] As Dr. Afifi explains, child maltreatment can involve both acute consequences and long term challenges. Reactions and coping mechanisms can also differ from one individual to the next; not all respond in the same way.

Aditi Desai [12:14] To learn more about the impacts of child maltreatment on the individual level, we spoke with Dr. Robert T. Muller. Dr. Muller is a professor of Psychology at York University and a practicing psychotherapist. He has authored two books, Trauma and the Struggle to Open Up: from Avoidance to Recovery and Growth, as well as Trauma and the Avoidant Client: Attachment-based Strategies for Healing. Dr. Muller told us about how emotional bonds formed between children and their primary caregiver early in life can actually shape how individuals experience and approach relationships later in life, a concept known as attachment theory.

Dr. Robert Muller [12:49] Attachment theory. There's a lot of evidence for it. And, it was the theory developed in the mid 1960s, really by John Bowlby, a British psychiatrist and psychoanalyst who was very interested in the question of why do children who are left for periods of time display these odd symptoms. Children, first of all, who are in abandoned because of being placed in orphanages, but then also children, when their mother goes to the hospital for a week and a half to have a child, these children would be, let's say, left in the care of somebody else, why would they go through these periods of behaving as they do? What accounts for childhood behavior when abandoned, what accounts for childhood behavior when children are in emotional distress. And so, what he argued was that ultimately, the best odds for survival for children are found when children protect their relationship with their parents. Children will do what is necessary, in other words, to protect the relationship with the parents, because it represents their best odds for survival, and children will therefore do whatever they need to do in order to protect that relationship even when the relationship is not a good one. So, when the relationship is a good one, things go okay; there's parental attunement to the child, and there's no problem. But if if children are securely attached, when the relationship is okay, then it's fine, but when you have situations of trauma where the parent shows either physical, emotional, or sexual abuse toward the child, kids will, at those times, even then they will protect the relationship with the parents because the relationship is so important, and that will affect them. They will learn to, rather than blame the parent, they will blame themselves if things happen. You see children who will recant disclosures of sexual abuse because they want to protect the relationship. So, the relationship is extremely important. Children will also develop defensive strategies in order to cope. And so, let's say, you have a parent who is dismissive of the child emotional needs. The child will learn to suppress their emotional needs in order to protect that relationship. And so, what you have is that the child may grow up learning that vulnerability is unacceptable, learning that expressing sadness, expressing anger, expressing emotions is unacceptable, and they will cut off their own emotional needs in order to accommodate to the needs of the parent-child relationship. And, this affects you later in life, you know. You learn to deal with feelings in a way that is potentially really problematic. And so, attachment theory can help explain why certain people, as they grow up, learn a model of relationships, what's called the working model of relationships, that can be really problematic later in life. So, someone who learns to cut off feelings may also need to do something with those feelings. So, they may engage in substance abuse, they may engage in risky behavior, they may engage in all kinds of coping strategies, because they don't know how to talk about their feelings because feelings were never acceptable in their family. It helps explain some of these strange things we see in terms of relationships and adults that have their origins in childhood.

Aditi Desai [16:13] So it sounds like childhood trauma can really have a different impact on people than say, trauma later in life as an adult.

Dr. Robert Muller [16:20] Absolutely. Childhood trauma has a really significant impact on people. The earlier the trauma happened, the more consistent; so if you have repeated emotional abuse, repeated physical or sexual abuse, repeated abandonment, repeated witnessing of community violence, that has a strong impact. What we know from research, something called the adverse childhood experiences studies, show that this has a cumulative effect on people; the more abuse and the more consistent it is and the earlier it was, the more profound the effects later on in life. This has a really big impact on functioning in terms of relationships, it has a big impact on emotional functioning, it has a big impact on how people relate to their own bodies. And so, for example, the ability to self-regulate emotionally and the ability to engage sexually, those are all affected by early trauma.

Aditi Desai [17:26] Thinking about therapy, is a possible to overcome these challenges?

