Anne McKechnie Consultant Forensic Clinical Psychologist, Glasgow Psychological Trauma Service
The mental health world has welcomed the recent increased interest in the impact of adverse experiences in childhood. Mental health and my own field of clinical psychology have been aware of the impact of childhood trauma for decades now, so the recognition of the impact on physical as well as mental health has helped raise the profile of a complex and often disturbing phenomenon. Carol Craig’s decision to relate this still further in an account of Lived Experience is yet more welcome, as it helps address issues of shame stemming from secrecy and fear surrounding adverse events in childhood
There is a risk however in misinterpretation of the statistics; the risk being that anyone who can identify with the experiences noted in the ACE may feel that they are inevitably seriously affected. The ACE research has highlighted a cumulative effect that often manifests in physical and mental health difficulties. As with many statistical models, the findings can be interpreted differently and need careful consideration. I have been aware of the concerns raised by many voiced in statements such as, ‘I have 4 ACEs so I must have a mental illness’. Equally, ‘I have a score of 7 in the ACE but am not affected; what does this mean?’
Mental health specialists are increasingly asking patients not ‘What’s wrong with you?’ but ‘What has happened to you?’ so it is good to see Maureen Watt, Scottish MSP and Minister for Mental Health, echoing these sentiments in her foreword to the National Health Service Education Scotland document, ‘National Trauma Training Framework’ But I propose the inclusion of a further question: ‘How has it affected you?’
The study of complex trauma has shown that any traumatic incidents in childhood either directly experienced or witnessed, and which are perpetrated by individuals on whom the child is dependent and has a close attachment, are likely to lead to longer-term psychological impact. Long term consequences can include:
Intrusive experiences such as flashbacks or nightmares;
Difficulty controlling emotions so people may have chronic anxiety, low mood or anger problems;
Having trouble establishing and maintaining relationships;
Avoiding reminders of the event to the extent that it interferes in daily life;
Feeling constantly on edge and believing that something terrible is going to happen imminently;
Feeling worthless and ashamed most of the time.
This is due to a number of factors: survivors of childhood interpersonal trauma are more likely to view the experience as their fault, may also believe that they deserve no better and that shame related to their experience is theirs, not that of their perpetrator. As Carol has also pointed out, the child abused in the family home often has disrupted attachment and consequently has not learned how to recognise and regulate their own emotions; they may in turn have limited ability to interpret others’ behaviours or intentions, further exacerbating difficulties in establishing trust.
It must be stressed that individuals can learn how to overcome the consequences of childhood adversity. Literature has noted that the human brain is ‘plastic’ i.e. open to the possibility of change and adapting established pathways, and therefore has the ability to learn new ways of coping. People can change how they view the world and how they perceive their place in it.
Long established research into the impact of Complex Post- Traumatic Stress Disorder (PTSD) and its treatment has shown great success using a phase-based approach. The lay person may be forgiven for assuming that in order to remedy the effects of childhood trauma, one must ‘get it out’, ‘lance the boil’ or ‘address the trauma’. This can be both difficult and daunting, particularly as it can lead to a resurgence or exacerbation of feelings of sadness, anger, fear or loss. The phase-based approach delivers treatment in three phases – safety and symptom stabilisation, remembrance and mourning, and skills building. Above all, these phases take place in the context of a safe, working and therapeutic relationship.
Treatment or management of the most severe consequences of childhood adversity may require input from mental health teams, trained in the assessment and treatment of Complex Post Traumatic Stress Disorder. In this case, it is vital that people are offered help by services which are properly accredited and registered with organisations such as Health Care Professions Council.
However, many of the interventions or treatments helpful in overcoming adverse reactions can also be sourced by individuals themselves. Understanding that the symptoms are a normal, natural reaction to an abnormal event and learning how to modify reactions is the first step toward healing and being able to move forward.
The first phase of treatment, known as safety and symptom stabilisation, consists of several treatments or skills building as detailed below. This was first proposed by trauma expert Marylene Cloitre and while this is the evidence-based treatment delivered by mental health professionals, individuals often find that trying some interventions for themselves, independently, can be highly effective. Here are some suggestions.
