It is a psychiatrist’s fate to sometimes arrive on the scene too late. I was reminded of that as Chris* told me about living with Hepatitis C. He hadn’t been very sick, just a little more tired each month. If left untreated, his liver would eventually become so scarred that it would fail and he would die. He said that he was probably infected while in the Maplehurst Correctional Complex in Milton, Ontario.
“They called it the Milton Hilton.”
“Why were you there?”
Chris looked at the floor, ashamed. “Because of hitting Carmen—my girlfriend then.”
“Was she badly hurt?”
“Yeah. She needed stitches.”
Chris didn’t look like a violent man. He didn’t even look like he had been in prison. He was dressed conservatively in a blue collared shirt and creased pants, as if he had thought about what to wear to an appointment with a psychiatrist. He was a little timid. I have interviewed many patients who scare me, but there was nothing frightening about Chris.
“How did it happen?”
He told me that he met Carmen at AA. What they had in common, more than anything else, was heroin. He surprised me again. Chris didn’t look like anyone’s idea of a drug addict.
Chris described rage that erupted when he was drunk. “Everything goes red. I am not even thinking.” Sometimes he could remember the trigger, often not. Sometimes he was able to walk away, often not. If he hurt someone, what often followed were shame and thoughts of suicide. He talked a bit about what it might have been like for Carmen to live with him, but not much. I had the impression that they hadn’t known each other very well.
“I think it started when I was a kid.”
At this point, the words came more easily to Chris. He had been drinking since he was eleven. He started smoking dope a couple of years later and then one thing led to another later in his teens. Eventually he was addicted to heroin.
Chris’s mom was eighteen when Chris was born. His father left shortly after. Before he was old enough to remember, his mother married another man, Wilson, who was bad news. Countless times, Chris watched Wilson hitting his mother or throwing things at her, too young and small to do anything at all.
I imagine that helplessly watching his mother being beaten was at the root of Chris’s rage. But rage wasn’t the feeling that pervaded and shaped his childhood—fear was. He was constantly thinking about what might happen next—anticipating, watching, planning and calculating all the ways that things might go wrong. He was afraid to go to sleep, afraid when he woke up, and afraid to open the front door when he returned from school. He joined sports teams in every season to make the school day last longer. Chris became recognized for his athletic ability; he liked that he was strong and the admiration that it sometimes brought.
But Chris’s fear would rise on his slow walk from school, and once at home it could be intolerable. By eleven, he was stealing Wilson’s liquor to calm his nerves. By thirteen, his mother was buying liquor for him to protect him from Wilson discovering his theft. She could see that it helped, at least for a while. She was too frightened herself to think about anything else to do.
“That was then.” Chris abruptly cut off the story of his childhood. “It’s just me now. I’m sober. Wilson was a sadistic asshole, but this is on me now. I just need to keep it together.”
Chris accepts responsibility for choices that have led him to this spot. In fact, his shame over his choices may be the largest part of his suffering now. Although he doesn’t want to talk about it anymore, he is right that this goes back to when he was a kid. It is no surprise that the harm done by the mistreatment of children has been right in front of us, as a society, for a very long time. Yet it remains difficult for most of us to see and accept.
Here is what I know now—truths as certain as the fact that smoking will make you sick. About one out of every three or four kids experiences serious physical or sexual abuse. A girl is more likely to be sexually abused and a boy is more likely to be beaten, but the opposite happens as well and they often go together.
Furthermore, there are many other harmful childhood experiences besides abuse. So-called ACEs (for adverse childhood experiences) include things like having a parent who makes you afraid, or swears at you and insults you. Living in a family where it feels like nobody loves you is an ACE, as is living in a family where there isn’t enough to eat or there aren’t clean clothes to wear. Being raised by parents who are too drunk, high, depressed, or frightened to look after you are each ACEs. Chris’s repeated experience of watching his mother get beaten up was an ACE. When his biological father left, that was an ACE. None of these experiences constitutes physical or sexual abuse, but each of them poses risks to health. The more types of ACE a kid is exposed to, the greater his or her risk of mental and physical illness as an adult.
