ANNALS OF CLINICAL PSYCHIATRY

ANNALS OF CLINICAL PSYCHIATRY 2014;26(2):97-110 RESEARCH ARTICLE

Empathy and childhood maltreatment:

A mixed-methods investigation

Simon C. Locher, B.SocSci. (Hons) BACKGROUND: Impaired empathy is regarded as a psychological conse-
Lisa Barenblatt, B.SocSci. (Hons)
quence of childhood maltreatment, yet few studies have explored this rela-
Department of Psychology tionship empirically. We investigated whether empathy differed in healthy
University of Cape Town
and maltreated individuals by examining their emotional responses to
Cape Town, South Africa
people in distress.
Melike M. Fourie, PhD
Department of Psychology
University of the Free State METHODS: Forty-nine individuals (age 20 to 60) viewed short film clips
Bloemfontein, South Africa from the South African Truth and Reconciliation Commission testimonies
Dan J. Stein, MD, PhD depicting dialogues between victims and perpetrators of gross human
Department of Psychiatry rights violations. Participants were divided into 3 groups based on their
University of Cape Town
scores on the Childhood Trauma Questionnaire: control (n = 18), moder-
Cape Town, South Africa
ate maltreatment (n = 21), and severe maltreatment (n = 10). We employed
Pumla Gobodo-Madikizela, PhD
a mixed-methods design to explore empathic responses to film clips both
Department of Psychology
University of the Free State quantitatively and qualitatively.
Bloemfontein, South Africa
RESULTS: Quantitative results indicated that self-reported empathy was
lower in the moderate maltreatment group compared to the control group,
but of similar strengths in the severe maltreatment and control groups.
However, qualitative thematic analysis indicated that both maltreatment
groups displayed themes of impaired empathy.

CONCLUSIONS: Our results support the notion that childhood maltreat-

ment is associated with impaired empathy, and suggest that such impair-
CORRESPONDENCE ment may differ depending on the level of maltreatment: moderate
Melike M. Fourie, PhD maltreatment was associated with emotional blunting and impaired cog-
Department of Psychology nitive empathy, whereas severe maltreatment was associated with emo-
University of the Free State
tional over-arousal and diminished cognitive insight.
Bloemfontein, South Africa, 9301

E-MAIL
KEYWORDS: empathy, child maltreatment, emotion regulation, attachment
marethem@gmail.com

