Who Cares? Relationship, Regulation, Resources

As all who have been in the world of trauma, whether as clinician, researcher, survivor, or some combination thereof know, the area of greatest injury to life and to function is the domain of relationship. That has certainly been the crippling pain, anxiety, shame, or simple cluelessness most likely to bring people to my therapy office door, and was certainly true for me. As mammals, attachment, connection, and interdependence are primordial, fundamental to survival. That would begin to explain the urgency and despair we experience in its absence. 

As human beings, love and relatedness are at the heart of what makes life most worth living, as exemplified in our art, music, literature, and all other media of expression around the world. It is a great motivator. It is the pivotal and most often missing ingredient in childhood neglect, especially in the developmental or earliest incidence of neglect, which is so much of what I see. By early, I mean the very tender and, of course, “unremembered” infant months and years. I say unremembered cautiously, because the desolation and uncertainty of isolation are in fact on record in the nervous system and the body. We know that by now, yet it is so “easy” to forget.

For many adult children of neglect, their mechanisms of compensation and disguise may be more skilled than what is turned out by the world’s top makeup artists. The void behind the facade of high function and success may thus be elusive to the naked eye, even to the self, at least some of the time. Because solitude becomes a default and even a “cozy” hiding place, it would be easy to chalk it up as being an introvert or “highly sensitive person” until some undeniable symptom compels attention, appearing in the form of a dramatic emergency – for example, my anorexic downfall, now almost 55 years ago to the day. I literally fell crashing out of my hiding place, certainly not on “conscious” purpose. Alcohol became another good clue if anyone had had a road map, but as has been endemic with neglect, nobody did

I flailed for a long time in a punitive world that lacked the psychological, neurobiological, and clinical options that we are now increasingly beginning to have, although critically insufficient. And I had the privilege of being white, middle class, with access to good schools and libraries to hide out in, which I liberally did. Even now, I often exclaim spontaneously to my husband, “I am so glad we live indoors!” I truly am, and so grateful.

I remember thinking I only began to learn how to be a “regular person” when I got my first waitressing job and spent enough hours with “regular people” that I could learn how to talk about movies, sports, television, and mainstream activities that I felt so ambivalent and clueless about. Of course, alcohol became a great companion in the process, as not only did it make it easier to fake it, but it also made me not care as much. Later on in therapy, I (not infrequently) would ask my infinitely patient therapist “So what do people do when…?” When they are at home in the evenings with their families, or on vacations with others? I still had only the vaguest clue.

I routinely admonished myself, “I just can’t get along with humans!”Although I have bristled against the term “impostor syndrome” dismissing it as too “pop psychology-esque,” it is probably too close to home. I was undeniably aware that I felt for many decades as if I was indeed of some other, probably mostly extinct and certainly less evolved species.

Central to the experience of childhood neglect is a devastating conundrum, a Gordian knot that, for many, plagues and tortures them throughout their lives if it has not been vanquished by early and prophylactic numbing (which it all too often is). Attachment researcher Mary Main has aptly called it the dilemma without solution: when the source of infant comfort and the source of terror are the same – the essentially needed primary caregiver. 

Abandonment, loss, and the absence of connection feel life-threatening which, certainly at the most vulnerable stages of life, it actually is. That is where the other side of the dilemma is congealed or constructed: the impenetrable Fort Knox of self-reliance. It is the safe house, the bomb shelter, the default survival mechanism until it breaks or fails, which it often does. The results are all too lethal both for the child of neglect themselves and for others in their wake, as we are all too often seeing these days as the disenfranchised “go off” and act out violently in the world. So many reasons that I am adamant about helping the world become “neglect informed.”

Neuroscience is forcing us to understand the profound and developmentally crucial impact of attachment on regulation.


Neuroscience is forcing us to understand the profound and developmentally crucial impact of attachment on regulation. Regulation is the management of energy in the organism, the balance between high and low-frequency electrical activation in the brain, sympathetic and parasympathetic, stress and calm, terror, rage or nameless anxiety, and a quiet return to a hopefully comfortable baseline. A flexible and adaptive flow and a reasonable level of control over life’s inevitable vicissitudes is the great blessing of secure attachment. It is the gift of the good enough caregiver, and increasingly we are coming to understand this. Even the larger, non-trauma specialized psychotherapy field is increasingly learning this (no disdain intended.) Regulation is profoundly necessary, and sadly, far too rare. The mainstream is all too slowly connecting the dots, often failing to recognize the devastating damage of the desperate attempt to find regulation somewhere to the self and others, especially when it has not been learned at the developmentally appropriate time. Discomfort, terror, rage, or sheer amorphous compulsivity fuels the search for a way to manage unbearable ups and downs.

Because the feelings and isolation are so often points of shame, people often ask, “What is wrong with me?” How many “friends” one has, certainly in the time of social media, is a measure of “value” or self-worth, so the isolated may be even more ambivalent than usual about their need. 

Interpersonal need is so lethal that the child of neglect keeps it carefully locked away, often even from themselves. Because they might look good on the outside, helpers and the world at large readily miss the cues, or do not even imagine such an outwardly successful individual as being so distraught. So they slip through the cracks and remain invisible. They often defy recognition, even among therapists, if they even think to approach therapists. Suicide rates among medical students and physicians are disproportionally high. Where can people turn? And where can they turn if they do not even know what is wrong, or that something is “legitimately” wrong?

Regulation is profoundly necessary, and sadly, far too rare


In the affluent town of San Francisco, the number of deaths by fentanyl overdoses beat the number of Covid-19 deaths in 2021. I find that to be chilling and profoundly alarming. In another story, six San Francisco fentanyl overdose deaths were stopped, and several lives were saved in the space of days by passersby administering Narcan to users who most likely would have died if not for such good samaritan luck. What if those good citizens had not walked by?

I am an avid supporter of local Crisis Support and Suicide Prevention organizations. I am so grateful to them for doing the essential crisis/emergency work that I am decidedly not good at. It is so needed, and so neglected. Oy vey. Neglect upon neglect upon neglect. It is literally deadly.

It saddens me that some of the most powerful treatment modalities we now have for restoring regulation are not yet accessible on a larger scale. Neurofeedback is such a godsend, and yet too expensive (for most prohibitively so) to provide on a large enough scale. Where do we start? Well, you and I can start by helping the world become “neglect informed.” It took 30 years for the ACE (Adverse Childhood Experiences) Study to hit the mainstream, but it finally has, and it does acknowledge neglect. Educate the world, support services, and policy insofar as we can, and we can save lives, not to mention ease unbearable suffering.

I was gratified to learn that our US Surgeon General, the young Vivek H. Murthy, has identified a major public health crisis in this country: loneliness! 22% of the US population self-identifies as profoundly lonely. We are coming to understand more and more of the consequence of that. This is the subject of his book, Together: The Healing Power of Human Connection in a Sometimes Lonely World. I find that gratifying and hopeful, as it joins mental health on the incipient roster of important social and political matters. Yay! 

Again, my deepest appreciation to the Trauma Research Foundation for tying political and social meaning to the epidemic of trauma. More than 40 years after the PTSD diagnosis was identified and named, the larger world is adopting the understanding and necessity of being “trauma-informed.” It is a term that people are coming to know, adhere to, and use. I would hope to do the same with neglect.

Today’s song:

My book “Working with the Developmental Trauma of Childhood Neglect: Using Psychotherapy and Attachment Theory Techniques in Clinical Practice” was published on August 31st. It provides psychotherapists with a multidimensional view of childhood neglect and a practical roadmap for facilitating survivors’ healing.

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