In 1985 I started to collaborate with psychiatrist Judith Herman, whose first book, Father-Daughter Incest, had recently been published. We were both working at Cambridge Hospital (one of Harvard’s teaching hospitals) and, sharing an interest in how trauma had affected the lives of our patients, we began to meet regularly and compare notes. We were struck by how many of our patients who were diagnosed with borderline personality disorder (BPD) told us horror stories about their childhoods. BPD is marked by clinging but highly unstable relationships, extreme mood swings, and self- destructive behavior, including self-mutilation and repeated suicide
attempts. In order to uncover whether there was, in fact, a relationship between childhood trauma and BPD, we designed a formal scientific study and sent off a grant proposal to the National Institutes of Health. It was rejected.
Undeterred, Judy and I decided to finance the study ourselves, and we found an ally in Chris Perry, the director of research at Cambridge Hospital, who was funded by the National Institutes of Mental Health to study BPD and other near neighbor diagnoses, so called personality disorders, in patients recruited from the Cambridge Hospital. He had collected volumes of valuable data on these subjects but had never inquired about childhood abuse and neglect. Even though he did not hide his skepticism about our proposal, he was very generous to us and arranged for us to interview fifty-
five patients from the hospital’s outpatient department, and he agreed to compare our findings with records in the large database he had already collected.
The first question Judy and I faced was: How do you take a trauma history? You can’t ask a patient point blank: “Were you molested as a kid?”
or “Did your father beat you up?” How many would trust a complete stranger with such delicate information? Keeping in mind that people universally feel ashamed about the traumas they have experienced, we
designed an interview instrument, the Traumatic Antecedents Questionnaire (TAQ).3 The interview started with a series of simple questions: “Where do you live, and who do you live with?”; “Who pays the bills and who does the cooking and cleaning?” It progressed gradually to more revealing questions:
“Who do you rely on in your daily life?” As in: When you’re sick, who does the shopping or takes you to the doctor? “Who do you talk to when you are upset?” In other words, who provides you with emotional and practical support? Some patients gave us surprising answers: “my dog” or
“my therapist”—or “nobody.”
We then asked similar questions about their childhood: Who lived in the household? How often did you move? Who was your primary
caretaker? Many of the patients reported frequent relocations that required them to change schools in the middle of the year. Several had primary caregivers who had gone to jail, been placed in a mental hospital, or joined the military. Others had moved from foster home to foster home or had lived with a string of different relatives.
The next section of the questionnaire addressed childhood
relationships: “Who in your family was affectionate to you?” “Who treated you as a special person?” This was followed by a critical question—one that, to my knowledge, had never before been asked in a scientific study:
“Was there anybody who you felt safe with growing up?” One out of four patients we interviewed could not recall anyone they had felt safe with as a child. We checked “nobody” on our work sheets and did not comment, but we were stunned. Imagine being a child and not having a source of safety, making your way into the world unprotected and unseen.
The questions continued: “Who made the rules at home and enforced the discipline?” “How were kids kept in line—by talking, scolding,
spanking, hitting, locking you up?” “How did your parents solve their disagreements?” By then the floodgates had usually opened, and many patients were volunteering detailed information about their childhoods. One woman had witnessed her little sister being raped; another told us she’d had her first sexual experience at age eight—with her grandfather. Men and women reported lying awake at night listening to furniture crashing and parents screaming; a young man had come down to the kitchen and found his mother lying in a pool of blood. Others talked about not being picked up at elementary school or coming home to find an empty house and spending the night alone. One woman who made her living as a cook had learned to prepare meals for her family after her mother was jailed on a drug
conviction. Another had been nine when she grabbed and steadied the car’s steering wheel because her drunken mother was swerving down a four-lane highway during rush hour.
Our patients did not have the option to run away or escape; they had nobody to turn to and no place to hide. Yet they somehow had to manage their terror and despair. They probably went to school the next morning and tried to pretend that everything was fine. Judy and I realized that the BPD group’s problems—dissociation, desperate clinging to whomever might be enlisted to help—had probably started off as ways of dealing with
overwhelming emotions and inescapable brutality.
After our interviews Judy and I met to code our patients’ answers—that is, to translate them into numbers for computer analysis, and Chris Perry then collated them with the extensive information on these patients he had stored on Harvard’s mainframe computer. One Saturday morning in April he left us a message asking us to come to his office. There we found a huge stack of printouts, on top of which Chris had placed a Gary Larson cartoon of a group of scientists studying dolphins and being puzzled by “those strange ‘aw blah es span yol’ sounds.” The data had convinced him that unless you understand the language of trauma and abuse, you cannot really understand BPD.
As we later reported in the American Journal of Psychiatry, 81 percent of the patients diagnosed with BPD at Cambridge Hospital reported severe histories of child abuse and/or neglect; in the vast majority the abuse began before age seven.4 This finding was particularly important because it
suggested that the impact of abuse depends, at least in part, on the age at which it begins. Later research by Martin Teicher at McLean Hospital showed that different forms of abuse have different impacts on various brain areas at different stages of development.5 Although numerous studies have since replicated our findings,6 I still regularly get scientific papers to review that say things like “It has been hypothesized that borderline patients may have histories of childhood trauma.” When does a hypothesis become a scientifically established fact?
Our study clearly supported the conclusions of John Bowlby.
When children feel pervasively angry or guilty or are chronically frightened about being abandoned, they have come by such
feelings honestly; that is because of experience. When, for
example, children fear abandonment, it is not in counterreaction to their intrinsic homicidal urges; rather, it is more likely because they have been abandoned physically or psychologically, or have been repeatedly threatened with abandonment. When children are pervasively filled with rage, it is due to rejection or harsh
treatment. When children experience intense inner conflict regarding their angry feelings, this is likely because expressing them may be forbidden or even dangerous.
Bowlby noticed that when children must disown powerful experiences they have had, this creates serious problems, including “chronic distrust of other people, inhibition of curiosity, distrust of their own senses, and the tendency to find everything unreal.”7 As we will see, this has important implications for treatment.
Our study expanded our thinking beyond the impact of particular horrendous events, the focus of the PTSD diagnosis, to look at the long- term effects of brutalization and neglect in caregiving relationships. It also raised another critical question: What therapies are effective for people with a history of abuse, particularly those who feel chronically suicidal and
deliberately hurt themselves?