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 RELATIONSHIP BETWEEN EMPATHY AND CHILDHOOD MALTREATMENT
I N T RO D U C T I O N
Early family relations are arguably the most important,
and most enduring social relationships that affect a child’s
development,1 yet millions of children across the world are
exposed to negative early interactions, including maltreat-
ment.2,3 Although the prevalence of childhood maltreat-
ment is high across the world, it is particularly prevalent
in South Africa.4
Childhood maltreatment is associated with a vari-
ety of adverse psychological effects among adults,5 one
reason being that maltreated children often grow up in
an environment that fails to provide appropriate oppor-
tunities that guide development.6,7 A psychological abil-
ity that has been implicated consistently in descriptions
of impairments due to maltreatment, is empathy.1,8,9
Notably, maltreated children tend to have difficulty shar-
ing with, caring for, or taking the perspectives of oth-
ers.10 Moreover, maltreating parents often have impaired
empathy themselves.11
Impaired empathy is a trait impacting most important
relationships, and one that may be modified by therapy.
Understanding the role that maltreatment contributes to
the development of impaired empathy is critically impor-
tant, and has significant clinical implications. In fact, vari-
ous clinical disorders with childhood maltreatment as a
major etiological factor have impaired empathy as a core
symptom (eg, Cluster B personality disorders and complex
posttraumatic stress disorder).12,13
Empathy
Empathy has been defined as the capacity to experience
and understand another’s emotional state in a manner
that is congruent with the other person’s emotions.14,15 A
long-standing tradition in psychology divides empathy
into 2 components: affective and cognitive.16 The affec-
tive component constitutes the sharing of another per-
son’s emotions via internal sensory representations of
their emotions. Based on a widely accepted framework,
Bateson and Ahmad17 divide affective empathy into:
1) emotion matching, which is the phenomenon where
one mirrors the emotional state displayed by another;
and 2) empathic concern, which is essentially sympathy.
The cognitive component of empathy reflects the ability
to infer and understand the mental state of another.18,19
These subcomponents of empathy are partially distinct,
but also highly interconnected. For example, emotion
matching may make the suffering of the other more
98 May 2014 | Vol. 26 No. 2 | Annals of Clinical Psychiatry
salient, which in turn may trigger empathic concern and
cognitive empathy to imagine how the other feels.20
Although some subcomponents of empathy,
like emotion matching, are present from birth, more
mature forms of cognitive empathy, like the capacity
for mentalization, develop later in childhood and ado-
lescence.21 The capacity to mentalize, or reflectively
engage with another’s thoughts and feelings, is an abil-
ity that is rooted in the child’s early attachment expe-
riences with parents.22,23 Empathic parents have the
capacity to observe the child’s mind, to understand and
contain their mental state, and to view the child as an
intentional being, which promotes the child’s under-
standing of minds.24-26
Child maltreatment and empathic
development
Although impaired empathy is cited commonly in the
literature as a consequence of child maltreatment,27-29
we found little empirical evidence that directly inves-
tigated this relationship. Most of the existing literature
is theoretical in nature, in which the fields of social
and developmental psychology,1,21 as well as neurosci-
ence,22 describe conceptual models that explore the role
of maltreatment in contributing to the development of
impaired empathy. Often these theories are based on
observations from clinical and case studies only.
Substantial indirect evidence points to a link
between maltreatment and empathy, however. In par-
ticular, many of the factors considered necessary for
the development of empathy are impaired in children
who experience maltreatment. For example, maltreated
children frequently 1) have insecure attachments with
their caregivers22; 2) develop negative internal working
models30; 3) are hypersensitive to emotional signals31;
and 4) have impaired emotion regulation.32 In the fol-
lowing section, we explore these 4 lines of evidence that
link maltreatment to impaired empathy.
The ability to empathize is nurtured from infancy,
starting with positive attachment experiences with
caregivers.22 Empathic parenting associated with secure
attachment encourages the child to explore the parent’s
mind, which in turn encourages the development of the
capacity to mentalize.1 By contrast, child maltreatment
typically leads to insecure attachment styles, which are
associated with impaired empathy.22,30,33 Moreover, mal-
treated children with insecure attachments typically
internalize negative working models. For example, they
 ANNALS OF CLINICAL PSYCHIATRY
view themselves as inadequate and unlovable; see oth-
ers as hostile and uncaring; and regard interpersonal
interactions as potentially dangerous and painful.34
Because these negative internal working models are
likely to foster disdain, fear, and mistrust of others, they
undermine the development of empathy.35,36
Because maltreated children often are faced with
continual fear, they also frequently become hypersen-
sitive to negative emotional signals.31 As a result, mal-
treated children often experience intense emotional
distress (devoid of sympathy) when faced with another’s
emotional distress.35,37,38 For example, one study showed
that maltreated children often became intensely dis-
tressed in the presence of another child crying in a play-
ground.39 Instead of soothing or helping the other child,
the maltreated children reacted with a combination of
fear, anger, and violence. Such forms of emotional dis-
tress hinder empathy because they foster a self-directed
focus that detracts from the suffering of others.15
Another factor necessary for the development of
empathy is emotion regulation.40 Cummings32 identi-
fied 3 distinct patterns of emotion regulation in chil-
dren when viewing another person in distress. These
are 1) adaptively concerned emotion regulation, which
is associated with moderate levels of negative affect that
are well modulated, together with empathy; 2) under-
controlled/ambivalent emotion regulation, which is
associated with underregulation of emotional behavior,
high reactivity, and prolonged elevation of both positive
and negative affect; and 3) overcontrolled/unresponsive
emotion regulation, which is associated with low emo-
tional and behavioral reactivity, and the inhibition of
signs of distress. Maltreated individuals typically exhibit
the latter 2 patterns, which are associated with signifi-
cant impairments in empathy.40
Study overview
In the present investigation, we used the context of the
South African Truth and Reconciliation Commission (TRC)
hearings to elicit current and ecologically valid empathic
responses in participants. The TRC was established after
apartheid with the purpose of engaging with and healing
the injustices of the past, mainly through exploring testi-
monial narratives of perpetrators and victims.
We used short, emotionally arousing clips from
the TRC hearings to explore empirically the relation-
ship between varying degrees of child maltreatment and
empathic responding in an adult participant sample. In
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light of the literature reviewed above, we hypothesized
that significant child maltreatment would be associated
with impaired empathy, and that the severity of maltreat-
ment would be related linearly to the degree of impaired
empathic responding.
METHODS
Participants
Forty-nine racially diverse participants (White: 25, Black:
12, Colored (people of mixed race): 12; 33 women)
between the ages of 20 and 60 participated in the study.
To increase the generalizability of our findings, we sourced
participants from the university campus and the local envi-
ronment through posters and an advertisement placed in
a local newspaper. We thus made use of non-probability
convenience sampling, and included all participants who
responded to our study advertisement.
All participants completed the procedures described
below and received 90 ZAR (approximately 10 USD) as
gratuity. The study protocol was approved by the Research
Ethics Committee of the University of Cape Town’s (UCT)
Department of Psychology.
Experimental design and setting
We utilized a mixed methods research design that incor-
porated both quantitative and qualitative data analysis.
This methodology enabled us to obtain rich, subjective
data indicative of participants’ experiences, in addition
to numerical measures of empathy and related emotions
amenable to statistical analysis. Specifically, we used a
within-subjects mixed-model design, where stages of data
collection took place sequentially. The study took place in
a laboratory at UCT’s Department of Psychology.
Stimuli
Empathy-eliciting stimuli were film clips taken from a
short documentary (A Long Night's Journey into Day,
Iris Films; 2000) depicting different encounters between
victims and perpetrators who testified at the TRC public
hearings. The hearings were of a case in which 7 young
men from the Gugulethu Township in Cape Town were
killed. The amnesty applicants were a white police offi-
cer, Captain Bellingan (the commander of the opera-
tion), and a black police collaborator, Mr. Mbelo. They
divulge 2 very different stories about their involvement
in the killings.
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 RELATIONSHIP BETWEEN EMPATHY AND CHILDHOOD MALTREATMENT
The TRC uncovered the following details: The black
