Over the years, I would discover many reasons for the overall lack of progress with regard to the behavioral sciences and mental illness. Among those reasons would be a common misunderstanding regarding abuse dynamics and their impact. This misunderstanding regularly makes itself known when exploring the childhood histories of those who experienced psychological abuse and/or neglect. Often, I will be listening to someone describe past familial relationship dynamics and then hear some version of the following phrase: “But it wasn’t that bad,” which is almost always in reference to their assumptions regarding physical and/or sexual abuse being the worst of all possibilities, and therefore something worthy of the symptoms and challenges that plague them. Unfortunately—as the research and my clinical experiences have routinely demonstrated—there is often more truth in this claim than initially realized: it wasn’t that bad, it was worse.
As I wrote in a previous piece, People Really Are Like Snowflakes, most people—including many within the profession itself—are unaware of the similarities and differences with human beings. Briefly, individual uniqueness will primarily be found in areas of creative interests, talents, passions, and purpose, whereas similarities will be found with regard to biological and psychological needs. And, whenever needs have not been sufficiently met, a corresponding symptomatic expression will develop. If, for example, someone’s oxygen supply was cut off, we would see a corresponding change in skin tone and a rapid increase in anxiety. If someone was malnourished, the body would also reflect that deprivation in a way most people could easily recognize as well. In either case, it would not matter the person’s age, gender, nationality, or socioeconomic status; the symptoms would be nearly identical. Similarly, as the ever-growing body of research continually demonstrates, when psychological needs have not been met during the developmental years, hereto, predictable symptoms will also result.
While a few early practitioners discovered these symptomatic relationships long ago, it wasn’t until what is known as the “ACE study” (which stands for Adverse Childhood Experiences) was published in the American Journal of Preventative Medicine in 1998, that these symptomatic relationships were first demonstrated and described scientifically. Some have argued, as have I, that this study was perhaps the most important ever conducted in the behavioral sciences, as it offered the clearest, most definitive answers surrounding the origins of mental and physical illness, addictions, and even premature death.
Given the ever-increasing burden of mental illness in modern times, such discoveries should have been immediately celebrated and placed in the mainstream and academic spotlight; however, due to the fierce, culturally taboo story these findings told, this study remained largely hidden for far too long. In fact, I started graduate school in 2002 and then went on to pursue a PhD in Counselor Education and Supervision at The University of Northen Colorado shortly thereafter, and it was never mentioned once in either program, despite the fact that research was a strongly encouraged component of the doctoral program I was in. Despite the significant educational investment, I would not learn about this study until I attended a continuing education seminar with renowned author, neuroscientist, and child psychiatrist, Bruce D. Perry, M.D., Ph.D., years after I had left the doctoral program. To this day, I find this unacceptable; however, I also admit that discovering this research after I reached the same conclusions following my first few years of close clinical observation was validating and certainly boosted my confidence regarding my clinical skill and assessment.
Due to the profound social and cultural implications of this study, I am of the opinion that it likely would never have been conducted if it weren’t initiated somewhat accidentally in the first place, as most people are both consciously and unconsciously adverse to looking in the direction of what is most disturbing—even if the keys to our liberation are to be found there. As it were, co-author of the study, Dr. Vincent Felitti, was working in the Department of Preventative Medicine at Kaiser Permanente at the time (a department he had been tasked with putting together). There, he and his colleagues were working on an obesity and weight loss program, which, in many ways, was a great success. Without surgical intervention, Felitti and his team were able to safely and reliably help people lose weight at a rate of about 300 pounds per year. However, Felitti had started to see a pattern that confused him greatly: He began to notice that those who were dropping out of the program at the highest rates were also those who had realized the most success. Because this outcome went counter to what he predicted, he decided to start interviewing many of the dropouts in effort to try and figure out what was behind this common, yet bizarre, phenomenon.
And then, one day—through an accidental slip of the tongue—he had written one of the interview questions to read, “How old were you when you first became sexually active?” and instead asked a former female study participant, “How much did you weight when you became sexually active?” to which the woman replied “40 pounds; it was with my father,” as she broke down in tears. Felitti was struck, yet intrigued, and in subsequent interviews he inquired about histories in similar fashion: 186 patients later, he discovered 55% of the dropouts had a history of childhood sexual abuse.[1] He was now learning what only a few of the more astute clinicians had learned as well, that excessive eating—especially highly-processed, carbohydrate and sugar-rich foods—is not only emotionally soothing, but that obesity is also a protective deterrent against further sexual abuse. As such, for these formally sexually abused participants, successful weight loss also meant the unconscious fears and memories were reactivated as their weight loss moved them too close to the potentials of the past experiences they feared most and had not worked through prior.
