I have long felt that psychosis is more adequately understood when it is seen as the most extreme form of dissociation - a need so intense that it is not the body, or emotions, or memories that are dissociated, it is reality itself.

Although it is reality that is dissociated (through delusions, hallucinations, paranoia, and cognitive distortions), it is fundamentally the emotions that are most important in making sense of the psychotic features and in bringing the client back. I have no doubt that meds are important for some, but not everyone benefits from the psychological numbing effects of the atypical antipsychotics.

What my clients have taught me is that the key to recover is to reclaim the body, and with it the emotions that are so painful the person needed to create a different reality, where the client is often a different person, with different origins, and who is much more important in some ways than they ever were in their "normal" life.

This is a free article (until the end of December) from the International Forum of Psychoanalysis in which Lawrence Kirshner offers a psychoanalytic take on psychosis and its roots in trauma (follow the links to read online or download).

Full Citation:
Kirshner, L.A. (2013, Jun 4). Trauma and psychosis: A review and framework for psychoanalytic
understanding. International Forum of Psychoanalysis, DOI: 10.1080/0803706X.2013.778422

Trauma and psychosis: A review and framework for psychoanalytic understanding

Lewis A. Kirshner

• Published online: 04 Jun 2013

Abstract

Empirical research substantiates Ferenczi's conception of the etiological importance of early neglect and abuse in the development of psychosis. Abuse can derail the development of language, identity, and social relationships that are intrinsic to schizophrenia, possibly through undermining secure attachment relationships. The Lacanian emphasis on language and early proto-dialogues with the Other can be useful in understanding this process. Some therapeutic implications for psychoanalytic approaches to the treatment of psychosis are proposed.

• View full text
• Download full text

 Here is a bit from a section further down in the article.

Development of language, the symbolic, and attachment

 

To understand how trauma and neglect may result in schizophrenic disorders, we need to connect the typical deficits and symptoms of psychosis with developmental processes. The importance of access to language seems a promising avenue, as positive symptoms in schizophrenia are only identified and reported as speech or thoughts, and the ability to use relationships with others to modulate traumatic experience or to act as a barrier to it depends on the use of semiotic functions. Within psychoanalysis, Lacan was perhaps the most important theorist to hypothesize an inability to use language as the source of psychotic symptoms, notably as the basis for hallucinations and delusions, which are language-dependent entities (see Sauvagnat, 2003, and Vanheule, 2011, for discussions of this model). Of course, the concept of a thought disorder (in fact, a speech disorder) has been a basic feature of schizophrenia since Bleuler's work, and, recalling Crow's hypotheses, subjectivity depending on speech may be our key species characteristic, closely related to important developmental concepts such as theory of mind and intersubjectivity that have also been linked to schizophrenia (Lysaker, Outcault, & Ringer, 2010).

 

And this is from a later section.

 

Treatment issues

 

Research by Karon and Bos (cited in Ver Eecke, 2003) found that experienced clinicians were more successful with schizophrenic inpatients, especially over longer time periods. One explanation for this result may be the greater ability of experienced therapists to build a relationship with psychotic patients, which can take a long time. In general psychiatry, there is a growing recognition that individually designed approaches to treatment can be quite helpful (Mojtibai et al., 1998; Shean, 2009), suggesting the uniqueness of each therapeutic couple's construction of basic communication links. The difficulty of building alliance and trust with psychotic subjects has been emphasized by many psychoanalytic practitioners and suggests why the application of classic forms of analytic treatment may be misguided.

 

The focus of psychoanalysis on the individual subject, however, does provide the cornerstone of a psychotherapeutic approach, although the techniques of treatment may be far from traditional models (e.g., Abensour, 2008; Benedetti, 2011; Lucas, 2009). The psychotic is a person, a subject like anyone, but his subjectivity may take unusual and cryptic forms that can discourage clinicians from pursuing a treatment relationship. Lacan (1993) wrote in a late seminar about helping psychotics to ground their subjectivity through creative processes, making something new that establishes their identity through an object. In a similar approach, Abensour (2011) described how creative writing served as a kind of anchor in reality for many of her patients who suffered from the dilemma of a floating self, disconnected from the body, a past history, and relationships with others. Creative products acquire a real existence in time (like the transitional object) that can confirm the continuity of the subject and express its inner states.

A recently developed model (late 1990s) for assessing early childhood experience as it relates to adult physical and mental health is the Adverse Childhood Experiences (ACE) assessment (Felitti, et al., 1998; get your score here). The ACE scale identifies ten forms of adverse childhood experience (occurring before the age of 18): (1) verbal and emotional abuse, (2) physical abuse, (3) sexual abuse, (4) emotional neglect, (5) physical neglect, (6) battered parent (originally included as “battered mother”), (7) household substance abuse, (8) household psychological distress, (9) parental separation or divorce, and (10) criminal household member(s) (Dong, et al., 2003). The more ACEs that have been experienced, the greater the risk for later life health issues (Weiss & Wagner, 1998), including heart disease (Dong, et al., 2004), obesity (Williamson, et al., 2002), cancer (Brown, et al., 2010), drug use (Dube, et al., 2003), suicide risk (Dube, et al., 2001), smoking (Anda, et al., 1999), and psychological distress (Anda, et al., 2007; Chapman, et al., 2004; Chapman, et al., 2007; Edwards, et al., 2003), among many others (Felitti, et al., 1998, Felitti, 2002).

None of this deals with the intense mental distress (depression, anxiety, PTSD, psychosis) than can result from ACEs.

The new study below shows that the impact of ACEs can be mitigated by mindfulness meditation.  

References

1. Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. & Marks, J.S. (1998, May). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine; 14(4):245-58.
2. Maxia Dong, M., Anda, R.E., Dube, S.R., Giles, W.H., and Felitti, V.J. (2003). The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect, and household dysfunction during childhood. Child Abuse & Neglect; 27: 625–639.
3. Weiss JS, Wagner SH. (1998). What explains the negative consequences of adverse childhood experiences on adult health? Insights from cognitive and neuroscience research (editorial). American Journal of Preventive Medicine; 14:356-360.
4. Dong M, Giles WH, Felitti VJ, Dube, SR, Williams JE, Chapman DP, Anda RF. (2004). Insights into causal pathways for ischemic heart disease: Adverse Childhood Experiences Study. Circulation; 110:1761-1766.
5. Williamson DF, Thompson TJ, Anda RF, Dietz WH, Felitti VJ. (2002). Adult Body Weight, Obesity, and Self-Reported Abuse in Childhood. International Journal of Obesity; 26: 1075–1082.
6. Brown DW, Anda RA, Felitti VJ, Edwards VJ, Malarcher AM, Croft JB, Giles WH. (2010). Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study. BMC Public Health; 10: 20-32.
7. Dube SR, Anda RF, Felitti VJ, Chapman DP, Giles WH. (2003). Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study. Pediatrics; 111:564-572.
8. Dube SR, Anda RF, Felitti VJ, Chapman D, Williamson DF, Giles WH. (2001). Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span: Findings from the Adverse Childhood Experiences Study. Journal of the American Medical Association; 286:3089-3096.
9. Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, Williamson DF, Giovino GA. (1999). Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association; 282:1652-1658.
10. Felitti VJ. (2002). The relationship between adverse childhood experiences and adult health: Turning gold into lead. The Permanente Journal; 6:44-47.