Dr. Robert Muller [17:30] There are a couple ways of thinking about psychotherapy for trauma. One thing is to think about it as we want people to be able to function. And, very often, when individuals have a trauma history, it really impacts their ability to manage in their everyday life. It impacts relationships, that impacts work, it impacts school. And so, people are very often what's referred to as triggered. I mean, we've heard this in the news "trigger warnings" and that sort of thing. What triggered means is that the individual is in their everyday life in the here and now. Something happens, and they have a memory or a flashback that takes them back to the there and then in their past. And when that happens, it makes it very difficult for them to be able to function. And so, if you're at work, and your boss gets mad at you and says something that they're irritated by, and even if it's fairly reasonable that your boss would say that, there may be a sensitivity on the part of the individual who has a history of trauma, maybe physical abuse or whatnot. And, if you get flashbacks or memory intrusions or nightmares as a result of this, it will really impact your everyday work experience and may make it more difficult to be assertive. People like that often have low self-esteem and may make it difficult to be able to explain yourself when asked something point blank, because you get overwhelmed and triggered. And so, you're shut down and you become very quiet. And, that has a huge impact on people. And so, we want to help people manage their triggers, and that's a very important piece of trauma work, and coping in their everyday life is managing those triggers. Very early on in the work, it's also really important to help them with something called psychoeducation, teaching people about what trauma is that they're not just acting ridiculous, they're not just being overly sensitive, but that they're actually being triggered by something and this has an impact on them. And so a little bit of psycho education is important. Working with triggers, emotion regulation skills are really important, and that's what we do in therapy early on. When people have a trauma history, something called grounding strategies where people feel when they're having a nightmare or a flashback or something like that, they're taken back to the past, they may need some help with being able to be grounded in the present. So obviously, if it's a nightmare you, when they wake up, they may be kind of really struggling, and they may need to do some grounding strategies, deep breathing skills, mindfulness strategies where they're very much focusing on the present, because it helps kind of keep them connected to what's going on right now in the here and now. Those are all coping strategies that we try to do early on in work. The idea is helping people be able to cope in their everyday life. Beyond that, trauma therapy can be helpful with assisting the individual to make sense of their experience in the past. And so, that would be sort of the next stage of trauma therapy, and the first stage, we really deal with the here and now, coping with everyday life stuff. In the second stage of trauma work, that's when we start to help the person explore their story, explore their past, and that can be very helpful for people because they often have questions about what happened to them. They may have questions about life, you know, things like, why me? Why did this happen to me? Or they may ask themselves, why not me? Why did this happen to my sister when she was younger, and it didn't happen to me? and that sort of thing. When we do work with children, trauma therapy with children, they may have similar questions. They may not frame it in the same way, but they may feel like they were bad kids, and that's why this happened to them or something like that. Children who, who grew up in homes where there's alcohol abuse, very often feel that they need to take control and become what's called parentafied children, the children who manage and take care of mom and dad, because mom and dad can't manage, let's say, and so they learn to kind of grow up too quickly, and that's a huge problem. So, we need to help those children make sense of what's happening in their lives, and that's where we do a little more exploratory work. That's called stage two of trauma work. There's a stage three as well. But, I mean, trauma work works in these sort of stages. First, where we really help the person cope with their everyday experience. And then only after when they feel a little bit more safe in their everyday life, then we help them be able to explore their questions about kind of what happened and why it happened. And then, we help them sort of tell the story in in a little bit more detail.

Aditi Desai [22:27] What does that look like to help patients tell their story?

