Author: Anum Sofea Muhamad Fadzli
Clinical Lead & Clinical Psychologist, Thrive Well.
I had a client; a woman in her late forties — well dressed, mild-mannered. Whenever she speaks, there’s always a hint of a smile in her words and a kindness in her gestures. Yet, she wasn’t able to hide the sorrowful tears behind her eyes.
She came into therapy to help her figure out her situation after escaping a violent spouse with her children. She got nowhere to go, and little money to her name. She’s also beginning to develop drinking habits to cope, and has been experiencing frequent anxiety attacks which made her underlying chronic medical conditions worse. She said she feels weak and useless, and her thoughts often spiral into a cycle of self-blame and helplessness.
After talking to her, I soon found out that on top of the recent incident, she had a history of the loss of a parent, physical abuse at home, bullying at school, and alcohol abuse in her childhood home. She told me that she had always been scared and timid growing up, having no adult around her that she could rely on for warmth and safety.
But of all the hardships she faced, one piece of her memory was stuck in her mind so vividly. She was six, and whenever the abuse got too much, she would hide under a small tree she had in her backyard to soothe herself. But one day, the tree got cut — leaving only an ugly stump on the ground.
Now, more than forty years later; she told me that she doesn't believe that there’s anything she could do to escape her psychological pain.
The Wounded Child: Unraveling the Impact of ACEs
Most would agree that childhood experiences will have a lifelong impact on a person. These experiences make us who we are and forms the basis of our understanding of the world. However, for a concept that is so collectively known, so little of it was understood.
Adverse Childhood Experiences or abbreviated as ACEs; is a relatively new scope of study that looks into the relationship between the exposure of trauma or negative events during childhood; and its impact on later life outcomes (Felitti, et. al.,1998.). These experiences can occur in early childhood, such as in infancy or toddlerhood, or during later childhood and adolescence. As of recently, there are ten main category of adverse childhood experiences; which are physical, emotional, or sexual abuse; physical or emotional neglect; or household dysfunctions such as witnessing violence, mental illnesses, substance use, divorce or battered mother.
Source: CDC: CDC - https://www.cdc.gov/violenceprevention/aces/index.html
These categories are based on the studies done in the West, where researchers have found that the effects of ACEs can accumulate over time, and individuals who experience multiple ACEs are at a higher risk of physical and mental health issues in adulthood. The impact of ACEs also varies depending on the timing, duration, and severity of the experiences, and as well as the individual's ability to cope and the presence of protective factors.
Although, as someone with a research background, and also a practicing therapist; I would like to highlight that there are little to no studies that’s been done in Malaysia to firmly conclude that we as a community; affected by the exact categories listed, and have the same associated risk. While I don’t doubt that there will be differences, my experience with clients showed me that the fundamentals of the ACEs concept are possibly the same.
With that said, there are online screenings available if you are interested to see your own risk factors.
However, I wanted to note that the risk levels are based on the result of your screenings, and might indicate risks — but not the exact outcomes. So you may have experienced some of the categories listed, but perhaps due to multiple factors, the effects might be more or less. The main thing I’d like the readers to understand is; once you are able to assess the ACEs factors that you’ve possibly accumulated throughout your childhood, you’d be able to assess the risks of negative outcomes that you’re potentially exposed to.
The Pained Person
While the topic of challenging childhood have interested sociologist and psychologists for decades in the West — from Freud’s classical psychoanalytic theories; to the more pragmatic approach of Erikson’s Stages Of Psychosocial Development; the study of ACEs revived the public interest because it brought into light what may have not been as widely discussed. That the cost of ACEs may go beyond psychological well-being.
When I first joined Thrive Well, the managing director; Ellisha Othman, handed me a book that she asked every newcomer to go through. The book; The Deepest Well by physician Nadine Burke Harris, was not only an engaging read, but also an important personal account of how the exposure of ACEs can affect a person to the biological level. How the brain development and growth trajectory changes merely from such experiences despite having no genetic predisposition for it.
Stunted growth, diabetes, asthma, skin-rashes, ADHD-like symptoms and many more were observed by Dr. Nadine when she worked in a pediatric clinic at a low-income community of color in San Francisco. Although seemingly unrelated in the outset, it's unlikely connection began to form. These children, at one point of their life, had experienced one or more of the events highlighted earlier in this post.