Here, then, is the article (a summary press release of the original article, which is behind a paywall).
 

Mindfulness protects adults' health from the impacts of childhood adversity

Date: September 13, 2014
Source: Temple University

Summary:
Adults who were abused or neglected as children are known to have poorer health, but adults who tend to focus on and accept their reactions to the present moment—or are mindful—report having better health, regardless of their childhood adversity, researchers report.

Adults who were abused or neglected as children are known to have poorer health, but adults who tend to focus on and accept their reactions to the present moment -- or are mindful -- report having better health, regardless of their childhood adversity. These findings, to be published in the October issue of Preventive Medicine, are based on the first study ever conducted to examine the relationship between childhood adversity, mindfulness, and health.

Led by Robert Whitaker, professor of public health and pediatrics at Temple University, the researchers surveyed 2,160 adults working in Head Start, the nation's largest federally-funded early childhood education program.

Survey respondents, who worked in 66 Pennsylvania Head Start programs, were asked if they experienced any of eight types of childhood adversity, such as being abused or having a parent with alcoholism or drug addiction. In addition, respondents were asked questions about their current health, as well their mindfulness, meaning their tendency in daily life to pay attention to what is happening in the moment and to be aware of and accepting of their thoughts and feelings.

Nearly one-fourth of those surveyed reported three or more types of adverse childhood experiences, and almost 30 percent reported having three or more stress-related health conditions like depression, headache, or back pain, noted the researchers. However, the risk of having multiple health conditions was nearly 50 percent lower among those with the highest level of mindfulness compared to those with the lowest. This was true even for those who had multiple types of childhood adversity.

Regardless of the amount of childhood adversity, those who were more mindful also reported significantly better health behaviors, like getting enough sleep, and better functioning, such as having fewer days per month when they felt poorly -- either mentally or physically, said Whitaker.

"Our results suggest that mindfulness may provide some resilience against the poor adult health outcomes that often result from childhood trauma," he said. "Mindfulness training may help adults, including those with a history of childhood trauma, to improve their own well-being and be more effective with children."

While many smaller studies have shown that learning mindfulness practices like meditation can improve psychological and physical symptoms such as depression and pain, more research is needed to see if interventions to increase mindfulness can improve the health and functioning of those who have had adverse childhood experiences, Whitaker said.

With nearly two-thirds of U.S. adults reporting one or more types of adverse childhood experiences, Whitaker noted that "mindfulness practices could be a promising way to reduce the high costs to our society that result from the trauma adults experienced during childhood."

The findings are a follow-up to the researchers' previous study which found that women working in Head Start programs reported higher than expected levels of physical and mental health problems. That study was published in 2013 in the journal Preventing Chronic Disease.


Story Source:
The above story is based on materials provided by Temple University. Note: Materials may be edited for content and length.

Journal Reference:
Robert C. Whitaker, Tracy Dearth-Wesley, Rachel A. Gooze, Brandon D. Becker, Kathleen C. Gallagher, Bruce S. McEwen. (2014). Adverse childhood experiences, dispositional mindfulness, and adult health. Preventive Medicine; 67: 147 DOI: 10.1016/j.ypmed.2014.07.029

This is an old (1997) NOVA documentary from PBS on one of the classic cases of a feral child. "Genie" was isolated and neglected in every possible way (other than barely enough food and water to keep her alive), and when discovered she was unable to speak and presented more as a wild animal than a 13-year-old girl.

Her case, and a handful of others, revealed that there is an age "cap" of socialization and language, after which it is nearly impossible to alter the brain and behavior. It also demonstrates how important the attachment system is in allowing infants to become human beings - in many ways, Genie was never fully human. 

Her case highlights the degree to which extreme neglect can destroy a human being. I have seen this film several times over the years, and it tears my heart each time I see it.

Genie: Secret of the Wild Child

NOVA Documentary | 1997 | Transcript



This is an Emmy Award-winning documentary about a girl who spent her early life chained in a bedroom. Brought up in confinement, "Genie" was primitive, brutish, and hardly capable of walking or talking. NOVA follows the contentious attempts to unbolt the secret of the wild child who has reached near maturity in an agonizing seclusion with almost no human contact.

The story begins in Los Angeles on November 4, 1970, when authorities have taken under protection a thirteen-year-old girl that was kept in such solitude imposed by her parents that she never even learned to talk. The parents have been accused of child abuse.

Genie was imprisoned in a bedroom and bound to a potty chair for the most of her early life. Fully kept under control, she was made to sit alone every day and night. She had almost nothing to look at and no one to talk to for more than a decade. The girl allegedly was emitting immature noises and was still in diapers when social workers found out about the case, but the officials were anticipating she may still possess a normal ability to learn.

The girl who gave an impression of an infant would be well known as "Genie." She was transported to Children's Hospital in Los Angeles where she instantly gained the affection of doctors and scientists. She was delicate, lovely and poignant... and Genie was about to put on trial an idea paramount to science and society: that caring, encouraging and affectionate environment could make up for even the most brutal past.

Genie had an awkward walk and other almost non-human features. She continuously spat, sniffed, and clawed. She hardly articulated anything or produced any noises. Investigation showed that she was abused for making noise and as a consequence, had learned, basically, not to vocalize. And she really didn't speak at all. She was mute most of the time.

Watch the full documentary now

We have known for quite a while that children who experience abuse and/or neglect in childhood are more likely to have metabolic disorders as adults (i.e., be overweight, have type-II diabetes, high blood pressure, and so on). The mechanisms of action have not been clear, other than an awareness that it involves inflammation.

The researchers looked at the weight-regulating hormones leptin, adiponectin, and irisin (as well as the inflammatory marker C-reactive protein) in the blood of adults who endured physical, emotional, or sexual abuse or neglect as children. They found that early-life adversity is directly associated with elevated circulating leptin and irisin, and indirectly associated with elevated CRP and decreased adiponectin.

Abuse Alters Hormones in Kids, Hikes Risk of Metabolic Disorders

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on March 21, 2014

 

A new endocrinology investigation suggests childhood abuse or neglect can lead to long-term hormone impairment that raises the risk of developing obesity, diabetes, or other metabolic disorders in adulthood.