Thankfully, because of Felitti’s position within the organization at the time of this most intriguing discovery, he had access to the necessary resources to put together a large-scale, epidemiologically sound study, involving more than 17,000 participants, and the ACE study was born—the largest epidemiological public health study of its kind ever conducted. The study looked at the prevalence of poor mental and physical health outcomes compared to an array of adverse childhood events. Each participant filled out a 10-item questionnaire related to three categories of adversity including abuse, neglect, and household dysfunction. This score was then compared to the prevalence and severity of mental and physical health outcomes later in life as identified by corresponding medical records. The results were as profoundly disturbing as they were statistically powerful. Here are a few of the discoveries made.
With regard to physical illness, ACEs are strongly correlated with the top 10 leading causes of death, including heart disease and cancer (number 1 and 2 respectively in the US). With an ACE score of 4 (out of 10), the risk of heart disease increases by 220%, and the risk of cancer increases by 190%.[2] What do numbers like these really mean? For context, studies from the University of Washington found that, “Exposure to glyphosate—the world’s most widely used, broad-spectrum herbicide and the primary ingredient in the weedkiller Roundup—increases the risk of some cancers by more than 40 percent.”[3] To date, Bayer corporation has paid roughly $10 billion to settle disputed claims based on this causal link between glyphosate and cancer, with a risk comparison only a little more than 1/5th the statistical power of an ACE score of 4 and the corresponding risk of cancer.[4]
With regard to mental illness and addiction, the relationships become stronger still. With an ACE score of 4, the risk of depression increased by 460%. And, not surprisingly, the risk of substance abuse also skyrockets (in effort to block the resulting intense emotional pain and to modulate a nervous system that developed under the exposure of such extreme, toxic stress). With that same ACE score of 4, the odds a person will consider themselves an alcoholic rises to 740%, the risk of illicit drug use rises by 470%, and the odds of becoming an IV drug user jumps by 1,030%.
But it gets worse, much worse. With an ACE of 4 there is also a 1,220% increased risk of attempted suicide in adulthood. In adolescence, as we move up to an ACE score of 6 or more, the risk of attempted suicide increases to between 31- and 50-fold; that is to say, a 3,100 and a 5,000% increase respectively. And even if someone who has faced such adversity does not succumb to suicide, ACEs are a death-sentence. In fact, people with 6 or more ACEs die nearly 20 years earlier on average than those without ACEs, and the average life expectancy is reduced to only 60.6 years.[5] Once more, for context, being a smoker—one of the most well-known causes of premature death—reduces life expectancy by 10-years, just half that as someone with an ACE score of 6.[6]
While largely hidden from public view as mentioned, this study slowly began to catch the attention of a few other researchers. With the ACE study, the questionnaire explored elements of physical, sexual, and psychological abuse, but they were not parsed out or measured independently of one another, making it difficult to determine if one type of abuse had a greater negative impact than another. This was a question researchers sought to answer next: Is all abuse the same, or is one form worse?