Dr. Robert Muller [22:30] Very often, when trauma stories are revealed at first at counseling, patients don't come in saying, "hey, I have this trauma story. I want to have help figuring it out." Instead, they come in with disguised symptoms, so depression, anxiety, eating disorders, headaches, substance abuse, sexual addictions, etc, etc. So, they often come in like that. The trick is not to make assumptions. There are lots of people who have depression who have not had a trauma history at all. So, you don't want to make an assumption, "oh, there's a trauma story underlying this depression." I don't know if there is or there isn't. I'm listening to my client, and I'm not making assumptions. On the other hand, if the person says something, "by the way," sort of as a as a kind of they drop it along the path to talking about something else, that's often called a trauma fragment. So, I have an example in the book of a client who I asked him about his childhood history of, you know, about his relationship with his mother, and he told me it was a good relationship. And I said, "okay, so tell me about the good relationship." And he said, "well, my mother tried to abort me." And then, he told this funny story about how his mother used to jump up and down trying, trying to get rid of him when he was a fetus. As a therapist, you want to start by just noticing that. That is what I would call a trauma fragment. It's a story that makes you sort of raise your eyebrows and go, "huh." He said his relationship with his mother was good, but he tells the story about how his mother tried to abort him two seconds later. Something doesn't add up. And, that's all you start with: a "hmm". You don't then jump in there and say to the person, "now, I think you've a trauma, trauma history and blah, blah." You know, no, you don't want to make suggestions. All you start with as a therapist is that "hmm, my eyebrow is raised. I'm wondering what's going on. I'm not sure what to make of this. This is curious. I'm skeptical that everything was so rosy at home. On the other hand, I'm not sure how... was it? I mean, I really don't know yet." And so, that's where you really want to start with, and let the client take the lead. So, you, but you, that's the piece that you want to just notice, but I would call that a trauma fragment, so a story that seems like it might have, there might be a backstory there. I'm wondering, "is there a backstory? I mean, I'm curious about this", and I I would listen carefully, and I would listen for the next few weeks to what what does he have to say, and what was his childhood like, and what else happened. And so, you never want to jump to conclusions based on one piece of data, but then you start to listen for themes; you start to listen for patterns. And with this particular client in my book, I talked about how, you know, it turned out that there were many themes. In fact, he was quite badly physically abused by his father. I asked him in a later session about, about his relationship with his father, about, you know, how did his father teach him the difference between right and wrong. And, he would talk about how his dad used to beat the crap out of him, I mean, like, really, to the point of times he had to go to the hospital; it was so terrible. So, it was quite clear that there was a trauma history. And when, when you have that happening in a home, then you, you know, then you've, you can clearly see these, these patterns. And it was quite, it was quite obvious not that long afterwards. But, that's called a trauma fragment, and that's, the important piece as a therapist is to notice trauma fragments, because clients will very often try to cover them up. Like I'm, like you mentioned, using humor, for example. And, this particular client, in fact, did use humor. He was a very, he was actually a very funny guy who would get people laughing all the time, and that's a very good coping strategy; to use humor is nothing wrong with that. But, when he would use humor, it would be as a way of suppressing sad stories. And so, I would notice this. I would notice that he would tell something that sort of sounded bittersweet, and there was something underneath it, and then he would very quickly make a joke out of it. And so, I would ask a little further. And I would say, "tell me more about that", and "what would happen there?" And, it was very clear that there was, there was a real sadness underlying the jokey facade. And, it didn't actually take that long with this particular guy to get there, in fact. But I think that's the piece; you're walking a fine line as a therapist. And that's, it's very important both not to make suggestions to people, to make assumptions of trauma happen but, on the other hand, to listen for what's there in the material. And, if there is a sadness underlying the facade, to notice that, to be curious about that, and then to ask the person to expand on it, that's called the art of the therapy. And, that's the subtlety that you want to, that you want to find. And, it takes training to be a good therapist and to know how to do that.

Aditi Desai [27:33] Yeah, that sounds very challenging. In your book, I remember you also warning about the dangers of rushing in as a therapist. Can you talk a little bit about that?

Dr. Robert Muller [27:43] One of the things about trauma stories, this is whether you're working with children or adults, is that very often, you know, if you're doing psychotherapy with children who have trauma histories, these kids are suffering. Something's happened to them. They don't understand it. If they were sexually abused, let's say, by a trusted member of, you know, friend of the families or a coach or a, an uncle or whatever, it's very confusing, and they very often children will very often blame themselves and think that they're bad and stupid, and, you know, and that sort of thing. So, they're really suffering. And so, there's a tendency among therapists to want to fix things quickly. There's a tendency, therefore, to want to rush in. If children are start talking about something that's personal, then to start you have, in your head, "oh, okay, now, we're getting to the important stuff" the therapist might say to themselves. And, the problem with rushing in when the client is suffering is that the client themselves, in part, may want to tell their story, because they want to unload it because it's a burden. On the other hand, they may really feel stupid and humiliated afterward. And so, they may really suffer after they tell their story because they may think, "Oh, my God, I spilled the beans. I told this thing. And now they'll feel like I was disloyal to my parent or to my uncle or to my coach, or whatever it was", and they feel stupid, and they feel like they've misbehaved. And, they really suffer and they may drop out of psychotherapy. If it's a teenager, let's say during therapy, they may tell their mom, "you know what, I don't want to go back", and then they don't. And so, that's the problem with rushing in is that very quickly, you get people who then want to drop out. Part of good psychotherapy for trauma is really taking a measured, paced approach, slowing everything down, helping the person by by exploring very, very gradually. The disadvantage of this is that it means that it takes longer, and trauma therapy does take longer. It's not like a, you know, I don't know, a fear of flying, or a spider phobia, or something that can, that can be done pretty quickly or something like that. It's a process that takes time. And so, you need to give yourself permission of the therapist and give the client the expectation that this isn't going to happen very quickly. This is going to take some time; it's going to take at least a few months, if not, very often in trauma work, it can even be a year or two or sometimes longer of therapy. It can take, it can take some time. It's not, a it's not a quick fix. And, why is that? Because trauma affects so many aspects of the person: emotional, physical, even I might say in spiritual. Like, there's so many ways in which it has an impact, that it just takes time to explore things and help people work it through.