officer, Mbelo, was sent to Cape Town to infiltrate a group
of young men and train them under the pretext that they
were going to become soldiers of the anti-apartheid strug-
gle. He then lured them into a trap where a team of police-
men, including Captain Bellingan, were waiting to kill
them. The press characterized the operation as a huge suc-
cess of the apartheid campaign against terrorists. During
the TRC hearings of Bellingan and Mbelo’s amnesty appli-
cation, the mothers of the 7 victims heard the horrifying
truth about what happened to their sons for the first time.
The clips for our study were taken from scenes of this
hearing, as well as from a meeting between the moth-
ers and the black officer (Mbelo). During this meeting,
Mbelo asked the mothers for forgiveness. The stimuli
consisted of 4 short clips (1 to 2 minutes each) and 1
long clip (12 minutes). The 4 short clips depicted: 1) a
forgiving mother, 2) an unforgiving mother, 3) a mother
in distress (sobbing), and 4) an unrepentant perpetra-
tor (Captain Bellingan). These 4 clips were contained
within the longer clip, which depicted the events of the
hearing in more detail, including the meeting between
the victims’ mothers and the remorseful perpetrator.
Measures
Self-reported emotion scales. Participants indicated their
current emotional state after viewing each of the 4 short
clips by rating 4 emotional qualities (empathy, shame,
anger, and sadness) on a 9-point Likert-type scale, rang-
ing from 1 (not at all) to 9 (very strongly/extremely).
Qualitative questionnaire. Participants completed
the qualitative questionnaire after they had viewed all
the clips. It consisted of 13 open-ended questions that
explored emotions and thoughts evoked by the foot-
age. For example, participants were asked to describe:
the overall feeling they experienced when watching the
film; personal memories that were triggered by the film;
and any emotional detachment they felt.
Childhood maltreatment. We used the Childhood
Trauma Questionnaire Short-Form (CTQ-SF)41 to assess
the severity of different types of child maltreatment.
CTQ-SF is a retrospective measure that consists of 25
items that measure the frequency with which differ-
ent events took place when participants “were growing
up”, ranging from 1 (never true) to 5 (very often true).
The CTQ-SF consists of 5 subscales: physical neglect,
emotional neglect, physical abuse, sexual abuse, and
emotional abuse. The CTQ-SF has high sensitivity and
100 May 2014 | Vol. 26 No. 2 | Annals of Clinical Psychiatry
specificity in nonclinical samples,42 and also shows high
test-retest reliability (.66 to .94) and internal consistency
with alphas ranging between .70 and .93.43
Participants were divided into 3 groups based
on their total CTQ-SF scores. The control group had
scores <36, which indicated no maltreatment or mild-
moderate maltreatment on 1 subscale. The moderate
maltreatment group had scores between 36 and 54,
which indicated mild-moderate and moderate-severe
maltreatment on multiple subscales. Finally, the severe
maltreatment group had scores >55, which indicated
moderate-severe and severe-extreme maltreatment on
multiple scales.
Procedure
On arrival, participants provided informed consent
and received general instructions regarding the proce-
dures. Each participant was seated in front of a 17-inch
computer monitor and given headphones and answer
booklets. To contextualize the clips, participants viewed
a PowerPoint presentation providing information about
the specific TRC case they were about to watch. They
then viewed the 4 short clips (1 to 2 minutes each) and
completed the self-reported emotion scales after each
clip. Clips were shown in 3 different random sequences
to avoid order effects. Finally, participants viewed the
longer (12 minutes) clip, and then completed the qualita-
tive questionnaire and the CTQ-SF. All participants were
thoroughly debriefed after the study procedure and given
the option to see a professional counsellor, if necessary.
Data analysis
We analyzed each of the emotions rated on the quantita-
tive self-report scales using a 3 (group: control, moderate,
and severe maltreatment) × 4 (clip type: forgiving mother,
unforgiving mother, distressed mother, and unrepentant
perpetrator) mixed factorial ANOVA. In instances where
the assumption of sphericity was violated, the degrees of
freedom were corrected using Greenhouse-Geisser epsi-
lon corrections. These correction factors are reported.
We also performed zero-order correlations between
participants’ total scores on the CTQ-SF and their mean
emotion ratings for each emotion. These mean emotion
ratings were calculated by averaging the 4 emotion rat-
ings after each film clip for each emotion.
Two researchers (SCL and LB), who were blind to
maltreatment status, analyzed the qualitative data using
thematic analysis in accordance with guidelines set out
 ANNALS OF CLINICAL PSYCHIATRY
by Braun and Clarke.44 Accordingly, patterns within the
data were coded, and extracts from the data were collated
into themes and subthemes. Themes were compared
against the data and further refined until they were inter-
nally consistent and distinctive, and offered a convincing
representation of the data. In general, we approached the
analysis in an inductive fashion. The themes empathy
and impaired empathy were approached in a deductive
fashion, however, based on the framework of empathy
suggested by Bateson and Ahmad.17 Our approach var-
ied between a semantic one, where themes were formed
from explicit or surface meanings of the data, and an
interpretive one, where the context of statements was
taken into account.45
To integrate the quantitative and qualitative data sets,
we used a multi-stage data analysis process that has been
suggested to be appropriate for mixed methods research.46
Briefly, we quantified the qualitative data by summing the
number of occurrences of each theme in each participant
and then divided this score by the number of participants
in each group. The frequency of each theme first was
rated independently by 2 researchers (SCL and LB), who
remained blinded to maltreatment status, and then aver-
aged to form the final score. The level of agreement between
these researchers was >85%. The thematic frequency esti-
mates per group were then compared with the quantitative
results to determine similarities and differences between
the data sets.
R E S U LT S
Participants
Based on participants’ CTQ-SF scores, 18 were classified
as having experienced no, or mild levels, of maltreat-
ment (control group), 21 were classified as having expe-
rienced moderate levels of maltreatment (moderate
maltreatment group), and 10 were classified as having
experienced severe levels of maltreatment (severe mal-
treatment group). Chi-square analyses indicated that
these study groups did not differ significantly in terms
of the distribution of age, sex, or racial representation
(P values > .39)
Quantitative results
Emotion ratings in response to the TRC clips. FIGURE
illustrates subjective emotion ratings obtained after
each short clip.
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The mixed factorial ANOVA for empathy ratings
detected a significant main effect for the type of clip,
F (2.29, 103.08) = 106.73, P < .001, ηp2 = .70, ε = .76. Post-
hoc contrasts indicated that empathy was significantly
higher following the distressed mother clip than the for-
giving mother, the unforgiving mother, and the unrepen-
tant perpetrator clips (P values < .001, r coefficients > .60).
Empathy following the unrepentant perpetrator clip was
also significantly lower than the forgiving mother and the
unforgiving mother clips (P values < .001, r coefficients
> .84), while empathy responses following the latter 2 clips
did not differ.
Empathy ratings also differed significantly between
the study groups, F (2, 45) = 6.75, P = .003, ηp2 = .23.
Bonferroni post-hoc testing revealed that empathy ratings
for the moderate maltreatment group were significantly
lower than that of the control group (P < .05, r = .41) and
the severe maltreatment group (P < .01, r = .42). However,
empathy ratings did not differ significantly between the
control and severe maltreatment groups (P = 1.00, r = .09).
Finally, there was no significant interaction between group
and type of clip, (P = .17).
Because empathy was the main focus of our study,
we summarize the results for sadness, shame, and
anger briefly. Mixed factorial ANOVA results indicated
that these analyses were all significant for the main
effect of type of clip (P values < .001). Post-hoc contrasts
revealed that sadness was significantly higher following
the distressed mother clip than the other clips (P values
< .001, r coefficients > .60), and significantly lower fol-
lowing the unrepentant perpetrator clip than the other
clips (P values < .001, r coefficients > .73). In terms of
shame, participants’ ratings were significantly higher
following the distressed mother clip than the other
three clips (P values < .01, r coefficients > .44). Finally,
ratings of anger were significantly higher following the
distressed mother clip than all the other clips (P val-
ues < .05, r coefficients > .36). Anger was also signifi-
cantly higher following the unremorseful perpetrator
clip than following the forgiving mother clip (P < .001,
r = .63), and significantly higher following the unforgiv-
ing mother clip than following the forgiving mother clip
(P < .001, r = .62).
In terms of group effects, ratings of shame differed
significantly between the study groups, F (2, 41) = 5.17,
P = .01, ηp2 = .20, with significantly higher ratings of
shame for the severe maltreatment group than for the
control group (P < .05, r = .39) and the moderate mal-
101
 RELATIONSHIP BETWEEN EMPATHY AND CHILDHOOD MALTREATMENT

