Body Keeps Score Pt 3 The Mind of Children Ch 7,8,9,10

 

PART THREE THE MINDS OF CHILDREN

CHAPTER 7 GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT

The roots of resilience. . . are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other.

—Diana Fosha

T he Children’s Clinic at the Massachusetts Mental Health Center was filled with kids who could not sit still and who hit and bit other children, and sometimes even the staff. They were wild creatures who could n with disturbed and disturbing.

They would run up to you and cling to you one moment and run away, terrified, the next. Some masturbated compulsively; others lashed out at objects, pets, and themselves. They were at once starving for affection and angry and defiant. The girls in particular could be painfully compliant. Whether oppositional or clingy, none of them seemed able to explore or play in ways typical for children their age. Some of them had hardly developed a sense of self—they couldn’t even recognize themselves in a mirror.

At the time, I knew very little about children, apart from what my two preschoolers were teaching me. But I was fortunate in my colleague Nina Fish-Murray, who had studied with Jean Piaget in Geneva, in addition to raising five children of her own. Piaget based his theories of child development on meticulous, direct observation of children themselves, starting with his own infants, and Nina brought this spirit to the incipient Trauma Center at MMHC.

Nina was married to the former chairman of the Harvard psychology

department, Henry Murray, one of the pioneers of personality theory, and she actively encouraged any junior faculty members who shared her interests. She was fascinated by my stories about combat veterans because they reminded her of the troubled kids she worked with in the Boston public schools. Nina’s privileged position and personal charm gave us access to the Children’s Clinic, which was run by child psychiatrists who had little interest in trauma.

Henry Murray had, among other things, become famous for designing the widely used Thematic Apperception Test. The TAT is a so-called projective test, which uses a set of cards to discover how people’s inner reality shapes their view of the world. Unlike the Rorschach cards we used with the veterans, the TAT cards depict realistic but ambiguous and somewhat troubling scenes: a man and a woman gloomily staring away from each other, a boy looking at a broken violin. Subjects are asked to tell stories about what is going on in the photo, what has happened previously, and what happens next. In most cases their interpretations quickly reveal the themes that preoccupy them.

Nina and I decided to create a set of test cards specifically for children, based on pictures we cut out of magazines in the clinic waiting room. Our first study compared twelve six-to eleven-year-olds at the children’s clinic with a group of children from a nearby school who matched them as closely as possible in age, race, intelligence, and family constellation.¹ What differentiated our patients was the abuse they had suffered within their families. They included a boy who was severely bruised from repeated beatings by his mother; a girl whose father had molested her at the age of four; two boys who had been repeatedly tied to a chair and whipped; and a girl who, at the age of five, had seen her mother (a prostitute) raped, dismembered, burned, and put into the trunk of a car. The mother’s pimp was suspected of sexually abusing the girl.

The children in our control group also lived in poverty in a depressed area of Boston where they regularly witnessed shocking violence. While the study was being conducted, one boy at their school threw gasoline at a classmate and set him on fire. Another boy was caught in crossfire while walking to school with his father and a friend. He was wounded in the groin, and his friend was killed. Given their exposure to such a high baseline level of violence, would their responses to the cards differ from those of the hospitalized children?

One of our cards depicted a family scene: two smiling kids watching dad repair a car. Every child who looked at it commented on the danger to the man lying underneath the vehicle. While the control children told stories with benign endings—the car would get fixed, and maybe dad and the kids would drive to

McDonald’s—the traumatized kids came up with gruesome tales. One girl said that the little girl in the picture was about to smash in her father’s skull with a hammer. A nine-year-old boy who had been severely physically abused told an elaborate story about how the boy in the picture kicked away the jack, so that the car mangled his father’s body and his blood spurted all over the garage.

As they told us these stories, our patients got very excited and disorganized. We had to take considerable time out at the water cooler and going for walks before we could show them the next card. It was little wonder that almost all of them had been diagnosed with ADHD, and most were on Ritalin—though the drug certainly didn’t seem to dampen their arousal in this situation.

The abused kids gave similar responses to a seemingly innocuous picture of a pregnant woman silhouetted against a window. When we showed it to the seven-year-old girl who’d been sexually abused at age four, she talked about penises and vaginas and repeatedly asked Nina questions like “How many people have you humped?” Like several of the other sexually abused girls in the study, she became so agitated that we had to stop. A seven-year-old girl from the control group picked up the wistful mood of the picture: Her story was about a

widowed lady sadly looking out the window, missing her husband. But in the end, the lady found a loving man to be a good father to her baby.

In card after card we saw that, despite their alertness to trouble, the children who had not been abused still trusted in an essentially benign universe; they could imagine ways out of bad situations. They seemed to feel protected and safe within their own families. They also felt loved by at least one of their parents, which seemed to make a substantial difference in their eagerness to engage in schoolwork and to learn.

The responses of the clinic children were alarming. The most innocent images stirred up intense feelings of danger, aggression, sexual arousal, and

terror. We had not selected these photos because they had some hidden meaning that sensitive people could uncover; they were ordinary images of everyday life. We could only conclude that for abused children, the whole world is filled with triggers. As long as they can imagine only disastrous outcomes to relatively benign situations, anybody walking into a room, any stranger, any image, on a screen or on a billboard might be perceived as a harbinger of catastrophe. In this light the bizarre behavior of the kids at the children’s clinic made perfect sense.²

To my amazement, staff discussions on the unit rarely mentioned the horrific real-life experiences of the children and the impact of those traumas on their feelings, thinking, and self-regulation. Instead, their medical records were filled with diagnostic labels: “conduct disorder” or “oppositional defiant disorder” for the angry and rebellious kids; or “bipolar disorder.” ADHD was a “comorbid” 동반질환 diagnosis for almost all. Was the underlying trauma being obscured by this blizzard of diagnoses?

Now we faced two big challenges. 

1. One was to learn whether the different worldview of normal children could account for their resilience and, on a deeper level, how each child actually creates her map of the world. 
2. The other, equally crucial, question was: Is it possible to help the minds and brains of brutalized children to redraw their inner maps and incorporate a sense of trust and confidence in the future?

1] MEN WITHOUT MOTHERS

The scientific study of the vital relationship between infants and their mothers was started by upper-class Englishmen who were torn from their families as young boys to be sent off to boarding schools, where they were raised in regimented same-sex settings. The first time I visited the famed Tavistock Clinic in London I noticed a collection of black-and-white photographs of these great twentieth-century psychiatrists hanging on the wall going up the main staircase: John Bowlby, Wilfred Bion, Harry Guntrip, Ronald Fairbairn, and Donald Winnicott. Each of them, in his own way, had explored how our early experiences become prototypes for all our later connections with others, and how our most intimate sense of self is created in our minute-to-minute exchanges with our caregivers.

Scientists study what puzzles them most, so that they often become experts in subjects that others take for granted. (Or, as the attachment researcher Beatrice Beebe once told me, “most research is me-search.”) These men who studied the role of mothers in children’s lives had themselves been sent off to school at a vulnerable age, sometime between six and ten, long before they should have faced the world alone. Bowlby himself told me that just such boarding-school experiences probably inspired George Orwell’s novel 1984, which brilliantly expresses how human beings may be induced to sacrifice everything they hold dear and true—including their sense of self—for the sake of being loved and approved of by someone in a position of authority.

Since Bowlby was close friends with the Murrays, I had a chance to talk with him about his work whenever he visited Harvard. He was born into an aristocratic family (his father was surgeon to the King’s household), and he trained in psychology, medicine, and psychoanalysis at the temples of the British establishment. After attending Cambridge University, he worked with delinquent boys in London’s East End, a notoriously rough and crime-ridden neighborhood that was largely destroyed during the Blitz. 

During and after his service in World War II, he observed the effects of wartime evacuations and group nurseries that separated young children from their families. He also studied the effect of hospitalization, showing that even brief separations (parents back then were not allowed to visit overnight) compounded the children’s suffering. 

By the late 1940s Bowlby had become persona non grata in the British psychoanalytic community, as a result of his radical claim that children’s disturbed behavior was a response to actual life experiences—to neglect, brutality, and separation— rather than the product of infantile sexual fantasies. Undaunted, he devoted the rest of his life to developing what came to be called attachment theory.³

2] A SECURE BASE

As we enter this world we scream to announce our presence. Someone immediately engages with us, bathes us, swaddles us, and fills our stomachs, and, best of all, our mother may put us on her belly or breast for delicious skin-to-skin contact. We are profoundly social creatures; our lives consist of finding our place within the community of human beings. I love the expression of the great French psychiatrist Pierre Janet: “Every life is a piece of art, put together with all means available.”

As we grow up, we gradually learn to take care of ourselves, both physically and emotionally, but we get our first lessons in self-care from the way that we

are cared for. Mastering the skill of self-regulation depends to a large degree on how harmonious our early interactions with our caregivers are. Children whose parents are reliable sources of comfort and strength have a lifetime advantage—a kind of buffer against the worst that fate can hand them.

John Bowlby realized that children are captivated by faces and voices and are exquisitely sensitive to facial expression, posture, tone of voice, physiological changes, tempo of movement and incipient action. He saw this inborn capacity as a product of evolution, essential to the survival of these helpless creatures. Children are also programmed to choose one particular adult (or at most a few) with whom their natural communication system develops. This creates a primary attachment bond. The more responsive the adult is to the child, the deeper the attachment and the more likely the child will develop healthy ways of responding to the people around him.

Bowlby would often visit Regent’s Park in London, where he would make systematic observations of the interactions between children and their mothers. While the mothers sat quietly on park benches, knitting or reading the paper, the kids would wander off to explore, occasionally looking over their shoulders to ascertain that Mum was still watching. But when a neighbor stopped by and absorbed his mother’s interest with the latest gossip, the kids would run back and stay close, making sure he still had her attention. When infants and young children notice that their mothers are not fully engaged with them, they become nervous. When their mothers disappear from sight, they may cry and become inconsolable, but as soon as their mothers return, they quiet down and resume their play.

Bowlby saw attachment as the secure base from which a child moves out into the world. Over the subsequent five decades research has firmly established that having a safe haven promotes self-reliance and instills a sense of sympathy and helpfulness to others in distress. From the intimate give-and-take of the attachment bond children learn that other people have feelings and thoughts that are both similar to and different from theirs. In other words, they get “in sync” with their environment and with the people around them and develop the self-awareness, empathy, impulse control, and self-motivation that make it possible to become contributing members of the larger social culture. These qualities were painfully missing in the kids at our Children’s Clinic.

3] THE DANCE OF ATTUNEMENT

Children become attached to whoever functions as their primary caregiver. 

But the nature of that attachment—whether it is secure or insecure—makes a huge difference over the course of a child’s life. Secure attachment develops when caregiving includes emotional attunement. 

Attunement starts at the most subtle physical levels of interaction between babies and their caretakers, and it gives babies the feeling of being met and understood. As Edinburgh-based attachment researcher Colwyn Trevarthen says: “The brain coordinates rhythmic body movements and guides them to act in sympathy with other people’s brains. Infants hear and learn musicality from their mother’s talk, even before birth.”⁴

In chapter 4 I described the discovery of mirror neurons, the brain-to-brain links that give us our capacity for empathy. Mirror neurons start functioning as soon as babies are born. When researcher Andrew Meltzoff at the University of Oregon pursed his lips or stuck out his tongue at six-hour-old babies, they promptly mirrored his actions.⁵ (Newborns can focus their eyes only on objects within eight to twelve inches—just enough see the person who is holding them). Imitation is our most fundamental social skill. It assures that we automatically pick up and reflect the behavior of our parents, teachers, and peers.

Most parents relate to their babies so spontaneously that they are barely aware of how attunement unfolds. But an invitation from a friend, the attachment researcher Ed Tronick, gave me the chance to observe that process more closely. Through a one-way mirror at Harvard’s Laboratory of Human Development, I watched a mother playing with her two-month-old son, who was propped in an infant seat facing her.

They were cooing to each other and having a wonderful time—until the mother leaned in to nuzzle him and the baby, in his excitement, yanked on her hair. The mother was caught unawares and yelped with pain, pushing away his hand while her face contorted with anger. The baby let go immediately, and they pulled back physically from each other. For both of them the source of delight had become a source of distress. Obviously frightened, the baby brought his hands up to his face to block out the sight of his angry mother. The mother, in turn, realizing that her baby was upset, refocused on him, making soothing sounds in an attempt to smooth things over. The infant still had his eyes covered, but his craving for connection soon reemerged. He started peeking out to see if the coast was clear, while his mother reached toward him with a concerned expression. As she started to tickle his belly, he dropped his arms and broke into a happy giggle, and harmony was reestablished. Infant and mother were attuned again. This entire sequence of delight, rupture, repair, and new delight took slightly less than twelve seconds.

Tronick and other researchers have now shown that when infants and caregivers are in sync on an emotional level, they’re also in sync physically.⁶ Babies can’t regulate their own emotional states, much less the changes in heart rate, hormone levels, and nervous-system activity that accompany emotions. When a child is in sync with his caregiver, his sense of joy and connection is reflected in his steady heartbeat and breathing and a low level of stress hormones. His body is calm; so are his emotions. The moment this music is disrupted—as it often is in the course of a normal day—all these physiological factors change as well. You can tell equilibrium has been restored when the physiology calms down.

We soothe newborns, but parents soon start teaching their children to tolerate higher levels of arousal, a job that is often assigned to fathers. (I once heard the psychologist John Gottman say, “Mothers stroke, and fathers poke.”) 

Learning how to manage arousal is a key life skill, and parents must do it for babies before babies can do it for themselves. If that gnawing sensation in his belly makes a baby cry, the breast or bottle arrives. If he’s scared, someone holds and rocks him until he calms down. If his bowels erupt, someone comes to make him clean and dry. Associating intense sensations with safety, comfort, and mastery is the foundation of self-regulation, self-soothing, and self-nurture, a theme to which I return throughout this book.

A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life.⁷ 

• Securely attached children learn what makes them feel good; 
• they discover what makes them (and others) feel bad, and 
• they acquire a sense of agency: that their actions can change how they feel and how others respond. 
• Securely attached kids learn the difference between situations they can control and situations where they need help. 
• They learn that they can play an active role when faced with difficult situations. 

