Trauma And the Impact of Misattunement in Early Childhood.
Journal of Psychiatry Reform vol. 11 #1, January 2024
Katrina Wood PhD
Wilshire Counseling Center in Los Angeles and Ventura in CA
The concept of Cumulative Trauma has been a growing focus of mental health research, slowly but steadily gaining more recognition within the field of psychology over the last 5-10 years.
Initially formulated by British-Indian psychoanalyst Dr. Masud Kahn in 1963, it emphasizes the impact of damaged parental caretaking as a protective shield failure during a child’s development. While Cumulative Trauma has essentially been neglected inside the analytic community, it has only recently been brought to the forefront, challenging the dominance of Post-Traumatic Stress Disorder (PTSD) in psychological discourse.
Masud Khan’s theory of Cumulative Trauma.
Object relations theorist Masud Kahn (1924-1989) was a Pakistani born British psychoanalyst. He was the collaborator, editor and “Principal disciple” of Dr. D.W. Winnicott, a British psychoanalyst and pediatrician, as well as his analysand. He was himself an analyst, as well as the chief editor of the International Psychoanalytical Library for 20 years. He wrote four books and served as training analyst for Christopher Bollas and Adam Phillips. It is also widely recognized that it was Winnicott’s acknowledged failure to successfully analyze Khan, declaring that he had “allowed him to fall into madness”. It is purported that Winnicott was unable to tolerate, or integrate parts of Kahn’s rage responses during treatment, and that because of this, it furthered his decision to recruit Kahn’s academic proficiencies as a co-author, rather than continue to pursue treatment with him.
In 1963 Khan develops the idea of the potentially traumatogenic effect that emanates from a damaged or impaired caretaking function of the ‘mother.’ Referencing Freud’s (1920g) formulation of a “breach in the stimulus protection” of an organism through a shock-like influence from the outside, the resulting “trauma syndrome” is defined as follows:
“My argument is that cumulative trauma is the result of the breaches in the mother’s role [parental or caregiver role would be more applicable today due to the more contemporary practice of sharing parental roles] as a protective shield over the whole course of the child’s development, from infancy to adolescence-that is to say, in all those areas of experience where the child continues to need the mother as an auxiliary ego to support his immature and unstable ego functions. […] Cumulative trauma thus derives from the strains and stresses that an infant-child experiences in the context of his ego dependence on the mother as his protective shield and auxiliary ego” (Khan, 1963, p. 290f).
Masud Khan’s Cumulative Trauma theory does not aim at overt abuse and massive deprivation scenarios to which children are exposed over a long period of time. Rather, it refers to the accumulation of more subtle inconsistencies in mother/parent-child interaction.
In this context, Grubrich-Simitis (1979) appropriately speaks of “inconspicuous failures of empathy” which take place primarily in preverbal, affective interaction processes between mother/parent and infant, leading to a disruption of the earliest structural formation of the infant’s personality, particularly concerning its ability for self-object differentiation.
The unreliability and instability in the maternal (or parental) care function is by no means to be misunderstood as intentional, and normally serves the child as a protective shield against sensual or affective overstimulation from inside or outside, but instead has a pathogenic effect.
The concept of a “good enough mother” originated in 1953 by Dr. D.W. Winnicott, suggested that children benefit when mothers fail to address a child’s every need, thereby learning over time to manage the challenges they will experience in life. A key distinction between Masud Kahn’s theory of cumulative trauma and good enough parenting lies in the lack of specificity provided by Winnicott regarding the term “good enough”.
Winnicott took a softer approach than Freud in his views about the role of parents, which helped popularize his teachings. He recognized and emphasized the need for children to realize that a mother is neither good nor bad, nor the product of illusion, but is a separate and independent entity: “The good-enough mother…starts off with an almost complete adaptation to her infant’s needs, and as time proceeds, she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure. Her failure to adapt to every need of the child helps them adapt to external realities.” (Winnicott, 1953). In other words, the child learns to draw on their own resources when the mother fails to meet all their needs.
Winnicott appears to rely on what he referred to as the “sound instincts of normal parents” of stable and healthy families. What he attempted to establish, based on the contention of good enough was, as Winnicott put it, “the good-enough environmental provision” which makes it possible for the offspring to “cope with the immense shock of loss of omnipotence”. Failing such provision, family interactions may be based on a fantasy bond, in a disengagement from genuine relating and merely suffices to foster the “false self”. This undercuts the ongoing ability for parents to foster the continued emotional growth offered by the good enough parent.