FIGURE
Mean ratings for (A) empathy, (B) sadness, (C) anger, and (D) shame for the control, moderate
maltreatment, and severe maltreatment groups in response to each clip. Error bars represent
standard errors
A Empathy B Sadness
9 Control 9
8 Moderate 8
Intensity rating (1-9)

Intensity rating (1-9)

7 Severe 7
6 6
5 5
4 4
3 3
2 2
1 1

Forgive+ Forgive- Distress+ Repent- Forgive+ Forgive- Distress+ Repent-

C Anger D Shame
9 9
8 8
Intensity rating (1-9)

Intensity rating (1-9)

7 7
6 6
5 5
4 4
3 3
2 2
-3
1 1

Forgive+ Forgive- Distress+ Repent- Forgive+ Forgive- Distress+ Repent-

Film clip Film clip

Forgive+: forgiving mother, Forgive- : unforgiving mother, Distress+: mother in distress, Repent-: unrepentant perpetrator.

treatment group (P = .01, r = .43). The main effects of
group did not reach significance for sadness, (P = .07, ηp2
= .12), or anger, (P = .08, ηp2 = .11).
Associations between maltreatment and elicited
emotions. TABLE 1 shows the mean self-reported emo-
tion-ratings for each emotion in each study group when
ratings for all 4 clips were averaged. This table shows a
general trend, such that mean emotion ratings for all
measured emotions were highest in the severe maltreat-
ment group, whereas they were lowest in the moderate
maltreatment group.
To explore further the relationship between sub-
jective emotion ratings and the degree of maltreat-
ment, we performed zero-order correlations between
total scores on the CTQ-SF and mean emotion ratings
across all groups. Significant positive correlations were
detected between CTQ-SF scores and ratings of shame
(P < .05; r = .33) as well as anger (P < .05; r = .26). Ratings
of empathy and sadness did not correlate significantly
with CTQ-SF scores.
Qualitative results
Thematic analysis. We identified 7 themes (which are
italicized) from our analysis of the qualitative data, which
differed markedly between groups. The themes empa-
thy, positive world view, and emotional awareness were
more common in the control group, whereas the themes
impaired empathy, malignant world view, and poor emo-
tional awareness, were more common in the 2 maltreat-
ment groups. The theme emotional distress was infrequent
in the control and moderate maltreatment groups, but was
expressed commonly in the severe maltreatment group.
Because empathy is the focus of this study, we discuss
the themes empathy and impaired empathy in detail. The

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 ANNALS OF CLINICAL PSYCHIATRY

TABLE 1
Mean self-reported emotion ratings from 1 (not at all) to 9 (very much) for each study group
Moderate Severe
Control maltreatment maltreatment
Emotion
(n = 18) (n = 21) (n = 10)
Mean (SD) Mean (SD) Mean (SD)
Empathy 5.94 (1.16) 4.69 (1.48) 6.25 (1.05)
Sadness 5.74 (1.25) 4.99 (1.56) 6.15 (0.98)
Anger 4.82 (1.96) 4.40 (1.95) 6.08 (1.50)
Shame 3.53 (1.88) 3.32 (1.73) 5.53 (1.89)
Means represent the mean self-reported emotion rating for each group across all 4 film clips.