Aditi Desai [30:47] Yeah. In your book, you also described how one of the important parts of telling your story is taking the time to actually process and try to understand what's happened and mourn what you might have lost.

Dr. Robert Muller [30:58] Trauma comes with many losses. Individuals experience loss of illusions about the world. You know, the idea that the world is a safe place is an illusion that we live with. And, there is a certain amount of safety we can expect. But sometimes, things happen out of the blue, and who could ever have predicted that we would have lived through a global pandemic, you know, two years ago now; things that are unpredictable just happen in life. So, there are all kinds of losses we have to deal with. So the loss that the world is a predictable place, the loss of the idea that childhood is always safe and happy. This is something we have an image of "Oh, children are happy, they play in playgrounds, they don't have a lot of worries," etc, etc. But, that's not always true, and when you've been through abuses as a kid, then you know better than anybody that childhood can be, in fact, a very scary time; it can be a time where you feel afraid, time where you feel unsafe in your own home, a time where you feel like you have no voice. All of that. And, it can be a really terrible time for for many people. Part of trauma work, part of trauma therapy is helping people to think about the losses that they've experienced in relation to traumatic events, and loss of childhood is a very important piece. I had a client who I worked with who was 16 years old, who had been raped, and she said it was a date rape situation, let's say. And, I remember we worked together for about six months. She did really good work, making sense of, you know, first first learning coping strategies to be able to manage in our everyday environment, then talking about the the rape in some detail so that we could actually work through her emotional experience of what happened and the question she had. And then, about nine or so months into the work, she was 17 at the time, she said, "you know, I don't know. Have I become smarter, or have I just become cynical?" and it was really kind of sad to hear a 17 year-old say that. But, she was a little bit cynical; she sounded like a 17 year old, who was kind of like a 30 year-old or something. Like, she could be a little jaded, a little bit like sad about about things. I worked with her for another year. And in fact, she improved even from there and did go on to have some very good relationships actually; a boyfriend really cared about her, and very positive experiences with friendships, and then continued in school. There's a certain amount of sadness that comes with exploring loss of childhood; the idea that, you know, I really lost something that I'm never going to get back, and that sadness also represents a little bit of wisdom. And, that's a hard thing to hear a kid say, but it is important because it also arms them with the idea that, you know, she, for example, learnt not to be so naive, which was a sad experience for her. At the same time, she was also kind of blaming herself, and I had to really work with her around around the self-blame that, as a 16 year-old, there was nothing she could have done different than what she did. I mean, you know, and so she would blame herself a lot. So, that took a lot of work. But yeah, I mean she really wrestled with this idea of losing your childhood. It can be a sad thing, but it can be a growthful thing as well at the same time.

Zeynep Kahramanoglu [34:40] Childhood trauma can have many long term consequences, such as feelings of having lost part of your childhood and difficulty navigating relationships later in life. As Dr. Muller described, psychotherapy can play an important role in helping individuals make sense of their trauma and facilitate healing and possibly even growth. Knowing all the impacts childhood trauma can have, how do we prevent child maltreatment in the first place? Dr. Afifi explains what makes addressing this issue so complex.