The study is published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism (JCEM).

For the study, researchers examined levels of the weight-regulating hormones leptin, adiponectin, and irisin in the blood of adults who endured physical, emotional, or sexual abuse or neglect as children.

Leptin is involved in regulating appetite and is linked to body-mass index (BMI) and fat mass. The hormone irisin is involved in energy metabolism. Adiponectin reduces inflammation in the body, and obese people tend to have lower levels of the hormone.

Researchers found that these important hormones were out of balance in people who had been abused or neglected as children.

“This study helps illuminate why people who have dealt with childhood adversity face a higher risk of developing excess belly fat and related health conditions,” said one of the study’s authors, Christos S. Mantzoros, M.D., D.Sc., Ph.D.

“The data suggest that childhood adversity places stress on the endocrine system, leading to impairment of important hormones that can contribute to abdominal obesity well into adulthood.”

The cross-sectional study examined hormone levels in the blood of 95 adults ages 35 to 65. Using questionnaires and interviews, each participant was assigned a score based on the severity of the abuse or neglect experienced during childhood.

Researchers divided the participants into three groups and compared hormone levels in people with the highest adversity scores to the other two-thirds of the participants.

Participants with the highest adversity scores tended to have higher levels of leptin, irisin, and the inflammatory marker C-reactive protein in their blood. All of these markers are linked to obesity.

In addition, the group of people who suffered the most adversity tended to have lower levels of adiponectin, another risk factor for obesity.

Even after researchers adjusted for differences in diet, exercise, and demographic variables among the participants, high levels of leptin and irisin continued to be associated with childhood adversity.

“What we are seeing is a direct correlation between childhood adversity and hormone impairment, over and above the impact abuse or neglect may have on lifestyle factors such as diet and education,” Mantzoros said.

“Understanding these mechanisms could help health care providers develop new and better interventions to address this population’s elevated risk of abdominal obesity and cardiometabolic risk later in life.”

Source: The Endocrine Society

* * * * *

Early Life Adversity Is Associated With Elevated Levels of Circulating Leptin, Irisin, and Decreased Levels of Adiponectin in Midlife Adults

Kyoung Eun Joung^*, Kyung-Hee Park^*, Lesya Zaichenko, Ayse Sahin-Efe, Bindiya Thakkar, Mary Brinkoetter, Nicole Usher, Dorothy Warner, Cynthia R. Davis, Judith A. Crowell, and Christos S. Mantzoros

DOI: http://dx.doi.org/10.1210/jc.2013-3669

Abstract

Context:

Early-life adversity, defined as physical, emotional, or sexual abuse and neglect before 18 years of age, is associated with metabolic syndrome, obesity, and type 2 diabetes mellitus in adult life. However, the underlying mechanism is not fully understood, and whether adipomyokines are associated with early-life adversity independent of other factors such as body mass index, psychosocial risks, and health behaviors is not known.

Objectives:

The objective of the study was to evaluate the association between early-life adversity and circulating the levels of the adipomyokines such as leptin, adiponectin, and irisin and the inflammatory marker, C-reactive protein (CRP).

Design/Subjects/Setting:

This study was a cross-sectional study of 95 adults at a university-based research center. We collected venous blood from participants and analyzed serum for leptin, adiponectin, irisin, and CRP.

Results:

Circulating leptin, irisin, and CRP levels were significantly higher in the highest adversity tertile group compared with low and middle tertile groups (P < .001 for leptin, P = .01 for irisin, and P = .02 for CRP). Adiponectin levels were lower in the highest tertile group compared with the low and middle tertile groups (P = .03). After adjusting for demographic variables, physical activity, diet, current mental health, and body mass index, the associations between early-life adversity leptin, irisin, and did not change. However, adiponectin and CRP levels were no longer significantly related to early life adversity.

Conclusion:

Early-life adversity is directly associated with elevated circulating leptin and irisin, and indirectly associated with elevated CRP and decreased adiponectin. These findings suggest that these adipomyokines may play a role in the pathogenesis of metabolic abnormality in a population with significant early life adversity.

Bessel van der Kolk - The Body Keeps the Score (Part Two)

The title of this talk is the nearly identical to that of a new book from Bessel van der Kolk due out in June, 2014 The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (pre-order at Amazon). I will be excited to see this new work - his research in the recent years has focused on yoga, tapping (Emotional Freedom Technique), chi gong, and neurofeedback, among other body-centered modalities for healing trauma.

What follows are my notes, as best as I can make them sensible from yesterday's 3 hour talk. This is part two - part one is here. This second installment is more than half of the talk and it gets into the neuroscience a lot more.


The Body Keeps the Score, Part II

Mental illness is now conceived of as a dysfunction in brain wiring or function. However, 80-90% of our brain function is outside of our conscious control (fast thinking, or Type I), and only 10-20% of our brain function is consciously controlled (slow thinking, or Type II). [I am including the references to Daniel Kahneman's work, BvdK didn' t make these references].

Our brain stem does the basic housekeeping in the brain - controlling arousal, sleep, breathing, food/elimination, and chemical balance, among other things. In working with trauma, these core regulation functions must be stabilized BEFORE we can do any kind of deeper work. All of these functions, however, are outside of our verbal influence - we cannot talk our way to better sleep or out of hyper-arousal. Traditional talk therapy is helpless to reset these physiological regulatory functions.

Development

The limbic system comes online at birth and develops extensively through about age six, after which the primate brain is more the developmental focus. The limbic system controls right brain function (see Allen Schore), including affect regulation, interpersonal skills, and the core map of our self in relation to the world. [When Schore writes about affect dys/regulation and the development of the self, he is basically outlining the ways trauma impacts this core self map.]

Survivors of incest or molestation, and/or extreme neglect often talk about how they are evil or damaged or worthless. When we tell them that is not true, it can make them feel even worse, more alone and misunderstood - despite our good intentions, we have just told them again how wrong they are, even about their own reality. They need for us, as their therapists, to get how ugly they feel about themselves, how ugly their core self map really is.

We need to help them go inside themselves with an adult ego and notice what happened to them without dissociating or avoiding. There is no need to relive the memories, only to witness them as an observer (the reliving of a memory is known entering the memory field). If they bring adult awareness to wounded child-part of themselves, it becomes easier to regulate the core brain stem functions. [This is the foundation of self compassion training.]

Brain Anatomy

According to Antonio Damasio, fear is held in the cerebellum and brain stem (including the amygdala), but these systems are not accessible by the cerebral cortex or the prefrontal cortex. In addition, the insula (which plays a major role in sense of self, acting as an integration point between body systems and higher order functions), is nearly always damaged in trauma survivors.