Dr Nadine postulates the interesting point that she took from the parables of a London physician named Snow in the 1850’s, when hundreds died of a cholera outbreak. At the time, many believed that the disease is spread through air, but he noticed that the outbreak was centered around a single community hand-pumped well. After the hand-pump was removed, the outbreak subsided. As Dr. Nadine wrote in her book — “if one hundred people all drink from the same well and ninety eight of them developed diarrhea”, one would wonder if antibiotics are the correct cure after all.
In the paper presented by Felitti, et. al. in 1998; the paper which started the spark of recent interest in ACEs, the researchers highlighted that there is a strong correlation between the number of adverse events a child was exposed to and the increased risks of diseases, risky behaviors and mortality; and that these effects increase with the increased number of experienced events.
Cited in the paper;
Furthermore, earlier this year, Thrive Well have had a wonderful opportunity to be trained by Dr. Elena Quintana, the Executive Director of the Institute on Public Safety and Social Justice at Adler University Chicago on the subject of ACEs. Her presentation highlighted a lot of the growing body of research that shows the impact childhood trauma has, not only on the psychological level, but also physical and genetic level as well.
Source: http://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html
Dr. Quintana and Thrive Well’s clinical director, Ivy Tan also recently had a podcast with BFM focusing on the impact of ACEs on intergenerational trauma; and how even at a genetic level can be passed down. But towards the end of the podcast, a strong message of hope was discussed;
That healing is certainly possible, and studies are beginning to prove that.
The podcast offered me — and hopefully the readers — with a newfound hope. While trauma and adversities could be wired down to our very biology, there are ways to heal, and there are ways to prevent more of these trauma from continuing to be passed down to our children.
The Healing Community: Strategies for Support and Recovery
When I first started my work as a therapist years ago, I had an idealized view of what a therapist can do. After all, that’s what the books, and the movies, and the TV shows told me what I can do. Clients will come into the session, and walk out a changed, happy person. It is a hopeful view, of course; but after being a therapist for a number of years, I can tell you that the reality is both remarkably better and astonishingly disappointing at the same time.
It’s so much better because I’ve seen clients with ACEs not only walk out of the session happier, but also improve their lives for the better. It is personally amazing to see how a change in perspective and behavior can transform a person. Which is why I’ll never understate the value of good mental health intervention, or even psychological support not just from trained therapists like me, but also those who can provide it.
However, this is also the point where I have to set aside my ego and disappointment about the limitations of my work. In fact, I would argue that my learnings from ACEs had validated my concerns. The impact of childhood trauma that already had rooted deep in a person could not be waved away completely in therapy, especially if the outside environment didn’t provide support to the clients.
Which is why I’d like to highlight that a healing environment is as important as therapy (CDC, 2023; Reavley, et. al. 2020). That everyone, including you, have the remarkable power to make the changes needed in society to heal the community. Whether you'd work as a community, as a group or even as an individual, you are capable of making an impactful shift.
Supportive Policies & Trauma-Informed Care (TIC):
If you are working in an organization, you’d understand how policies can create a culture within that organization. TIC approach is an approach that recognizes the impact of trauma, and provides a healthy environment for each member within the environment to feel safe and supported. This includes being sensitive to the needs of individuals who have experienced trauma and ACE.
Moreover, if you are involved in making decisions in your organizations, you would be delighted to know that policies at the local and national levels can have a significant impact. Advocating for policies that support individuals affected by ACEs, such as funding for mental health services and child abuse prevention programs, can make a difference in a large scale. If you can help your organization to adopt TIC values, you have already able to provide safety, trust, collaboration, and empowerment for your environment
Parenting, Family & Education Awareness:
A child’s core experience will largely depend on the pivotal roles played by the adults around them. And naturally, one would find that parents, family members and teachers (as well as the education system) are the pivotal adults that shape these experiences.
If you are a parent, someone with a growing child in your family, or if you are working within the education sector; your knowledge of ACEs can greatly impact the way these children grow under your care. Understanding positive family dynamics, good parenting skills, child development and trauma knowledge can improve your understanding on how to support a physically and emotionally healthy child.
On the other hand, schools can implement trauma-informed practices that create a safe and supportive environment for students who have experienced trauma. Supportive schools that incorporate concepts of TIC and ACEs are not only capable to mitigate ACEs, but also heal a child. So, if you are part of this environment, you can advocate for, or improve the system by providing family support, counseling services and training for teachers on how to recognize and support students with ACEs.