Dr. Tracie Afifi [35:12] Yeah, so preventing child maltreatment is not an easy task and for lots of reasons. Part of the reasons are that sometimes, we don't know why it occurs. And, sometimes, we do know why it occurs, but it might be really big issues. It might, for example, poverty might be related to child maltreatment. And, solving poverty might reduce those children who get abused, but, you know, solving poverty is not an easy task. So, they're all big concepts related to what can we do to reduce violence against children, but there's a lot of evidence and data out there, we can do it, it's just not an easy task. And, I think, in order to prevent violence against children, it's not just one thing that we need to do. It's lots of things that we need to do. And so, some of those examples are, we need to, you know, if we think of it at the higher level, starting at the highest level, sort of social norms, and and how we think of violence against children at the societal level. And in many societies, including in Canada, we have this tolerance for violence against children that it's almost like it's it's okay that children can experience violence. And, that's written into the Criminal Code of Canada, where we are still allowed to hit children as a means of discipline in Canada, and 61 countries worldwide have bans, legal bans on physical punishment of children. So, we're really far behind other countries that; Canada should be leading the way in protecting children and children's rights. But in fact, we're not. We're really far behind; 61 other countries have changed their laws to protect children, and we haven't. So changing laws is one thing to do, because it helps to shift how we think about violence against children. We're not allowed to hit adults. So, we shouldn't be allowed to hit children. Children should have the same rights as adults. That alone would make a difference. And, it would help, but it wouldn't solve all of our problems. So, that along with educating parents on a non-physical discipline for children, so how can we discipline children without using any physical force or violence, because once we start using physical discipline, that often can escalate into more severe acts of physical discipline, because you might spank a child because they're misbehaving or or doing something that you can perceive as a misbehavior. And so, the child might be spanked, and then they might stop in the moment and then later do it again, that discipline, next time, might have to be more severe. And so, if we keep escalating that, it becomes, it can become very violent for that child. We have to provide parents with the knowledge and understanding that using physical discipline does have potentially have risks for children. So, for some kids who experience spanking, that is related to poor outcomes for some children. So, we're increasing the likelihood of things like poor relationships, increased behavioral problems, mental health problems, substance use later in life; these are all related to spanking. And, it's also related to physical abuse. So, understanding that, that these behaviors do have risks, and we could also replace those with non-physical discipline. And so, we need to help parents learn that and then also give them the tools to replace the physical discipline with non-physical discipline. And so, we need to be supporting parents in learning how to use discipline that doesn't include any physical force. So, those are two big things I think that would would be quite helpful. And, we need to think about gender-based violence. We need to think about how how different genders experience violence and how that is perceived and how that is a reality for people in Canada and worldwide. So, that's an important concept. These are big, big areas to tackle. So, it's not an easy thing to prevent, but it's definitely something we can prevent if we sort of bring all these things together.

Aditi Desai [39:28] A global leader in child abuse prevention strategies is Dr. Katreena Scott, a professor and clinical psychologist whose research focuses on ending violence and families. She's completed a number of studies on the impact of violence and abuse in families and on innovative interventions. In particular, she specializes in how we can work with men and fathers who have caused harm in their families and help them have safer, healthier relationships with their loved ones. We asked Dr. Scott about effective interventions to prevent child maltreatment.

Dr. Katreena Scott [40:00] What people's first instinct is, is always "okay, let's just make sure that this guy is out of these people's lives," right? That's kind of the first thing that we always think about. I think that when we start to think about that, though, and and wonder whether or not does that actually work, we have to kind of think about some of the disadvantages. So one thing is that, let's say we are successful, and we get men out of the family. And now, there's a separation. Well, one of the things that we often think is, well, once the separation happens, that the risks to kids, the risk to moms, the risk of violence goes down. In fact, the opposite happens. The risk goes up; separation is a time of increased risk, not a time of decreased risk. And, we know that there are most often fathers have contact and ongoing contact with their kids, often family court orders require that, and it's often the case, in fact, that fathers may have more unsupervised contact with their kids than they did before. So, in one sense, we're not actually decreasing risk through separation; we may actually be increasing risk. The other thing is that fathers go on to other families. So, just because you successfully end contact with one set of kids, the chance that that dad won't go on and have a relationship with another woman who has kids herself. And now, they're step kids, and step kids, we know, are at greater risk period from step parents than they are from biological parents. So, fathers are having other kids with other people and becoming step parents. We also know that when we managed to kind of make sure that you're separated from the family, nobody's talking to him, what we're also doing is isolating him. And, we know that men's depression, and suicidality, and desperation, all of those actually increased risk of his perpetrating violence against others. And then, finally, it gets us into a really weird situation. And, we see this playing out in child protection. We can see it playing out also in a sort of child mental health or even in health interventions, where we get into this situation where we're monitoring moms, and we're kind of telling her and making sure that she understands that kids' exposure to domestic violence, for example, or kids' experience of their dads and exposure to his abuse, that that's harmful for kids. And she needs to then take actions to protect those kids. And then, we monitor whether or not she does that, and we we even sometimes punish her or threaten her if she isn't able to protect the kids from dad. But, if you think about it, what we're actually doing is asking mom to protect your kids from somebody that she's not able to protect herself from. And again, we're not having the conversations with the person who we need to talk to, which is him, and say, you know, "you need to be safe around your kids. You need to be safe in your families. You need to be the kind of dad that you want to be. So, how are you going to get there?" So really, I think that it makes sense that our first thought is "okay, let's just get this guy out of here." But, if you think about it a little bit more closely, you realize that the thought actually is probably not going to be a solution, at least not for a majority of cases. You know, one of the things that I also learned when I started to do work with with dads is that often, despite the fact that the dads that I have worked with have often caused quite a bit of harm and trauma in their families, that's not what they're, they're aiming for. That's not the dad they wanted to be. It's not the relationship they want to have. It's not who they want their kids to see them as. And, sometimes just being a dad is something that they're most proud of in their life espite all of this. Their, the motivation to do better is strong. And so, the other thing is that when we don't actually even offer those kinds of intervention opportunities, we don't actually even give people a chance to try to do a better job.