other themes and subthemes are summarized in TABLE 2
(see TABLE 3 for examples of quotes from each theme).
THEME 1: EMPATHY. Participants who displayed highly
empathic responses (mostly those in the control group)
tended to have numerous examples of each empathy sub-
theme, which illustrates how the component processes of
empathy combine in highly empathic responses.
Participants demonstrated the subtheme imagine-self
perspective when they imagined how they would feel if they
were in the position of 1 of the people portrayed in the TRC
footage. For example, 1 participant stated:
“I absolutely understood her need to know [the
mother, who was asking Mbelo why he killed
her son]. In the face of such brutality, you have
to know, especially if it is your loved one… I
could relate.”
Similarly, the imagine-other perspective reflects the
ability to imagine how another thinks or feels given their
situation. In relation to the scene where Mbelo appealed to
the mothers for forgiveness, 1 participant stated:
“I perceived [Mbelo] differently in that context
with the mothers. I perceived him to be truly
remorseful. I was heartened by his genuineness,
the fact that he took responsibility.”
Emotional contagion (“emotion catching”) could
be described as instances in which an individual
feels the same emotion that they observe in another.
For example:
“The despair of the mothers was heart-breaking, I
cried uncontrollably, I empathized.”
Finally, the subtheme empathic concern/sympathy
was detected in statements that demonstrated sympathy
and compassion toward the protagonists of the film foot-
age, for example:
“Seeing Mbelo’s face in response to the unfor-
giving mother. I felt deeply sorry for him as his
expression was accepting of anything that the
mothers may say.”
THEME 2: IMPAIRED EMPATHY. This theme was marked
by responses that revealed a lack of empathy, including
statements showing difficulty understanding the mental
states of others. We observed impaired empathy most
frequently in the responses of the maltreatment groups.
The subtheme poor understanding of others’ mental
states reflects an impairment of the imagine-other per-
spective. For example, in response to a scene showing
one of the mothers crying out in pain after viewing foot-
age of her dead son, 1 participant in the moderate mal-
treatment group wrote:
“I felt detached from the mother who screamed/
performed in front of all the people. One doesn’t
have to ‘perform’ to show one’s grief. I keep it
inside.”
Some participants demonstrated an absence of emo-
tional contagion in statements showing emotional blunting
and difficulty feeling emotions in response to others’ pain.
For example, when asked to describe “your overall feeling
after watching the film” a participant in the moderate mal-
treatment group stated:
“[I felt] very little as I’m not someone who expe-
riences emotions easily. I felt a little sad but
that’s all.”
Absence of sympathy was shown by remarks indicating
a lack of concern for others’ pain.
Finally, we observed extreme impairments in empathy
in bizarre misattributions, where the participant displayed
strange misattributions of emotions, as in this example
from a participant in the severe maltreatment group:

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TABLE 2
Summary of themes and subthemes from the qualitative thematic analysis
Theme Subthemes
1. Empathy Imagine-self perspective; imagine-other perspective; emotional contagion; empathic concern/sympathy
2. Impaired empathy Poor understanding of others’ mental states; absence of emotional contagion; absence of sympathy;
bizarre attribution of another’s behavior
3. Positive world view Positive attitude towards forgiveness; faith in goodness of humanity; sense that life has meaning
4. Malignant world view Despair; absence of hope; distrust towards others; attitude that perpetrators are inherently evil
5. Emotional distress Intense feelings of anger and hatred; fear and horror; guilt and shame; triggering of traumatic memories;
somatic distress
6. Emotional awareness Focus on emotional signals; rich and complex understanding of others’ emotions; proficiency in
understanding personal emotions
7. Poor emotional Poor understanding of emotions in self and others; emotional blunting; avoidance tendencies
awareness

“I felt anger when Mbelo was talking about staying
drunk to mask pain. [It was] as though he was hav-
ing a good time forgetting.”
The footage the participant referred to, in fact,
showed a guilt-stricken Mbelo explaining how he drank
as a form of escapism to forget the (unacceptable) actions
that he had committed.
Links between qualitative and quantitative
results
TABLE 4 presents the quantification of themes across the
study groups. We combined the quantified qualitative
results with the quantitative results in order to detect a
pattern that differentiated between the 3 study groups.
We found that the qualitative data overlapped clearly
with the quantitative data, yet we also observed some
significant differences between the 2 sets of data. We
describe the most important similarities and differ-
ences below.
With regard to empathy, the control group displayed
higher levels than the moderate maltreatment group
across both data sets. However, for the severe maltreatment
group, empathic responses differed markedly; whereas the
thematic analysis indicated that this group had the lowest
ratings for empathy and the highest for impaired empathy,
their quantitative empathy ratings were high (similar to that
of the control group).
In terms of emotional distress, both data sets indi-
cated that the control and moderate maltreatment groups
experienced relatively low levels of emotional distress.
However, the severe maltreatment group displayed high
frequencies of the emotional distress theme, and also
had significantly higher ratings of shame (and to a lesser
extent anger) than the other 2 groups on the quantitative
emotion scales. This pattern of increased emotional dis-
tress in the severe maltreatment group was corroborated
by the significant positive correlations between ratings of
shame and anger, and total CTQ-SF scores. Thus greater
levels of maltreatment were associated with higher rat-
ings of shame and anger in general.
DISCUSSION
In this study, we examined the relationship between
child maltreatment and empathy in a cohort of adult
individuals. Participants were divided into 3 study
groups based on their scores on the CTQ-SF: 1) control
(little to no maltreatment), 2) moderate maltreatment,
and 3) severe maltreatment. Consistent with our pre-
dictions, the control group displayed high empathy on
both the quantitative and qualitative measures, and the
moderate maltreatment group displayed low levels of
empathy on both measures. However, we did not expect
to see the results we observed in the severe maltreat-
ment group. This group displayed low levels of empathy
on the qualitative measure, but high levels of empathy
on the quantitative measure. We contend that distinct
patterns of empathic responding in the 2 maltreatment
groups may have resulted from differences in factors
such as emotion regulation, attachment, and emotional
avoidance.