Lane Stathearn, MD, PhD, principal author of a multi-national, 8,000 participant, 20-year longitudinal study reported in The Journal of Pediatrics was someone with such a question. In response to the findings of this study, he concluded, “Emotional abuse and neglect are often hidden from view, but may result in the most severe and debilitating long-term outcomes.” He added, “The problems observed in adulthood are extremely serious and difficult to treat. Our community suffers on so many levels as a result of emotional abuse and neglect.”[7]
Another study in the Journal of Child and Adolescent Trauma reported similar findings: “Participants who reported emotional abuse reported higher scores for depression, anxiety, stress, and neuroticism personality compared to the participants who reported only physical, only sexual, or combined physical and sexual abuse.” The author continues: “Emotional abuse has been found to cause adverse development consequences equivalent to, or more severe than, those of other forms of abuse including physical and sexual abuse.”[8]
And finally, another large-scale reported by the APA (American Psychological Association), concluded that psychological maltreatment, identified as, “caregiver-inflicted bullying, terrorizing, coercive control, severe insults, debasement, threats, overwhelming demands, shunning and/or isolation,” when compared to physical and/or sexual abuse, discovered that, “Psychological maltreatment that occurred alongside physical or sexual abuse was associated with significantly more severe and far-ranging negative outcomes than when children were sexually and physically abused and not psychologically abused. . . Moreover, sexual and physical abuse had to occur at the same time to have the same effect as psychological abuse alone on behavioral issues at school, attachment problems and self-injurious behaviors.”[9]
To be clear, all forms of abuse lead to devastating, life-long outcomes, and none should be condoned or practiced. And while psychological abuse is often found to be the most damaging form of abuse, and the most difficult to recover from as well, I would be remiss if I didn’t highlight a particular form of psychological abuse that remains the most overlooked: neglect! As author, addiction and developmental trauma expert, Dr. Gabor Maté is fond of saying, “Trauma isn’t just the bad things that happened that shouldn’t have, but it’s also the good things that should have happened but didn’t.” And he is correct: where there is absence of necessary positive experiences such as unconditional love, acceptance, joyful play, and encouragement regarding a child’s unique talents and interests, symptoms of mental illness will inevitably develop as a result.
One article I came across also described it well: “Abuse is often intentional; it’s a purposeful choice to act in a way that is harmful. While emotional neglect can be an intentional disregard for a child’s feelings, it can also be failure to act or notice a child’s emotional needs. Parents who emotionally neglect their children may still provide care and necessities. They just miss out on or mishandle this one key area of support. One example of emotional neglect is a child who tells their parent they’re sad about a friend at school. The parent brushes it off as a childhood game instead of listening and helping the child cope. Over time, the child begins to learn that their emotional needs are not important. They stop seeking support.”[10]
Yes, avoiding abuse and/or the neglect of material needs is not the only parental or care-giver obligation. It is equally important that children are provided the necessary, healthy psychological inputs they need as well, and consistent loving attention and emotional support and guidance when processing difficult emotional states are fundamental needs of children. In his latest book, The Myth of Normal, Gabor Maté described the “irreducible needs of children” as:
- “The attachment relationship: children’s deep sense of contact and connection with those responsible for them.
- A sense of attachment security that allows the child to rest from the work of earning his right to be who he is and as he is.
- Permission to feel one’s emotions, especially grief, anger, sadness and pain—in other words, the safety to remain vulnerable.
- The experience of free play in order to mature.”[11]
Yes, to the surprise of many, the most common form of child maltreatment (CM) is neglect, making up 75% of the 674,000 substantiated claims to Health and Human Services in 2017, compared to 18% for physical abuse and 8.6% for sexual abuse. Thankfully, where awareness has increased, progress has been made, and both physical and sexual abuse cases have decreased in recent years, whereas neglect has not, as reported in a recent 2022 publication in the Journal of Interpersonal Violence. Here, this group of researchers also found strong associations between neglect and anxiety, depression, and difficulty in interpersonal relationships, particularly with regard to the likelihood of becoming involved in intimate partner aggression and violence dynamics as either victim or perpetrator later in life. And these researchers also noted something I have routinely observed myself: “As part of this longitudinal study, it was striking that the youth rated their relationships with their parent or primary caregiver quite positively. . . Neglected children and youth might not know what to expect and might not perceive themselves to be lacking care or supervision. . . Neglect is generally construed as an ongoing pattern of unmet needs; it is a form of CM that is often especially recalcitrant to intervention.”[12]
As far as I can tell from my own clinical observations, there are two significant barriers for the neglected population that decrease their amenability to treatment as described. First, their scars are on the inside, and the wounds of neglect are often only recognizable through the symptoms and behavioral patterns they produce, which are still not easily recognizable by most people, mental health clinicians included. Secondly, denial is a very attractive and powerful defense mechanism, and the pain associated with missing out on the unconditional love of parents is the most devastating of human experiences. As such, because of their hidden nature and the intensity of the pain associated with such truths, most people remain convinced, “It wasn’t that bad.”
