When the Body Says No

by Gabor Maté

That a specialist would dismiss the link between body and mind was not astonishing. Dualism—cleaving into two that which is one—colours all our beliefs on health and illness. We attempt to understand the body in isolation from the mind. We want to describe human beings—healthy or otherwise—as though they function in isolation from the environment in which they develop, live, work, play, love and die. These are the built-in, hidden biases of the medical orthodoxy that most physicians absorb during their training and carry into their practice. Unlike many other disciplines, medicine has yet to assimilate an important lesson of Einstein’s theory of relativity: that the position of an observer will influence the phenomenon being observed and affect the results of the observation. The unexamined assumptions of the scientist both determine and limit what he or she will discover, as the pioneering Czech-Canadian stress researcher Hans Selye pointed out. “Most people do not fully realize to what extent the spirit of scientific research and the lessons learned from it depend upon the personal viewpoints of the discoverers,” he wrote in The Stress of Life. “In an age so largely dependent upon science and scientists, this fundamental point deserves special attention.”1

Our immune system does not exist in isolation from daily experience.

How may stress be transmuted into illness? Stress is a complicated cascade of physical and biochemical responses to powerful emotional stimuli. Physiologically, emotions are themselves electrical, chemical and hormonal discharges of the human nervous system. Emotions influence—and are influenced by—the functioning of our major organs, the integrity of our immune defences and the workings of the many circulating biological substances that help govern the body’s physical states. When emotions are repressed, as Mary had to do in her childhood search for security, this inhibition disarms the body’s defences against illness. Repression—dissociating emotions from awareness and relegating them to the unconscious realm—disorganizes and confuses our physiological defences so that in some people these defences go awry, becoming the destroyers of health rather than its protectors.

There is no true responsibility without awareness. One of the weaknesses of the Western medical approach is that we have made the physician the only authority, with the patient too often a mere recipient of the treatment or cure. People are deprived of the opportunity to become truly responsible. None of us are to be blamed if we succumb to illness and death. Any one of us might succumb at any time, but the more we can learn about ourselves, the less prone we are to become passive victims.

The fundamental problem is not the external stress, such as the life events quoted in the studies, but an environmentally conditioned helplessness that permits neither of the normal responses of fight or flight. The resulting internal stress becomes repressed and therefore invisible. Eventually, having unmet needs or having to meet the needs of others is no longer experienced as stressful. It feels normal. One is disarmed.

Artistic expression by itself is only a form of acting out emotions, not a way of working them through.

Interactions with other human beings—in particular, emotional interactions—affect our biological functioning in myriad and subtle ways almost every moment of our lives. They are important determinants of health, as we will see throughout this book. Understanding the intricate balance of relationships among our psychological dynamics, our emotional environment and our physiology is crucial to well-being. “This may seem odd,” wrote Selye. “You may feel that there is no conceivable relationship between the behaviour of our cells, for instance in inflammation, and our conduct in everyday life. I do not agree.”2

For those habituated to high levels of internal stress since early childhood, it is the absence of stress that creates unease, evoking boredom and a sense of meaninglessness. People may become addicted to their own stress hormones, adrenaline and cortisol, Hans Selye observed. To such persons stress feels desirable, while the absence of it feels like something to be avoided. When people describe themselves as being stressed, they usually mean the nervous agitation they experience under excessive demands—most commonly in the areas of work, family, relationships, finances or health. But sensations of nervous tension do not define stress—nor, strictly speaking, are they always perceived when people are stressed.

There is no uniform and universal relationship between a stressor and the stress response. Each stress event is singular and is experienced in the present, but it also has its resonance from the past. The intensity of the stress experience and its long-term consequences depend on many factors unique to each individual. What defines stress for each of us is a matter of personal disposition and, even more, of personal history.

The research literature has identified three factors that universally lead to stress: uncertainty, the lack of information and the loss of control.8 All three are present in the lives of individuals with chronic illness.

the salient stressors in the lives of most human beings today—at least in the industrialized world—are emotional. Just like laboratory animals unable to escape, people find themselves trapped in lifestyles and emotional patterns inimical to their health. The higher the level of economic development, it seems, the more anaesthetized we have become to our emotional realities. We no longer sense what is happening in our bodies and cannot therefore act in self-preserving ways. The physiology of stress eats away at our bodies not because it has outlived its usefulness but because we may no longer have the competence to recognize its signals.

Self-regulation, writes Ross Buck, “involves in part the attainment of emotional competence, which is defined as the ability to deal in an appropriate and satisfactory way with one’s own feelings and desires.”12 Emotional competence presupposes capacities often lacking in our society, where “cool”—the absence of emotion—is the prevailing ethic, where “don’t be so emotional” and “don’t be so sensitive” are what children often hear, and where rationality is generally considered to be the preferred antithesis of emotionality.