104 May 2014 | Vol. 26 No. 2 | Annals of Clinical Psychiatry

 ANNALS OF CLINICAL PSYCHIATRY

TABLE 3
Examples of quotes for each theme and subtheme, and relation to maltreatment status
Theme Subtheme Quotes
Empathy Imagine-self perspective “I absolutely understood her need to know [the mother, who was asking Mbelo why
he killed her son]. In the face of such brutality, you have to know, especially if it is your
loved one… I could relate.”a
Imagine-other perspective “I perceived [Mbelo] differently in that context with the mothers. I perceived him
to be truly remorseful. I was heartened by his genuineness, the fact that he took
responsibility.”a
Emotional contagion “The despair of the mothers was heart-breaking, I cried uncontrollably, I empathized.”a
Empathic concern “Seeing Mbelo’s face in response to the unforgiving mother. I felt deeply sorry for him
as his expression was accepting of anything that the mothers may say.”a
Impaired Poor understanding of others’ “I felt detached from the mother who screamed/performed in front of all the people.
empathy mental states One doesn’t have to ‘perform’ to show one’s grief. I keep it inside.”b
Absence of emotional “[I felt] very little as I’m not someone who experiences emotions easily. I felt a little sad
contagion but that’s all.”b
Absence of sympathy “I didn’t feel any pain personally…”b
Bizarre misattributions “I felt anger when Mbelo was talking about staying drunk to mask pain. [It was] as
though he was having a good time forgetting.”c
Positive world Positive attitude towards “[When the] mother offered forgiveness—I was amazed. I felt a sense of healing and
view forgiveness an ability to move forward. Her wisdom and character made me feel she had done the
right thing.”a
Faith in the goodness “I keep on being in awe with us humans, [with our] inner power and strength.”a
of humanity
Malignant Absence of hope “[My past experiences] made me think that people can and will do anything to each
world view other and sometimes there’s nothing to do but be in pain.”c
Despair “I feel guilt, shame, and defeat for my situation and those on the video. Pity. Pity. Pity.”b
Distrust of others, attitude “I would scream and run away from them [the perpetrators] in fear. They have killed
that all perpetrators are before and will again. Something is mentally wrong with them.”c
inherently evil
Emotional Intense feelings of fear and “Seeing the footage was heart-stopping… My brain was pounding, my breathing was
distress horror heavier.”c
Guilt and shame “I am feeling the guilt and shame that Bellingan and Mbelo should be feeling.”c
Extreme somatic distress “I experienced… chills down my spine, felt as if my hair was being electrocuted….”c
Emotional Focus on emotional signals “I was desperately searching [Bellingan] for any hint of emotion or remorse, but I never
awareness found it.”a
Rich and complex “I felt her [the unforgiving mother] battle was the hardest as she was in conflict between
understanding of others’ how she truly felt and what a transcendent moral code demanded of her.”a
emotions
Proficiency in understanding “[My detachment from the mother in distress] was related not to the events unfolding in
personal emotions the court but rather my own issues.”a
Poor Poor understanding of “[I felt] no guilt or shame – [I was] not there at the time.”b
emotional emotions in self and others “…Mbelo described smilingly how it was just another day on the job” [referring to a
awareness scene where Mbelo was clearly ashamed].b
Emotional blunting “I feel a little detached because it hasn’t affected me personally.”b
“I find it difficult to love and sometimes I can’t [feel] sorry for other people.”b

a Control group.
bModerate maltreatment group.
cSevere maltreatment group.