Comprising a category broader than abuse, ACEs are so common that some might call them normal—but they are not. Childhood adversity is a far greater threat to our health and well-being than most people realize.
As anyone who has read Dickens knows, there is nothing modern about kids being abused. It took until 1962, however, for the “battered child syndrome” to be named by Henry Kempe. His paper in the Journal of the American Medical Association laid out how commonly this occurred (302 cases from 71 hospitals over one year), how severe it could be (murder), what they could figure out about why parents and foster parents did this, and how to spot it on an x-ray. He knew that his estimate of how often children were beaten was too low, but Kempe would have been astonished to find out how far off it was.
I don’t think we had a lecture on child abuse when I was in medical school in the 1980s. When I trained in psychiatry, post-traumatic stress disorder was something that was usually associated with combat. But once I started to practice, most of the patients I saw had experienced some kind of serious trauma, many in childhood. I know this now, in retrospect, because rates of trauma in mental health settings are extremely high, we see it in as many as 90 percent of patients, and I see it every day. But even though it must have been in front of my eyes every day from the start, it didn’t occur to me for several years that helping people manage the after-effects of those ACEs was a core part of my job.
ACEs are more common among families that are poor or marginalized, but as Kempe pointed out in 1962, abuse “also occurs among people with good education, and stable financial and social situations.” Indeed, the ground-breaking study of how these childhood experiences lead to illness, known as the ACE Study, was conducted in 1998 by Vincent Felitti and his colleagues among almost 10,000 of the mostly white, well-educated, middle class members of a San Diego Health Maintenance organization. In spite of their privilege, they were still as likely as not to have experienced at least one kind of ACE.
The costs of abuse and ACEs to health are staggering in their magnitude and breadth. Studies that have followed the original ACE study show, for example, that your risk of suicide rises with each type of harmful
experience; people like Chris with four or more ACEs are twelve times more likely to commit suicide than someone who gets through childhood unscathed. The consequences are not limited to mental health; abuse and ACEs also increase your risk of chronic respiratory diseases and heart disease—major killers. Indeed, being maltreated as a child is a “cause of causes” of disease. It makes it more likely that you will smoke, drink too much, become obese, or take chances with sex. The “causes of causes” led to Chris’s hepatitis, but it might as easily have led to cancer or diabetes. There is nothing subtle about the impact of childhood harm on health.
When I talk in public or among friends about how common it is for kids to be abused, most people are dubious. There are a number of ways they challenge this idea.
Maybe they studied the wrong demographic? If you try to assess how many people commit crimes by handing out surveys in the exercise yard of the “Milton Hilton,” you will come up with a highly-inflated number. Maybe something like that happened because the researchers inadvertently studied groups of people who are extra-prone to having been maltreated. Nope. Surveys of childhood adversity have now been conducted multiple times in people carefully selected to be representative of the general population. In Canada, as early as 1997, Harriet MacMillan and her colleagues from the Centre for Studies of Children at Risk at McMaster University reported that of over 9,000 people randomly chosen from the respondents of the Ontario Health Survey, 31 percent of males and 21 percent of females reported childhood physical abuse. Thirteen percent of females reported childhood sexual abuse.
The numbers were probably under-estimates because the Ontario Health Supplement at that time excluded people who lived in institutions, First Nations people living on reserves and the homeless, groups for whom rates of childhood abuse can be higher. When a similar survey was repeated nationally in 2012 by Tracie Afifi of the University of Manitoba as well as MacMillan and others, the results were very similar; the overall rate of any abuse was 32 percent. Large, carefully conducted studies in the U.S. have produced similar results.
