THE AFTERMATH OF ABUSE AND NEGLECT
The ultimate cause of any form of psychological disorder is likely a combination of a variety of factors: genetics / biology, temperament, and environment -- environments both proximal (near to) and distal (far from) the current experience of disorder. Most disorders, including those resulting from adverse childhood experiences are thus thought to be a result of a “stress-diathesis” framework of factors – the result of an individual with a pre-existing vulnerability to suffering a disorder, particular to that individual, reacting adversely to environmental stressors – an “environmental pathogen”. Psychologically “hardy” individuals lack these vulnerabilities (rather than, necessarily, being of better character) and so will be less prone to suffer the effects of these pathogens. So, too, the means by which that disorder can “best” be dealt with might be not one factor, but an interplay between a combination of factors. Of course, what “best" be dealt with means will vary across individuals, perspectives (patient, doctor, being only two possibilities), the particular opportunities available at the time, and personal preferences and values. However, while much still remains to be learnt about the “cause” of most psychological disorders, including those resulting from childhood abuse and neglect, progress is being made in learning what particular issues must be addressed in treatment, and the interaction between factors that may be productive of optimal outcomes. Such therapeutic processes are likely different for different people. Whether or not you suffer “severe mental illness” as a result of childhood abuse and neglect, this blog has been setup to speak for the needs and rights of those who have suffered one or more types of abuse during their childhood – emotional / psychological, physical, or sexual abuse, and / or the neglect of their needs, with different forms of abuse tending to occur together in over 90 per cent of cases --- (Pears, Kim, & Fisher, 2008). Such vital needs would include the need for safety; the need for respectful, caring, non-violating forms of intimacy, appropriate for the individual's level of maturity and life experience; and the need to be able to relate to and trust those closest to oneself.
The majority of forms of trauma experienced by children are interpersonal – abuse perpetrated by members of their family or by those close to the family, war, community violence (van der Kolk, 2005) – available for download here – a paper I feel is remarkable for the degree of depth of compassion and accurate empathy and understanding it displays – I believe all those concerned with the nature of childhood developmental, and adult complex, trauma should read and have available for re-reading; clinicians would be interested in these slides from last year's webinar from the Mental Health Practitioners Network inn Australia -- [link]). Additionally, some people might not have suffered abuse or neglect per se but might have had their relationships with those closest to them disrupted, for example by the death or serious illness of those closest to them, and who later haven't been able to successfully recover from that loss or disrupted relationship (Mannorino & Cohen, 2011). Whatever the cause of loss of early attachment, secure early relationships are vital (Crittenden, 1995)for people's emotional, social and personal development, and disruption of early close relationships may later lead to later difficulties satrisfactorily entering into, and maintaining, satisfying and successful interpersonal, work and social relationships as well as individual functioning. As a result, some people may need improved understanding, of themselves and others, and enhanced social support and caregiving in many areas of their lives. Most people can safely take such relationships for granted as part of a ''normal'' everyday, healthy, and full life. Those with disrupted early relationships learn all too well that they cannot. I hope this blog can help you understand the processes by which abuse-related suffering, and the loss of early intimate relationships, affect later personal functioning, and further, which processes might help in recovery from these unfortunate experiences. Along the way I hope to increase the power of people who have survived such negative experiences so they may more fully enjoy the kind of life they want. Unless otherwise stated, I shall include “neglect” under the general term "abuse”, and loss of early intimate attachments under “neglect”-- there was no one there to provide the necessary emotional nurturing.
A variety of terms have been used to describe the effects of early childhood experience of trauma, loss and neglect. A more detailed discussion of diagnostic issues is available here In the current section, however, I only wish to say I have little time for current psychiatric diagnostic practices for those with histories of childhood abuse and receiving inadequate care. Much of it is based on atheoretical enumeration of behavioral features (signs and symptoms) without much attempt at “understanding in context”. More broadly theoretically, for some time, the bulk of the published research has focused on the effects of childhood sexual abuse, especially for women. Of particular note, Finkelhor and Browne developed a Traumagenic Dynamics Model (1985) that highlighted the role of traumatic sexualization, betrayal, stigmatization, and powerlessnes in the development of traumatic reactions to sexual abuse. More recently (van Harmelen et al, 2010), research has highlighted the great impact of non-sexual forms of abuse, in particular emotional abuse, in producing trauma reactions, with these forms of abuse having an impact at times even greater than that of ''sexual abuse'' – although here, clearly, we can see the at times artificially distinct lines between different forms of abuse – how easily can we distinguish between sexual and emotional abuse, with the former clearly involving violation of emotional boundaries (betrayal) – here I can only suggest you read the papers citing such effects to see how the researchers have tried to deal with this question.