In contrast, children with histories of abuse and neglect learn that

•  their terror, pleading, and crying do not register with their caregiver. 
• Nothing they can do or say stops the beating or brings attention and help. 
• In effect they’re being conditioned to give up when they face challenges later in life.

4] BECOMING REAL

Bowlby’s contemporary, the pediatrician and psychoanalyst Donald Winnicott, is the father of modern studies of attunement. 

• His minute observations of mothers and children started with the way mothers hold their babies. 
• He proposed that these physical interactions lay the groundwork for a baby’s sense of self—and, with that, a lifelong sense of identity. 
• The way a mother holds her child underlies “the ability to feel the body as the place where the psyche lives.”⁸ 

This visceral and kinesthetic sensation of how our bodies are met lays the foundation for what we experience as “real.”⁹

Winnicott thought that the vast majority of mothers did just fine in their attunement to their infants—it does not require extraordinary talent to be what he called a “good enough mother.”¹⁰ But things can go seriously wrong when mothers are unable to tune in to their baby’s physical reality. If a mother cannot meet her baby’s impulses and needs, “the baby learns to become the mother’s idea of what the baby is.” Having to discount its inner sensations, and trying to adjust to its caregiver’s needs, means the child perceives that “something is wrong” with the way it is. 

Children who lack physical attunement are vulnerable to shutting down the direct feedback from their bodies, the seat of pleasure, purpose, and direction.

In the years since Bowlby’s and Winnicott’s ideas were introduced, attachment research around the world has shown that the vast majority of children are securely attached. When they grow up, their history of reliable, responsive caregiving will help to keep fear and anxiety at bay. 

Barring exposure to some overwhelming life event—trauma—that breaks down the self-regulatory system, they will maintain a fundamental state of emotional security throughout their lives. 

Secure attachment also forms a template for children’s relationships. They pick up what others are feeling and early on learn to tell a game from reality, and they develop a good nose for phony situations or dangerous people. Securely attached children usually become pleasant playmates and have lots of self-affirming experiences with their peers. Having learned to be in tune with other people, they tend to notice subtle changes in voices and faces and to adjust their behavior accordingly. They learn to live within a shared understanding of the world and are likely to become valued members of the community.

This upward spiral can, however, be reversed by abuse or neglect. Abused kids are often very sensitive to changes in voices and faces, but they tend to respond to them as threats rather than as cues for staying in sync. Dr. Seth Pollak of the University of Wisconsin showed a series of faces to a group of normal eight-year-olds and compared their responses with those of a group of abused

children the same age. Looking at this spectrum of angry to sad expressions, the abused kids were hyperalert to the slightest features of anger.¹¹

This is one reason abused children so easily become defensive or scared. Imagine what it’s like to make your way through a sea of faces in the school corridor, trying to figure out who might assault you. Children who overreact to their peers’ aggression, who don’t pick up on other kids’ needs, who easily shut down or lose control of their impulses, are likely to be shunned and left out of sleepovers or play dates. Eventually they may learn to cover up their fear by putting up a tough front. Or they may spend more and more time alone, watching TV or playing computer games, falling even further behind on interpersonal skills and emotional self-regulation.

The need for attachment never lessens. Most human beings simply cannot tolerate being disengaged from others for any length of time. People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation.

A few years ago, on Christmas Eve, I was called to examine a fourteen-year-old boy at the Suffolk County Jail. Jack had been arrested for breaking into the house of neighbors who were away on vacation. The burglar alarm was howling when the police found him in the living room.

The first question I asked Jack was who he expected would visit him in jail on Christmas. “Nobody,” he told me. “Nobody ever pays attention to me.” It turned out that he had been caught during breakins numerous times before. He knew the police, and they knew him. With delight in his voice, he told me that when the cops saw him standing in the middle of the living room, they yelled, “Oh my God, it’s Jack again, that little motherfucker.” Somebody recognized him; somebody knew his name. A little while later Jack confessed, “You know, that is what makes it worthwhile.” Kids will go to almost any length to feel seen and connected.

5] LIVING WITH THE PARENTS YOU HAVE

Children have a biological instinct to attach—they have no choice. Whether their parents or caregivers are loving and caring or distant, insensitive, rejecting, or abusive, children will develop a coping style based on their attempt to get at least some of their needs met.

We now have reliable ways to assess and identify these coping styles, thanks largely to the work of two American scientists, Mary Ainsworth and Mary Main, and their colleagues, who conducted thousands of hours of observation of mother-infant pairs over many years. Based on these studies, Ainsworth created a research tool called the Strange Situation, which looks at how an infant reacts to temporary separation from the mother. Just as Bowlby had observed, securely attached infants are distressed when their mother leaves them, but they show delight when she returns, and after a brief check-in for reassurance, they settle down and resume their play.

But with infants who are insecurely attached, the picture is more complex. Children whose primary caregiver is unresponsive or rejecting learn to deal with their anxiety in two distinct ways. The researchers noticed that some seemed chronically upset and demanding with their mothers, while others were more passive and withdrawn. In both groups contact with the mothers failed to settle them down—they did not return to play contentedly, as happens in secure attachment.

In one pattern, called “avoidant attachment,” the infants look like nothing really bothers them—they don’t cry when their mother goes away and they ignore her when she comes back. However, this does not mean that they are unaffected. In fact, their chronically increased heart rates show that they are in a constant state of hyperarousal. My colleagues and I call this pattern “dealing but not feeling.”¹² Most mothers of avoidant infants seem to dislike touching their children. They have trouble snuggling and holding them, and they don’t use their facial expressions and voices to create pleasurable back-and-forth rhythms with their babies.

In another pattern, called “anxious” or “ambivalent” attachment, the infants constantly draw attention to themselves by crying, yelling, clinging, or screaming: They are “feeling but not dealing.”¹³ They seem to have concluded that unless they make a spectacle, nobody is going to pay attention to them. They become enormously upset when they do not know where their mother is but derive little comfort from her return. And even though they don’t seem to enjoy

her company, they stay passively or angrily focused on her, even in situations when other children would rather play.¹⁴

Attachment researchers think that the three “organized” attachment strategies (secure, avoidant, and anxious) work because they elicit the best care a particular caregiver is capable of providing. Infants who encounter a consistent pattern of care—even if it’s marked by emotional distance or insensitivity—can adapt to maintain the relationship. That does not mean that there are no problems: Attachment patterns often persist into adulthood. Anxious toddlers tend to grow into anxious adults, while avoidant toddlers are likely to become adults who are out of touch with their own feelings and those of others. (As in, “There’s nothing wrong with a good spanking. I got hit and it made me the success I am today.”) In school avoidant children are likely to bully other kids, while the anxious children are often their victims.¹⁵ However, development is not linear, and many life experiences can intervene to change these outcomes.

But there is another group that is less stably adapted, a group that makes up the bulk of the children we treat and a substantial proportion of the adults who are seen in psychiatric clinics. Some twenty years ago, Mary Main and her colleagues at Berkeley began to identify a group of children (about 15 percent of those they studied) who seemed to be unable to figure out how to engage with their caregivers. The critical issue turned out to be that the caregivers themselves were a source of distress or terror to the children.¹⁶

Children in this situation have no one to turn to, and they are faced with an unsolvable dilemma; their mothers are simultaneously necessary for survival and a source of fear.¹⁷ They “can neither approach (the secure and ambivalent ‘strategies’), shift [their] attention (the avoidant ‘strategy’), nor flee.”¹⁸ If you observe such children in a nursery school or attachment laboratory, you see them look toward their parents when they enter the room and then quickly turn away. Unable to choose between seeking closeness and avoiding the parent, they may rock on their hands and knees, appear to go into a trance, freeze with their arms raised, or get up to greet their parent and then fall to the ground. Not knowing who is safe or whom they belong to, they may be intensely affectionate with strangers or may trust nobody. Main called this pattern “disorganized attachment.” Disorganized attachment is “fright without solution.”¹⁹

6] BECOMING DISORGANIZED WITHIN

Conscientious parents often become alarmed when they discover attachment research, worrying that their occasional impatience or their ordinary lapses in attunement may permanently damage their kids. In real life there are bound to be misunderstandings, inept responses, and failures of communication. Because mothers and fathers miss cues or are simply preoccupied with other matters, infants are frequently left to their own devices to discover how they can calm themselves down. Within limits this is not a problem. Kids need to learn to handle frustrations and disappointments. With “good enough” caregivers, children learn that broken connections can be repaired. The critical issue is whether they can incorporate a feeling of being viscerally safe with their parents or other caregivers.²⁰

In a study of attachment patterns in over two thousand infants in “normal” middle-class environments, 62 percent were found to be secure, 15 percent avoidant, 9 percent anxious (also known as ambivalent), and 15 percent disorganized.²¹ Interestingly, this large study showed that the child’s gender and basic temperament have little effect on attachment style; for example, children with “difficult” temperaments are not more likely to develop a disorganized style. Kids from lower socioeconomic groups are more likely to be disorganized,²² with parents often severely stressed by economic and family instability.

Children who don’t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older. By kindergarten, many disorganized infants are either aggressive or spaced out and disengaged, and they go on to develop a range of psychiatric problems.²³ They also show more physiological stress, as expressed in heart rate, heart rate variability,²⁴ stress hormone responses, and lowered immune factors.²⁵ Does this kind of biological dysregulation automatically reset to normal as a child matures or is moved to a safe environment? So far as we know, it does not.

Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection.^26,27 While all parents need all the help they can get to help raise secure children, traumatized parents, in particular, need help to be attuned to their children’s needs.

Caregivers often don’t realize that they are out of tune. I vividly remember a videotape Beatrice Beebe showed me.²⁸ It featured a young mother playing with

her three-month-old infant. Everything was going well until the baby pulled back and turned his head away, signaling that he needed a break. But the mother did not pick up on his cue, and she intensified her efforts to engage him by bringing her face closer to his and increasing the volume of her voice. When he recoiled even more, she kept bouncing and poking him. Finally he started to scream, at which point the mother put him down and walked away, looking crestfallen. She obviously felt terrible, but she had simply missed the relevant cues. It’s easy to imagine how this kind of misattunement, repeated over and over again, can gradually lead to a chronic disconnection. (Anyone who’s raised a colicky or hyperactive baby knows how quickly stress rises when nothing seems to make a difference.) Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child.

In practice it often is difficult to distinguish the problems that result from disorganized attachment from those that result from trauma: They are often intertwined. My colleague Rachel Yehuda studied rates of PTSD in adult New Yorkers who had been assaulted or raped.²⁹ Those whose mothers were Holocaust survivors with PTSD had a significantly higher rate of developing serious psychological problems after these traumatic experiences. The most reasonable explanation is that their upbringing had left them with a vulnerable physiology, making it difficult for them to regain their equilibrium after being violated. Yehuda found a similar vulnerability in the children of pregnant women who were in the World Trade Center that fatal day in 2001.³⁰

Similarly, the reactions of children to painful events are largely determined by how calm or stressed their parents are. My former student Glenn Saxe, now chairman of the Department of Child and Adolescent Psychiatry at NYU, showed that when children were hospitalized for treatment of severe burns, the development of PTSD could be predicted by how safe they felt with their mothers.³¹ The security of their attachment to their mothers predicted the amount of morphine that was required to control their pain—the more secure the attachment, the less painkiller was needed.

Another colleague, Claude Chemtob, who directs the Family Trauma Research Program at NYU Langone Medical Center, studied 112 New York City children who had directly witnessed the terrorist attacks on 9/11.³² Children whose mothers were diagnosed with PTSD or depression during follow-up were six times more likely to have significant emotional problems and eleven times

more likely to be hyperaggressive in response to their experience. Children whose fathers had PTSD showed behavioral problems as well, but Chemtob discovered that this effect was indirect and was transmitted via the mother. (Living with an irascible, withdrawn, or terrified spouse is likely to impose a major psychological burden on the partner, including depression.)

If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. If you conclude that you must be a terrible person (because why else would your parents have you treated that way?), you start expecting other people to treat you horribly. You probably deserve it, and anyway, there is nothing you can do about it. When disorganized people carry self-perceptions like these, they are set up to be traumatized by subsequent experiences.³³

7] THE LONG-TERM EFFECTS OF DISORGANIZED ATTACHMENT

In the early 1980s my colleague Karlen Lyons-Ruth, a Harvard attachment researcher, began to videotape face-to-face interactions between mothers and their infants at six months, twelve months and eighteen months. She taped them again when the children were five years old and once more when they were seven or eight.³⁴ All were from high-risk families: 100 percent met federal poverty guidelines, and almost half the mothers were single parents.

Disorganized attachment showed up in two different ways: One group of mothers seemed to be too preoccupied with their own issues to attend to their infants. They were often intrusive and hostile; they alternated between rejecting their infants and acting as if they expected them to respond to their needs. Another group of mothers seemed helpless and fearful. They often came across as sweet or fragile, but they didn’t know how to be the adult in the relationship and seemed to want their children to comfort them. They failed to greet their children after having been away and did not pick them up when the children were distressed. The mothers didn’t seem to be doing these things deliberately— they simply didn’t know how to be attuned to their kids and respond to their cues and thus failed to comfort and reassure them. The hostile/intrusive mothers were more likely to have childhood histories of physical abuse and/or of witnessing domestic violence, while the withdrawn/dependent mothers were more likely to have histories of sexual abuse or parental loss (but not physical abuse).³⁵

I have always wondered how parents come to abuse their kids. After all, raising healthy offspring is at the very core of our human sense of purpose and meaning. What could drive parents to deliberately hurt or neglect their children? Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse.

About eighteen years later, when these kids were around twenty years old, Lyons-Ruth did a follow-up study to see how they were coping. Infants with seriously disrupted emotional communication patterns with their mothers at eighteen months grew up to become young adults with an unstable sense of self, self-damaging impulsivity (including excessive spending, promiscuous sex, substance abuse, reckless driving, and binge eating), inappropriate and intense anger, and recurrent suicidal behavior.

