Death by a Thousand Cuts: The Insidious Impact of Psychological Maltreatment

Introduction

For those who grew up in environments that were chronically critical, invalidating, lonely, dismissive, insulting, or all of the above, navigating life can often feel like stumbling through the world wounded by invisible cuts and bruises. Such experiences fall under the type of complex trauma exposure known as psychological maltreatment.

What is Psychological Maltreatment?

Psychological maltreatment is an overarching term which includes multiple, often subtle forms of interpersonal trauma. Most often these occur in the context of relationships with parents, caregivers, and authority figures. The most prominent forms of psychological maltreatment are emotional abuse and emotional neglect. Other forms of psychological maltreatment include gaslighting, parentification, and excessive demands placed on a person, especially a child or adolescent, by an adult upon whom they are physically, emotionally, or financially dependent. This latter type of psychological maltreatment can include undue pressures about someone’s weight or appearance or their academic, athletic, or artistic performance and achievements.

Psychological maltreatment can often take the form of overt and malevolent traumas of commission, including intentional physical neglect, verbal abuse, or deprivation of social interaction. Alternatively, many forms of psychological maltreatment can be categorized as traumas of omission that involve various expressions of emotional neglect. This could include persistent failure to provide adequate emotional nurturance, affection, soothing, or protection from overwhelming stressors in the home or community. For caregivers impaired by mental illness, substance abuse, a chronic medical condition, or the impact of their own unresolved trauma history, such acts of omission can often be unintentional.

How Harm Occurs

Trauma has historically been defined in the academic literature by identifying specific painful past events or experiences. However, this only tells a portion of the story for many survivors. Psychological maltreatment encompasses the indispensable needs that were not met in childhood. For development of healthy self-regulation and a positive sense of identity, children need caregivers who can provide attunement and validation of their emotions and experiences. In contrast, chronic emotional deprivation leaves children feeling alone in their pain. Between trying to decipher confusing adult behavior, soothe their own distress, and make sense of incomprehensible pain, such children often find themselves in a persistent state of survival. This can compromise one’s ability to engage in play, imagination, creativity, or exploration.

Doubting My Experience: It’s Not You, It’s Me

Due to the insidious nature of psychological maltreatment, children and adults alike often question their historical experience throughout life. They might attribute struggles with psychological suffering and social or vocational functioning to personal weakness, failure, or personality flaws, rather than understanding themselves through a lens of complex trauma.

Sometimes these self-defeating views evolve because during childhood one’s primary caregivers were simultaneously or alternately loving and abusive or neglectful. This can be unbearably perplexing to a child: the parent they love and admire is intermittently frightening or withdrawn. In other families, caregivers blatantly deny ongoing abusive and neglectful treatment, otherwise known as gaslighting. This pattern can leave a person with long-term questions of whether or not they can trust their own perception and emotional experience.

It is also common for survivors of psychological maltreatment to come to believe that their experiences of trauma were less severe or significant than those of other people with identifiable histories of physical or sexual abuse. This can lead victims of emotional abuse or emotional neglect to invalidate or minimize their own lifelong suffering.

However, the research data on this topic tells a quite different story. In Unseen Wounds, Dr. Joseph Spinazzola and his colleagues compared the effects of physical abuse, sexual abuse, and psychological maltreatment on psychiatric disorders and risk behaviors in over 5,000 treatment-seeking children and adolescents across the United States. This landmark study found that youth with histories of psychological maltreatment had equal or greater frequency and severity of symptoms and difficulties compared to those with histories of physical and or sexual abuse across all 30 outcomes measured. In particular, youth exposed to chronic psychological maltreatment exhibited equal severity of PTSD symptoms with greater depression, anxiety, substance abuse, and attachment difficulties than observed in youth with histories of both physical and sexual abuse.

The Enduring Wounds

Over time, a variety of painful and self-limiting reactions, patterns, and beliefs about self and others can result from psychological maltreatment. Those who endured prolonged emotional abuse or neglect, or who were raised by chronically-impaired caregivers, often report some constellation of the following:

• • Living with chronic shame, self-doubt, or self-hatred
  • Identifying as damaged, defective, inadequate, or unworthy of love
  • Feeling invisible, insignificant, or alone in the world
  • Lacking a sense of self or identity
  • Believing they take up too much space in the world
  • Never feeling competent
  • Not feeling like an adult
  • Experiencing the world as unsafe or unpredictable
  • Experiencing others as hard to trust
  • Finding difficulty asking for help or support
  • Believing the world is functioning around them or better off without them

The impact for some can feel like a slow death by the gradual accumulation of wounds over time. Individuals learn to survive in diverse ways, some of which are connected to risky health behaviors such as substance use, problem eating, or self-harm to help displace or numb the pain. For others, the impact is most notably seen in patterns of relational distress. Because relationships often simultaneously embody the most significant threat and the deepest unmet longings, some people learn to adapt and get their needs met on a continuum between:

• • Withdrawing and denying their own relational needs because it feels too vulnerable or dangerous to leave oneself susceptible to additional shame, rejection, or abandonment, or
  • Constantly seeking new relationships in a seemingly futile effort to fill an immense internal void.

These patterns, although meant to support survival, can have lasting harmful effects on parenting and relationships with friends and intimate partners. They can also complicate other spheres of life, such as school or work.

Hope and Inequity: A Double-Edged Sword in Psychotherapy

For those who have identified psychological maltreatment in their history and ongoing life struggles, there is significant hope for growth and healing. Although the undertaking is undeniably arduous, people who develop a language and frame to make sense of difficult past experiences and the ways they were affected by them often begin to experience more meaningful engagement in life. Recognizing the subtleties of this work, Drs. Frances Grossman, Joseph Spinazzola, and colleagues combined psychoanalytic and relational-cultural models of change with mind-body and narrative-based and clinical dissociation-focused approaches to trauma intervention to create CBP, a new psychotherapy framework specifically designed for adult survivors of childhood emotional abuse and neglect.

At the same time, it is important to acknowledge an injustice that is inherent to trauma therapy. Survivors are called upon to grieve the losses of unmet childhood needs while learning to care for themselves in a manner that the adults who had been responsible for them were not able to provide. This task is fundamentally unfair and begs the question:  “Why am I stuck doing this painful work, while my caregivers are not able or willing to acknowledge the ways they harmed me?”

Through this paradoxical process, however, individuals come to recognize their strengths, passions, and capability, and tap into a sense of empowerment. Most importantly, they discover that they are able to inventory and seal emotional wounds that once seemed too innumerable to count and too deep to heal.