Most tragically, while such a belief can be effective at keeping the full intensity of the related pain at bay, no healing and recovery opportunities are available while in a state of denial. When it comes to genuine recovery, the truth is a mandatory and non-negotiable prerequisite, and the body is the ultimate lie detector, as brilliantly discovered by the late author and clinician, Alice Miller. As indicated in the title of one of her many important books, The Truth Will Set You Free, Miller asserts: “If your cognitive system asserts the opposite of what the cells in your body unerringly identify as the truth, you will be living in a state of permanent inner discord. But once both systems are allowed to have the same knowledge, the bodily functions can resume their normal activity.”[13]
I have been awestruck witnessing the phenomenon Miller described every time the opportunity has presented itself. It is an incredible thing to witness such unrelenting symptoms cease in an instant, especially anxiety, as someone stumbles upon such truths and admits them aloud. When someone confesses realties such as, “I was abused,” or “I didn’t get what I needed and deserved,” or “I wasn’t wanted,” or “I wasn’t allowed to be the real me,” anxiety symptoms in particular halt; and then, the tears come, which were fueling the anxiety the whole time from their unprocessed, suppressed state. Sadly, because of our profoundly sick culture, which teaches children that tears (and certainly much of the information that produces them) are bad and unwelcome expressions, which often lead to painful rejection (neglect), many people choose to trade them back in for the previous symptomatic expression because the historical pain is too great, and their fear of not making it through is too strong.
Grief: The Only Way Out
While I have witnessed progress made regarding every form of abuse, my clinical experience is corroborated by the research: I routinely find that psychological abuse and neglect are the most difficult to recover from. And in every case where progress is made, the ability to see and speak the truth is a necessary precursor to engaging with the related grief work that is mandatory for any significant degree of recovery to be realized. I have yet to see any sustained progress without it.
Yes, such realities are extremely difficult to grapple with; therefore, shortcuts will forever remain attractive, including denial, premature and self-delusional forgiveness, and the culturally sanctioned addiction to always, “focus on the positive,” which remain the most common endorsements, including those from within the field itself. Unfortunately, while trying to help people avoid such profound pain is understandable and certainly kind in intention, it only serves to further delay individual healing and recovery, and the necessary evolution humanity desperately needs at this time. And in that way, it is not actually therapeutically viable or health-promoting in any way. Further, I argue that competency with grief is the most fundamental and necessary psychological skill humans need, as it mediates the capacity for love—our most fundamental psychological need.
As I argued in a previous post on Grief & Love, the two simply cannot be separated as we previously hoped and wished they could be. Whenever someone is successful in their effort to close their heart to protect from future loss and grief, the cost is proportionally closing it to love as well. While there are degrees, love can only flow in and out from openness, and the heart can never only be open to love. It is simply a law of our psychological nature that we cannot prevent the bad (heartbreak) without also sacrificing the good (love): Where love is concerned, it’s a packaged deal.
It is a fundamental fact of life that everything of value and importance will be lost in time: every relationship, prized possession, and even our physical bodies and their remarkable abilities will one day pass, never to be experienced again. And I certainly wish it were different too. I often reflect on a brief conversation I had with my paternal grandfathers’ oldest brother the last time I saw him; he was in his mid-80’s at the time. His passion was hunting, which he did as often as he could since he was a kid. Of course, he was as emotionally repressed as any man from that time period, and I suspect it may have been decades since he had last allowed himself to cry, but when he shared with me that he had reached the point where his body was no longer physically capable of hunting, he broke into tears. And as these tears fell from his eyes, he said: “The hardest thing in life is no longer being able to do what you love.” Love and grief: inseparable as ever.
My great uncle allowed himself to love this activity, and he was later wrecked by it in an equally proportional and reciprocal way. Had he not cared all that much for it, he could have avoided shedding those tears. Tragically, that remains the choice most people continually make, especially regarding human connection. Less heart = less heart-brokenness is the calculous and choice most people make, as Stephen Jenkinson, the wise elder and author of the immensely important book, Die Wise, argues from his observations as a former palliative care worker.[14]
From what I have observed, whenever humans play God and attempt to argue with or rewrite the laws of nature, more problems are the result. Disable the capacity for grief and the array of painful, scary, and overwhelming negative emotions that come with it, and the capacity for love is also disabled. And because we have a need for love, and no viable substitutes, we become very sick; that is, mentally ill, as a result of this impossible position. Therefore, in accordance with the laws of nature, if we ever wish to become a psychologically healthy species, we will have to learn to honor creation itself, instead of trying to make it bend to our wishes and desires for it to be otherwise.