Aditi Desai [43:58] What can cause violence within families in the first place?

Dr. Katreena Scott [44:02] There's a lot of complex reasons that violence happens in families. And, the most recent data from Statistics Canada shows that, for the third year in a row now, violence, at least police-reported violence against women in or police-reported intimate partner violence and police-reported violence against kids and adolescence, is on the increase. And, that's after many years of decrease. And so, we really need to think about sort of broadly in our society what's going wrong that violence in families and families are becoming less safe rather than more safe. But, I think we can think about some of the factors that function at the social level. We think about the kinds of stresses that are on families. We think about the kinds of expectations that we have of men as fathers, and quite frankly, we don't expect as much of men as fathers as we do of women as moms. So, we might want to raise some of the expectations from men. We can think about the fact that parenting is hard, right? Parenting is not an easy job. And, when you have a combination of kind of lower expectations or a higher level of entitlement that kids should kind of do what I want or, you know, to be a good dad, I have to be really controlling, or my kids have to behave in a certain way. When you add that to some more emotional regulation, when you add that to a level of stress, when you add that to a level of entitlement you have, and maybe add that to a family situation, which is complicated, you have a situation where, without sort of intervention, without some supports, without some people saying,"no, no. That's, you can't do it that way. We have to find another way to do this. We have to find a way through this," you have a situation where patterns of abuse can and do develop.

Aditi Desai [45:51] During her grad school journey, Dr. Scott realized that there were major gaps in the health care and welfare system for supporting and intervening with fathers who were perpetrating harm. So, Dr. Scott, with the help of some of her other colleagues, created a program to help men who had perpetrated violence understand the consequences of their actions and develop strategies to avoid it in the future. We asked Dr. Scott to describe the program called Caring Dads.

Dr. Katreena Scott [46:16] We realized that there was this big gap in services. To that, I started to have conversations with people. One of the people I had conversations with was Tim Kelly, and Tim Kelly is, now he wasn't there, but he's now the Executive Director of program called Changing Ways in London, which works with men who have perpetrated violence within their families, within their intimate partner relationships. And, he also told stories, he told stories about working in the field for a long time and seeing the sons of men that he had treated for intimate partner violence before. So, two generations of father first, and then, you know, 15 years later, a son has been arrested for perpetrating violence against his partner. And, his thought as well was, you know, we have to break this cycle; there has to be something that we can do. So, that, this doesn't happen over and over again. It was in fact, during at that early point that I started to have conversations. And then, when I graduated, we brought together a committee that included people who work with men, and who worked with kids, and who worked as women's advocates and worked with women who had been abused. We started to put together a program to talk to dads to think about dads who were at high risk of being abusive in their families, who or who had already caused harm in their families. And, we started to bring them together and say, "okay, how are we going to fix this? What do we need to do?" And, we went through multiple iterations, and we tried different things out, and we worked with men themselves, and we talked to their partners, and we talked to their kids, and we talked to the professionals. And eventually, we created a program called Caring Dads helping fathers value their kids. We started to offer this program, and then, we started to write a bit about it and say, "look at here. This is what was happening in Ontario. We just didn't have anything. And so, we looked around, we couldn't find anything. But then, we created this program. And and, this is what's happening, and here's what dads are learning, here's what they're saying, and here's what partners are saying, and here's what kids are saying." It turns out that this gap wasn't a Canadian gap. It wasn't Ontario gap. It was a global gap. And so then, people in England called and said, "well, wait a second. We have this same gap in our services." And so, we started to offer Caring Dads in England. And then, there were a number of other European countries that came on board as well, and said, "well, wait a second. We're not having these conversations, either." And then, Australia came on board. So Caring Dads, which was originally designed to fill a need in a community where we didn't have a service, just grew and grew and grew. And now, there is a network of Caring Dads program providers across the world in multiple different countries who come together regularly and talk about, you know, what are we doing? And how do we improve the program? And what is its efficacy? What Caring Dads does, it's got kind of four major parts of it. We work with men in a group, and we have some individual sessions as well. We do outreach to kids' moms to talk to them. The first part of the program is just working with men around engagement, and having conversations, and connecting with them around what's going on for them and who do they want to be. We then talk a lot about what would it mean to be child-centered as a father? How could you make your kids' needs like, what is it that you need to do? What would be safe and healthy in your relationship with your kids recognizing that kids are only safe when they're also not worried about their other caregivers. Then, we work with dads around change, you know what's going to make your kids safer, and we work with them in with an individually decided goal about change. And then, we talk about what's it gonna take for everybody to trust things again, how are you going to make sure that you are able to continue to build this relationship? That's kind of the program in a nutshell that we use kind of a range of two different strategies therapeutically. We use motivational interviewing. We use cognitive behavioral work. We use some psycho-education and some modeling. It's a trauma- and violence-informed program. So, we understand that fathers are coming from a range of different places. We need to engage with them in a way that's safe and healthy for them and have really clear conversations with them about being safe and healthy with the people that they have in their lives.