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 RELATIONSHIP BETWEEN EMPATHY AND CHILDHOOD MALTREATMENT
TABLE 4
Frequencies of themes in each study group
Association
with empathy Theme
Positive Empathy
Positive world view   +++
Emotional awareness
Negative Impaired empathy
Emotional distress
Malignant world view
Poor emotional awareness
Frequencies were determined by calculating the mean number of occurrences of each theme in each group: + very infrequent; ++ infrequent; +++ frequent; ++++ very frequent.
Empathic responses in the maltreatment
groups
In terms of the quantitative emotion data, the severe
maltreatment group displayed significantly higher
empathy than the moderate maltreatment group.
However, they also displayed high levels of anger and
sadness, and significantly higher levels of shame than
both the moderate maltreatment and control groups.
These elevated levels of negative affect could be argued
to reflect increased emotional distress. Our qualitative
thematic analysis supported this interpretation, show-
ing that the severe maltreatment group had the high-
est ratings of the theme emotional distress. The single
self-rating of empathy we employed may therefore
not have been as specific to empathy as we intended,
and also may have been influenced by feelings of
emotional distress.
The elicitation of an isomorphic emotional
response to that observed in another is an integral com-
ponent of affective empathy, termed emotion match-
ing.47 But an empathic response also involves sympathy
and cognitive empathy.17 Our qualitative results indi-
cated that the severe maltreatment group was charac-
terized by extraordinary affective responses to the clips,
indicative of emotional over-arousal or distress, but also
by low levels of cognitive empathy and sympathy (ie,
low ratings for empathy and emotional awareness, and
high ratings for impaired empathy and poor emotional
awareness). The severe maltreatment group’s data thus
suggest a pattern of decreased cognitive empathy and
sympathy, in addition to increased emotion contagion.
106 May 2014 | Vol. 26 No. 2 | Annals of Clinical Psychiatry
Moderate Severe
Control maltreatment maltreatment
+++ ++ +
++ ++
+++ ++ +
+ ++ +++
++ + ++++
+ ++ +++
+ +++ ++++
In contrast to the severe maltreatment group, par-
ticipants in the moderate maltreatment group displayed
impairments in empathy across both the qualitative
and quantitative data sets. In particular, the moderate
maltreatment group showed significantly lower empa-
thy ratings than the other 2 groups. They also displayed
low empathy and high impaired empathy themes, and
often displayed poor understanding of others’ mental
states, possibly reflecting poor cognitive empathy. The
moderate maltreatment group had very low levels of the
theme emotional distress, and did not have high ratings
of shame, anger, or sadness (as seen in the severe mal-
treatment group). Therefore, the moderately maltreated
group displayed blunted affect as well as impairments in
both affective and cognitive empathy.
We found it intriguing that the moderate and severe
maltreatment groups showed such contrasting affective
responses, yet both groups displayed impaired cognitive
empathy and sympathy. Below, we first consider how
these different affective response patterns could poten-
tially inhibit empathic responding. We then explore
the potential mechanisms that may underlie these pat-
terns. Finally, we describe factors that may contribute
to impaired empathy that may be common across both
maltreatment groups.
Patterns of affective responding
and impaired empathy
When an individual matches the emotion they observe in
another in a well-modulated manner, it is likely that this
emotion matching will act as a trigger for cognitive empa-
 ANNALS OF CLINICAL PSYCHIATRY
thy and sympathy.17 We detected this “ideal” response
frequently in the qualitative responses of our control
group: participants’ moderate distress in response to
the footage appeared to trigger both sympathy and an
attempt to understand the other’s mental state (ie, cogni-
tive empathy).
In contrast to the control group, we observed
blunted affect in response to the empathy-eliciting stim-
uli for the moderate maltreatment group. Blunting and/
or avoidance is likely to prevent the affective synchrony
that may develop when an individual is exposed to
another’s distress, because blunting removes the emo-
tional stimulus that triggers an empathic response.14,22 It
is not surprising therefore that participants in the mod-
erate maltreatment group showed little sympathy and
cognitive empathy.
Participants in the severe maltreatment group
tended to display emotional distress in response to the
footage, but with low levels of empathy and sympa-
thy. It has been proposed that uncontrollable distress
in response to another’s suffering may overwhelm the
individual to the extent that it detracts from the other’s
experience of pain.15 Because intense distress is an
uncomfortable sensation, it is likely to lead to a self-
directed focus, which then undermines the salience of
the other person’s suffering. Decety and Lamm15 rightly
notes that, “in the case of empathy, the best response
to another’s distress may not be distress, but efforts to
soothe that distress.” Therefore the inability to regulate
negative emotions in the severe maltreatment group
may have prevented them from experiencing cognitive
empathy and sympathy.
Potential mechanisms underlying impaired
empathy in maltreatment
Emotion regulation. Research has shown that the major-
ity of maltreated individuals have impaired emotion reg-
ulation,32,40 which has been linked to impaired empathy.14
The behavioral patterns that are characteristic of the
forms of emotion regulation typically exhibited by mal-
treated individuals show considerable overlap with the
patterns of responses we observed in the present study.
For example, the blunted emotionality and unempathic
responses of the moderate maltreatment group may be
associated with the overcontrolled/unresponsive emo-
tion regulation pattern described by Cummings.32 By
contrast, the intense, uncontrollable, and unempathic
responses of the severe maltreatment group could be lik-
AACP.com Annals of Clinical Psychiatry | Vol. 26 No. 2 | May 2014
ened to the undercontrolled emotion regulation pattern
described by Cummings.32
Attachment styles. Insecure attachment styles
are present in the majority of maltreated individuals,
and also have been linked to impaired empathy.30,48
Although we did not measure attachment directly in the
present study, we offer some interpretations here about
the nature of attachment styles in our 2 maltreatment
groups based on previous research and speculation.
An avoidant attachment style is associated with
blunted affect, and a tendency toward being emotion-
ally distant from others.49 This affective pattern resem-
bles the blunted affect we observed for participants in
our moderate maltreatment group. By contrast, the anx-
ious and disorganized attachment styles are associated
with elevated negative affect and unregulated (disorga-
nized) emotional responses, respectively. Both of the
latter affective patterns are consistent with the intense
affect we observed in our severe maltreatment group.
Emotional avoidance. It is well documented that
maltreated individuals have a tendency to experience
intense, uncontrollable negative affect.31 However, vari-
ous authors also describe manifestations of emotional
avoidance in maltreated individuals, including emo-
tional suppression,50 and avoidant coping strategies.51
Although intense emotionality and emotion avoid-
ance appear to be diametrically opposed, they may be
related closely. For example, because distressing stimuli
often elicit intense negative affect and feelings of shame
in maltreated individuals,52 these individuals may be
motivated to adopt an avoidant emotional stance. This
behavior is consistent with our findings for the mod-
erate maltreatment group, but does not explain the
heightened distress observed for the severe maltreat-
ment group.
One possible explanation for the above discrepancy
is that, although distress may motivate avoidance in mal-
treated individuals, some may be incapable of imple-
menting this defense. In particular, severely maltreated
individuals may be unable to inhibit negative affect (even
when they are highly motivated to do so) because of
undercontrolled emotion regulation, anxious/disorga-
nized attachment, or the post-traumatic phenomenon of
triggering, which is observed more readily following high
levels of trauma.34
The tendency toward emotional avoidance in mal-
treated individuals also has conceptual overlap with
Freud’s53 theory of repression. This defense mechanism
107
 RELATIONSHIP BETWEEN EMPATHY AND CHILDHOOD MALTREATMENT
may remain intact in moderate maltreatment, but may
become overwhelmed with severe maltreatment, lead-
ing to overwhelming negative affect due to the emer-
gence of disturbing unconscious material.54,55
Common features across the maltreatment
groups
Besides the differences highlighted above, participants in
our maltreatment groups also may share features associ-
ated with impaired empathy. One such feature is impaired
mentalization, which has been linked to poor cognitive
empathy.56 Fonagy1 argued that maltreatment often results
in impaired mentalization because abusive or neglectful
parents typically fail to engage with the thoughts and feel-
ings of the child. The child’s internal experience therefore
remains unlabeled and confusing, which, in turn, hinders
the child from forming accurate representations of others’
mental states.57,58
Another shared feature may be impaired sympathy,
which has been linked to maltreatment because abused
children often internalize the unsympathetic behavior of
their parents.59,60 We observed a lack of sympathy in both
maltreatment groups, which may be linked to the theme
malignant world view. For example, when a mother in the
footage forgave her son’s killer, she was described as weak;
when a mother cried, she was seen as “performing”; and
when a perpetrator begged for forgiveness, he was viewed
as a “cold-hearted liar.”
Limitations and directions for future research
The current study contributed significantly to our under-
standing of impaired empathy as one of the enduring
effects of child maltreatment. A number of methodologi-
cal limitations should be noted, however. First, retro-
spective methods of assessing child maltreatment have
important limitations61; corroborative evidence should
thus be used whenever possible. Second, our relatively
small sample size may have reduced the power of our
analyses. Third, because of the exploratory nature of
this study, we did not employ a randomized sampling
method with groups matched for third variables that
may influence empathy (eg, age, sex, race, or develop-
mental timing and chronicity of maltreatment).19,62,63 It
should be noted, however, that our groups did not dif-
fer statistically in terms of age, sex, or race. We also did
not group participants according to the type of maltreat-
ment they experienced, which may be a confounding
factor because different types of maltreatment may affect
108 May 2014 | Vol. 26 No. 2 | Annals of Clinical Psychiatry
empathic impairment differently.9 However, most of our
participants had experienced >1 type of maltreatment; it
was thus impossible to group them according to type of
maltreatment.
A fourth limitation was our use of a single, global,
self-rating for empathy, which may have been influenced
by emotional distress in some subjects. Our rationale for
employing this measure was to save time, that is, we did
not want measures of state affect between clips to detract
from participants’ emotional engagement with the foot-
age. A more accurate way to assess empathic responding
may be to include several adjectives describing different
emotional states that load onto empathy and personal
distress, respectively.64
Finally, because we did not assess participants’
attachment styles and emotion regulation patterns, some
of our conclusions may be speculative. Future research
may benefit from assessing the contribution of these
factors that potentially may mediate the relationship
between empathy and maltreatment.
CONCLUSIONS
In this study, we found empirical evidence that child
maltreatment is associated with impaired empathy.
Furthermore, our results suggest that such impairments
manifest differently in moderately and severely maltreated
individuals. Specifically, moderately maltreated partici-
pants displayed blunted affect in response to the empa-
thy-eliciting clips, which could result from overcontrolled
emotion regulation, avoidant attachment, or a proclivity
toward avoiding distressing psychological content. By con-
trast, severely maltreated participants displayed intense,
uncontrollable emotional distress in response to the clips,
which could result from lack of emotion regulation, anxious
or disorganized attachment, or “unsuccessful” emotional
avoidance.
The findings of the present study, though exploratory
in nature, may be of practical value in understanding psy-
chopathology and informing current treatment programs.
Our findings reinforce the notion that empathy training
should form an integral component of treatment pro-
grams following maltreatment.65 In addition, the thera-
peutic process may benefit from a better understanding
of the nature of impaired empathy in maltreated indi-
viduals. For example, a vital component of psychother-
apy involves enabling patients to develop an awareness
 ANNALS OF CLINICAL PSYCHIATRY