While sound in its presentation, Winnicott’s theory lacks specificity and contextual clarity regarding the terms “normal” and “healthy”. As a doctor treating patients shortly after the Second World War, Winnicott was presenting the concept of “a good enough mother”, while not examining the impact of intergenerational trauma states. Parents who had been devastated and shattered by the war were themselves suffering from complex trauma in an environment ill-equipped to provide treatment of such mental suffering. The “shell-shocked” approach to PTSD at this time left many in isolation at a time when mental health treatment was considered both a stigma and suited only for the mentally ill. This population was now raising a generation of children who were becoming child-bearing adults. Absent consideration of this trauma, the destabilizing psychological consequences of this event were largely disregarded, if not completely ignored.
It is not until relatively recently that the term PTSD was coined in the United States, referring to veterans returning from war in Vietnam. Winnicott would not have been aware of such complex trauma, or the impact of intergenerational trauma states passed on pre-reflectively. Consequently, Cumulative Trauma would inevitably have been transferred to children to greater or lesser degrees, manifesting in conflicting influences regarding child rearing practices. Parenting styles referred to as “normal” and “healthy” seem to lack reflective insight when the impact of trauma states and Post Traumatic Stress remained so largely unrecognized.
Masud Kahn presented a unique focus on the powerful, yet discreet, discrepancies with the normalizing of so called “healthy families”, a term coined by Winnicott. Kahn particularly focused on repetitive mother and child inconsistences, which resulted in inadequate parenting due to missing key indicators and were thus inconsistent with Winnicott’s emphasis on so called necessary “attunement”, or good enough mothering.
These discreet inconsistencies disrupt a child’s basic ability to attach emotionally and psychologically with the parent or caregiver, initially usually the mother. If attunement is consistently absent, the disruption of an internal sense of continuity and security (vital to a child’s foundational sense of a developing self), leads to ongoing strains and stressors affecting further healthy developmental growth.
Due in part to the period in which Kahn was studying and writing, babies of the 1950s and 1960s spent considerably more time with their mothers, as males were more dominant in the workforce. Around 65% of American families lived this way. Today it seems there is no “typical” family structure. Some statistics show 22% of children under 15 years of age continue to live in this type of environment, 34% in dual-income families, 23% are being raised by single mothers, 3% by single fathers, and 3% by grandparents.
Sadly, Kahn’s sagacious observations became relegated to the repository of unrecognized “trauma” by the general community, as PTSD took center stage due to its evidence of clearly identifiable symptomatology connected with an identifiable “singular event”. The assessment of cumulative trauma states in children due to parental misattunement had until only recently been relegated to a sidebar.
Behaviorists have traditionally suggested that it was a basic need for food and survival that led to the forming of attachment behavior. However, British Psychiatrist Dr. John Bowlby and others demonstrated that nurturance and responsiveness were the primary determinants of mother baby “attachment”. The theory was built around the emotional and psychological development of a child focusing on “attachment” as a central foundation of relational connectivity.
Mary Ainsworth, a psychologist and student of John Bowlby, studied the development of attachment in infants. Based on responses researchers observed in lab tests, she described three major styles of attachment: secure attachment, ambivalent-insecure attachment, avoidant-insecure attachment. Later, Mary Main and Judith Solomon, based on their own research, added a fourth attachment style called disorganized-insecure attachment (1986). However, Michael Rutter, sometimes described as the “father of child psychology”, stated that this diagnoses “undoubtedly identifies behavioral features of considerable theoretical and clinical significance, but the meaning of the pattern remains rather unclear”.
DSM-5 and ICD 10/11 Diagnosis.
Despite its significance, Cumulative Trauma continues to remain largely overlooked as a formal diagnosis by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), overshadowed by the prominence of Post-Traumatic Stress Disorder (PTSD). The ICD11 defines Complex Trauma, or CPTSD within clusters of symptoms generally mirroring Post Traumatic Stress Disorder. However, CPTSD is typically developed during childhood, usually resulting from various forms of abuse, often discreet, and including neglect. This repetitive trauma creates a kind of non-existence in the child, coupled with a perpetual fear of abandonment. Symptoms supporting a diagnosis of CPTSD include disturbances of self-organization, including avoidance and emotional dysregulation. In October 2023, recognition of two additional types of traumata were added to the 2024 edition of the International Classification of Diseases (ICD 10/11) diagnostic criteria; Z91.49, described as “Other personal history of psychological trauma, personal risk factors not elsewhere classified”, and F43.9, “Reaction to severe stress”. While the descriptions are ambiguous and broad, it is a small step toward recognizing that in addition to Post Traumatic Stress Disorder and CPTSD, there needs to be a deeper understanding of the nuanced, undefined, hidden, or concealed variables contributing to other types of prolonged trauma states.