Aditi Desai [50:22] We imagine that to engage in this program, men have to be quite vulnerable and introspective, reflecting on their behavior. Do you find that dads are receptive to starting this kind of program and wanting to implement some of the strategies that they're taught?

Dr. Katreena Scott [50:37] One of the things we learned really early on is that that's the first go off, right, to try to create an environment and trying to draw out and draw through that being receptive to open to trusting to the possibility of change, because I think, for any person, to start to talk about the ways that you're ashamed of your own behavior, to talk about things that you wish you'd never done, to talk about ways that you've hurt other people that you love. Those are vulnerable conversations. So, our first aim, our first goal, the first work we have to do with dads is really to create that space and create that openness. And lots of times, you know, men come into the room with in different ways. Some men come into the room understanding that "I am looking like my dad. I vowed I would never be the kind of dad that I had. And, I think I'm doing the same thing." Other men come into the room with the idea, really, you know, "my kid is out to get me, and I, my kid is trying to like, game the system against me." And, you know, it's really all about that. And, other men come in with the idea that their partner is out to get them and she's making them out to be somebody that he's not. So, at the beginning, there's a lot of kind of joining with women that are add and bringing them together on what is shared aim, as I said, for most men, which is to be a better father to their child. There's a lot of power in being able to talk in a group of men with men about their experiences that, and so, men in general talk about the value of having, although it is anxiety provoking at the beginning, the value of being able to hear other people's stories, share their stories, have these conversations is something that is important. And, it's also important in thinking about accountability. So, you know, sometimes it's easier to see the harm being caused in somebody else that it isn't yourself. So, it's sometimes easier for the men to see the patterns of harm in person sitting beside them. And then slowly, they can see as the person beside them sees the patterns of harm that they're causing and that they can kind of hear that, but it's also useful to have some individual sessions to be really clear on the kind of change goals that men are working towards. So, there's a bit of both. The program is 17 weeks. So, that's kind of medium term, I would say. It's kind of the shortest possible time to work with abusive behavior in a group of people where they're not necessarily starting totally voluntarily, right; they're not necessarily coming into the room with the idea that I have something to change. As I said, some of them are coming into the room and thinking it's really about somebody else. Some men come voluntarily in the sense that they've seen that. Some of them come voluntarily in that they aren't ordered by anybody except that it might be that their partner left a note on the table that said, "you go to Caring Dads and then we'll talk." So, that's kind of voluntary. Or, they may have been suggested by their child protection worker maybe you should do this, or maybe their pastor or somebody else in their life is saying said, you know, this is really not okay. So, there's a range of people, as I said, that come into the room in a range of ways not only personally but in terms of the situations that brought them there. When you you're starting from that point, you really do need some time to do the work. And in terms of 17 weeks, could it be longer? Absolutely. We need more services. We need, We need a follow-up service. We need a way that men can come together afterwards. Caring Dads is one of really a very few programs that are available in Ontario to talk to men about what it means to be a dad.