Karlen and her colleagues had expected that hostile/intrusive behavior on the part of the mothers would be the most powerful predictor of mental instability in their adult children, but they discovered otherwise. Emotional withdrawal had the most profound and long-lasting impact. Emotional distance and role reversal (in which mothers expected the kids to look after them) were specifically linked to aggressive behavior against self and others in the young adults.

8] DISSOCIATION: KNOWING AND NOT KNOWING

Lyons-Ruth was particularly interested in the phenomenon of dissociation, which is manifested in feeling lost, overwhelmed, abandoned, and disconnected from the world and in seeing oneself as unloved, empty, helpless, trapped, and weighed down. She found a “striking and unexpected” relationship between maternal disengagement and misattunement during the first two years of life and dissociative symptoms in early adulthood. Lyons-Ruth concludes that infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and to see.”³⁶

Infants who live in secure relationships learn to communicate not only their

frustrations and distress but also their emerging selves—their interests, preferences, and goals. Receiving a sympathetic response cushions infants (and adults) against extreme levels of frightened arousal. But if your caregivers ignore your needs, or resent your very existence, you learn to anticipate rejection and withdrawal. You cope as well as you can by blocking out your mother’s hostility or neglect and act as if it doesn’t matter, but your body is likely to remain in a state of high alert, prepared to ward off blows, deprivation, or abandonment. Dissociation means simultaneously knowing and not knowing.³⁷

Bowlby wrote: “What cannot be communicated to the [m]other cannot be communicated to the self.”³⁸ If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation.³⁹ Maybe the most devastating long-term effect of this shutdown is not feeling real inside, a condition we saw in the kids in the Children’s Clinic and that we see in the children and adults who come to the Trauma Center. When you don’t feel real nothing matters, which makes it impossible to protect yourself from danger. Or you may resort to extremes in an effort to feel something—even cutting yourself with a razor blade or getting into fistfights with strangers.

Karlen’s research showed that dissociation is learned early: Later abuse or other traumas did not account for dissociative symptoms in young adults.⁴⁰ Abuse and trauma accounted for many other problems, but not for chronic dissociation or aggression against self. The critical underlying issue was that these patients didn’t know how to feel safe. Lack of safety within the early caregiving relationship led to an impaired sense of inner reality, excessive clinging, and self-damaging behavior: Poverty, single parenthood, or maternal psychiatric symptoms did not predict these symptoms.

This does not imply that child abuse is irrelevant⁴¹, but that the quality of early caregiving is critically important in preventing mental health problems, independent of other traumas.⁴² For that reason treatment needs to address not only the imprints of specific traumatic events but also the consequences of not having been mirrored, attuned to, and given consistent care and affection: dissociation and loss of self-regulation.

9] RESTORING SYNCHRONY

Early attachment patterns create the inner maps that chart our relationships throughout life, not only in terms of what we expect from others, but also in terms of how much comfort and pleasure we can experience in their presence. I doubt that the poet e. e. cummings could have written his joyous lines “i like my body when it is with your body. . . . muscles better and nerves more” if his earliest experiences had been frozen faces and hostile glances.43 

Our relationship maps are implicit, etched into the emotional brain and not reversible simply by understanding how they were created. You may realize that your fear of intimacy has something to do with your mother’s postpartum depression or with the fact that she herself was molested as a child, but that alone is unlikely to open you to happy, trusting engagement with others.

However, that realization may help you to start exploring other ways to connect in relationships—both for your own sake and in order to not pass on an insecure attachment to your own children. In part 5 I’ll discuss a number of approaches to healing damaged attunement systems through training in rhythmicity and reciprocity.⁴⁴ Being in synch with oneself and with others requires the integration of our body-based senses—vision, hearing, touch, and balance. If this did not happen in infancy and early childhood, there is an increased chance of later sensory integration problems (to which trauma and neglect are by no means the only pathways).

Being in synch means resonating through sounds and movements that connect, which are embedded in the daily sensory rhythms of cooking and cleaning, going to bed and waking up. Being in synch may mean sharing funny faces and hugs, expressing delight or disapproval at the right moments, tossing balls back and forth, or singing together. At the Trauma Center, we have developed programs to coach parents in connection and attunement, and my patients have told me about many other ways to get themselves in synch, ranging from choral singing and ballroom dancing to joining basketball teams, jazz bands and chamber music groups. All of these foster a sense of attunement and communal pleasure.

CHAPTER 8  TRAPPED IN RELATIONSHIPS:  THE COST OF ABUSE AND NEGLECT

The “night sea journey” is the journey into the parts of ourselves that are split off, disavowed, unknown, unwanted, cast out, and exiled to the various subterranean worlds of consciousness. . . . The goal of this journey is to reunite us with ourselves. Such a homecoming can be surprisingly painful, even brutal. In order to undertake it, we must first agree to exile nothing.

—Stephen Cope

as

M arilyn was a tall, athletic-looking woman in her midthirties who worked an operating-room nurse in a nearby town She told me that a few months earlier she’d started to play tennis at her sports club with a Boston fireman named Michael. She usually steered clear of men, she said, but she had gradually become comfortable enough with Michael to accept his invitations to go out for pizza after their matches. They’d talk about tennis, movies, their nephews and nieces—nothing too personal. Michael clearly enjoyed her company, but she told herself he didn’t really know her.

One Saturday evening in August, after tennis and pizza, she invited him to stay over at her apartment. She described feeling “uptight and unreal” as soon as they were alone together. She remembered asking him to go slow but had very little sense of what had happened after that. After a few glasses of wine and a rerun of Law & Order, they apparently fell asleep together on top of her bed. At around two in the morning, Michael turned over in his sleep. When Marilyn felt

.

his body touch hers, she exploded—pounding him with her fists, scratching and biting, screaming, “You bastard, you bastard!” Michael, startled awake, grabbed his belongings and fled. After he left, Marilyn sat on her bed for hours, stunned by what had happened. She felt deeply humiliated and hated herself for what she had done, and now she’d come to me for help in dealing with her terror of men and her inexplicable rage attacks.

My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem. Therapy often starts with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when somebody looks you in the eye, finding yourself covered with blood after cutting yourself with a piece of glass, or deliberately vomiting up every meal. It takes time and patience to allow the reality behind such symptoms to reveal itself.

1] TERROR AND NUMBNESS

As we talked, Marilyn told me that Michael was the first man she’d taken home in more than five years, but this was not the first time she’d lost control when a man spent the night with her. She repeated that she always felt uptight and spaced out when she was alone with a man, and there had been other times when she’d “come to” in her apartment, cowering in a corner, unable to remember clearly what had happened.

Marilyn also said she felt as if she was just “going through the motions” of having a life. Except for when she was at the club playing tennis or at work in the operating room, she usually felt numb. A few years earlier she’d found that she could relieve her numbness by scratching herself with a razor blade, but she had become frightened when she found that she was cutting herself more and more deeply, and more and more often, to get relief. She had tried alcohol, too, but that reminded her of her dad and his out-of-control drinking, which made her feel disgusted with herself. So, instead, she played tennis fanatically, whenever she could. That made her feel alive.

When I asked her about her past, Marilyn said she guessed that she “must have had” a happy childhood, but she could remember very little from before age twelve. She told me she’d been a timid adolescent, until she had a violent confrontation with her alcoholic father when she was sixteen and ran away from home. She worked her way through community college and went on to get a degree in nursing without any help from her parents. She felt ashamed that

during this time she’d slept around, which she described as “looking for love in all the wrong places.”

As I often did with new patients, I asked her to draw a family portrait, and when I saw her drawing (reproduced above), I decided to go slowly. Clearly Marilyn was harboring some terrible memories, but she could not allow herself to recognize what her own picture revealed. She had drawn a wild and terrified child, trapped in some kind of cage and threatened not only by three nightmarish figures—one with no eyes—but also by a huge erect penis protruding into her space. And yet this woman said she “must have had” a happy childhood.

As the poet W. H. Auden wrote:

Truth, like love and sleep, resents Approaches that are too intense.¹

I call this Auden’s rule, and in keeping with it I deliberately did not push Marilyn to tell me what she remembered. In fact, I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing

what they know. This may take weeks or even years. I decided to start Marilyn’s treatment by inviting her to join an established therapy group where she could find support and acceptance before facing the engine of her distrust, shame, and rage.

As I expected, Marilyn arrived at the first group meeting looking terrified, much like the girl in her family portrait; she was withdrawn and did not reach out to anybody. I’d chosen this group for her because its members had always been helpful and accepting of new members who were too scared to talk. They knew from their own experience that unlocking secrets is a gradual process. But this time they surprised me, asking so many intrusive questions about Marilyn’s love life that I recalled her drawing of the little girl under assault. It was almost as though Marilyn had unwittingly enlisted the group to repeat her traumatic past. I intervened to help her set some boundaries about what she’d talk about, and she began to settle in.

Three months later Marilyn told the group that she had stumbled and fallen a few times on the sidewalk between the subway and my office. She worried that her eyesight was beginning to fail: She’d also been missing a lot of tennis balls recently. I thought again about her drawing and the wild child with the huge, terrified eyes. Was this some sort of “conversion reaction,” in which patients express their conflicts by losing function in some part of their body? Many soldiers in both world wars had suffered paralysis that couldn’t be traced to physical injuries, and I had seen cases of “hysterical blindness” in Mexico and India

Still, as a physician, I wasn’t about to conclude without further assessment that this was “all in her head.” I referred her to colleagues at the Massachusetts Eye and Ear Infirmary and asked them to do a very thorough workup. Several weeks later the tests came back. Marilyn had lupus erythematosus of her retina, an autoimmune disease that was eroding her vision, and she would need immediate treatment. I was appalled: Marilyn was the third person that year whom I’d suspected of having an incest history and who was then diagnosed with an autoimmune disease—a disease in which the body starts attacking itself.

After making sure that Marilyn was getting the proper medical care, I consulted with two of my colleagues at Massachusetts General, psychiatrist Scott Wilson and Richard Kradin, who ran the immunology laboratory there. I told them Marilyn’s story, showed them the picture she’d drawn, and asked them to collaborate on a study. They generously volunteered their time and the considerable expense of a full immunology workup. We recruited twelve women

with incest histories who were not taking any medications, plus twelve women who had never been traumatized and who also did not take meds—a surprisingly difficult control group to find. (Marilyn was not in the study; we generally do not ask our clinical patients to be part of our research efforts.)

When the study was completed and the data analyzed, Rich reported that the group of incest survivors had abnormalities in their CD45 RA-to-RO ratio, compared with their nontraumatized peers. CD45 cells are the “memory cells” of the immune system. Some of them, called RA cells, have been activated by past exposure to toxins; they quickly respond to environmental threats they have encountered before. The RO cells, in contrast, are kept in reserve for new challenges; they are turned on to deal with threats the body has not met previously. The RA-to-RO ratio is the balance between cells that recognize known toxins and cells that wait for new information to activate. In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells.

Our study showed that, on a deep level, the bodies of incest victims have trouble distinguishing between danger and safety. This means that the imprint of past trauma does not consist only of distorted perceptions of information coming from the outside; the organism itself also has a problem knowing how to feel safe. The past is impressed not only on their minds, and in misinterpretations of innocuous events (as when Marilyn attacked Michael because he accidentally touched her in her sleep), but also on the very core of their beings: in the safety of their bodies.²

3] A TORN MAP OF THE WORLD

How do people learn what is safe and what is not safe, what is inside and what is outside, what should be resisted and what can safely be taken in? The best way we can understand the impact of child abuse and neglect is to listen to what people like Marilyn can teach us. One of the things that became clear as I came to know her better was that she had her own unique view of how the world functions.

As children, we start off at the center of our own universe, where we interpret everything that happens from an egocentric vantage point. If our

parents or grandparents keep telling us we’re the cutest, most delicious thing in the world, we don’t question their judgment—we must be exactly that. And deep down, no matter what else we learn about ourselves, we will carry that sense with us: that we are basically adorable. As a result, if we later hook up with somebody who treats us badly, we will be outraged. It won’t feel right: It’s not familiar; it’s not like home. But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of our self is marked by contempt and humiliation, and we are more likely to think “he (or she) has my number” and fail to protest if we are mistreated.

Marilyn’s past shaped her view of every relationship. She was convinced that men didn’t give a damn about other people’s feelings and that they got away with whatever they wanted. Women couldn’t be trusted either. They were too weak to stand up for themselves, and they’d sell their bodies to get men to take care of them. If you were in trouble, they wouldn’t lift a finger to help you. This worldview manifested itself in the way Marilyn approached her colleagues at work: She was suspicious of the motives of anyone who was kind to her and called them on the slightest deviation from the nursing regulations. As for herself: She was a bad seed, a fundamentally toxic person who made bad things happen to those around her.

When I first encountered patients like Marilyn, I used to challenge their thinking and try to help them see the world in a more positive, flexible way. One day a woman named Kathy set me straight. A group member had arrived late to a session because her car had broken down, and Kathy immediately blamed herself: “I saw how rickety your car was last week; I knew I should have offered you a ride.” Her self-criticism escalated to the point that, only a few minutes later, she was taking responsibility for her sexual abuse: “I brought it on myself: I was seven years old and I loved my daddy. I wanted him to love me, and I did what he wanted me to do. It was my own fault.” When I intervened to reassure her, saying, “Come on, you were just a little girl—it was your father’s responsibility to maintain the boundaries,” Kathy turned toward me. 

“You know, Bessel,” she said, “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusely. After all, I am an incest survivor—I was trained to take care of the needs of grown-up, insecure men. But after two years I trust you enough to tell you that those comments make me feel terrible. Yes, it’s true; I instinctively blame myself for everything bad that happens to the people around me. I know that isn’t rational, and I feel really dumb for feeling this way, but I do. When you try to talk me into being more reasonable I only feel even more lonely and isolated—and it confirms the feeling that nobody in the whole world will ever understand what it feels like to be me.”

I genuinely thanked her for her feedback, and I’ve tried ever since not to tell my patients that they should not feel the way they do. Kathy taught me that my responsibility goes much deeper: I have to help them reconstruct their inner map of the world.

As I discussed in the previous chapter, attachment researchers have shown that our earliest caregivers don’t only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time.

