Bringing Attention to Childhood Emotional Abuse in Psychotherapy with Adults

The Silence and Severity of Childhood Emotional Abuse

Although treatment considerations for adults with histories of childhood physical and sexual abuse has grown over the years, psychotherapeutic treatment focusing on adults with childhood emotional abuse histories is in its nascency—at best. Emotional abuse and its impacts also tend to remain unseen, unacknowledged, and underreported by the general public and professionals (Chamberland, et al., 2005; Twaite & Rodriguez-Srednicki, 2004). The relatively common American adage of “Sticks and stones may break my bones, but words will never hurt me!” exemplifies social misconceptions surrounding emotional abuse. Childhood emotional abuse only appears covert because it is more difficult to detect and define than other forms of abuse (Hornor, 2012), especially because there is not one prevailing definition of emotional abuse that all can reference. For instance, childhood emotional abuse has been conceptualized as all of the following:

• “verbal assaults on a child’s sense of worth or well-being or any humiliating or demeaning behavior directed toward a child by an adult or older person” (Bernstein et al., 2003);
• “persistent, non-physical, harmful interactions with the child by the caregiver, which include both commission [abuse] and omission [neglect]” (Glaser, 2011);
• “repeated patterns of caregiver behavior or a serious incident that transmits to the child that [they are] worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs” (American Professional Society on the Abuse of Children; Myers et al., 2002).

Despite the nebulousness and silence surrounding this form of abuse, 36% of identified childhood abuse cases report incidence of emotional abuse (Chamberland et al., 2011; Sedlak et al., 2010; Tonmyr et al., 2011) with emerging evidence that its detrimental impacts are at least equivalent to, and in some studies, found to be greater than among those who experience other forms of abuse (e.g., physical abuse, sexual abuse; Burns et al., 2010; Dias et al., 2015; Hodgdon et al., 2018; Nguyen-Feng et al., 2017; Wright et al., 2009). Even when controlling for exposure to physical and sexual abuse, which tend to overlap experiences of emotional abuse (Dias et al., 2015), associations between emotional abuse and distress still persist (Paul & Eckenrode, 2015). Furthermore, childhood emotional abuse has been linked with a host of increased mental and physical health concerns in adulthood, such as:

anxiety (Taillieu et al., 2016); bipolar disorder (Etain et al., 2010); borderline traits (Allen, 2008; Kuo et al., 2015); depression (Gibb et al., 2007; Taillieu et al., 2016; van Harmelen et al., 2010); disordered eating (Feinson & Hornik-Lurie, 2016); dissociative symptoms (Briere & Runtz, 1988); externalizing conduct problems (Caples & Barrera, 2006); low self-esteem (Mullen et al., 1995); negative affect (Nguyen-Feng et al., 2019); paranoid ideation (Dias et al., 2015); perceived stress (Nguyen-Feng et al., 2019); post-traumatic stress (Wekerle et al., 2009); relationship difficulties (Bigras et al., 2015); sexual problems (Mullen et al., 1995); sleep problems (Wijma et al., 2007); social anxiety (Reinelt et al., 2013); somatic symptoms (Samelius et al., 2007); and suicidal behaviors (Bifulco et al., 2002).

In light of this, we hope to break the silence around the severity of childhood emotional abuse and discuss possible psychotherapy considerations for adult clients with childhood emotional abuse histories.

Why is Childhood Emotional Abuse So Hurtful in Adulthood?

There are a few ideas that may explain why the impact of childhood emotional abuse is so long-standing, negatively impacting various domains across adulthood. Emotional abuse tends to occur more often than other forms of abuse that may occur in discrete, singular incidents—furthermore, emotional abuse co-occurs more commonly than not with other forms of abuse and maltreatment; in addition to being more frequent, is also often more chronic due to it being unrecognized (Dias et al., 2015; Spinhoven et al., 2010). The chronicity of emotional abuse, which targets how children see and feel about themselves, is compounded with important developmental periods in a child’s life where they develop secure attachment (Erikson et al., 1996; Sroufe et al., 2005) and a positive sense of abilities and self (Shonk & Cicchetti, 2001; Arslan, 2017; Stuewig & McCloskey, 2005; Taussig & Culhane, 2010).