So, what does grief have to do with meeting the psychological needs of children regarding matters of psychological abuse and neglect, and why am I talking about it in this context? Well, every irreducible, psychological need of a child as Maté described is love-based, and since those needs can only be sufficiently met by those who are grief literate, it is where all progress begins. Often, when I make such suggestions, people become quite angry and defensive. If they happen to be parents, they regularly assert that I am terribly mistaken and how dare I suggest they may not be overflowing with love for those they proport to care about, especially their own children. However, more often than not, what it being described as love is actually an intense dependance rooted in pronounced fear (of future loss and grief), and the intensity of their fear is what is overflowing, and due to the degree of the intensity, it is commonly confused with love.
Instead, where there is sufficient skill in grief—which develops when someone successfully works with the hurt, pain, sadness, despair, fear, anger, etc. that come with significant loss—fear no longer suffocates love. But absent such experiential skill and knowledge, the strategy inevitably defaults to either excessive avoidance or possessive and controlling tendencies, including pathological parental enmeshment (all protective strategies against heartbreak and grief, and always Pyrrhic victories). Again, the desire for emotional protection through avoidance is understandable, but also completely ineffective because love is a non-negotiable human need and the two cannot be separated.
It is likely that psychological abuse and neglect have been found to be the most devastating because those are the conditions where love was most needed and most absent. Further, when those who were entrusted with helping us learn how to work through the difficult emotional experiences associated with significant loss are instead the ones perpetuating painful loss, the negative impact is certainly amplified. And unfortunately—as I have learned and mentioned previously—intention does not equal impact, and desire does not confer ability, no matter the intensity. This is a problem that cannot be solved by wanting to do better. It is simply the case that sufficient skill with grief—developed through intense and deliberate practice with proper support—is the only curative and preventative option available, since the human need for love is not going anywhere.
[1] Felitti, V. (2010). ACE’s by Vince Felitti, MD. YouTube. https://www.youtube.com/watch?v=Me07G3Erbw8&t=160s
[2] Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8
[3] UW study: Exposure to chemical in Roundup increases risk for cancer. UW News. (n.d.). https://www.washington.edu/news/2019/02/13/uw-study-exposure-to-chemical-in-roundup-increases-risk-for-cancer/
[4] Bayer hit with $2 billion roundup verdict in US state of Georgia cancer case | Reuters. (n.d.). https://www.reuters.com/business/healthcare-pharmaceuticals/bayer-hit-with-2-bln-roundup-verdict-us-state-georgia-cancer-case-2025-03-22/
[5] Brown, D. W., Anda, R. F., Tiemeier, H., Felitti, V. J., Edwards, V. J., Croft, J. B., & Giles, W. H. (2009). Adverse childhood experiences and the risk of premature mortality. American Journal of Preventive Medicine, 37(5), 389–396. https://doi.org/10.1016/j.amepre.2009.06.021
[6] Centers for Disease Control and Prevention. (2020, April 28). Tobacco-related mortality. Centers for Disease Control and Prevention. https://archive.cdc.gov/www_cdc_gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm
[7] Emotional abuse, neglect may be more harmful long-term than physical, sexual abuse. University of Iowa Health Care Stead Family Children’s Hospital. (n.d.). https://uihc.org/childrens/news/emotional-abuse-neglect-may-be-more-harmful-long-term-physical-sexual-abuse
[8] Dye, H. L. (2019a). Is emotional abuse as harmful as physical and/or sexual abuse? Journal of Child & Adolescent Trauma, 13(4), 399–407. https://doi.org/10.1007/s40653-019-00292-y
[9] American Psychological Association. (n.d.). American Psychological Association. https://www.apa.org/news/press/releases/2014/10/psychological-abuse
[10] Holland, K. (2021, October 21). Childhood emotional neglect: What it is, and how it can affect you. Healthline. https://www.healthline.com/health/mental-health/childhood-emotional-neglect
[11] Maté, G., & Maté, D. (2022). The myth of normal: Trauma, illness, & healing in a toxic culture. Avery, an imprint of Penguin Random House.
[12] Dubowitz, H., Roesch, S., Lewis, T., Thompson, R., English, D., & Kotch, J. B. (2022). Neglect in childhood, problem behavior in adulthood. Journal of Interpersonal Violence, 37(23–24). https://doi.org/10.1177/08862605211067008
[13] Miller, A. (2003). The truth will set you free: Overcoming emotional blindness and finding your true adult self. Basic Books.
[14] Jenkinson, S. (2015). Die wise: A manifesto for sanity and soul. North Atlantic Books.