This doesn’t mean, however, that our maps can’t be modified by experience. A deep love relationship, particularly during adolescence, when the brain once again goes through a period of exponential change, truly can transform us. So can the birth of a child, as our babies often teach us how to love. Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. In contrast, previously uncontaminated childhood maps can become so distorted by an adult rape or assault that all roads are rerouted into terror or despair. These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs. Our maps of the world are encoded in the emotional brain, and changing them means having to reorganize that part of the central nervous system, the subject of the treatment section of this book.

Nonetheless, learning to recognize irrational thoughts and behavior can be a useful first step. People like Marilyn often discover that their assumptions are not the same as those of their friends. If they are lucky, their friends and colleagues will tell them in words, rather than in actions, that their distrust and self-hatred makes collaboration difficult. But that rarely happens, and Marilyn’s experience was typical: After she assaulted Michael, he had absolutely no interest in working things out, and she lost both his friendship and her favorite tennis partner. It is at this point that smart and courageous people like Marilyn, who maintain their curiosity and determination in the face of repeated defeats,

start looking for help.

Generally the rational brain can override the emotional brain, as long as our fears don’t hijack us. (For example, your fear at being flagged down by the police can turn instantly to gratitude when the cop warns you that there’s an accident ahead.) But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to “own” our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable.

4] LEARNING TO REMEMBER

About a year into Marilyn’s group, another member, Mary, asked permission to talk about what had happened to her when she was thirteen years old. Mary worked as a prison guard, and she was involved in a sadomasochistic relationship with another woman. She wanted the group to know her background in the hope that they would become more tolerant of her extreme reactions, such as her tendency to shut down or blow up in response to the slightest provocation.

Struggling to get the words out, Mary told us that one evening, when she was thirteen years old, she was raped by her older brother and a gang of his friends. The rape resulted in pregnancy, and her mother gave her an abortion at home, on the kitchen table. The group sensitively tuned in to what Mary was sharing and comforted her through her sobbing. I was profoundly moved by their empathy—they were consoling Mary in a way that they must have wished somebody had comforted them when they first confronted their traumas.

When time ran out, Marilyn asked if she could take a few more minutes to talk about what she had experienced during the session. The group agreed, and she told us: “Hearing that story, I wonder if I may have been sexually abused myself.” My mouth must have dropped open. Based on her family drawing, I had always assumed that she was aware, at least on some level, that this was the case. She had reacted like an incest victim in her response to Michael, and she chronically behaved as if the world were a terrifying place.

Yet even though she’d drawn a girl who was being sexually molested, she— or at least her cognitive, verbal self—had no idea what had actually happened to her. Her immune system, her muscles, and her fear system all had kept the score,

but her conscious mind lacked a story that could communicate the experience. She reenacted her trauma in her life, but she had no narrative to refer to. As we will see in chapter 12, traumatic memory differs in complex ways from normal recall, and it involves many layers of mind and brain.

Triggered by Mary’s story, and spurred on by the nightmares that followed, Marilyn began individual therapy with me in which she started to deal with her past. At first she experienced waves of intense, free-floating terror. She tried stopping for several weeks, but when she found she could no longer sleep and had to take time off from work, she continued our sessions. As she told me later: “My only criterion for whether a situation is harmful is feeling, ‘This is going to kill me if I don’t get out.’”

I began to teach Marilyn calming techniques, such as focusing on breathing deeply—in and out, in and out, at six breaths a minute—while following the sensations of the breath in her body. This was combined with tapping acupressure points, which helped her not to become overwhelmed. We also worked on mindfulness: Learning to keep her mind alive while allowing her body to feel the feelings that she had come to dread slowly enabled Marilyn to stand back and observe her experience, rather than being immediately hijacked by her feelings. She had tried to dampen or abolish those feelings with alcohol and exercise, but now she began to feel safe enough to begin to remember what had happened to her as a girl. As she gained ownership over her physical sensations, she also began to be able to tell the difference between past and present: Now if she felt someone’s leg brush against her in the night, she might be able to recognize it as Michael’s leg, the leg of the handsome tennis partner she’d invited to her apartment. That leg did not belong to anyone else, and its touch didn’t mean someone was trying to molest her. Being still enabled her to know—fully, physically know—that she was a thirty-four-year-old woman and not a little girl.

When Marilyn finally began to access her memories, they emerged as flashbacks of the wallpaper in her childhood bedroom. She realized that this was what she had focused on when her father raped her when she was eight years old. His molestation had scared her beyond her capacity to endure, so she had needed to push it out of her memory bank. After all, she had to keep living with this man, her father, who had assaulted her. Marilyn remembered having turned to her mother for protection, but when she ran to her and tried to hide herself by burying her face in her mother’s skirt, she was met with only a limp embrace. At times her mother remained silent; at others she cried or angrily scolded Marilyn

for “making Daddy so angry.” The terrified child found no one to protect her, to offer strength or shelter.

As Roland Summit wrote in his classic study The Child Sexual Abuse Accommodation Syndrome: “Initiation, intimidation, stigmatization, isolation, helplessness and self-blame depend on a terrifying reality of child sexual abuse. Any attempts by the child to divulge the secret will be countered by an adult conspiracy of silence and disbelief. ‘Don’t worry about things like that; that could never happen in our family.’ ‘How could you ever think of such a terrible thing?’ ‘Don’t let me ever hear you say anything like that again!’ The average child never asks and never tells.”³

After forty years of doing this work I still regularly hear myself saying, “That’s unbelievable,” when patients tell me about their childhoods. They often are as incredulous as I am—how could parents inflict such torture and terror on their own child? Part of them continues to insist that they must have made the experience up or that they are exaggerating. All of them are ashamed about what happened to them, and they blame themselves—on some level they firmly believe that these terrible things were done to them because they are terrible people.

Marilyn now began to explore how the powerless child had learned to shut down and comply with whatever was asked of her. She had done so by making herself disappear: The moment she heard her father’s footsteps in the corridor outside her bedroom, she would “put her head in the clouds.” Another patient of mine who had a similar experience made a drawing that depicts how that process works. When her father started to touch her, she made herself disappear; she floated up to the ceiling, looking down on some other little girl in the bed.⁴ She was glad that it was not really her—it was some other girl who was being molested.

Looking at these heads separated from their bodies by an impenetrable fog really opened my eyes to the experience of dissociation, which is so common among incest victims. Marilyn herself later realized that, as an adult, she had continued to float up to the ceiling when she found herself in a sexual situation. In the period when she’d been more sexually active, a partner would occasionally tell her how amazing she’d been in bed—that he’d barely recognized her, that she’d even talked differently. Usually she did not remember what had happened, but at other times she’d become angry and aggressive. She had no sense of who she really was sexually, so she gradually withdrew from dating altogether—until Michael.

5] HATING YOUR HOME

Children have no choice who their parents are, nor can they understand that parents may simply be too depressed, enraged, or spaced out to be there for them or that their parents’ behavior may have little to do with them. Children have no choice but to organize themselves to survive within the families they have. Unlike adults, they have no other authorities to turn to for help—their parents are the authorities. They cannot rent an apartment or move in with someone else: Their very survival hinges on their caregivers.

Children sense—even if it they are not explicitly threatened—that if they talked about their beatings or molestation to teachers they would be punished. Instead, they focus their energy on not thinking about what has happened and not feeling the residues of terror and panic in their bodies. Because they cannot tolerate knowing what they have experienced, they also cannot understand that their anger, terror, or collapse has anything to do with that experience. They don’t talk; they act and deal with their feelings by being enraged, shut down, compliant, or defiant.

Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them. Terror increases the need for attachment, even if the source of comfort is also the source of terror. I have never met a child below the age of ten who was tortured at home (and who had broken bones and burned skin to show for it) who, if given the option, would not have chosen to stay with his or her family rather than being placed in a foster home. Of course, clinging to one’s abuser is not exclusive to childhood. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them; victims of domestic violence often cover up for their abusers. Judges often tell me how humiliated they feel when they try to protect victims of domestic violence by issuing restraining orders, only to find out that many of them secretly allow their partners to return.

It took Marilyn a long time before she was ready to talk about her abuse: She was not ready to violate her loyalty to her family—deep inside she felt that she still needed them to protect her against her fears. The price of this loyalty is unbearable feelings of loneliness, despair, and the inevitable rage of helplessness. Rage that has nowhere to go is redirected against the self, in the form of depression, self-hatred, and self-destructive actions. One of my patients told me, “It is like hating your home, your kitchen and pots and pans, your bed, your chairs, your table, your rugs.” Nothing feels safe—least of all your own body.

Learning to trust is a major challenge. One of my other patients, a schoolteacher whose grandfather raped her repeatedly before she was six, sent me the following e-mail: “I started mulling the danger of opening up with you in traffic on the way home after our therapy appointment, and then, as I merged into Route 124, I realized that I had broken the rule of not getting attached, to you and to my students.”

During our next meeting she told me she had also been raped by her lab instructor in college. I asked her whether she had sought help and made a

complaint against him. “I couldn’t make myself cross the road to the clinic,” she replied. “I was desperate for help, but as I stood there, I felt very deeply that I would only be hurt even more. And that might well have been true. Of course, I had to hide what had happened from my parents—and from everyone else.”

After I told her that I was concerned about what was going on with her, she wrote me another e-mail: “I’m trying to remind myself that I didn’t do anything to deserve such treatment. I don’t think I have ever had anyone look at me like that and say they were worried about me, and I am holding on to it like a treasure: the idea that I am worth being worried about by someone I respect and who does understand how deeply I am struggling now.”

In order to know who we are—to have an identity—we must know (or at least feel that we know) what is and what was “real.” We must observe what we see around us and label it correctly; we must also be able trust our memories and be able to tell them apart from our imagination. Losing the ability to make these distinctions is one sign of what psychoanalyst William Niederland called “soul murder.” Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust.⁵

6] REPLAYING THE TRAUMA

One memory of Marilyn’s childhood trauma came to her in a dream in which she felt as if she were being choked and was unable to breathe. A white tea towel was wrapped around her hands, and then she was lifted up with the towel around her neck, so that she could not touch the ground with her feet. She woke in a panic, thinking that she was surely going to die. Her dream reminded me of the nightmares war veterans had reported to me: seeing the precise, unadulterated images of faces and body parts they had encountered in battle. These dreams were so terrifying that they tried to not fall asleep at night; only daytime napping, which was not associated with nocturnal ambushes, felt halfway safe.

During this stage of therapy Marilyn was repeatedly flooded with images and sensations related to the choking dream. She remembered sitting in the kitchen as a four-year-old with swollen eyes, a sore neck, and a bloody nose, while her father and brother laughed at her and called her a stupid, stupid girl. One day Marilyn reported, “As I was brushing my teeth last evening, I was overcome with feelings of thrashing around. I was like a fish out of water,

violently turning my body as I fought against the lack of air. I sobbed and choked as I brushed my teeth. Panic was rising up out of my chest with the feeling of thrashing. I had to use every bit of strength I had not to scream, ‘NONONONONONO,’ as I stood over the sink.” She went to bed and fell asleep but woke up like clockwork every two hours during the rest of the night.

Trauma is not stored as a narrative with an orderly beginning, middle, and end. As I’ll discuss in detail in chapters 11 and 12, memories initially return as they did for Marilyn: as flashbacks that contain fragments of the experience, isolated images, sounds, and body sensations that initially have no context other than fear and panic. When Marilyn was a child, she had no way of giving voice to the unspeakable, and it would have made no difference anyway—nobody was listening.

Like so many survivors of childhood abuse, Marilyn exemplified the power of the life force, the will to live and to own one’s life, the energy that counteracts the annihilation of trauma. I gradually came to realize that the only thing that makes it possible to do the work of healing trauma is awe at the dedication to survival that enabled my patients to endure their abuse and then to endure the dark nights of the soul that inevitably occur on the road to recovery.

CHAPTER 9 WHAT’S LOVE GOT TO DO WITH IT?

Initiation, intimidation, stigmatization, isolation, helplessness and self-blame depend on a terrifying reality of child sexual abuse. . . . “Don’t worry about things like that; that could never happen in our family.” “How could you ever think of such a terrible thing?” “Don’t let me ever hear you say anything like that again!” The average child never asks and never tells.

—Roland Summit The Child Sexual Abuse Accommodation Syndrome

Marilyn,

H ow do we organize our thinking with regard to individuals like

Mary and Kathy and what can we do to help them? The way we define

their problems, our diagnosis, will determine how we approach their care. Such patients typically receive five or six different unrelated diagnoses in the course of their psychiatric treatment. If their doctors focus on their mood swings, they will be identified as bipolar and prescribed lithium or valproate. If the professionals are most impressed with their despair, they will be told they are suffering from major depression and given antidepressants. If the doctors focus on their restlessness and lack of attention, they may be categorized as ADHD and treated with Ritalin or other stimulants. And if the clinic staff happens to take a trauma history, and the patient actually volunteers the relevant information, he or she might receive the diagnosis of PTSD. None of these diagnoses will be completely off the mark, and none of them will begin to meaningfully describe who these patients are and what they suffer from.

Psychiatry, as a subspecialty of medicine, aspires to define mental illness as

,             ,

precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts.

The first serious attempt to create a systematic manual of psychiatric diagnoses occurred in 1980, with the release of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the official list of all mental diseases recognized by the American Psychiatric Association (APA). The preamble to the DSM-III warned explicitly that its categories were insufficiently precise to be used in forensic settings or for insurance purposes. Nonetheless it gradually became an instrument of enormous power: Insurance companies require a DSM diagnosis for reimbursement, until recently all research funding was based on DSM diagnoses, and academic programs are organized around DSM categories. DSM labels quickly found their way into the larger culture as well. Millions of people know that Tony Soprano suffered from panic attacks and depression and that Carrie Mathison of Homeland struggles with bipolar disorder. The manual has become a virtual industry that has earned the American Psychiatric Association well over $100 million.¹ The question is: Has it provided comparable benefits for the patients it is meant to serve?

A psychiatric diagnosis has serious consequences: Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects. Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves. I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo.