Because of this, the core experiential self (Damasio's proto-self) gets hijacked by the trauma - yet this experiential self is essential in healing the trauma. The only way to heal this self through verbal approaches is to describe it in very precise sensory detail (smells, sounds, tastes, pressure on the skin, and so on). Again, this is a challenge because the left anterior prefrontal cortex (including Broca's Area) goes offline when the trauma system is activated, which limits the ability to talk about it.

When the trauma system is activated there is a shift to right brain function, including the amygdala, the insula, and the anterior temporal lobe. As this occurs, the dorsal lateral prefrontal cortex (site of working memory, integrating past, present, and future) goes offline, which is why we get stuck in the trauma as if we are always in that horrific moment/experience. Negative cognition's are often a form of verbal flashback to thoughts we had while in the neurochemical soup of the trauma experience.

The thalamus integrates sensory and temporal data into a story explaining who we are, where we are, and what we are doing. This process is seriously compromised in trauma so any sense data similar to the original sensory data triggers a flashback experience.

People who shut down or dissociate during the trauma experience can often remain in that state even while retelling their story - unless we can get them to focus on their interiority (interception) as experienced in sensory data during the traumatic event. In these survivors, brain activity throughout the whole brain is two standard deviations lower than the norm.

Emotional Freedom Technique

BvdK uses "tapping" to get dissociated people back into their bodies. EFT, which is based on pressure points, causes a decrease in limbic system activity, making it a solid grounding technology even where the verbal system fails. He is currently researching EFT, qi gong, chanting, and "om-ing," which seem to offer similar benefits.

Amygdala

The following information is based on a graph based on the work of Joseph LeDoux.

There are two pathways for threats to follow when they activate the limbic/amygdala (LA):

1. The threat can move from the LA to the basal ganglia, associated with movement, which leads to active coping (planning, action)

2. The threat can move from the LA to the central nucleus of the amygdala, which leads to passive coping (freeze, despondency). [BvdK did not mention this directly, but this what we often see in those with a number of adverse childhood experiences.]

Van den Kolk believes an amygdala stuck in these patterns can be rewired. Action resets the amygdala. Activities like boxing, tai chi, akido, and other martial arts are treatments, not simply physical activity. We need a visceral impact of something that felt bad (being connected to and in our bodies) now feeling good in order to rewire the amygdala. He is doing research on exactly this idea.

More information from Joseph LeDoux that supports BvdK's model:

As mentioned above, the dorsal lateral prefrontal cortex is where our working memory resides, as well as being the location of planning. It has no direct access to the amygdala and the limbic system, information out simply feeds back in.

However, the medial prefrontal cortex (and to a lesser extent, the posterior cingulate), which is where we process inner experience or interoception has a direct link to the amygdala and limbic system. This is the only system through which we can access and change our emotional self. This is the power of mindfulness practice, it's centered in the MPC. Dan Siegel is the current expert in this realm.

The moment of trauma often feels like forever because the dorsal lateral prefrontal cortex is offline during the initial trauma experience. The fact that Broca's Area also is offline during the experience means we have no words or language associated with the experience. We have images and other sense data, but not language.

The Body in Trauma

Trauma survivors often can't tell us where they feel things in their bodies. The body is too scary of a place to go into for them. We need to be persistent to get them to go inside, to activate the MPC. However, the earlier the trauma the harder it is to get them to go inside because they have no experience of interception that is not terrifying.

Part of the healing process involves helping them to feel safe in their own interior world, possibly for the first time. However, when clients go into the images, sounds, scents - into the wounding - the arousal system is activated, so we must monitor their reactions to keep them in the experience and not retreating into the story.

Trauma Repetition

BvdK has a theory that part of trauma repetition might be due to the release of endogenous opioid chemicals (about 8 mg worth) during the original trauma experience. Replaying the trauma activates all of them same brain chemicals as the original trauma, but in the absence of pain, the opioid drugs alter consciousness and can also generate nausea (many clients describe feeling sick after a replay of the original trauma.

Part of trauma repetition may be self-medicating with our own brain chemicals.

Internal Family Systems

BvdK has done considerable work with Richard Schwartz on his Internal Family Systems Therapy model, including appearances at the IFS conference. In this final piece of the talk, he brings in IFS as a way to work with emotions "exiled" in the body.

Allowing ourselves to feel the grief or fear or terror of the trauma and then use our adult self to comfort that wounded part of us brings the medial prefrontal cortex into connection with the trauma. It's somatic, experiential, and nonverbal.

Incest survivors almost universally hate and/despise the child part that was the victim of the molestation, which is likely true in survivors of repeated physical abuse or neglect.

These hated and despised parts of ourselves are known as exiles in the IFS model. It is the exile that holds the trauma memories and sensory data.

[ME: The psyche, through manager parts (pleaser, perfectionist, inner critic, for example) try to keep the exiled part locked a psychological closet, preferably forever. Should the managers fail, there are parts called firefighters whose job it is to jump into action and prevent those pesky exiles from breaking through into consciousness, usually through addictive behaviors (and even the addictive behaviors will one day fail.)

What Do Grown Children Owe Their Abusive Parents?

This article appeared in Slate a few weeks ago. I suspect this is a topic relevant to a lot of people out there, even some who read this blog. How adult children should relate to (if they should relate at all) their verbally and emotionally abusive and neglectful families is a tough topic that I deal with almost daily in my clients.

Even those who were not sexually or physically abused as children can be set up for that kind of abuse as teens or adults, often because of the emotional/verbal abuse they suffered from their parents. Generally this is the child that is scapegoated, or exiled, or otherwise made to feel "less than" his or her siblings.

We know that childhood sexual abuse often leads to adult sexual trauma, but I would wager that there are an equally high percentage of adult survivors who were, as children, neglected (physically or emotionally), verbally and/or emotionally abused, harshly criticized, subjected to inconsistent or extreme punishment, and any number of other forms of abuse.

It's easy for me to sit in these sessions and feel the person should cut all ties with those parents, and sometimes with the whole family of origin, but the client such an act if often unthinkable. I'd guess that only one in five are able to make that decision and stick to it. The other four keep hoping, from the perspective of a wounded child, that some day they will figure out how to make mom and/or dad love them. Giving up that hope - and mourning the loss of the parents they always needed - is simply not an option for them.

The Debt

When terrible, abusive parents come crawling back, what do their grown children owe them?

By Emily Yoffe | Posted Monday, Feb. 18, 2013

Illustration by Charlie Powell

What do we owe our tormentors? It’s a question that haunts those who had childhoods marked by years of neglect and deprivation, or of psychological, physical, and sexual abuse at the hands of one or both parents. Despite this terrible beginning, many people make it out successfully and go on to build satisfying lives. Now their mother or father is old, maybe ailing, possibly broke. With a sense of guilt and dread, these adults are grappling with whether and how to care for those who didn’t care for them.