Maybe they asked the wrong questions? When CBC News reported on the study by Afifi and her colleagues that revealed that almost half of our military personnel had experienced abuse as children, one commenter opined that “The definition of abuse must be as wide as harsh words and sour looks for this to be true.” Nope. The military study, like many of the best designed studies of physical and sexual abuse including the ones quoted in the previous paragraph, used very explicit questions about what happened. They asked about three kinds of physical abuse. The mildest is being slapped on the face, head or ears, or hit with something hard three or more times. Next is being pushed, grabbed or shoved, or having something thrown at you to hurt you three or more times. The most severe is being kicked, bit, punched, choked, burned or physically attacked. Definitions of sexual abuse were similarly clear and severe.
Maybe people made things up? This is one of the most pernicious concerns about reports of child abuse. It is a weak argument, but it can’t be dismissed entirely. Adults are vulnerable to tricks of memory. Things get forgotten. Separate events get conflated into single memories. Bad experiences may be remembered as more severe during times when one is feeling depressed or anxious. To overestimate rates of trauma, however, people have to create memories of abuse that did not happen. Our brains can do that; false memories are a problem for courtrooms that rely on eye-witness accounts, for example. However, acknowledging that memories are sometimes wrong falls far short of undermining the consistently repeated results of one well-conducted study after another. Is it somehow more convincing or reassuring to think that between a third and a half of adults want to lie about childhood abuse and other kinds of adversity or are mistaken about it, than to think that they have experienced it? If an otherwise reliable adult says that he or she was pushed, grabbed, shoved, or targeted with a thrown plate or ashtray, I take it as true. Whether or not you felt loved as a kid may be hard to say with certainty, but most ACEs are more objective than that. I don’t think Chris is exaggerating or lying.
So, the facts are established, but there is yet one more barrier to seeing what is in front of us. In my slow awakening to the reality of child abuse, I learned that it was very tempting to reduce complex, painful stories to half-truths that I found more comfortable because they were simpler and only demanded one emotional response from me at a time. If Chris was a helpless victim, I could be strengthened by my rage against his tormentor; if he was just Carmen’s abuser, I could help him see the harm that he did and use his remorse to motivate change; if he was a scared child, I could comfort him; if he was a self-serving manipulator, I could at least try to help him see how he appeared to others.
Unfortunately for me (and him, of course), Chris is all of these people—and others I haven’t imagined as well. Acting on one half-truth at a time, without acknowledging the others, without opening my ears to hear someone like Chris tell me about the others, made me less helpful. I think we need to be uncomfortable in order to see the truth and do something about it.
The dominoes in Chris’ story—fear, intoxication, rage, and shame—lead in an almost straight path from his mother’s addiction and Wilson’s violence to Chris’s own mental illness, his abuse of Carmen, and a life-threatening disease. Psychiatrists are poorly positioned to end the cycles of scared kids and broken grown-ups because we arrive on the scene long after the damage has been done. I can’t turn back the clock to prevent the harm that Chris experienced or the damage he did to Carmen. Still, when Chris and I work together to heal his body and mind, we’ll do it not only for his own good, but to prevent him from being a “Wilson” for some other kid or woman.
As a society, we could do much more. ACEs are not a black mark that distinguishes between good parents and bad parents. They don’t emerge, usually, from malevolent hearts. To end the cycle, we need to change the environment in which families operate. The changes that are required are big: effective treatment for mental illness and addiction, livable incomes, support for parents who need to work and parents who need to stay home, well-resourced day care, education that helps parents to tune into a child’s world and respond with sensitivity.
We can’t even start to make big changes until we all see what is actually in front of us instead of what we expect or wish for. To do that, I suspect that some people will need to find a path that is similar to the one that my career forced upon me—from blindness or denial, to the half-truths we most prefer, to something far more complicated, compromised, and human.
*Chris is an amalgam of several people with details changed.
Robert Maunder and Jonathan Hunter are psychiatrists at Mount Sinai Hospital in Toronto and the authors of Love, Fear, and Health: How Our Attachments to Others Shape Health and Health Care.