None of these diagnoses takes into account the unusual talents that many of our patients develop or the creative energies they have mustered to survive. All too often diagnoses are mere tallies of symptoms, leaving patients such as Marilyn, Kathy, and Mary likely to be viewed as out-of-control women who need to be straightened out.

The dictionary defines diagnosis as “

a. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data. 

b. The opinion derived from such an evaluation.”² I

In this chapter, and the next, I will discuss

the chasm between official diagnoses and what our patients actually suffer from and discuss how my colleagues and I have tried to change the way patients with chronic trauma histories are diagnosed.

1] HOW DO YOU TAKE A TRAUMA HISTORY?

In 1985 I started to collaborate with psychiatrist Judith Herman, whose first book, Father-Daughter Incest, had recently been published. We were both working at Cambridge Hospital (one of Harvard’s teaching hospitals) and, sharing an interest in how trauma had affected the lives of our patients, we began to meet regularly and compare notes. We were struck by how many of our patients who were diagnosed with borderline personality disorder (BPD) told us horror stories about their childhoods. BPD is marked by clinging but highly unstable relationships, extreme mood swings, and self-destructive behavior, including self-mutilation and repeated suicide attempts. In order to uncover whether there was, in fact, a relationship between childhood trauma and BPD, we designed a formal scientific study and sent off a grant proposal to the National Institutes of Health. It was rejected.

Undeterred, Judy and I decided to finance the study ourselves, and we found an ally in Chris Perry, the director of research at Cambridge Hospital, who was funded by the National Institutes of Mental Health to study BPD and other near neighbor diagnoses, so called personality disorders, in patients recruited from the Cambridge Hospital. He had collected volumes of valuable data on these subjects but had never inquired about childhood abuse and neglect. Even though he did not hide his skepticism about our proposal, he was very generous to us and arranged for us to interview fifty-five patients from the hospital’s outpatient department, and he agreed to compare our findings with records in the large database he had already collected.

The first question Judy and I faced was: How do you take a trauma history? You can’t ask a patient point blank: “Were you molested as a kid?” or “Did your father beat you up?” How many would trust a complete stranger with such delicate information? Keeping in mind that people universally feel ashamed about the traumas they have experienced, we designed an interview instrument, the Traumatic Antecedents Questionnaire (TAQ).³ The interview started with a series of simple questions: “Where do you live, and who do you live with?”; “Who pays the bills and who does the cooking and cleaning?” It progressed

gradually to more revealing questions: “Who do you rely on in your daily life?” As in: When you’re sick, who does the shopping or takes you to the doctor? “Who do you talk to when you are upset?” In other words, who provides you with emotional and practical support? Some patients gave us surprising answers: “my dog” or “my therapist”—or “nobody.”

We then asked similar questions about their childhood: Who lived in the household? How often did you move? Who was your primary caretaker? Many of the patients reported frequent relocations that required them to change schools in the middle of the year. Several had primary caregivers who had gone to jail, been placed in a mental hospital, or joined the military. Others had moved from foster home to foster home or had lived with a string of different relatives.

The next section of the questionnaire addressed childhood relationships: “Who in your family was affectionate to you?” “Who treated you as a special person?” This was followed by a critical question—one that, to my knowledge, had never before been asked in a scientific study: “Was there anybody who you felt safe with growing up?” One out of four patients we interviewed could not recall anyone they had felt safe with as a child. We checked “nobody” on our work sheets and did not comment, but we were stunned. Imagine being a child and not having a source of safety, making your way into the world unprotected and unseen.

The questions continued: “Who made the rules at home and enforced the discipline?” “How were kids kept in line—by talking, scolding, spanking, hitting, locking you up?” “How did your parents solve their disagreements?” By then the floodgates had usually opened, and many patients were volunteering detailed information about their childhoods. One woman had witnessed her little sister being raped; another told us she’d had her first sexual experience at age eight—with her grandfather. Men and women reported lying awake at night listening to furniture crashing and parents screaming; a young man had come down to the kitchen and found his mother lying in a pool of blood. Others talked about not being picked up at elementary school or coming home to find an empty house and spending the night alone. One woman who made her living as a cook had learned to prepare meals for her family after her mother was jailed on a drug conviction. Another had been nine when she grabbed and steadied the car’s steering wheel because her drunken mother was swerving down a four-lane highway during rush hour.

Our patients did not have the option to run away or escape; they had nobody to turn to and no place to hide. Yet they somehow had to manage their terror and

despair. They probably went to school the next morning and tried to pretend that everything was fine. Judy and I realized that the BPD group’s problems— dissociation, desperate clinging to whomever might be enlisted to help—had probably started off as ways of dealing with overwhelming emotions and inescapable brutality.

After our interviews Judy and I met to code our patients’ answers—that is, to translate them into numbers for computer analysis, and Chris Perry then collated them with the extensive information on these patients he had stored on Harvard’s mainframe computer. One Saturday morning in April he left us a message asking us to come to his office. There we found a huge stack of printouts, on top of which Chris had placed a Gary Larson cartoon of a group of scientists studying dolphins and being puzzled by “those strange ‘aw blah es span yol’ sounds.” The data had convinced him that unless you understand the language of trauma and abuse, you cannot really understand BPD.

As we later reported in the American Journal of Psychiatry, 81 percent of the patients diagnosed with BPD at Cambridge Hospital reported severe histories of child abuse and/or neglect; in the vast majority the abuse began before age seven.⁴ This finding was particularly important because it suggested that the impact of abuse depends, at least in part, on the age at which it begins. Later research by Martin Teicher at McLean Hospital showed that different forms of abuse have different impacts on various brain areas at different stages of development.⁵ Although numerous studies have since replicated our findings,⁶ I still regularly get scientific papers to review that say things like “It has been hypothesized that borderline patients may have histories of childhood trauma.” When does a hypothesis become a scientifically established fact?

Our study clearly supported the conclusions of John Bowlby.

When children feel pervasively angry or guilty or are chronically frightened about being abandoned, they have come by such feelings honestly; that is because of experience. When, for example, children fear abandonment, it is not in counterreaction to their intrinsic homicidal urges; rather, it is more likely because they have been abandoned physically or psychologically, or have been repeatedly threatened with abandonment. When children are pervasively filled with rage, it is due to rejection or harsh treatment. When children experience intense inner conflict regarding their angry feelings, this is likely because expressing them may be forbidden or even dangerous.

Bowlby noticed that when children must disown powerful experiences they have had, this creates serious problems, including “chronic distrust of other people, inhibition of curiosity, distrust of their own senses, and the tendency to find everything unreal.”⁷ As we will see, this has important implications for treatment.

Our study expanded our thinking beyond the impact of particular horrendous events, the focus of the PTSD diagnosis, to look at the long-term effects of brutalization and neglect in caregiving relationships. It also raised another critical question: What therapies are effective for people with a history of abuse, particularly those who feel chronically suicidal and deliberately hurt themselves?

2] SELF-HARM

During my training I was called from my bed at around 3:00 a.m. three nights in a row to stitch up a woman who had slashed her neck with whatever sharp object she could lay her hands on. She told me, somewhat triumphantly, that cutting herself made her feel much better. Ever since then I’d asked myself why. Why do some people deal with being upset by playing three sets of tennis or drinking a stiff martini, while others carve their arms with razor blades? Our study showed that having a history of childhood sexual and physical abuse was a strong predictor of repeated suicide attempts and self-cutting.⁸ I wondered if their suicidal ruminations had started when they were very young and whether they had found comfort in plotting their escape by hoping to die or doing damage to themselves. Does inflicting harm on oneself begin as a desperate attempt to gain some sense of control?

Chris Perry’s database had follow-up information on all the patients who were treated in the hospital’s outpatient clinics, including reports on suicidality and self-destructive behavior. After three years of therapy approximately two-thirds of the patients had markedly improved. Now the question was, which members of the group had benefited from therapy and which had continued to feel suicidal and self-destructive? Comparing the patients’ ongoing behavior with our TAQ interviews provided some answers. The patients who remained self-destructive had told us that they did not remember feeling safe with anybody as a child; they had reported being abandoned, shuttled from place to place, and generally left to their own devices.

I concluded that, if you carry a memory of having felt safe with somebody long ago, the traces of that earlier affection can be reactivated in attuned relationships when you are an adult, whether these occur in daily life or in good therapy. However, if you lack a deep memory of feeling loved and safe, the receptors in the brain that respond to human kindness may simply fail to develop.⁹ If that is the case, how can people learn to calm themselves down and feel grounded in their bodies? Again, this has important implications for therapy, and I’ll return to this question throughout part 5, on treatment.

3] THE POWER OF DIAGNOSIS

Our study also confirmed that there was a traumatized population quite distinct from the combat soldiers and accident victims for whom the PTSD diagnosis had been created. People like Marilyn and Kathy, as well as the patients Judy and I had studied, and the kids in the outpatient clinic at MMHC that I described in chapter 7, do not necessarily remember their traumas (one of the criteria for the PTSD diagnosis) or at least are not preoccupied with specific memories of their abuse, but they continue to behave as if they were still in danger. They go from one extreme to the other; they have trouble staying on task, and they continually lash out against themselves and others. To some degree their problems do overlap with those of combat soldiers, but they are also very different in that their childhood trauma has prevented them from developing some of the mental capacities that adult soldiers possessed before their traumas occurred.

After we realized this, a group of us¹⁰ went to see Robert Spitzer, who, after having guided the development of the DSM-III, was in the process of revising the manual. He listened carefully to what we told him. He told us it was likely that clinicians who spend their days treating a particular patient population are likely to develop considerable expertise in understanding what ails them. He suggested that we do a study, a so-called field trial, to compare the problems of different groups of traumatized individuals.¹¹ Spitzer put me in charge of the project. First we developed a rating scale that incorporated all the different trauma symptoms that had been reported in the scientific literature, then we interviewed 525 adult patients at five sites around the country to see if particular populations suffered from different constellations of problems. Our populations fell into three 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.

There were clear differences among these groups, particularly those on the extreme ends of the spectrum: victims of child abuse and adults who had survived natural disasters. The adults who had been abused as children often had trouble concentrating, complained of always being on edge, and were filled with self-loathing. They had enormous trouble negotiating intimate relationships, often veering from indiscriminate, high-risk, and unsatisfying sexual involvements to total sexual shutdown. They also had large gaps in their memories, often engaged in self-destructive behaviors, and had a host of medical problems. These symptoms were relatively rare in the survivors of natural disasters.

Each major diagnosis in the DSM had a workgroup responsible for suggesting revisions for the new edition. I presented the results of the field trial to our DSM-IV PTSD work group, and we voted nineteen to two to create a new trauma diagnosis for victims of interpersonal trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS), or “Complex PTSD” for short.12,13 We then eagerly anticipated the publication of the DSM-IV in May 1994. But much to our surprise the diagnosis that our work group had overwhelmingly approved did not appear in the final product. None of us had been consulted.

This was a tragic exclusion. It meant that large numbers of patients could not be accurately diagnosed and that clinicians and researchers would be unable to scientifically develop appropriate treatments for them. You cannot develop a treatment for a condition that does not exist. Not having a diagnosis now confronts therapists with a serious dilemma: How do we treat people who are coping with the fall-out of abuse, betrayal and abandonment when we are forced to diagnose them with depression, panic disorder, bipolar illness, or borderline personality, which do not really address what they are coping with?

The consequences of caretaker abuse and neglect are vastly more common and complex than the impact of hurricanes or motor vehicle accidents. Yet the decision makers who determined the shape of our diagnostic system decided not to recognize this evidence. To this day, after twenty years and four subsequent revisions, the DSM and the entire system based on it fail victims of child abuse and neglect—just as they ignored the plight of veterans before PTSD was introduced back in 1980.

4] THE HIDDEN EPIDEMIC

How do you turn a newborn baby with all its promise and infinite capacities into a thirty-year-old homeless drunk? As with so many great discoveries, internist Vincent Felitti came across the answer to this question accidentally.

In 1985 Felitti was chief of Kaiser Permanente’s Department of Preventive Medicine in San Diego, which at the time was the largest medical screening program in the world. He was also running an obesity clinic that used a technique called “supplemented absolute fasting” to bring about dramatic weight loss without surgery. One day a twenty-eight-year-old nurse’s aide showed up in his office. Felitti accepted her claim that obesity was her principal problem and enrolled her in the program. Over the next fifty-one weeks her weight dropped from 408 pounds to 132 pounds.

However, when Felitti next saw her a few months later, she had regained more weight than he thought was biologically possible in such a short time. What had happened? It turned out that her newly svelte body had attracted a male coworker, who started to flirt with her and then suggested sex. She went home and began to eat. She stuffed herself during the day and ate while sleepwalking at night. When Felitti probed this extreme reaction, she revealed a lengthy incest history with her grandfather.

This was only the second case of incest Felitti had encountered in his twenty-three-year medical practice, and yet about ten days later he heard a similar story. As he and his team started to inquire more closely, they were shocked to discover that most of their morbidly obese patients had been sexually abused as children. They also uncovered a host of other family problems.

In 1990 Felitti went to Atlanta to present data from the team’s first 286 patient interviews at a meeting of the North American Association for the Study of Obesity. He was stunned by the harsh response of some experts: Why did he believe such patients? Didn’t he realize they would fabricate any explanation for their failed lives? However, an epidemiologist from the Centers for Disease Control and Prevention (CDC) encouraged Felitti to start a much larger study, drawing on a general population, and invited him to meet with a small group of researchers at the CDC. The result was the monumental investigation of Adverse Childhood Experiences (now know at the ACE study), a collaboration between the CDC and Kaiser Permanente, with Robert Anda, MD, and Vincent Felitti, MD, as co–principal investigators.

More than fifty thousand Kaiser patients came through the Department of Preventive Medicine annually for a comprehensive evaluation, filling out an extensive medical questionnaire in the process. Felitti and Anda spent more than

a year developing ten new questions¹⁴ covering carefully defined categories of 

adverse childhood experiences, including physical and sexual abuse, physical and emotional neglect, and family dysfunction, 

such as having had parents who were divorced, mentally ill, addicted, or in prison. They then asked 25,000 consecutive patients if they would be willing to provide information about childhood events; 17,421 said yes. Their responses were then compared with the detailed medical records that Kaiser kept on all patients.