Rochelle, 37, wrote to me in my role as Slate’s Dear Prudence because of the pressure she was getting from friends to reach out to her mother. Rochelle is a banquet waitress in the Midwest. She has a boyfriend but lives alone and has no children. She and her younger brother grew up with an angry, alcoholic mother who was on welfare but cleaned houses off the books to supplement the check. Rochelle’s parents were never married and split when she was young. Her mother always told her not to have children. “We were the reason her life turned out as it did,” Rochelle says. She told Rochelle she was so stupid that she’d need to find a rich husband to support her. She said she couldn’t wait for Rochelle to turn 18 and get out of her house. Rochelle’s younger brother had difficulties from the start—she looks back and thinks he might have been autistic. Her mother used to take a belt to him and call him the devil and say she wished he’d never been born.

Rochelle started waitressing when she was 15. By 18, she was indeed out of the house and into an abusive relationship with an older man. She broke up with him, got her own apartment, a decent boyfriend, and started working to put herself through college. Then her brother was killed at age 18, shot in the heart during a silly fight over a girl. Rochelle stepped up and took care of all the funeral arrangements. Her father came and, when he left, hugged her goodbye. “That was the first time he ever hugged me,” she recalls. Her mother called later that night, drunk, and said that, by hugging her, Rochelle’s father was trying to molest Rochelle. Rochelle wrote her mother a letter saying she had a drinking problem and needed help. In response she got a letter saying that she was a horrible daughter and she would get what she deserved and that her brother was defective and needed to die.

That was Rochelle’s breaking point—after that, she didn’t see her mother for the next 13 years. Even though Rochelle was barely scraping by, she would sometimes send her mother money for rent, knowing she probably used it for booze. Occasionally, a friend would check on her mother and give her a report. Then last year a tornado struck the town where Rochelle’s mother lived, and Rochelle went to make sure she was all right. That began a sort of rapprochement. Rochelle started taking her mother out to lunch every other Sunday. She did it not because she felt she owed her mother anything: “Absolutely not.” Instead it was for her own sense of self. “To me being a good person means helping people when you can.”

The visits took a toll. Rochelle describes a physical response that sounds a lot like post-traumatic stress disorder. “All the stuff I tried to let go of seeps in. One little thing—the scent of her cigarettes, a mannerism, a word—floods back all these memories.” Rochelle started chewing gum on the drive to see her mother, she says, “because I’m clenching my jaw, white-knuckling the steering wheel.”

Rochelle found that being a good person to her mother was so draining that it left her sleepless and snapping at the people she did love. Her mother’s verbal abuse resumed and her demands started escalating—she wanted more attention, more money. Rochelle got a therapist, and with her help, has again cut ties with her mother. Rochelle says, “I can’t sacrifice my life and sanity in order to try to save her.”

In an essay in the New York Times, psychiatrist Richard Friedman writes that the relationship of adults to their abusive parents “gets little, if any, attention in standard textbooks or in the psychiatric literature.” But Rochelle is not alone. I have been hearing from people in her position for years, adult children weighing whether to reconnect with parents who nearly ruined their lives. Sometimes it’s a letter writer such as “Comfortably Numb” who has cut off contact with a parent but is now being pressured by family members, and even a spouse, to reconcile and forgive. Sometimes a correspondent, like “Her Son,” has hung on to a thread of a relationship, but is now fearful of being further yoked emotionally or financially to a declining parent.

One hallmark of growing up in a frightening home is for the children to think they are the only ones in such circumstances. Even when they reach adulthood and come to understand that many others have had dire childhoods, they might not reveal the details of their abuse to anyone. “The profound isolation that’s imposed on people is a very painful and destructive thing,” says Dr. Vincent Felitti, co-principal investigator of the Adverse Childhood Experiences Study. According to the Centers for Disease Control and Prevention, about 3.3 million cases of abuse or neglect were reported to child protective service agencies in 2010. This vastly undercounts the actual number of horrific and painful childhoods, as most never make it into any official record. The CDC notes that some studies estimate that 20 percent of children will be the victims of such maltreatment. That means a lot of people are wrestling with this legacy.

Loved ones and friends—sometimes even therapists—who urge reconnecting with a parent often speak as if forgiveness will be a psychic aloe vera, a balm that will heal the wounds of the past. They warn of the guilt that will dog the victim if the perpetrator dies estranged. What these people fail to take into account is the potential psychological cost of reconnecting, of dredging up painful memories and reviving destructive patterns.

Eleanor Payson, a marital and family therapist in Michigan and the author of The Wizard of Oz and Other Narcissists, sees some clients who feel it would be immoral to abandon a now-feeble parent, no matter how destructive that person was. Payson says she advises them to find ways to be caring while protecting themselves from further abuse. “One of my missions is helping people not be tyrannized by false guilt or ignore their own pain and needs,” she says. Setting limits is crucial: “You may need to keep yourself in a shark cage with no opportunity to let that person take a bite out of you.” It’s also OK for the conversation to be anodyne. “You can say something respectful, something good-faith-oriented. ‘I wish you well’; ‘I continue to work on my own forgiveness.’ ”

There is no formula for defining one’s obligations to the parents who didn’t fulfill their own. The stories of famous people with abusive parents reveal the wide range of possible responses. Abraham Lincoln couldn't stand his brutish father, Thomas, who hated Abraham’s books and sent him out as a kind of indentured servant. As an adult, Lincoln did occasionally bail out his father financially. But during his father’s final illness, Lincoln ignored letters telling him the end was near. Finally, he wrote not to his father, but his stepbrother to explain his absence: “Say to him that if we could meet now, it is doubtful whether it would not be more painful than pleasant.” Lincoln didn’t attend his father’s funeral.

Warren Buffett remained distantly dutiful to his mother, who had subjected her children to endless, rabid verbal attacks. On the occasions he visited her at the end of her life, he was a “wreck” of anxiety, sitting silently while his female companions made conversation. He was 66 when she died at 92. His tears at her death were not because he was sad or because he missed her, he said in his biography, The Snowball. “It was because of the waste.”

Bruce Springsteen’s frustrated, depressive father took out much of his rage on his son. In a New Yorker profile, David Remnick writes that long after Springsteen’s family had left his unhappy childhood home, he would obsessively drive by the old house. A therapist said to him, “Something went wrong, and you keep going back to see if you can fix it or somehow make it right.” Springsteen finally came to accept he couldn’t. When he became successful he did give his parents the money to buy their dream house. But Springsteen says of this seeming reconciliation, “Of course, all the deeper things go unsaid, that it all could have been a little different.”

We all accept that there is an enduring bond between parent and child. One of the Ten Commandments is to “honor your father and your mother,” though this must have been a difficult admonition for the children of, for example, Abraham, Rebecca, and Jacob. Yet the loyalty of children to even the worst of parents makes perfect biological sense. From an evolutionary perspective, parents, even poor ones, are a child’s best chance for food, shelter, and survival.

