Why Therapy Gets Hard Before It Gets Better: Understanding ACEs and the Drop-Off

Over the past few decades, research has increasingly pointed to something many people have long felt but couldn’t quite name: our early experiences shape us in profound and lasting ways.

This is captured in what is known as Adverse Childhood Experiences (ACEs)—a set of 10 categories of early life stressors, including abuse, neglect, and household dysfunction.

The original Adverse Childhood Experiences Study, conducted by Vincent Felitti and Robert Anda in collaboration with the Centers for Disease Control and Prevention and Kaiser Permanente, found that individuals with higher ACE scores face significantly increased risks for a range of health outcomes.

One of the most striking findings:

Individuals with 4 or more ACEs have a dramatically increased likelihood of developing substance use issues in adulthood.

But substance use is just one expression.

The ACE framework identifies 10 categories of early life adversity that occur before the age of 18. These are grouped into three main areas: abuse, neglect, and household challenges.

1. Abuse

• Emotional abuse

• Physical abuse

• Sexual abuse

2. Neglect

• Emotional neglect (feeling unloved, unsupported)

• Physical neglect (lack of basic care such as food, safety, supervision)

3. Household Challenges

• Exposure to domestic violence (e.g., one parent harming another)

• Household substance use

• Household mental illness or suicide attempt

• Parental separation or divorce

• Incarceration of a household member

Each category counts as one point, for a total possible score of 10.

It’s important to note:

• ACEs are not about comparison—one person’s “2” is not another person’s “2”

• The score doesn’t capture severity, frequency, or protective factors

• And most importantly, an ACE score is not a life sentence

What it does offer is a lens:

a way to understand how early experiences may still be shaping present-day patterns.

How ACEs Show Up in Adulthood

ACEs don’t disappear—they adapt.

They often show up as:

• negative automatic thoughts (“I’m not enough,” “I’ll be abandoned”)

• self-sabotaging patterns

• chronic guilt or shame

• difficulty trusting others

• emotional reactivity or numbness

These are not character flaws.
They are adaptations to early environments.

The Good News: These Patterns Are Treatable

Once we can clearly identify how early experiences are showing up in the present, we can begin to work with them.

Evidence-based approaches such as:

• trauma-focused CBT

• EMDR

• somatic and attachment-informed therapies

can help process these patterns and gradually bring people back toward a more regulated baseline.

This body of work has been further expanded by researchers and clinicians like Bessel van der Kolk (author of The Body Keeps the Score), whose work has helped translate the impact of trauma into both science and clinical practice.

So Why Do People Drop Out of Therapy?

Despite growing awareness, many people begin therapy… and then stop.

Not because it isn’t working.
But often because it is.

In my clinical experience working as a psychotherapist in the Ottawa community, one of the most common reasons for drop-off is this:

Therapy often feels worse before it feels better.

A Different Way to Understand Therapy

Therapy is not always immediately relieving.

In fact, it can feel more like treating a stubborn wart.

If you’ve ever had one on your foot or hand, you’ll know the process:

• the wart is shaved down to the skin so the blood vessels are visible

• then liquid nitrogen is applied to it

• when you return next week, the wart has regrown, in an even more irregular shape

• however, the process keeps getting repeated…

• until one day you wake up and it has fallen off.

• Simply…gone.

What This Means for You

If you’ve started therapy and found yourself thinking:

• “This is too much”

• “I feel worse, not better”

• “Maybe this isn’t working”

You’re not alone.

And it doesn’t necessarily mean therapy is failing.

It may mean:

you’ve reached the part where real change begins.

The Takeaway

ACEs help us understand why certain patterns exist.
Therapy helps us change how they continue.

But that process requires:

• time (weeks to months, not days)

• consistency (weekly, biweekly)

• and a willingness to move through discomfort (imagine physical workout)

Not because something is wrong with you—
but because something happened to you.

And with the right support, those patterns can shift.