This combination of negative events during this critical time period leads to a “perfect storm” in which children may begin to internalize and believe what they are told about themselves, manifesting in both hurtful cognitive and emotional manners. That is, these verbal degradations that are part of emotional abuse (e.g., “you’re useless”; “why were you even born?”) directly target the formation of negative cognitions, which in turn increases vulnerability to distress (Rose & Abramson, 1992). Similarly, verbal degradation or discounting of a child’s emotional hurt and feelings may lead to the child being particularly sensitive (Bounoua et al., 2015) and unable to accept their own emotions later on in life (Gratz et al., 2007), resulting in avoidance both outwardly and inwardly (Gratz et al., 2007; Reddy et al., 2006). This snowballs into an inability to cope effectively. However, by understanding theories on why childhood emotional abuse is so hurtful, mental health professionals can have a better sense of what to target to allow such clients to thrive.

As Mental Health Professionals, What Can We Do?

Until enough research provides rigorous evidence on best practices in treating adult clients with histories of emotional abuse, we may only offer light suggestions on what we can do as mental health professionals. These are our five key suggestions, although there are surely various other areas that practitioners may explore:

1. Screen for emotional abuse during intakes, initial assessments, and as needed during the psychotherapeutic process. Prioritize and assess for emotional abuse as you would any other risk factor or potentially traumatic event. Psychological maltreatment screeners that have adequate psychometric properties include: Childhood Maltreatment Interview Schedule (Briere, 1992); Childhood Trauma Interview (Fink et al., 1995); Childhood Trauma Questionnaire (Bernstein & Fink, 1998).

Practitioners may also choose to ask about childhood emotional abuse with the following questions:

1. 1. Growing up, did anyone in your home say or do things that led you to feel worthless / flawed / unworthy of love / unloved / unwanted / unsafe / of little value aside from meeting others’ needs?
   2. In your childhood, did you feel as though any caregiver / adult / older person emotionally hurt you? What did they say or do to you?
   3. Thinking back to your childhood, what were some of the most positive words that your caregiver(s) said to you? What were some of the most negative words that your caregiver(s) said to you?

Although these suggestions focus on adult clients, we recommend that practitioners working with youth also conduct these screenings for a holistic and preventive approach to trauma treatment. For instance, the Trauma History Profile of the National Child Traumatic Stress Network’s Core Data Set screens for psychological maltreatment among children and adolescents.

1. Focus effort and attention toward the therapeutic alliance. Because adults with childhood emotional abuse histories may be distrustful and sensitive to perceived negative feedback at times, mental health practitioners need to be particularly mindful in building rapport. Through a strong working alliance, practitioners and clients may also feel more comfortable in discussing alliance ruptures as they arise.
2. Encourage a curious stance towards the client’s emotions and internal states. Turning inwards tends to be avoided among childhood emotional abuse survivors. Thus, it is important to teach coping skills around mindfulness, distress tolerance, acceptance, and perceived control in emotions that arise and how to respond to them.
3. Explore how childhood emotional abuse has impacted client’s social support and functioning. Psychotherapy may involve delineating healthy attachment styles as well as willingness to seek support, which are areas commonly impacted by childhood emotional abuse. Provide positive reinforcement to client for efforts in making changes in these areas.
4. Unpack client’s negative self-schemas and self-concepts. Examine how these constructs relate to client’s self-esteem, self-worth, and psychological and somatic health concerns. Gently challenge and assist client in rewriting these negative, seemingly ingrained narratives to become evolving stories of resilience and growth.

With these general suggestions in mind, we hope that the mental health field may shift its attention to this unseen, unacknowledged, and unreported yet deeply detrimental form of childhood abuse. In turn, we hope that mental health professionals create a path for the understanding of childhood emotional abuse in the broader human services field as well as the general public. Ultimately, we hope to squash the silence around childhood emotional abuse so that it may be viewed, assessed, reported, and researched with the same serious considerations of other abuse types.

Summary

The impact of childhood emotional abuse goes beyond the critical developmental periods in which the abuse occurs. Childhood emotional abuse has been linked to both mental and physical impairments and other negative sequelae well into adulthood. However, emotional abuse remains difficult to detect and recognize; this invisibility is partly due to lack of clarity in defining emotional abuse despite its high prevalence and co-occurrence with other forms of abuse. As mental health practitioners, we need to screen for and validate experiences of emotional abuse among adults whom we treat and serve. Since trust and healthy self-narratives may be eroded by this chronic and deeply rooted form of abuse, we need to provide a particular focus on the therapeutic alliance in addition to the client’s internal states, social support, and self-schemas. With these suggestions in mind, we hope that adult clients with silent experiences of childhood emotional abuse will finally be heard and seen. Further, we hope for increased awareness, acknowledgement, and attention around emotional abuse that will ultimately lead to better informed psychotherapeutic practices.