CHILDHOOD ABUSE & NEGLECT AND LATER HEALTH OUTCOMES
Sadly, childhood abuse and neglect may have not only immediate but very long lasting, significant. and wideranging psychologically damaging effects [Briere & Elliott, 1994; Briere, Kaltman & Green, 2008] they may also contribute to a range of physical health disorders. Some of the earliest large-scale research was the Adverse Childhood Experiences Study by the insurer Kaiser Permanente (Felitti, Anda, et al 1998). In this study, with similar findings more recently being found in several others, the PREVALENCE of a range of childhood adverse experiences was found to be much higher than previously realised: eleven per cent of the sample were found to have been emotionally abused, thirty per cent physically abused, twenty per cent sexually abused, twenty-three per cent had been exposed to family alcohol abuse, nineteen per cent had been exposed to mental illness, five per cent had been exposed to family drug abuse, and thirteen per cent had witnessed their mother being battered. The study confirmed earlier investigations that found a highly significant relationship between adverse early experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, obesity, physical inactivity, and sexually transmitted diseases. Moreover, the more adverse experiences reported, the greater the severity and types of psychological disorders they later experienced, and the more likely they were to report problems of heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease.CHILDHOOD ABUSE AND NEGLECT -- LEGACY OF SHAME
Results obtained locally, from the Dunedin long term developmental study are consistent witht the seminal study of Felitti et al and continue to show these effects of early adverse experiences. This is not to suggest that all forms of ''abuse“, defined external to the supposed victim, “cause”, by themselves, directly and independently, trauma or psychological damage – this is a huge, vastly important question, but one best answered, perhaps, on another day. For the sake of brevity, I wish now only to cite Wilson, Drozdek, and Turkovic (2006) -- [link] who, in reviewing the results of several studies, concluded that the effects of abuse are often due to experiences of shame and guilt, particularly in terms of how these emotions influence a victim's experience of “self” through:
- self-attribution processes (the person blames him/her self for bad experiences)
- emotional states and capacity for emotion self-regulation (such as being able to stop or control emotional pain being experienced) -- [link]
- appraisal and interpretation of actions (in part related to the difficulty accurately recognising others' emotional responses, and confusion over the real "cause" of a situation)
- the impact of states of shame and guilt on personal identity (with related poor view of oneself and a sense of unworthiness)
- suicidality (and related feelings of hopelessness, and helplessness, lack of power, or worthiness to bring about a better outcome for oneself)
- defensive patterns (especiallly forms of primitive psychological defenses against perceived attack or feeling of being “at risk”
- proneness to psychopathology (mental illness, including anxiety and depression) and PTSD
- the overall dimensions and “conformation” of the self-structure affected by shame and guilt
I'll be examining these and related processes in future writings, suggesting that focusing on them in the course of therapy may provide a useful agenda for therapy compared to some morein terms of diagnostic labels. This issue is explored in more detail in the proposal by the US National Child Traumatic Stress Network for the inclusion of a diagnosis for children and adolescents in the forthcoming DSM-V. For now, I wish only to highlight the significance of such psychological processes in the development of what van der Kolk (2005) has called “Developmental Trauma Disorder”.
DISORDER DUE TO CHILDHOOD ABUSE AND NEGLECT -- DEVELOPMENTAL TRAUMA DISORDER (DTD)
van der Kolk and colleagues have suggested the following set of diagnostic criteria for DTD, with a similar set of features for DESNOS:
- A. Exposure. The individual as a child or adolescent experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
- A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
- A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse
- B. Affective and Physiological Dysregulation. The individual exhibits impaired normative competencies related to arousal regulation, including at least two of the following:
- B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme temper outbursts, or immobilization
- B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds;disorganization during routine transitions)
- B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states
- B. 4. Impaired capacity to describe emotions or bodily states -- Recent research (Lee et al., 2012) has indicated that there is an underlying neuroendocrinological basis, similar to that of chronic PTSD, for this physiological dysregulation; present even when the individual with a history of childhood trauma currently is not suffering from depression or PTSD, thus clearly providing a basis for a “diathesis” and ongoing vulnerability to the effects of stress.
