the lasting impact of childhood emotional neglect

the lasting impact of childhood emotional neglect

At this point, hopefully most of us are on the same page that physical or sexual abuse of a child is wrong (read: as morally repugnant as it gets) and incredibly harmful to them long-term. If you're not yet familiar with the term "Adverse Childhood Experiences" (ACEs) or the landmark ACEs study done by CDC and Kaiser, taking a few minutes to explore these will help you understand the link between early childhood trauma and the majority of our societal and public health issues — like substance abuse, depression, and the cycles of poverty and violent crime, to name just a few.

While some people who enter into therapy know they have endured traumatic experiences (and might also know that these experiences are at the root of the other things they struggle with, like anxiety, an eating disorder, or relationship issues), many others have minimized their childhood experiences to an extent that they are not "connecting the dots" with how they are still being impacted by the things that happened (or should have happened and didn't) in their early years of life. 

The Risk of Overlooking Covert Trauma

Emotional abuse tends to be a particularly slippery issue. For instance, if someone is physically or sexually abused during childhood and doesn't know at the time that this was wrong and not "normal," often they learn this fairly early in adulthood. (Though due to the internalized shame of abuse, sometimes it takes increasing pain from dysfunctional coping behaviors before a person is ready to enter therapy for help.) Hopefully with this recognition, and the support of a skilled trauma therapist, the wounds they need to heal are fairly evident, and the path for healing, though not easy, is clear.

With emotional abuse and neglect, however, the experience is often more covert, and thus harder to identify as the root cause of whatever present-day issues someone is struggling with. Sure, some types of emotional abuse are more overt; but again, hopefully in these cases the person is aware that what was happening was not okay, and then has the opportunity to heal. But many times, the impact of more subtle forms of emotional abuse or neglect are like a rust that erodes a person's sense of self (healthy ego development) over time, until she takes on a world view that she is inadequate, does not matter, cannot trust others, will not be loved if others find out who she really is, and basically, better be able to figure things out on her own. She may not make the connection that the impact of a highly critical grandfather and workaholic mother is still impacting her beliefs about herself 25 years later. (And if no one ever helps her to make that connection and do the healing work, she will likely struggle with feeling like no amount of affirmations, anti-depressants, and cognitive behavioral therapy ever seems to help, so she must be right about herself that she's just fundamentally flawed.) 

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what everyone should know about trauma and trauma resolution

Trauma robs you of the feeling that you are in charge of yourself, [or what is referred to as 'self-leadership'.] The challenge of recovery is to reestablish ownership of your body and your mind — of your self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed.  - Bessel van der Kolk

Recently, I finished reading Bessel van der Kolk’s new book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. I can’t recommend it enough; the book is incredibly well-written and accessible, and an equally important read for clinicians, trauma survivors, and their loved ones. This post is not intended to be a comprehensive review of the book, but rather a few points that I wanted to pull out and highlight to convey some of the “big picture” ideas about traumatic stress and trauma resolution.

Why Diagnosing Trauma Matters

As a psychiatrist at the Veterans Administration (VA)  in the late 1970’s, van der Kolk witnessed first-hand the impact of traumatic stress on vets returning from Vietnam. At that point, there was no diagnosis for traumatic stress, and very little research into the impacts of trauma on the functioning of mind and body, or how to successfully treat the symptoms these vets were struggling with. In 1980, a group of researchers and clinicians lobbied the American Psychological Association (APA) to include Post-Tramatic Stress Disorder (PTSD) in the DSM-III (third edition of the Diagnostic and Statistical Manual of Mental Disorders). (Gotta love the alphabet soup of healthcare, eh?) The creation of this new diagnosis resulted in a flurry of interest and funding for research and the development of effective interventions for treating post-traumatic stress.