Currently the theories of PTSD and CPTSD continue to focus on the impact of a series of events (trauma states), rather than cumulative traumatic experiences resulting from the absence of emotional and psychological relatedness. Discontinuances in the protective shield or stimulus-protective function of maternal care (or more broadly formulated: the early holding environment) “collide” with the unprotected child’s “psyche-soma” and cumulate “silently and invisibly” through the developmental process. “They achieve the value of trauma only cumulatively and in retrospect” (Khan, 1963, p. 291).
Pathological Adaptation-How children cope.
Pathological adaptation, a coping mechanism employed by children in response to developing cumulative trauma, involves silent compliance for survival and attachment needs. Traditional focus on overt abuse neglects the evolution of cumulative trauma through repetitive subtle emotional, and psychological neglect. Unhealthy communication patterns from parents and caregivers are unintentionally modeled and normalized within families, and contribute to the fragmented attention paid to a child’s emotional and developmental needs.
Misattunement can be illustrated by scenarios like that of a child, when expressing fear of fireworks, is told by a parent “there is nothing to be afraid of” or “my child is not scared of anything”. Or a child returning from school with a B grade for a project they worked hard on only to hear “that’s not bad, but what happened to the A?” A child sharing their artwork, only to dominated by a parent’s describing memories of their own personal artistic skills when they were at school, eclipsing the child’s need to be seen. The child feeling the pain of emotional and psychological annihilation, bearing the burden of misattunment, and now carrying shame in isolation. Such seemingly small, misattuned comments, when repetitively reinforced, lead to emotional dysregulation and anticipatory withdrawal. When normal feelings of fear, interest and pain are repeatedly unseen, a child slowly develops feelings of nonexistence. Winnicott writes of a how a child’s true self remains in “cold storage”.
Despite these repetitive painful annihilating experiences, children seek to preserve the illusion of a cohesive and stable family bond, sacrificing their developmental path for the good of the “system”, and to maintain the indispensable tie. Cumulative Trauma is reinforced in the form of self-neglect, as pre-reflective intergenerational relational trauma states are blindly passed on.
Absent sufficient attuned, corrective experiences during developmental adolescence and adult life, misdiagnosis becomes a common pitfall as children and adults exhibit symptoms such as ADHD, depression, anxiety, panic, ADHD Bi-Polar disorder, OCD, chronic anxiety, obsessive-compulsive traits, Suicidal Ideation and Suicide. Arguably resulting from insecure attachments formed during early repetitive misattunement.
Providers often fail to recognize a child’s pathological adaptation to parental narcissistic needs. Now the child’s condition or diagnosis becomes separate and distinct from the impact of the family system’s parenting disconnect. Unintended parental messaging further exacerbates the issue, as children learn to dissociate from expressing emotions associated with pain, loneliness, and potential loss. Shallow platitudes and quick dismissal of a child’s emotions contribute to an internalized message that not only do their experiences not matter, but often that they themselves do not matter.
Inadequate treatment compounds the problem. While cognitive-behavioral management skills may address maladaptive behaviors in part, therapists often disregard the impact of repetitive relational losses, possibly due to the absence of exploration of their own childhood traumas. A therapist may at times enable the parent by conspiring to agree with a child’s diagnosis of oppositional defiant disorder at the expense of exploring losses being protested rather than opposed. A developing child will continue to remain in a state of arrested development when an inadequate diagnosis fails to address the emerging unattended trauma states. While focusing on interpreting maladaptive behaviors required to meet target behavioral goals and evidence-based results, a therapist may wonder why patients terminate prematurely or drop out altogether.
A child, then a teen, now an adult, learns to repeat adaptive behaviors formed in childhood, continuing to marginalize emotional and psychological needs by imposing harsher self-talk and constricting limitations concealing more vulnerable states of being
Examples of Trauma Repetitive Experiences Resulting from A Pre-Reflective Childhood.