- C. Attentional and Behavioral Dysregulation: The individual exhibits impaired normative competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
- C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
- C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
- C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation, alcohol or substance abuse, gambling, gorging/purging/bulimia)
- C. 4. Habitual (intentional or automatic) or reactive self-harm
- C. 5. Inability to initiate or sustain goal-directed behavior
- D. Self and Relational Dysregulation. The individual exhibits impaired normative competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
- D. 1. Intense preoccupation with safety of the partner or other loved ones
- D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
- D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with others
- D. 4. Reactive physical or verbal aggression toward others
- D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on others for safety and reassurance
- D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others
- E. Posttraumatic Spectrum Symptoms. The individual exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.-- symptoms involving reexperiencing of the traumatic event (Criterion B); symptoms involving avoidance of, or emotional numbing in the presence of trauma-related stimuli (Criterion C), and symptoms involving hyperarousal (Criterion D).
- F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E for at least 6 months.
- G. Functional Impairments. The disturbance causes clinically significant distress or impairment in at least two of the following areas of functioning:
- -- Scholastic: under-performance, non-attendance, drop-out, failure to complete degree/credential(s), conflict with school / college or University personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
- -- Familial: conflict, avoidance/passivity, excessive attachment or detachment from family members, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
- -- Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age inappropriate affiliations or style of interaction.
- -- Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
- -- Health: physical illness or problems that cannot be fully accounted for by physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.
- -- Vocational : disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.
Clearly, Criteria A are purposely, and appropriately, restrictive, and many other individuals will present with similar psychological difficulties, whilst not meeting all of these criteria, as a result of suffering less severe forms of abuse and emotional deprivation, as will many of those having such other commonly occurring conditions as borderline personality disorder, depression and anxiety disorders including PTSD (see Lewis & Grenyer, 2009). I anticipate considerable controversy over this listing of features, as I have borrowed directly from the features of Developmental Trauma Disorder for children and adolescents, but similar problems seem to be experienced by those suffering from “Complex Trauma”, a possible adult form of DTD. There is currently no available DSM or ICD classification for adults matching these criteria, and we are awaiting developments in the forthcoming DSM V, and such classification has been the subject of much discussion (see for example Friedman et al). Much research still needs te be done examining this issue but these features seem common in those who progress to the adult penal correctional system – also see Spermon, Darlington, and Gibney (2010) for a more detailed examination of adult complex trauma, and treatment issues from a psychodynamic perspective.
The introduction of the diagnosis of Developmental Trauma Disorder remains controversial -- see Schmid et al (2013) [LINK] and my Blog Post here [LINK]
LOCAL RECOGNITION AND ACCEPTANCE OF THE PROBLEM
-- MY EXPERIENCE
By “local” I am referring to the situation in Australia and New Zealand, and most particularly in Dunedin in New Zealand's South Island. I have suffered personally from the complications of complex trauma throughout my life (see section My Story). Despite these challenges I was able to achieve, academically and vocationally, before repeated problems with work relationships lead me to give up on my career, but continuing with private research and social service activities, such as this blog. Throughout my several hospitalisations, no clinician has ever comprehensively assessed and tried to help me deal with my trauma issues – eventually I attracted diagnoses of “major depressive disorder”, “alcohol dependence”, and “personality disorder” (see section on Diagnosis – no clinician, despite all the literature available to them, has ever joined the dots together to come up with the “answer = complex trauma” equation. No clinician has ever given me the diagnosis of Posttraumatic Stress Disorder (PTSD) – even though PTSD often co-occurs with substance use, depressive and other disorders. Clearly, if my experience is like that of others, there must be very very few clinicians who have developed the knowledge to diagnose, appropriatel, adults with histories of childhood abuse andn neglect. In learning to cope with the effects of these experiences, unfortunately, I have had to be mostly by trial and error, mostly error.