Regina Sullivan is a research professor of child and adolescent psychiatry at the NYU Langone School of Medicine who studies emotional attachment in rats. In experiments with rats raised by mothers who neglect or physically hurt their pups, Sullivan has teased out that, when in the presence of the caregiver, the infant brain’s fear and avoidance circuits are suppressed. Attachment “programs the brain,” she says. “The ability of an adult who can say to you, I had a horrible childhood, I don’t like my parents, but then do things to continue to get the parents’ approval, is an example of the strength of human attachment in early life.”

As Springsteen’s experience shows, one doesn’t just leave such childhoods behind, like outgrowing a fear of the dark. Study after study has found that just as an emotionally warm, intellectually stimulating childhood is typically a springboard for a happy, healthy life, an abusive one can cause a litany of problems.

Abuse victims are more likely to suffer from depression, substance abuse, broken relationships, chronic diseases, and even obesity. Many of the high-functioning people I hear from who are wrestling with their debt to their parents have struggled with some of these issues. Rochelle says, “I was a very angry kid, I got into fights in grade school. I’ve worked on it a lot, on not being the spiteful angry person all the time.” She also says she has dealt with food issues her whole life. Her mother brought home groceries once a month and she and her brother would devour the food before unpacking it. “We were starving,” she says. “If I have an addiction, it’s eating.”

Those who refuse to make peace with a failing parent may also find themselves judged harshly. In his memoir Closing Time, Joe Queenan writes of the loathing he and his sisters felt for their alcoholic, physically and psychologically abusive father. When they were grown, Queenan writes: “We talked about him as if he were already dead; such wishful thinking was rooted in the hope that he would kick the bucket before reaching the age when he might expect one of us to take him in,” although they agreed none would. When the father finally died, he wrote, “Clemency was not included in my limited roster of emotions.” In a review of the book in the Wall Street Journal, Alexander Theroux writes, “It is a shameful confession to make in any book.”

In his New York Times essay, Richard Friedman acknowledges that some parent-child relationships are so toxic that they must be severed. But he adds, “Of course, relationships are rarely all good or bad; even the most abusive parents can sometimes be loving, which is why severing a bond should be a tough, and rare decision.” But substitute “husband” for “parents,” and surely Friedman would not advise a woman in such a relationship to carry on because her battering spouse had a few redeeming qualities.

I know from my own inbox that many people are looking for someone, anyone, to tell them they should not feel guilty for declining to care for their abuser. I’m happy to do it. In private correspondence with these letter writers, I sometimes point out that, judging by their accounts, there doesn’t seem to be any acknowledgement of guilt on the part of the parent for neglecting to meet their most basic responsibilities.

A woman I’ll call Beatrice wrote to me as she wrestled with how to respond to a series of emails, calls, and letters from her long-estranged parents. Beatrice, 42, has a doctorate, is a professor of mathematics at a Midwestern university, and lives with her supportive boyfriend. She thinks of herself simultaneously as a “self-made person” and a “damaged” one. She decided long ago not to have children. “I have never felt confident I could trust another person to be the other parent. I’m not sure I could be a competent parent because of what I’ve been through.”

Of her childhood she says, “I don’t remember any happy days at all.” Her father had violent rages; he once knocked her down a flight of stairs. If she couldn’t finish dinner, she would have to sit at the table all night, then get beaten by him if she didn’t clean her plate. Her mother never intervened. Her parents divorced when she was young and her father refused to pay child support. A few years later, her mother became the fifth wife of Beatrice’s new stepfather and life got much worse.

He was unemployed and always around. Beatrice was a young teen and when she got home from school he would go into her bedroom, put his fingers up her vagina, and say he was giving her a massage. He made her touch his genitals. He let his friends come over and “have fun” with her, as long as they didn’t take her virginity. When she was 17, she finally stood up to him and he kicked her out of the house. He told her mother she had taken off of her own accord. By that time she was working 40 hours a week at a crafts store in addition to going to school, and a co-worker let her move into herbasement. She contacted her mother and asked her to meet her for lunch. Beatrice explained everything that had been going on with her stepfather. “She told me she didn’t believe a word and didn’t want to hear anymore,” Beatrice says. “That was the last time I saw her.” That was 25 years ago.

Beatrice says that during her childhood she would sometimes feel sorry for herself. Her friends would complain about their parents, or about having bad days, and she would think they had no idea what a bad day was. But she says of being on her own at 17, “The day my stepdad kicked me out, my life got better. I could come home and no one was trying to do anything bad to me. I didn’t have to hide. I didn’t worry about getting hit. That meant everything.”

Last year, separately and out of the blue, Beatrice’s mother and father each got in touch. Her biological father sent a small gift and a card with an update: He was in debt, out of work, and was supporting Beatrice’s troubled sister. A few months later, there was a message on her answering machine. “This is your mother,” the voice said. She wanted Beatrice to know her stepfather had only a few days to live. She told Beatrice she was willing to forgive her. “That made me laugh,” Beatrice says. Her mother started sending emails and Beatrice sent her a reply saying she was busy and couldn’t deal with any of this. She hasn’t heard back from her mother since. But she fears that both her parents will contact her again and explicitly ask for help.

“I’m worried about that happening. I’m worried she’ll call and say, ‘I have cancer.’ I don’t know what I’m going to do,” Beatrice says. “If she knows I’m a professor, I’m sure everyone thinks I make a huge salary and I’m going to save them. My salary is enough for me to do what I want.”

Dr. Ronald Rohner, an emeritus professor of family studies and anthropology at the University of Connecticut, has devoted much of his career to studying parental rejection and its effects. He says there’s little research on adult role reversal—that is, what happens when the parent is vulnerable and wants support from the child. But he says the studies that do exist demonstrate that “it really truly is as you sow, so shall you reap. Those parents who raised children less than lovingly are putting their own dependent old age at risk for being well and lovingly cared for themselves.”

In a 2008 essay in the journal In Character, history professor Wilfred McClay writes that as a society we have twisted the meaning of forgiveness into a therapeutic act for the victim: “[F]orgiveness is in danger of being debased into a kind of cheap grace, a waiving of standards of justice without which such transactions have no meaning.” Jean Bethke Elshtain, a professor at the University of Chicago Divinity School writes that, “There is a watered-down but widespread form of ‘forgiveness’ best tagged preemptory or exculpatory forgiveness. That is, without any indication of regret or remorse from perpetrators of even the most heinous crimes, we are enjoined by many not to harden our hearts but rather to ‘forgive.’ ”

I agree with these more bracing views about what forgiveness should entail. Choosing not to forgive does not doom someone to being mired in the past forever. Accepting what happened and moving on is a good general principle. But it can be comforting for those being browbeaten to absolve their parents to recognize that forgiveness works best as a mutual endeavor. After all, many adult children of abusers have never heard a word of regret from their parent or parents. People who have the capacity to ruthlessly maltreat their children tend toward self-justification, not shame.