The ACE study revealed that traumatic life experiences during childhood and adolescence are far more common than expected. The study respondents were mostly white, middle class, middle aged, well educated, and financially secure enough to have good medical insurance, and yet only one-third of the respondents reported no adverse childhood experiences.

1. One out of ten individuals responded yes to the question “Did a parent or other adult in the household often or very often swear at you, insult you, or put you down?”
2. More than a quarter responded yes to the questions “Did one of your parents often or very often push, grab, slap, or throw something at you?” and “Did one of your parents often or very often hit you so hard that you had marks or were injured?” In other words, more than a quarter of the U.S. population is likely to have been repeatedly physically abused as a child.
3. To the questions “Did an adult or person at least 5 years older ever have you touch their body in a sexual way?” and “Did an adult or person at least 5 years older ever attempt oral, anal, or vaginal intercourse with you?” 28 percent of women and 16 percent of men responded affirmatively.
4. One in eight people responded positively to the questions: “As a child, did you witness your mother sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her?” “As a child, did you witness your mother sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?”¹⁵

Each yes answer was scored as one point, leading to a possible ACE score ranging from zero to ten. For example, a person who experienced frequent verbal abuse, who had an alcoholic mother, and whose parents divorced would have an ACE score of three. Of the two-thirds of respondents who reported an adverse

experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher.

In short, Felitti and his team had found that adverse experiences are interrelated, even though they’re usually studied separately. People typically don’t grow up in a household where one brother is in prison but everything else is fine. They don’t live in families where their mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are never stand-alone events. And for each additional adverse experience reported, the toll in later damage increases.

Felitti and his team found that the effects of childhood trauma first become evident in school. More than half of those with ACE scores of four or higher reported having learning or behavioral problems, compared with 3 percent of those with a score of zero. As the children matured, they didn’t “outgrow” the effects of their early experiences. As Felitti notes, “Traumatic experiences are often lost in time and concealed by shame, secrecy, and social taboo,” but the study revealed that the impact of trauma pervaded these patients’ adult lives. For example, high ACE scores turned out to correlate with higher workplace absenteeism, financial problems, and lower lifetime income.

When it came to personal suffering, the results were devastating. As the ACE score rises, chronic depression in adulthood also rises dramatically. For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared with an overall rate of 12 percent in those with an ACE score of zero. The likelihood of being on antidepressant medication or prescription painkillers also rose proportionally. As Felitti has pointed out, we may be treating today experiences that happened fifty years ago—at ever-increasing cost. Antidepressant drugs and painkillers constitute a significant portion of our rapidly rising national health-care expenditures.¹⁶ (Ironically, research has shown that depressed patients without prior histories of abuse or neglect tend to respond much better to antidepressants than patients with those backgrounds.¹⁷)

Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts. The more isolated and unprotected a person feels, the more death will feel like the only escape. When the media report an environmental link to a 30 percent increase in the risk of some cancer, it is headline news, yet these far more dramatic figures are overlooked.

As part of their initial medical evaluation, study participants were asked,

“Have you ever considered yourself to be an alcoholic?” People with an ACE score of four were seven times more likely to be alcoholic than adults with a score of zero. Injection drug use increased exponentially: For those with an ACE score of six or more, the likelihood of IV drug use was 4,600 percent greater than in those with a score of zero.

Women in the study were asked about rape during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at a score of four or more it was 33 percent. Why are abused or neglected girls so much more likely to be raped later in life? The answers to this question have implications far beyond rape. For example, numerous studies have shown that girls who witness domestic violence while growing up are at much higher risk of ending up in violent relationships themselves, while for boys who witness domestic violence, the risk that they will abuse their own partners rises sevenfold.¹⁸ More than 12 percent of study participants had seen their mothers being battered.

The list of high-risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and sexually transmitted diseases. Finally, the toll of major health problems was striking: Those with an ACE score of six or above had a 15 percent or greater chance than those with an ACE score of zero of currently suffering from any of the ten leading causes of death in the United States, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer and four times as likely to have emphysema. The ongoing stress on the body keeps taking its toll.

5] WHEN PROBLEMS ARE REALLY SOLUTIONS

Twelve years after he originally treated her, Felitti again saw the woman whose dramatic weight loss and gain had started him on his quest. She told him that she’d subsequently had bariatric surgery but that after she’d lost ninety-six pounds she’d become suicidal. It had taken five psychiatric hospitalizations and three courses of electroshock to control her suicidality. Felitti points out that obesity, which is considered a major public health problem, may in fact be a personal solution for many. Consider the implications: If you mistake someone’s solution for a problem to be eliminated, not only are they likely to fail treatment, as often happens in addiction programs, but other problems may emerge.

One female rape victim told Felitti, “Overweight is overlooked, and that’s

the way I need to be.”¹⁹ Weight can protect men, as well. Felitti recalls two guards at a state prison in his obesity program. They promptly regained the weight they had lost, because they felt a lot safer being the biggest guy on the cellblock. Another male patient became obese after his parents divorced and he moved in with his violent alcoholic grandfather. He explained: “It wasn’t that I ate because I was hungry and all of that. It was just a place for me to feel safe. All the way from kindergarten I used to get beat up all the time. When I got the weight on it didn’t happen anymore.”

The ACE study group concluded: “Although widely understood to be harmful to health, each adaptation [such as smoking, drinking, drugs, obesity] is notably difficult to give up. Little consideration is given to the possibility that many long-term health risks might also be personally beneficial in the short term. We repeatedly hear from patients of the benefits of these ‘health risks.’ The idea of the problem being a solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely coexist in biological systems. . . . What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort.”

6] CHILD ABUSE: OUR NATION’S LARGEST PUBLIC HEALTH PROBLEM

The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular health. But when the ACE study data started to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters.²⁰ It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.

When the surgeon general’s report on smoking and health was published in 1964, it unleashed a decades-long legal and medical campaign that has changed daily life and long-term health prospects for millions. The number of American

smokers fell from 42 percent of adults in 1965 to 19 percent in 2010, and it is estimated that nearly 800,000 deaths from lung cancer were prevented between 1975 and 2000.²¹

The ACE study, however, has had no such effect. Follow-up studies and papers are still appearing around the world, but the day-to-day reality of children like Marilyn and the children in outpatient clinics and residential treatment centers around the country remains virtually the same. Only now they receive high doses of psychotropic agents, which makes them more tractable but which also impairs their ability to feel pleasure and curiosity, to grow and develop emotionally and intellectually, and to become contributing members of society.

CHAPTER 10 DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. There is no known evidence of developmental disruptions that were preceded in time in a causal fashion by any type of trauma syndrome.

—From the American Psychiatric Association’s rejection of a Developmental Trauma Disorder diagnosis, May 2011

Research on the effects of early maltreatment tells a different story: that early maltreatment has enduring negative effects on brain development. Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with strife, but at the cost of deep, enduring wounds. Childhood abuse isn’t something you “get over.” It is an evil that we must acknowledge and confront if we aim to do

anything about the unchecked cycle of violence in this country.

—Martin Teicher, MD, PhD, Scientific American

to

T here are hundreds of thousands of children like the ones I am about describe and they absorb enormous resources often without appreciable benefit. They end up filling our jails, our welfare rolls, and our medical clinics. Most of the public knows them only as statistics. Tens of thousands of schoolteachers, probation officers, welfare workers, judges, and mental health professionals spend their days trying to help them, and the taxpayer pays the bills.

Anthony was only two and a half when he was referred to our Trauma Center by a childcare center because its employees could not manage his constant biting and pushing, his refusal to take naps, and his intractable crying, head banging, and rocking. He did not feel safe with any staff member and fluctuated between despondent collapse and angry defiance.

When we met with him and his mother, he anxiously clung to her, hiding his face, while she kept saying, “Don’t be such a baby.” He startled when a door banged somewhere down the corridor and then burrowed deeper into his mom’s lap. When she pushed him away, he sat in a corner and started to bang his head. “He just does that to bug me,” his mother remarked. When we asked about her own background, she told us that she’d been abandoned by her parents and raised by a series of relatives who hit her, ignored her, and started to sexually abuse her at age thirteen. She’d become pregnant by a drunken boyfriend who left her when she told him she was carrying his child. Anthony was just like his father, she said—a good-for-nothing. She had had numerous violent rows with subsequent boyfriends, but she was sure that this had happened too late at night for Anthony to notice.

If Anthony were admitted to a hospital, he would likely be diagnosed with a host of different psychiatric disorders: depression, oppositional defiant disorder, anxiety, reactive attachment disorder, ADHD, and PTSD. None of these diagnoses, however, would clarify what was wrong with Anthony: that he was scared to death and fighting for his life, and he did not trust that his mother could help him.

Then there’s Maria, a fifteen-year-old Latina, one of the more than half a million kids in the United States who grow up in foster care and residential treatment programs. Maria is obese and aggressive. She has a history of sexual, physical, and emotional abuse and has lived in more than twenty out-of-home placements since age eight. The pile of medical charts that arrived with her described her as mute, vengeful, impulsive, reckless, and self-harming, with extreme mood swings and an explosive temper. She describes herself as “garbage, worthless, rejected.”

After multiple suicide attempts Maria was placed in one of our residential treatment centers. Initially she was mute and withdrawn and became violent when people got too close to her. After other approaches failed to work, she was

placed in an equine therapy program where she groomed her horse daily and learned simple dressage. Two years later I spoke with Maria at her high school graduation. She had been accepted by a four-year college. When I asked her what had helped her most, she answered, “The horse I took care of.” She told me that she first started to feel safe with her horse; he was there every day, patiently waiting for her, seemingly glad upon her approach. She started to feel a visceral connection with another creature and began to talk to him like a friend. Gradually she started talking with the other kids in the program and, eventually, with her counselor.

Virginia is a thirteen-year-old adopted white girl. She was taken away from her biological mother because of the mother’s drug abuse; after her first adoptive mother fell ill and died, she moved from foster home to foster home before being adopted again. Virginia was seductive with any male who crossed her path, and she reported sexual and physical abuse by various babysitters and temporary caregivers. She came to our residential treatment program after thirteen crisis hospitalizations for suicide attempts. The staff described her as isolated, controlling, explosive, sexualized, intrusive, vindictive, and narcissistic. She described herself as disgusting and said she wished she were dead. The diagnoses in her chart were bipolar disorder, intermittent explosive disorder, reactive attachment disorder, attention deficit disorder (ADD) hyperactive subtype, oppositional defiant disorder (ODD), and substance use disorder. But who, really, is Virginia? How can we help her have a life?¹

We can hope to solve the problems of these children only if we correctly define what is going on with them and do more than developing new drugs to control them or trying to find “the” gene that is responsible for their “disease.” The challenge is to find ways to help them lead productive lives and, in so doing, save hundreds of millions of dollars of taxpayers’ money. That process starts with facing the facts.

1] BAD GENES?

With such pervasive problems and such dysfunctional parents we would be tempted to ascribe their problems simply to bad genes. 

Technology always produces new directions for research, and when it became possible to do genetic testing, psychiatry became committed to finding the genetic causes of mental illness. Finding a genetic link seemed particularly relevant for schizophrenia, a fairly common (affecting about 1 percent of the population), severe, and perplexing form of mental illness and one that clearly runs in families. And yet after thirty years and millions upon millions of dollars’ worth of research, we have failed to find consistent genetic patterns for schizophrenia—or for any other psychiatric illness, for that matter.² Some of my colleagues have also worked hard to discover genetic factors that predispose people to develop traumatic stress.³ That quest continues, but so far it has failed to yield any solid answers.⁴

Recent research has swept away the simple idea that “having” a particular gene produces a particular result. It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or off by attaching methyl groups, a cluster of carbon and hydrogen atoms, to the outside of the gene (a process called methylation), making it more or less sensitive to messages from the body. 

While life events can change the behavior of the gene, they do not alter its fundamental structure. Methylation patterns, however, can be passed on to offspring—a phenomenon known as epigenetics. Once again, the body keeps the score, at the deepest levels of the organism.

One of the most cited experiments in epigenetics was conducted by McGill University researcher Michael Meaney, who studies newborn rat pups and their mothers.⁵ He discovered that how much a mother rat licks and grooms her pups during the first twelve hours after their birth permanently affects the brain chemicals that respond to stress—and modifies the configuration of over a thousand genes. The rat pups that are intensively licked by their mothers are braver and produce lower levels of stress hormones under stress than rats whose mothers are less attentive. They also recover more quickly—an equanimity that lasts throughout their lives. They develop thicker connections in the hippocampus, a key center for learning and memory, and they perform better in an important rodent skill—finding their way through mazes.

We are just beginning to learn that stressful experiences affect gene expression in humans, as well. Children whose pregnant mothers had been trapped in unheated houses in a prolonged ice storm in Quebec had major epigenetic changes compared with the children of mothers whose heat had been restored within a day.⁶ McGill researcher Moshe Szyf compared the epigenetic profiles of hundreds of children born into the extreme ends of social privilege in the United Kingdom and measured the effects of child abuse on both groups. Differences in social class were associated with distinctly different epigenetic profiles, but abused children in both groups had in common specific modifications in seventy-three genes. In Szyf’s words, “Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world.”^7,8

2] MONKEYS CLARIFY OLD QUESTIONS ABOUT NATURE VERSUS NURTURE

One of the clearest ways of understanding how the quality of parenting and environment affects the expression of genes comes from the work of Stephen Suomi, chief of the National Institutes of Health’s Laboratory of Comparative Ethology.⁹ For more than forty years Suomi has been studying the transmission of personality through generations of rhesus monkeys, which share 95 percent of human genes, a number exceeded only by chimpanzees and bonobos. Like humans, rhesus monkeys live in large social groups with complex alliances and status relationships, and only members who can synchronize their behavior with the demands of the troop survive and flourish.

Rhesus monkeys are also like humans in their attachment patterns. Their infants depend on intimate physical contact with their mothers, and just as Bowlby observed in humans, they develop by exploring their reactions to their environment, running back to their mothers whenever they feel scared or lost. Once they become more independent, play with their peers is the primary way they learn to get along in life.