Aditi Desai [54:31] Throughout a conversation, you've often use language like men who perpetrate violence as opposed to abusers. Is that intentional?

Dr. Katreena Scott [54:38] Yes, it is. I think, for me, it's part of, part of understanding that the people who have engaged in abuse are brothers. They're our fathers. They're our sons. They're our neighbors. They're our co workers. Gender-based violence is common; gender-based violence happens. That includes intimate partner violence. It includes sexual violence. It includes violence that happens in the family towards kids. These are not uncommon problems. We need to be able to have conversations about them. And, we need to have conversations about the kinds of behaviors and actions that are harmful. And, when we start to cut to have conversations that are about people who need to be out of society, right, the abusers that need to be excluded, we get back into that same problem we were talking about at the beginning. That's not actually a viable way forward; that doesn't reflect the nature, and the severity, and the frequency of the problem. And, it's not going to work as a strategy. We're much better off to have conversations with people about behaviors that are hurtful to others, and that have caused harm to others, and are abusive and are controlling, and are violent. When we start to have those conversations about those behaviors, we can have them, in a way, that doesn't require that we start by kind of labeling oneself as I am an abuser.

Aditi Desai [56:10] Dr. Scott had some final thoughts about what we can do if we're concerned about violence within families.

Dr. Katreena Scott [56:15] I guess the only other thing that I would say is if you see something or hear something that makes you feel uncomfortable, that that you are concerned about something, and maybe it's because you're concerned about how a male friend, or colleague, or a family member, how he's talking about his kids, or how he's talking about his partner or how he's talking about his family, you can say, "here's what I'm hearing, you know. This is what I'm hearing, and I'm wondering if everybody around you is okay. I'm wondering if you need some help." You can have that conversation, of course, with partners and kids as well. Absolutely. But, I think that abuse, all forms of abuse, family violence, thrive in secrecy. The more we can name what we see, the more we can have conversations that say, "well, wait a second. I'm not sure that was an okay thing to do," the more we're going to be able to address this problem.

Zeynep Kahramanoglu [57:16] Prevention and intervention strategies in child maltreatment helps children have better outcomes in their journey through life. Keeping families together and nurturing those good relationships to help children thrive is also important. Everyone's experience is unique and personal. Dr. Afifi says at best.

Dr. Tracie Afifi [57:34] An important message is that it's not about blaming people who have experienced violence or who are perpetrators of violence towards their children or to other people. It's understanding that they probably also were victims of violence themselves for a lot of these individuals. And, we need as a society to support each other and not blame each other and to find solutions for these problems. So, we need to support people, and we need to intervene early. If we can do that, I think we can have better outcomes. We can strengthen families, then when those kids grow up and become parents themselves, they have more resources, and they have more tools in their parenting toolkit to support their own children feel like in the past. And still today, people would be ashamed of their these experiences, and they would want to keep it a secret, and they don't want to talk about it. And, that's fine. You people can can keep that as a personal experience. I think there's utility in knowing that it's not a rare event and it's not your fault if you've experienced these things and that lots of people have adversity in their, in their background. And, I think that is helpful to some people to know that they're not alone. I want people to feel that if they've experienced these problems, that they're not destined to have a lifetime of poor outcomes. But, there is help available, and we need to continue to invest in those treatments and do research so that we can continue to figure out better ways to help people.

Aditi Desai [59:05] I would like to thank our guests today, Dr. Tracy Afifi, Dr. Robert T. Muller, and Dr. Katrena Scott for sharing with us their expertise and compassion for this topic. If you suspect a child may be in need of help or protection, please contact your Local Children's Aid Society. We have provided a link in our show notes to an Ontario directory plus links to other resources and more information about some of the topics addressed today.

Zeynep Kahramanoglu [59:30] This episode was hosted by myself Zeynep Kahramanoglu and Aditi Desai. James Saravanamuttu helped conduct the interviews, and Tsukiko Miyata was our Content Creator. Esther Silk was our Audio Engineer, and Jesse Knight was our Executive Producer. Tune in again in two weeks where we'll explore the topic of medical assistance in dying or MAiD. Raw Talk is a student presentation of the Institute of Medical Science in the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the Faculty of Medicine, or the University. To learn more about the show, visit our website rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook @rawtalkpodcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.