Thirty-five years later, thanks to a wealth of research as well as major advancements in neuroscience, we know a lot about how trauma affects the mind and body and how to effectively treat it. But we’re far from done. Many studies have pointed to the need for additional trauma-based diagnoses, as traumatized individuals don’t all fall into one homogenous category. Different types of trauma impact the body and brain in different ways, and a one-size-fits all diagnostic and treatment approach is woefully insufficient. One study found that traumatized people fell into three basic groups: those with histories of childhood physical or sexual abuse by caregivers, recent victims of domestic violence, and people who had recently been through a natural disaster. The failure of the APA to acknowledge a need for additional diagnoses like Developmental Trauma Disorder (DTD) and Complex PTSD (also known as DESNOS, Disorders of Extreme Stress, Not Otherwise Specified for victims of interpersonal trauma) has a very real impact, as a lack of sufficient funding for research and treatment directly impacts individuals struggling with traumatic stress that do not fit in the “traditional PTSD” box. I will avoid going off on a tangent about just how broken the DSM is, but suffice to say that the American Journal of Psychiatry and the National Institute of Mental Health have both published strong criticisms of the DSM-V, with NIMH’s president stating that the agency could no longer support DSM’s “symptom-based diagnosis.”

One of the topics that fascinated me most in The Body Keeps the Score was the information van der Kolk presents about DTD. I could see so many of my clients in his case studies and descriptions of how traditional mental health treatment fall short for these individuals. He makes a compelling case for child abuse as our nation’s largest public health problem, and as a therapist working with traumatized clients, I couldn’t agree more. So, whether the DSM ever gets on board or not, clinicians need to acknowledge these distinctions and the unique needs of trauma survivors that may not look like the “typical” PTSD patients. Where do we start?

“Top-Down” and “Bottom-Up” Regulation

Van der Kolk asserts that, when your brain has been impacted by traumatic stress and the areas responsible for emotion regulation are out of whack, we essentially have three choices for how to help our brain regulate, utilizing its own natural neuroplasticity. Some of the examples of treatment modalities and interventions below actually combine two or all three of these, and trauma survivors almost always need a combination of these rather than just one in order to achieve regulation.

1) Top-down regulation (via modulating messages from the medial prefrontal cortex):This type of regulation involves “talking, re-connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma.” It's also about strengthening your mind’s ability to monitor your body’s sensations, so mindfulness, meditation, and yoga can be helpful interventions. More traditional methods of psychotherapy such as Cognitive Behavioral Therapy (CBT), and coping skills training like Dialectical Behavior Therapy (DBT) can be valuable for this type of regulation as well, but it’s important to remember that talk therapy alone is not enough for trauma resolution.

2) Working directly with the brain: This can be achieved through taking psychiatric medications that “shut down inappropriate alarm reactions” or utilizing technologies such as neurofeedback and eye movement desensitization and reprocessing (EMDR) that fundamentally change the way the brain organizes information.

3) Bottom-up regulation (via the reptilian brain, specifically the amygdala): This type of regulation focuses on "allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.”  From a neuroscience perspective, it involves recalibrating the autonomic nervous system, which can be accessed through breath, movement, or touch. Thus, interventions such as breath work, dance, massage, somatic and experiential therapies, and utilizing biofeedback (for example, to improve heart rate variability) can be very effective. Yoga is also valuable for bottom-up regulation, as it is proven to significantly improve arousal problems in traumatized individuals, increase self-awareness and self-regulation, and cultivate interoception by "gaining a relationship with the interior world, and with it a caring, loving, sensual relationship to the self.”

What Does it All Boil Down To? 

At the end of the day, trauma treatment is about helping people to:

  • find a way to become calm and focused;
  • learn to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind them of the past;
  • find a way to be fully alive in the present and engaged with the people around them; and
  • not have to keep secrets from themselves, including secrets about the ways they have managed to survive (often self-destructive behavior patterns that originated as protective defenses.)

As van der Kolk reminds us, “these goals are not steps to be achieved, one by one, in some fixed sequence. They overlap, and some may be more difficult than others, depending on individual circumstances.”

I was tremendously inspired by this book, as it validated many of the trauma treatment methods we use with clients on a daily basis at The Ranch, and helped me understand more about the neuropsychological underpinnings of both trauma and trauma recovery. I’m also excited to get my EMDR certification later this year as well as start yoga teacher training in the fall. We need a lot more clinicians who understand the “big picture” of trauma treatment based on the most recent research, and are open to the wide range of holistic interventions to help people find health and healing in mind, body, and spirit.

Is trauma a topic that interests you, and/or has touched your own life? I’d love to hear any thoughts, questions, or stories you’d like to share. Leave a comment or drop me a line at valerie@wakingupinwonder.com