Early Intervention:
If you are a pediatrician, educator, and a professional who works with children, you have the important role to play as the person who steps in to intervene and address ACEs as early as possible. The knowledge of how to screen for ACEs, understanding how to provide the first level of support, and how to provide resources to the families and children affected can be a significant part of the healing processes.
Community Resilience Building:
This point will probably need its own entire blog post, but if I could summarize it the best that I could; community building involves multiple stakeholders that supports the community in mitigating the effects of ACEs and trauma. Community organizations, local government, schools, healthcare providers, and residents are all involved in this effort. There’s a large chance that you would be a part of more than one of these stakeholders.
By the stakeholders working together by improving access to resources, overall health and well-being of the community, it is possible to minimize the impact of ACEs and other sources of trauma to build a more resilient community. In our training with Dr. Elena, these are the few points that she highlighted about the kind of support that are impactful according to studies:
Support: A community that can provide support that makes a person feel socially and emotionally advocated for and fostered; which leads to a person’s feelings of hopefulness. This can be residents having the training and capabilities to emotionally support each other; or a system that provides this type of support in an accessible way.
Help: Having two or more people within the community that provide concrete help when needed. For example, certain communities might be able to provide resources that can provide tangible, immediate help such as social aid, financial aid, or even members of the community that have the capabilities to do so.
Community Reciprocity: This refers to a community that can effectively rely on each other. For example, in the community, they are able to watch out for each other childrens, intervene when there is trouble, and are capable of relying on each other for favors. So members who understand the importance of this, and trained on providing this types of support will be very valuable in the community.
Social Bridging: A community that is resourceful is indeed powerful. Social bridging means that the members of the communities are capable to help direct or refer someone to help outside of the community circles. The best example of this are members who can provide numbers to legal help, aid or counseling services. So this basically refers to a community that is collectively well-versed in strategic community mapping or has the knowledge about the resources that’s available around them.
Therefore, community resilience building that focuses on these key elements are bound to be a community that is capable to withstand, adapt to, and recover from a variety of challenges and crises; including the effects of ACEs and other sources of trauma.
Final Reflections
I hope to be able to succinctly summarize my thoughts and conclusion about this topic, but as I’m writing this conclusion for the blog post; I began to reflect on my journey as a therapist who is involved with trauma work and community building. I’ve met individuals within the health system, the education system, the community, and even individuals who have so much passion, expertise and potential in healing the community from ACEs, whether they realized it or not.
Therefore, perhaps instead of summarizing the key takeaway from this blog post, I believe it is more valuable for me to point out how valuable your efforts are, and how much more we can do as a team. I hope this post inspires you, and is able to convince you that you have the capabilities to make the impactful changes that our community needs. After all, it takes a village to raise a child, and therefore; I trust that it would take so much more to prevent and heal trauma.
The Hopeful Message: Stories of Transformation
As a final message, I wanted to go back to the client I introduced in the beginning. I want the readers to know that through the therapy sessions, she had found strength to finally open up to the possible experiences around her. I was so proud when I saw her become brave, and begin to open up and rely on people that she never thought she’s capable of relying on, those she never felt that she’s good enough to burden.
Her children, her siblings, her trusted friends managed to give her the encouragement she needs. Those in her church offered good words and tangible help. Because of her efforts, and the people around her, she’s now connected to a lawyer to finalize her divorce, an NGO to provide her financial aid, and some good people who are able to help prepare her for job-seeking. Her life has been tough, but she’s now seeing the potential she has, instead of the things that are holding her back.
In our final session, she happily told me that the memory of her beloved tree will forever serve as a reminder of what she didn’t have in her past; but she believed that she is fully capable of being that tree for her growing children.
We hope this blog post was able to provide insights of how you can help and be a part of the healing process. Thrive Well is dedicated to provide psychological help and provide Trauma Informed Care knowledge in all levels of the community. To partner or connect with us, you can reach out to us via info@thethrive.center.
References
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
National Center for Injury Prevention and Control, Division of Violence Prevention. (2023, June 29). Aces can be prevented. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/prevention.html
Reavley, N., Morgan, A., Bee, M., Yap, H., Reupert, A., Loftus, H., & Jorm, A. (2020). Summary of interventions to prevent adverse childhood experiences and reduce their negative impact on children’s mental health: An evidence based review Berhe Sahle. https://www.childhoodadversity.org.au/media/olcjn2nw/summary_evidence_interventions_report_final_aug20.pdf