of their own and others’ mental states, thereby finding
meaning in their behavior.1 The present study’s findings
may help therapists gain deeper insight into the differ-
ent behavioral patterns associated with impaired empa-
thy (eg, emotional overarousal or blunted affect), thereby
enabling them to better assist patients in identifying prob-
lematic patterns of cognition and behavior. Our research
also suggests that, rather than using a single intervention,
empathy treatment programs may need to be tailored
according to the particular kind of empathic deficit.
In sum, our study shows that child maltreat-
ment can have a significant impact on an individual’s
empathic responding toward others. Because empathy
plays such a vital role in social relations, it is important
to explore further how maltreatment impairs empathy,
and how the burden of impaired empathy can be treated
or prevented. Our study has made important first steps
in exploring these complex relationships. ■
DISCLOSURES: Mr. Locher, Ms. Barenblatt, Dr. Fourie, and
Dr. Gobodo-Madikizela report no financial relationship
with any company whose products are mentioned in this
article or with manufactuers of competing products. Dr.
Stein has received research grants and/or consultancy
honoraria from AMBRF, Biocodex, Lundbeck, National
Responsible Gambling Foundation, Novartis, Servier, and
Sun.
ACKNOWLEDGMENTS: We thank Professor Mark Solms for
editorial comments as well as for his conceptual input.
This article was part of a 3-year research project (2009 to
2012), "Empathy: Emotional responses to video-taped
scenes from the Truth and Reconciliation Commission
of South Africa," funded by the Fetzer Institute and the
National Research Foundation.
Authors S.C. Locher and L. Barenblatt contributed
equally to this article.

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Providing psychiatrists with peer-reviewed, practical, and up-to-date advice

by leading authorities on common clinical challenges

110 May 2014 | Vol. 26 No. 2 | Annals of Clinical Psychiatry