Real-life examples highlight the long-lasting impact of Cumulative Trauma. A woman reaches the breaking point in an unhappy marriage and files for divorce. During her initial sessions in therapy, she realizes that the persistent critical voice she experienced and tolerated in her marriage was the familiar voice of a father who expressed deep regret at not having a son. Adapting and bearing considerable shame over the years, she finds she has replicated cumulative trauma with a partner who repeatedly expressed regret at not marrying someone who was more accomplished. All attempts to be good enough were met with repeated disappointment as in childhood. When pain of echoing voices from the past becomes unbearable, reflective work provides an option to break free from the constraints of her past trauma. Seeking help offered a path of individuation, thawing frozen states from childhood and leading to developmental maturation in a hopeful and positive way.
A teenager whose aspiration to become a musician are thwarted by a parent’s insistence he would never amount to anything (a repetitive traumatic message) unless he pursued a career in law. Initially, to the satisfaction of the father, he did. Over time, complying with parental demands created profound depression and emptiness. With courage and commitment to his soul’s code, the male finds a way to access his love of music, walk away from the so-called safety of the parent’s narcissistic needs, and pursue a path as a musician. Great risk was taken by the son, as the father saw such a choice as a betrayal of his values. No longer being controlled by his father’s needs, a less burdened and creative path was forged. No longer sacrificing his needs, the path of this musician was solidified.
Conclusion A Pathway Forward
Dr. James Hollis writes in his book The Middle Passage, what he calls an “inevitable appointment with the self”; in mid-life, destructive or harmful experiences appearing “out of the blue” may be viewed as opportunities for reflection.
However, with early intervention and insights into the formation of cumulative trauma, such “appointments with the self” could be averted. Being acutely mindful when patients minimize negative experiences from childhood may help provide clues into how developmental obstacles are preserved. Sustained, empathic and attuned inquiry, particularly with reference to the more subtle comments made by a patient, is required for every child and adult coming into treatment. Through reflective listening and validation, combined with the significance of how developing cumulative trauma can be reinforced by well-intentioned parents, brings lucidity to this complex diagnosis.
Children have unique ways of being in the world. A parent who thinks their child should be a certain way with respect to the child’s proficiencies, often are experienced by the child as overbearing and annihilating. A child’s developmental milestones are fragile and unformed, dependent on parents’ sensitive indicators concerning their developing selves. A parent’s deep listening and validating skills will contribute to helping a child know that they deeply matter. Gentle steady inquiry with reflective pauses, inquiry about certain words, body language, sighs, and enthusiasm, all contribute to the self-affirming child transitioning to the authentic adult.
Brandchaft Bernard (2010) Towards an Emancipatory Psychoanalysis. Routledge. Taylor Francis Group.
Stolorow Robert D. (2007) Trauma and Human Existence. The Analytic Press.
Stolorow Robert D & George Atwood (2019) The Power of Phenomenology. Routledge.
Hopkins Linda (2008) False Self – The Life of Masud Khan. Karnac Books.
Khan, M.M.R (2017) The Concept of cumulative trauma.1st Edition. Routledge
Gianluca Crepaldi & Pia Andreatta (2021) The Concept of Cumulative Trauma in Times of Covid 19: Could Kahns theory become useful again? Institute of Psychosocial Intervention. University of Innsbruk (Austria) 2021
In R. S Eissler, A Freud, H Hartmann @ M. Kris (Eds.) Psychoanalytic study of the child (Vol. XV111, pp. 286-306). New York: International Universities Press.
Diamond Stephen A. (1996) Anger Madness and the Daimonic. State University of New York Press: Albany.
Sage Press. Bradshaw. John (1988) Healing the Shame that Binds You. Health Communications Inc.
Jacobs Michael J. (1999) D. W. Winnicott.
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 2012. American Psychiatric Association. VA.
International Classification of Diseases Eleventh Revision (ICD-11). Geneva: World Health Organization; 2022. License: CC BY-ND 3.0 IGO.
Wood, Katrina (2013 Volume 21) Trauma, Shame and Rage. The Therapist CAMFT Magazine.
Adam Phillips/Barbara Taylor, On Kindness (2004) Picador Publishers.
W. Bingham/A.M. Sidorkin, No Education Without Relation(2004). Peter Lang Inc, International Academic Publishers.