Suomi identified two personality types that consistently ran into trouble: 

• uptight, anxious monkeys, who become fearful, withdrawn, and depressed even in situations where other monkeys will play and explore; and 
• highly aggressive monkeys, who make so much trouble that they are often shunned, beaten up, or killed. 

Both types are biologically different from their peers. Abnormalities in arousal levels, stress hormones, and metabolism of brain chemicals like serotonin can be detected within the first few weeks of life, and neither their biology nor their behavior tends to change as they mature. Suomi discovered a wide range of genetically driven behaviors. For example, the uptight monkeys (classified as such on the basis of both their behavior and their high cortisol levels at six months) will consume more alcohol in experimental situations than the others when they reach the age of four. The genetically aggressive monkeys also overindulge—but they binge drink to the point of passing out, while the

uptight monkeys seem to drink to calm down.

And yet the social environment also contributes significantly to behavior and biology. The uptight, anxious females don’t play well with others and thus often lack social support when they give birth and are at high risk for neglecting or abusing their firstborns. But when these females belong to a stable social group they often become diligent mothers who carefully watch out for their young. Under some conditions being an anxious mom can provide much needed protection. The aggressive mothers, on the other hand, did not provide any social advantages: very punitive with their offspring, there is lots of hitting, kicking, and biting. If the infants survive, their mothers usually keep them from making friends with their peers.

In real life it is impossible to tell whether people’s aggressive or uptight behavior is the result of parents’ genes or of having been raised by an abusive mother—or both. But in a monkey lab you can take newborns with vulnerable genes away from their biological mothers and have them raised by supportive mothers or in playgroups with peers.

Young monkeys who are taken away from their mothers at birth and brought up solely with their peers become intensely attached to them. They desperately cling to one another and don’t peel away enough to engage in healthy exploration and play. What little play there is lacks the complexity and imagination typical of normal monkeys. 

These monkeys grow up to be uptight: scared in new situations and lacking in curiosity. Regardless of their genetic predisposition, peer-raised monkeys overreact to minor stresses: Their cortisol increases much more in response to loud noises than does that of monkeys who were raised by their mothers. Their serotonin metabolism is even more abnormal than that of the monkeys who are genetically predisposed to aggression but who were raised by their own mothers. This leads to the conclusion that, at least in monkeys, early experience has at least as much impact on biology as heredity does.

Monkeys and humans share the same two variants of the serotonin gene (known as the short and long serotonin transporter alleles). 

In humans the short allele has been associated with impulsivity, aggression, sensation seeking, suicide attempts, and severe depression. Suomi showed that, at least in monkeys, the environment shapes how these genes affect behavior. Monkeys with the short allele that were raised by an adequate mother behaved normally and had no deficit in their serotonin metabolism. Those who were raised with their peers became aggressive risk takers.¹⁰ 

Similarly, New Zealand researcher Alec Roy found that humans with the short allele had higher rates of depression than those with the long version but that this was true only if they also had a childhood history of abuse or neglect. The conclusion is clear: Children who are fortunate enough to have an attuned and attentive parent are not going to develop this genetically related problem.¹¹

Suomi’s work supports everything we’ve learned from our colleagues who study human attachment and from our own clinical research: Safe and protective early relationships are critical to protect children from long-term problems. In addition, even parents with their own genetic vulnerabilities can pass on that protection to the next generation provided that they are given the right support.

3] THE NATIONAL CHILD TRAUMATIC STRESS NETWORK

Nearly every medical disease, from cancer to retinitis pigmentosa, has advocacy groups that promote the study and treatment of that particular condition. But until 2001, when the National Child Traumatic Stress Network was established by an act of Congress, there was no comprehensive organization dedicated to the research and treatment of traumatized children.

In 1998 I received a call from Adam Cummings from the Nathan Cummings Foundation telling me that they were interested in studying the effects of trauma on learning. I told them that while some very good work had been done on that subject,¹² there was no forum to implement the discoveries that had already been made. The mental, biological, or moral development of traumatized children was not being systematically taught to childcare workers, to pediatricians, or in graduate schools of psychology or social work.

Adam and I agreed that we had to address this problem. Some eight months later we convened a think tank that included representatives from the U.S. Department of Health and Human Services and the U.S. Department of Justice, Senator Ted Kennedy’s health-care adviser, and a group of my colleagues who specialized in childhood trauma. We all were familiar with the basics of how trauma affects the developing mind and brain, and we all were aware that childhood trauma is radically different from traumatic stress in fully formed adults. The group concluded that, if we hoped to ever put the issue of childhood trauma firmly on the map, there needed to be a national organization that would promote both the study of childhood trauma and the education of teachers, judges, ministers, foster parents, physicians, probation officers, nurses, and

mental health professionals—anyone who deals with abused and traumatized kids.

One member of our work group, Bill Harris, had extensive experience with child-related legislation, and he went to work with Senator Kennedy’s staff to craft our ideas into law. The bill establishing the National Child Traumatic Stress Network was ushered through the Senate with overwhelming bipartisan support, and since 2001 it has grown from a collaborative network of 17 sites to more than 150 centers nationwide. Led by coordinating centers at Duke University and UCLA, the NCTSN includes universities, hospitals, tribal agencies, drug rehab programs, mental health clinics, and graduate schools. Each of the sites, in turn, collaborates with local school systems, hospitals, welfare agencies, homeless shelters, juvenile justice programs, and domestic violence shelters, with a total of well over 8,300 affiliated partners.

Once the NCTSN was up and running, we had the means to assemble a clearer profile of traumatized kids in every part of the country. My Trauma Center colleague Joseph Spinazzola led a survey that examined the records of nearly two thousand children and adolescents from agencies across the network.¹³ We soon confirmed what we had suspected: The vast majority came from extremely dysfunctional families. More than half had been emotionally abused and/or had a caregiver who was too impaired to care for their needs. Almost 50 percent had temporarily lost caregivers to jail, treatment programs, or military service and had been looked after by strangers, foster parents, or distant relatives. About half reported having witnessed domestic violence, and a quarter were also victims of sexual and /or physical abuse. In other words, the children and adolescents in the survey were mirrors of the middle-aged, middle-class Kaiser Permanente patients with high ACE scores that Vincent Felitti had

studied in the Adverse Childhood Experiences (ACE) Study.

4] THE POWER OF DIAGNOSIS

In the 1970s there was no way to classify the wide-ranging symptoms of hundreds of thousands of returning Vietnam veterans. As we saw in the opening chapters of this book, this forced clinicians to improvise the treatment of their patients and prevented them from being able to systematically study what approaches actually worked. The adoption of the PTSD diagnosis by the DSM III in 1980 led to extensive scientific studies and to the development of effective

treatments, which turned out to be relevant not only to combat veterans but also to victims of a range of traumatic events, including rape, assault, and motor vehicle accidents.¹⁴ An example of the far-ranging power of having a specific diagnosis is the fact that between 2007 and 2010 the Department of Defense spent more than $2.7 billion for the treatment of and research on PTSD in combat veterans, while in fiscal year 2009 alone the Department of Veterans Affairs spent $24.5 million on in-house PTSD research.

The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” causing “intense fear, helplessness, or horror,” which results in a variety of manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability). 

This description suggests a clear story line: A person is suddenly and unexpectedly devastated by an atrocious event and is never the same again. The trauma may be over, but it keeps being replayed in continually recycling memories and in a reorganized nervous system.

How relevant was this definition to the children we were seeing? After a single traumatic incident—a dog bite, an accident, or witnessing a school shooting—children can indeed develop basic PTSD symptoms similar to those of adults, even if they live in safe and supportive homes. As a result of having the PTSD diagnosis, we now can treat those problems quite effectively.

In the case of the troubled children with histories of abuse and neglect who show up in clinics, schools, hospitals, and police stations, the traumatic roots of their behaviors are less obvious, particularly because they rarely talk about having been hit, abandoned, or molested, even when asked. Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.¹⁵ Because they often are shut down, suspicious, or aggressive they now receive pseudoscientific diagnoses such as “oppositional defiant disorder,” meaning “This kid hates my guts and won’t do anything I tell him to do,” or “disruptive mood dysregulation disorder,” meaning he has temper tantrums. Having as many problems as they do, these kids accumulate numerous diagnoses over time. Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels. If they receive treatment at all, they get whatever is being promulgated as the method of management du jour: medications, behavioral modification, or exposure therapy. These rarely work and often cause more damage.

As the NCTSN treated more and more kids, it became increasingly obvious that we needed a diagnosis that captured the reality of their experience. We began with a database of nearly twenty thousand kids who were being treated in various sites within the network and collected all the research articles we could find on abused and neglected kids. These were winnowed down to 130 particularly relevant studies that reported on more than one hundred thousand children and adolescents worldwide. A core work group of twelve clinician/researchers specializing in childhood trauma¹⁶ then convened twice a year for four years to draft a proposal for an appropriate diagnosis, which we decided to call Developmental Trauma Disorder.¹⁷

As we organized our findings, we discovered a consistent profile: 

(1) a pervasive pattern of dysregulation, 

(2) problems with attention and concentration, and 

(3) difficulties getting along with themselves and others. 

These children’s moods and feelings rapidly shifted from one extreme to another —from temper tantrums and panic to detachment, flatness, and dissociation. When they got upset (which was much of the time), they could neither calm themselves down nor describe what they were feeling.

Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. 

To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine-motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted.

Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they can not help but define themselves as defective and worthless. They come by their self-loathing, sense of defectiveness, and worthlessness honestly. Was it any surprise that they didn’t trust anyone? Finally, the combination of feeling fundamentally despicable and

overreacting to slight frustrations makes it difficult for them to make friends.

We published the first articles about our findings, developed a validated rating scale,¹⁸ and collected data on about 350 kids and their parents or foster parents to establish that this one diagnosis, Developmental Trauma Disorder, captured the full range of what was wrong with these children. It would enable us to give them a single diagnosis, as opposed to multiple labels, and would firmly locate the origin of their problems in a combination of trauma and compromised attachment.

In February 2009 we submitted our proposed new diagnosis of Developmental Trauma Disorder to the American Psychiatric Association, stating the following in a cover letter:

Children who develop in the context of ongoing danger, maltreatment and disrupted caregiving systems are being ill served by the current diagnostic systems that lead to an emphasis on behavioral control with no recognition of interpersonal trauma. Studies on the sequelae of childhood trauma in the context of caregiver abuse or neglect

consistently demonstrate chronic and severe problems with emotion regulation, impulse control, attention and cognition, dissociation, interpersonal relationships, and self and relational schemas. 

In absence of a sensitive trauma-specific diagnosis, such children are currently diagnosed with an average of 3–8 co-morbid disorders. The continued practice of applying multiple distinct co-morbid diagnoses to

traumatized children has grave consequences: it defies parsimony, obscures etiological clarity, and runs the danger of relegating treatment and intervention to a small aspect of the child’s psychopathology rather than promoting a comprehensive treatment approach.

Shortly after submitting our proposal, I gave a talk on Developmental Trauma Disorder in Washington DC to a meeting of the mental health commissioners from across the country. They offered to support our initiative by writing a letter to the APA. The letter began by pointing out that the National Association of State Mental Health Program Directors served 6.1 million people annually, with a budget of $29.5 billion, and concluded: “We urge the APA to add developmental trauma to its list of priority areas to clarify and better characterize its course and clinical sequelae and to emphasize the strong need to address developmental trauma in the assessment of patients.”

I felt confident that this letter would ensure that the APA would take our proposal seriously, but several months after our submission, Matthew Friedman, executive director of the National Center for PTSD and chair of the relevant DSM subcommittee, informed us that DTD was unlikely to be included in the DSM-5. The consensus, he wrote, was that no new diagnosis was required to fill a “missing diagnostic niche.” One million children who are abused and neglected every year in the United States a “diagnostic niche”?

The letter went on: “The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. This statement is commonly made but cannot be backed up by prospective studies.” In fact, we had included several prospective studies in our proposal. Let’s look at just two of them here.

5] HOW RELATIONSHIPS SHAPE DEVELOPMENT

Beginning in 1975 and continuing for almost thirty years, Alan Sroufe and his colleagues tracked 180 children and their families through the Minnesota Longitudinal Study of Risk and Adaptation.¹⁹ At the time the study began there was an intense debate about the role of nature versus nurture, and temperament versus environment in human development, and this study set out to answer those questions. Trauma was not yet a popular topic, and child abuse and neglect were not a central focus of this study—at least initially, until they emerged as the most important predictors of adult functioning.

Working with local medical and social agencies, the researchers recruited first-time (Caucasian) mothers who were poor enough to qualify for public assistance but who had different backgrounds and different kinds and levels of support available for parenting. The study began three months before the children were born and followed the children for thirty years into adulthood, assessing and, where relevant, measuring all the major aspects of their functioning and all the significant circumstances of their lives. It considered several fundamental questions: How do children learn to pay attention while regulating their arousal (i.e., avoiding extreme highs or lows) and keeping their impulses under control? What kinds of supports do they need, and when are these needed?

After extensive interviews and testing of the prospective parents, the study really got off the ground in the newborn nursery, where researchers observed the

newborns and interviewed the nurses caring for them. They then made home visits seven and ten days after birth. Before the children entered first grade, they and their parents were carefully assessed a total of fifteen times. After that, the children were interviewed and tested at regular intervals until age twenty-eight, with continuing input from mothers and teachers.