PSYCHO-EDUCATION OR LEARNING HOW OUR BRAINS WORK. When faced with life-threatening experiences, our brain automatically goes into Fight, Flight or Freeze mode. This involves the most primitive part of the brain identifying a source of threat and doing all it can to protect the body. It is a normal reaction and core to our survival as a species. With Post Traumatic Stress Disorder, the brain is triggered into this survival mode by responding to signals from our senses. Common triggers can be things we see, smell or feel that remind us, often subconsciously, of a frightening experience. The brain responds by preparing the body to run away, attack or freeze. This is often in the absence of a current threat and can lead to people feeling that they are ‘losing their mind’, ‘going mad’, or are seriously ill. Understanding that how we are feeling is a normal reaction to an unrealistic threat, sometimes present and real, sometimes a memory, can help reduce that sense of shame, and fear that we may be losing our minds.
SKILLS BUILDING. When faced with threat and lacking a safe place to learn how to manage feelings, we often find unhelpful ways to make ourselves feel safe or ‘better’. Using drugs, alcohol or food to self soothe might have been helpful at one point, even if it isn’t now. Equally, becoming involved in fights because we feel irritable can help us find a place for our anger. Feeling sad, angry or depressed is a common and understandable consequence of childhood adversity. Cognitive Behavioural Therapy has been shown to be highly effective in changing some of the beliefs that may underlie unhelpful coping.
Some websites offer very useful advice and exercises to help address anxiety, anger or low mood. Try:
Mindfulness and relaxation. As human beings we often find it hard to switch off thoughts, leading to risks of increasing levels of anxiety or low mood. Learning to relax and ignore thoughts is very helpful. Websites worth visiting for helpful discussion about the usefulness of this technique include:
STRUCTURE AND ROUTINE. Planning a day that involves some exercise, a little activity, and contact with people with whom we feel safe helps to distract and keeping busy reduces feelings of low mood or the opportunity to dwell on unhelpful thoughts.
DEVELOP SELF-COMPASSION. We are often guilty of thinking that we must simply ‘pull ourselves together’ or that not managing is a sign of weakness. Being kind to and understanding ourselves is not easy, and arguably we are culturally discouraged from doing so. Clinical psychologists Paul Gilbert and Deborah Lee have demonstrated the huge impact that self-compassion can have on the ability to heal after adverse events.
COMPLEMENTARY THERAPIES . Therapies such as massage, Reiki, Yoga and Mindfulness are not in isolation enough to help one overcome reactions to childhood adversity but, in the context of improved self-care and taking time for oneself, can be very helpful.
BUILDING TRUST. Many who have been abused are slow to trust others. Engaging slowly in relationships, for example through shared activities or hobbies, can help build trust. It can also be important to recognise that while barriers may have been helpful in the past, they can hinder future progress
Staying safe. While some individuals are afraid to trust, others trust too easily; they may often and too rapidly fall ‘in love’, with a desire to belong and feel safe in a relationship. Building trust slowly alongside assessing for risk is key to feeling safe. It is also important to develop an understanding of what a healthy relationship looks like.
SELF CARE. Improving diet, reducing alcohol and tobacco use, getting a balance between time alone and time meaningfully connecting with others.
Improved sleep hygiene. Having a restful sleep is crucial to managing our mental health. Exactly how much sleep we need can vary between individuals so being concerned about the amount is less helpful than concentrating on the quality of sleep. The following website provides useful advice:
DEALING WITH FLASHBACKS. Sudden intrusive and distressing memories of upsetting events can lead to feeling overwhelmed by anger, grief or anxiety. Flashbacks represent the mind recalling a traumatic event, witnessed or directly experienced, and reacting as if it were happening currently. Techniques such as grounding and distraction are useful.
http://www.getselfhelp.co.uk offers several techniques. It is worth experimenting with a few before deciding what works best for you.
Overcoming shame. Understanding that you were a child and not responsible for adults’ decisions to hurt, neglect or adequately care for you is key to overcoming childhood adversity. There is nothing a child does, no matter how naughty or badly- behaved they may have been, that warrants behaviour which induces fear or shame in them.
This book has contributed greatly to our understanding of how Adverse Childhood Experiences may be felt throughout a lifetime and contributes further to the exploration and remedying of social and health inequalities. We are fortunate in Scotland to have a number of national mental health and social drivers set to reduce the potential of individual children experiencing ACEs. When an individual is unlucky enough to have been adversely affected, I strongly advocate robust evidence-based treatment so the likelihood of further impact on individual health and social inequalities, as well as the impact for transference across generations, is reduced.