Even apologies can have their limits, as illustrated by a Dear Prudence letter from a mother who called herself “Sadder but Wiser.” She verbally humiliated her son when he was a boy, realized the damage she had done, changed her ways, and apologized. But her son, who recently became a father, has only a coolly cordial relationship with her, and she complained that she wanted more warmth and caring. I suggested that she should be glad that he did see her, stop whining for more, and tell her son she admires that he is giving his little boy the childhood he deserves and that he didn’t get.

It’s wonderful when there can be true reconciliation and healing, when all parties can feel the past has been somehow redeemed. But I don’t think Rochelle, Beatrice, and others like them should be hammered with lectures about the benefits of—here comes that dread word—closure. Sometimes the best thing to do is just close the door.

Brain Scans Show the Impact of Neglect on a Child's Brain Size

This is not new information - infants have been known to die as a result of no touch or affection, a phenomena first studied in orphanages following World War II, and codified by John Bowbly by request of the U.N. Bowlby's work paralleled that of his contemporary, René Spitz, who observed children's grief at being separated from caregivers, and he proposed "that "psychotoxic" results were brought about by inappropriate experiences of early care.[67][68]"

However, to see the actual brain scans of nurtured children versus those subjected to neglect is startling and, as the headline suggests, chilling.

Chilling Brain Scans Show the Impact of a Mother's Love on a Child's Brain Size

A shocking comparison of brain scans from two three-year-old children reveals new evidence of the remarkable impact a mother's love has on a child's brain development.

BY CHRISTINE HSU | OCT 29, 2012

(Photo : Bruce D. Perry, M.D., Ph.D./Child Trauma Academy) Neurologists say that the sizeable difference between these two brains of two different 3-year-olds has one primary cause: the way that their mothers treated them.

The chilling images reveal that the left brain, which belongs to a normal 3-year-old, is significantly larger and contains fewer spots and dark "fuzzy" areas than the right brain, which belongs to that of a 3-year-old who has suffered extreme neglect.

Neurologists say that the latest images provide more evidence that the way children are treated in their early years is important not only for the child's emotional development, but also in determining the size of their brains.

Experts say that the sizeable difference in the two brains is primarily caused by the difference in the way each child was treated by their mothers.

While at first glance, the images might indicate that the child with the right brain might have suffered a serious accident or illness, neurologists said that the truth is that the child with the shrunken brain was neglected and abused by its mother, and the child with the larger and more fully developed brain was raised in a loving, supportive home and was looked after by its mother, according to The Sunday Telegraph.

Researchers told the UK newspaper that the image of the brain scan on the right shows that the child lacks some of the most fundamental areas that are present in the image of the brain scan on the left.

They say that the child on the left with the larger brain will be more intelligent and will be more likely to develop the social ability to empathize with others compared to the child on the right.

On the other hand, the child with the smaller brain on the right will be more likely to become addicted to drugs, be involved in violent crimes, be unemployed and dependent on government benefits in the future.

Furthermore, the child with the shrunken brain is significantly more likely to develop mental and other serious health-related problems.

Professor Allan Schore from the University of California, Los Angeles (UCLA) said that in the first two years, babies rely on a strong bond with their mothers for healthy brain development.

"The development of cerebral circuits depends on it," he said, adding that because 80 percent of brain cells grow in the first two years of life, problems in that development can affect people for the rest of their lives.

Furthermore, researchers said that the more severe the mother's neglect, the more pronounced the brain damage can be.

Researchers said the process of childhood neglect is a vicious cycle because the parents of neglected children were also neglected by their parents and do not have fully developed brain.

However, past research has shown that the cycle can be broken if there is early intervention and families are supported.

The latest study supports research released earlier this year that showed that children brought up by mothers who provide love and affection early in life are smarter and have a greater capacity to learn.

Researchers at Washington University School of Medicine in St. Louis, found that children whose mothers nurtured them early in life have a larger hippocampus, a key brain structure that is essential to learning, memory and response to stress, according to a study published in the Proceedings of the National Academy of Sciences Early Edition.

Wired - How Childhood Neglect Stunts the Brain

In terms of long-term damage, neglect is every bit as damaging to a child's biopsychosocial development as is physical or sexual abuse - and sometimes worse.

How Childhood Neglect Stunts the Brain

• By Brandon Keim
• September 13, 2012

Photo: D. Sharon Pruitt/Flickr

Science is painting a dramatic picture of how childhood neglect damages developing brains, so stunting them that neglect might be likened to physically violent abuse.

The latest addition to this research narrative comes from a study of mice placed in isolation early in their lives, an experiment that, on its surface, might seem redundant: After all, we already know that neglect is bad for humans, much less mice.

But they key to the study is in the details. The researchers found striking abnormalities in tissues that transmit electrical messages across the brain, suggesting a specific mechanism for some of the dysfunctions seen in neglected human children.

“This is very strong evidence that changes in myelin cause some of the behavioral problems caused by isolation,” said neurologist Gabriel Corfas of Harvard Medical School, a co-author of the new study, released Sept. 13 in Science.


Corfas and his team, led by fellow Harvard Med neuroscientist Manabu Makinodan, put 21-day-old mice in isolation for two weeks, then returned them to their colonies. When the mice reached adolescence, the researchers compared their brains and behavior to mice who hadn’t been isolated.
The isolated mice were antisocial, with striking deficits in memory. Their myelin, a cell layer that forms around neuronal networks like insulation around wires, was unusually thin, especially in the prefrontal cortex, a brain region central to cognition and personality.

'The first years of life are crucially important for brain architecture.'

Similar patterns of behavior have been seen, again and again, in children raised in orphanages or neglected by parents, as have changes to a variety of brain regions, including the prefrontal cortex. The myelin deficiencies identified by Corfas and Makinodan may underlie these defects.

“This is incredibly important data, because it gives us the neural mechanisms associated with the deleterious changes in the brain” that arise from neglect, said Nathan Fox, a cognitive neuroscientist at the University of Maryland.

Fox was not involved in the new study, but is part of a research group working on a long-term study of childhood neglect that is scientifically striking and poignantly tragic. Led by Harvard Medical School pediatricians Charles Nelson and Margaret Sheridan, the project has tracked for the last 12 years children who started their lives in an orphanage in Bucharest, Romania, a country infamous for the spartan, impersonal conditions of its orphanages.