Sroufe and his colleagues found that quality of care and biological factors were closely interwoven. It is fascinating to see how the Minnesota results echo —though with far greater complexity—what Stephen Suomi found in his primate laboratory. Nothing was written in stone. Neither the mother’s personality, nor the infant’s neurological anomalies at birth, nor its IQ, nor its temperament—including its activity level and reactivity to stress—predicted whether a child would develop serious behavioral problems in adolescence.²⁰ The key issue, rather, was the nature of the parent-child relationship: how parents felt about and interacted with their kids. As with Suomi’s monkeys, the combination of vulnerable infants and inflexible caregivers made for clingy, uptight kids. Insensitive, pushy, and intrusive behavior on the part of the parents at six months predicted hyperactivity and attention problems in kindergarten and beyond.²¹

Focusing on many facets of development, particularly relationships with caregivers, teachers, and peers, Sroufe and his colleagues found that caregivers not only help keep arousal within manageable bounds but also help infants develop their own ability to regulate their arousal. Children who were regularly pushed over the edge into overarousal and disorganization did not develop proper attunement of their inhibitory and excitatory brain systems and grew up expecting that they would lose control if something upsetting happened. This was a vulnerable population, and by late adolescence half of them had diagnosable mental health problems. There were clear patterns: The children who received consistent caregiving became well-regulated kids, while erratic caregiving produced kids who were chronically physiologically aroused. The children of unpredictable parents often clamored for attention and became intensely frustrated in the face of small challenges. Their persistent arousal made them chronically anxious. Constantly looking for reassurance got in the way of playing and exploration, and, as a result, they grew up chronically nervous and nonadventurous.

Early parental neglect or harsh treatment led to behavior problems in school and predicted troubles with peers and a lack of empathy for the distress of others.²² This set up a vicious cycle: Their chronic arousal, coupled with lack of

parental comfort, made them disruptive, oppositional, and aggressive. Disruptive and aggressive kids are unpopular and provoke further rejection and punishment, not only from their caregivers but also from their teachers and peers.²³

Sroufe also learned a great deal about resilience: the capacity to bounce back from adversity. By far the most important predictor of how well his subjects coped with life’s inevitable disappointments was the level of security established with their primary caregiver during the first two years of life. Sroufe informally told me that he thought that resilience in adulthood could be predicted by how lovable mothers rated their kids at age two.²⁴

6] THE LONG-TERM EFFECTS OF INCEST

In 1986 Frank Putnam and Penelope Trickett, his colleague at the National Institute of Mental Health, initiated the first longitudinal study of the impact of sexual abuse on female development.²⁵ Until the results of this study came out, our knowledge about the effects of incest was based entirely on reports from children who had recently disclosed their abuse and on accounts from adults reconstructing years or even decades later how incest had affected them. No study had ever followed girls as they matured to examine how sexual abuse might influence their school performance, peer relationships, and self-concept, as well as their later dating life. Putnam and Trickett also looked at changes over time in their subjects’ stress hormones, reproductive hormones, immune function, and other physiological measures. In addition they explored potential protective factors, such as intelligence and support from family and peers.

The researchers painstakingly recruited eighty-four girls referred by the District of Columbia Department of Social Services who had a confirmed history of sexual abuse by a family member. These were matched with a comparison group of eighty-two girls of the same age, race, socioeconomic status, and family constellation who had not been abused. The average starting age was eleven. Over the next twenty years these two groups were thoroughly assessed six times, once a year for the first three years and again at ages eighteen, nineteen, and twenty-five. Their mothers participated in the early assessments, and their own children took part in the last. A remarkable 96 percent of the girls, now grown women, have stayed in the study from its inception.

The results were unambiguous: Compared with girls of the same age, race, and social circumstances, sexually abused girls suffer from a large range of

profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation. They dropped out of high school at a higher rate than the control group and had more major illnesses and health-care utilization. They also showed abnormalities in their stress hormone responses, had an earlier onset of puberty, and accumulated a host of different, seemingly unrelated, psychiatric diagnoses.

The follow-up research revealed many details of how abuse affects development. For example, each time they were assessed, the girls in both groups were asked to talk about the worst thing that had happened to them during the previous year. As they told their stories, the researchers observed how upset they became, while measuring their physiology. During the first assessment all the girls reacted by becoming distressed. Three years later, in response to the same question, the nonabused girls once again displayed signs of distress, but the abused girls shut down and became numb. Their biology matched their observable reactions: During the first assessment all of the girls showed an increase in the stress hormone cortisol; three years later cortisol went down in the abused girls as they reported on the most stressful event of the past year. Over time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends, and others are not likely to notice that a girl is upset; she may not even register it herself. By numbing out she no longer reacts to distress the way she should, for example, by taking protective action.

Putnam’s study also captured the pervasive long-term effects of incest on friendships and partnering. Before the onset of puberty nonabused girls usually have several girlfriends, as well as one boy who functions as a sort of spy who informs them about what these strange creatures, boys, are all about. After they enter adolescence, their contacts with boys gradually increase. In contrast, before puberty the abused girls rarely have close friends, girls or boys, but adolescence brings many chaotic and often traumatizing contacts with boys.

Lacking friends in elementary school makes a crucial difference. Today we’re aware how cruel third-, fourth-, and fifth-grade girls can be. It’s a complex and rocky time when friends can suddenly turn on one another and alliances dissolve in exclusions and betrayals. But there is an upside: By the time girls get to middle school, most have begun to master a whole set of social skills, including being able to identify what they feel, negotiating relationships with others, pretending to like people they don’t, and so on. And most of them have built a fairly steady support network of girls who become their stress-debriefing

team. As they slowly enter the world of sex and dating, these relationships give them room for reflection, gossip, and discussion of what it all means.

The sexually abused girls have an entirely different developmental pathway. They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out. They can’t keep up in the normal envy-driven inclusion/exclusion games, in which players have to stay cool under stress. Other kids usually don’t want anything to do with them—they simply are too weird.

But that’s only the beginning of the trouble. The abused, isolated girls with incest histories mature sexually a year and a half earlier than the nonabused girls. Sexual abuse speeds up their biological clocks and the secretion of sex hormones. Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group.

Results of Putnam and Trickett’s study continue to be published, but it has already created an invaluable road map for clinicians dealing with sexually abused girls. At the Trauma Center, for example, one of our clinicians reported on a Monday morning that a patient named Ayesha had been raped—again— over the weekend. She had run away from her group home at five o’clock on Saturday, gone to a place in Boston where druggies hang out, smoked some dope and done some other drugs, and then left with a bunch of boys in a car. At five o’clock Sunday morning they had gang-raped her. Like so many of the adolescents we see, Ayesha can’t articulate what she wants or needs and can’t think through how she might protect herself. Instead, she lives in a world of actions. Trying to explain her behavior in terms of victim/perpetrator isn’t helpful, nor are labels like “depression,” “oppositional defiant disorder,” “intermittent explosive disorder,” “bipolar disorder,” or any of the other options our diagnostic manuals offer us. Putnam’s work has helped us understand how Ayesha experiences the world—why she cannot tell us what is going on with her, why she is so impulsive and lacking in self-protection, and why she views us as frightening and intrusive rather than as people who can help her.

7] THE DSM-5: A VERITABLE SMORGASBORD OF “DIAGNOSES”

When DSM-5 was published in May 2013 it included some three hundred

disorders in its 945 pages. It offers a veritable smorgasbord of possible labels for the problems associated with severe early-life trauma, including some new ones such as Disruptive Mood Regulation Disorder,²⁶ Non-suicidal Self Injury, Intermittent Explosive Disorder, Dysregulated Social Engagement Disorder, and Disruptive Impulse Control Disorder.²⁷

Before the late nineteenth century doctors classified illnesses according to their surface manifestations, like fevers and pustules, which was not unreasonable, given that they had little else to go on.²⁸ This changed when scientists like Louis Pasteur and Robert Koch discovered that many diseases were caused by bacteria that were invisible to the naked eye. Medicine then was transformed by its attempts to discover ways to get rid of those organisms rather than just treating the boils and the fevers that they caused. With DSM-5 psychiatry firmly regressed to early-nineteenth-century medical practice. Despite the fact that we know the origin of many of the problems it identifies, its “diagnoses” describe surface phenomena that completely ignore the underlying causes.

Even before DSM-5 was released, the American Journal of Psychiatry published the results of validity tests of various new diagnoses, which indicated that the DSM largely lacks what in the world of science is known as “reliability”— the ability to produce consistent, replicable results. In other words, it lacks scientific validity. Oddly, the lack of reliability and validity did not keep the DSM-5 from meeting its deadline for publication, despite the near-universal consensus that it represented no improvement over the previous diagnostic system.²⁹ Could the fact that the APA had earned $100 million on the DSM-IV and is slated to take in a similar amount with the DSM-5 (because all mental health practitioners, many lawyers, and other professionals will be obliged to purchase the latest edition) be the reason we have this new diagnostic system?

Diagnostic reliability isn’t an abstract issue: If doctors can’t agree on what ails their patients, there is no way they can provide proper treatment. When there’s no relationship between diagnosis and cure, a mislabeled patient is bound to be a mistreated patient. You would not want to have your appendix removed when you are suffering from a kidney stone, and you would not want have somebody labeled as “oppositional” when, in fact, his behavior is rooted in an attempt to protect himself against real danger.

In a statement released in June 2011, the British Psychological Society complained to the APA that the sources of psychological suffering in the DSM-5 were identified “as located within individuals” and overlooked the “undeniable

social causation of many such problems.”³⁰ This was in addition to a flood of protest from American professionals, including leaders of the American Psychological Association and the American Counseling Association. Why are relationships or social conditions left out?³¹ If you pay attention only to faulty biology and defective genes as the cause of mental problems and ignore abandonment, abuse, and deprivation, you are likely to run into as many dead ends as previous generations did blaming it all on terrible mothers.

The most stunning rejection of the DSM-5 came from the National Institute of Mental Health, which funds most psychiatric research in America. In April 2013, a few weeks before DSM-5 was formally released, NIMH director Thomas Insel announced that his agency could no longer support DSM’s “symptom-based diagnosis.”³² Instead the institute would focus its funding on what are called Research Domain Criteria (RDoC)³³ to create a framework for studies that would cut across current diagnostic categories. For example, one of the NIMH domains is “Arousal/Modulatory Systems (Arousal, Circadian Rhythm, Sleep and Wakefulness),” which are disturbed to varying degrees in many patients.

Like the DSM-5, the RDoC framework conceptualizes mental illnesses solely as brain disorders. This means that future research funding will explore the brain circuits “and other neurobiological measures” that underlie mental problems. Insel sees this as a first step toward the sort of “precision medicine that has transformed cancer diagnosis and treatment.” Mental illness, however, is not at all like cancer: Humans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength.

Everything about us—our brains, our minds, and our bodies—is geared toward collaboration in social systems. This is our most powerful survival strategy, the key to our success as a species, and it is precisely this that breaks down in most forms of mental suffering. As we saw in part 2, the neural connections in brain and body are vitally important for understanding human suffering, but it is important not to ignore the foundations of our humanity: relationships and interactions that shape our minds and brains when we are young and that give substance and meaning to our entire lives.

People with histories of abuse, neglect, or severe deprivation will remain mysterious and largely untreated unless we heed the admonition of Alan Sroufe: “To fully understand how we become the persons we are—the complex, step-by-step evolution of our orientations, capacities, and behavior over time—requires

more than a list of ingredients, however important any one of them might be. It requires an understanding of the process of development, how all of these factors work together in an ongoing way over time.”³⁴

Frontline mental health workers—overwhelmed and underpaid social workers and therapists alike—seem to agree with our approach. Shortly after the APA rejected Developmental Trauma Disorder for inclusion in the DSM, thousands of clinicians from around the country sent small contributions to the Trauma Center to help us conduct a large scientific study, known as a field trial, to further study DTD. That support has enabled us to interview hundreds of kids, parents, foster parents, and mental health workers at five different network sites over the last few years with scientifically constructed interview tools. The first results from these studies have now been published, and more will appear as this book is going to print.³⁵

8] WHAT DIFFERENCE WOULD DTD MAKE?

One answer is that it would focus research and treatment (not to mention funding) on the central principles that underlie the protean symptoms of chronically traumatized children and adults: pervasive biological and emotional dysregulation, failed or disrupted attachment, problems staying focused and on track, and a hugely deficient sense of coherent personal identity and competence. These issues transcend and include almost all diagnostic categories, but treatment that doesn’t put them front and center is more than likely to miss the mark. Our great challenge is to apply the lessons of neuroplasticity, the flexibility of brain circuits, to rewire the brains and reorganize the minds of people who have been programmed by life itself to experience others as threats and themselves as helpless.

Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment. Recognizing the profound effects of trauma and deprivation on child development need not lead to blaming parents. We can assume that parents do the best they can, but all parents need help to nurture their kids. Nearly every industrialized nation, with the exception of the United States, recognizes this and provides some form of guaranteed support to families. James Heckman, winner of the 2000 Nobel Prize in Economics, has shown that quality early-childhood programs that involve parents and promote basic skills in disadvantaged children more than pay for themselves in improved outcomes.³⁶

In the early 1970s psychologist David Olds was working in a Baltimore day­care center where many of the preschoolers came from homes wracked by poverty, domestic violence, and drug abuse. Aware that only addressing the children’s problems at school was not sufficient to improve their home conditions, he started a home-visitation program in which skilled nurses helped mothers to provide a safe and stimulating environment for their children and, in the process, to imagine a better future for themselves. Twenty years later, the children of the home-visitation mothers were not only healthier but also less likely to report having been abused or neglected than a similar group whose mothers had not been visited. They also were more likely to have finished school, to have stayed out of jail, and to be working in well-paying jobs. Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.³⁷

When I go to Europe to teach, I often am contacted by officials at the ministries of health in the Scandinavian countries, the United Kingdom, Germany, or the Netherlands and asked to spend an afternoon with them sharing the latest research on the treatment of traumatized children, adolescents, and their families. The same is true for many of my colleagues. These countries have already made a commitment to universal health care, ensuring a guaranteed minimum wage, paid parental leave for both parents after a child is born, and high-quality childcare for all working mothers.

Could this approach to public health have something to do with the fact that the incarceration rate in Norway is 71/100,000, in the Netherlands 81/100,000, and the US 781/100,000, while the crime rate in those countries is much lower than in ours, and the cost of medical care about half? Seventy percent of prisoners in California spent time in foster care while growing up. The United States spends $84 billion per year to incarcerate people at approximately $44,000 per prisoner; the northern European countries a fraction of that amount. Instead, they invest in helping parents to raise their children in safe and predictable surroundings. Their academic test scores and crime rates seem to reflect the success of those investments.