Among children who spent their first two years in the orphanage, the researchers observed high levels developmental problems, cognitive deficits, mental illness, and significant reductions in brain size. When the researchers measured the sheer amount of electrical activity generated by the brains of children who’d been isolated as toddlers, “it was like you’d had a rheostat, a dimmer, and dimmed down the amount of energy in these institutionalized children,” said Fox.

These problems persisted even when toddlers were later adopted, suggesting a crucial importance for those early years in setting a life’s neurological trajectory. “There’s a sensitive period for which, if a child is taken out of an institution, the effects appear to be remediated, and after which remediation is very, very difficult,” Fox said. The same pattern was observed in Corfas and Makinodan’s mice.

One phenomenon not studied in the mice, but regularly found in people neglected as children, are problems with stress: mood disorders, anxiety, and general dysfunction in a body’s stress responses.

Controlled for gender and age, average white matter volumes in the brains of children who grew up in a Romanian orphanage (left), started in an orphange but were placed in foster care (center), or never lived in an orphanage at all (right). Image: Sheridan et al./PNAS

Those mechanisms have been studied in another animal, the rhesus monkey. While deprivation studies on non-human primates — and in particular chimpanzees — are controversial, the results from the monkey studies have been instructive.

Early-life isolation sets off a flood of hormones that permanently warp their responses to stress, leaving them anxious and prone to violent swings in mood.

Isolation is so damaging because humans, especially as infants, literally depend on social stimulation to shape their minds, said psychologist John Cacioppo of the University of Chicago.

“Human social processes were once thought to have been incidental to learning and cognition,” Cacioppo wrote in an e-mail. “However, we now think that the complexities and demands of social species have contributed to the evolution of the brain and nervous system and to various aspects of cognition.”

Corfas and Makinodan’s team linked specific genetic changes to the abnormalities in their mice, and hope they might someday inform the development of drugs that can help reverse isolation’s effects.

A more immediate implication of the research is social. As evidence of neglect’s severe, long-term consequences accumulates, it could shape the way people think not just of orphanages, but policy matters like maternity and paternity leave, or the work requirements of single parents on welfare.

“What this work certainly says is that the first years of life are crucially important for brain architecture,” Fox said. “Infants and young children have to grow up in an environment of social relationships, and experiencing those is critical for healthy cognitive, social and psychological development. As a society, we should be figuring out how to encourage all that to happen.”

Citation: “A Critical Period for Social Experience–Dependent Oligodendrocyte Maturation and Myelination.” By Manabu Makinodan, Kenneth M. Rosen, Susumu Ito, Gabriel Corfas. Science, Vol. 337 No. 6090, 14 September 2012.

Psychological Abuse and Neglect as Damaging to Children as Physical Abuse

Via WebMD, a new report suggests psychological child abuse is more common than most people think, and goes under-reported in the U.S. - this from the nation's largest pediatric health group, the American Academy of Pediatrics (AAP).

In my work, it is often the psychological and emotional abuse from parents that generates the deepest and most troubling wounds in clients. I don't know if there is research on this, but I would guess there is a greater likelihood of later rape or sexual abuse in adults who suffer psychological and emotional abuse as children than there is in those who suffer sexual abuse or incest as children.

Psychological Abuse of Children May Be Common

Neglect as Damaging as Physical Abuse, Report Finds

By Salynn Boyles
WebMD Health News

Reviewed by Louise Chang, MD

 

July 30, 2012 -- Psychological child abuse is common but underreported in the U.S., the nation's largest pediatric health group says.

Like physical and sexual abuse, psychological abuse can cause devastating and lifelong harm.

In a new report, the American Academy of Pediatrics (AAP) is calling on pediatricians to be alert to signs of such abuse in young patients.

"Psychological maltreatment often occurs with other forms of abuse, but this isn't always the case," says co-author Roberta Hibbard, MD, of Riley Hospital for Children at Indiana University Health in Indianapolis.

"It is one of the most devastating forms of abuse," she says. "Broken bones heal, but being belittled, terrorized, or neglected by a parent can impact self-esteem, attachments, and other aspects of development for a lifetime."

What Is Psychological Abuse?

There is no universally agreed upon definition of psychological abuse. But most cases involve a pattern of behaviors by a parent or other caregiver that leads a child to believe he or she is unloved or unwanted.

Specific types of psychological abuse identified in the report include these actions by a parent or caregiver:

Ridiculing a child. Comments or actions, especially in public, that:

• Belittle a child
• Criticize a child in a derogatory way

Terrorizing a child. For example, if you:

• Place a child in a dangerous situation
• Threaten to harm a child if unrealistic expectations aren't met

Isolating a child. For example, if you:

• Confine or imprison a child
• Restrict a child's social interactions

Exploiting a child. For example, if you take steps that exploit or corrupt a child, such as:

• Encourage or be a model for anti-social behavior
• Encourage behavior that's not appropriate for the child's age

Being detached from your child. For example, if you:

• Interact with your child only when necessary
• Don't nurture your child
• Fail to praise your child

"All parents do things they may regret from time to time. But a chronic pattern of belittling, denigrating, or neglecting a child constitutes psychological abuse," says Harriet MacMillan, MD. She is a professor of psychiatry and behavioral sciences at McMaster University in Ontario, Canada.

Brandi's Story

As director of Riley Hospital's Child Protection Program, Hibbard and her team evaluate about 2,000 cases of suspected child abuse every year.

She remembers the cases of Brandi Zachary and her older brother as among the worst examples of neglect she has ever seen.

The two were victims of psychological neglect and malnourishment at the hands of their parents until a friend became suspicious and called child protective services.

The children were kept in a filthy, locked closet day and night for at least a year.

When the abuse was discovered Brandi was 2 1/2 years old and weighed just 14 pounds. She had not yet learned to walk or talk.

Now 19, Brandi went public with her story earlier this year in an effort to help make people aware of the importance of reporting abuse and neglect.

Her birth parents were convicted of felony neglect, and she has had no contact with them since she was removed from the home 17 years ago. She was adopted several years later.

She changed her last name from Zachary to that of her adoptive parents. She's on track to complete her undergraduate degree in psychology in two years, despite being legally blind as a result of the neglect she suffered.

"Her story is amazing. And it really does illustrate the importance of speaking up if you suspect abuse," Hibbard says. "Someone who knows or suspects that a child is being neglected has a moral, if not a legal, obligation to report it."

Treating Abused Kids, More Research Needed

It's not clear how many children experience ongoing psychological abuse at the hands of parents or other caregivers. That's because such abuse is widely underreported, the report noted.

In one large study conducted in the U.S. and U.K., about 9% of women and 4% of men reported exposure to severe psychological abuse during childhood.

Other surveys conducted in the U.S. found emotional abuse to be the most frequently reported form of victimization.

The report calls for more research to develop and test effective treatments for children who have experienced psychological abuse, either alone or combined with other forms of abuse.

The report is published in the August issue of Pediatrics.