Emotional competence requires • the capacity to feel our emotions, so that we are aware when we are experiencing stress; • the ability to express our emotions effectively and thereby to assert our needs and to maintain the integrity of our emotional boundaries; • the facility to distinguish between psychological reactions that are pertinent to the present situation and those that represent residue from the past. What we want and demand from the world needs to conform to our present needs, not to unconscious, unsatisfied needs from childhood. If distinctions between past and present blur, we will perceive loss or the threat of loss where none exists; and • the awareness of those genuine needs that do require satisfaction, rather than their repression for the sake of gaining the acceptance or approval of others.

Emotional competence is what we need to develop if we are to protect ourselves from the hidden stresses that create a risk to health, and it is what we need to regain if we are to heal. We need to foster emotional competence in our children, as the best preventive medicine.

The life histories of people with ALS invariably tell of emotional deprivation or loss in childhood. Characterizing the personalities of ALS patients are relentless self-drive, reluctance to acknowledge the need for help and the denial of pain whether physical or emotional. All these behaviours and psychological coping mechanisms far predate the onset of illness. The conspicuous niceness of most, but not all, persons with ALS is an expression of a self-imposed image that needs to conform to the individual’s (and the world’s) expectations. Unlike someone whose human characteristics emerge spontaneously, the individual seems trapped in a role, even when the role causes further harm. It is adopted where a strong sense of self should be—a strong sense of self that could not develop under early childhood conditions of emotional barrenness. In people with a weak sense of self, there is often an unhealthy fusion with others.

For the child it is no relief to feel sadness or anger if no one is there to receive those emotions and to provide some comfort and containment. Everything had to be held in rigidly. The physical rigidity of ALS may well be a consequence. There is perhaps only so much energy the nervous system can expend pushing down powerful emotions that cry out for expression. At some point in particularly susceptible individuals, it seems reasonable to suppose, nerves may lose the ability to renew themselves. Could ALS be a result of an exhausted nervous system no longer being capable of replenishing itself?

Rage and anguish exist underneath the veneer of niceness, no matter how sincerely a person mistakes the facade for her true self. “My mother is still alive, and I love her dearly,” says the sister of a man diagnosed with ALS two years ago, “but she is very domineering, superficial in her understanding of emotions and insensitive to other people’s needs and wants. She does not allow you to have your own self. It was very difficult to find your own identity with my mother. When I consider my brother’s illness, I think we all did our work to figure out how to become separate individuals. It’s been hard, but we did—except my brother, who somehow didn’t. He said to me last time I was there—I’m fifty-four now, and he’s forty-six—‘I hate Mom.’ And yet, he is the one who is the nicest to my mother of us all. He will go there—he has ALS and can hardly walk—but he will take soup to her. When he is in my mom’s presence he will be a cute little boy—the good little kid he always was, and I was not.”

Hawking’s vocation and the unstinting support of his wife were accompanied by something else that has probably aided his survival: the liberation of his aggression by his illness. The “niceness” of most ALS patients represents more than the innate goodness and sweetness of some human beings; it is an emotion in extremis. It is magnified out of healthy proportion by a powerful suppression of assertiveness. Assertiveness in defence of our boundaries can and should appear aggressive, if need be. Hawking’s intellectual self-assuredness became the ground for that aggression to manifest itself, particularly after the onset of his physical decline. Jane Hawking notes in her memoir that “curiously, as his gait became more unsteady so his opinions became more forceful and defiant.”

It is artificial to impose a separation between hormones and emotions. While it is perfectly true that hormones are active promoters or inhibitors of malignancy, it is not true that their actions have nothing to do with stress. In fact, one of the chief ways that emotions act biologically in cancer causation is through the effect of hormones. Some hormones—estrogen, for example—encourage tumour growth. Others enhance cancer development by reducing the immune system’s capacity to destroy malignant cells. Hormone production is intimately affected by psychological stress. Women have always known that emotional stress affects their ovarian function and their menstrual cycles—excessive stress may even inhibit menstruation. The body’s hormonal system is inextricably linked with the brain centres where emotions are experienced and interpreted. In turn, the hormonal apparatus and the emotional centres are interconnected with the immune system and the nervous system. These are not four separate systems, but one super-system that functions as a unit to protect the body from external invasion and from disturbances to the internal physiological condition. It is impossible for any stressful stimulus, chronic or acute, to act on only one part of the super-system. What happens to one will affect all. In chapter 7 we will examine the workings of this super-system more closely.

“Warmth and affection have nothing to do with achievement: they are there regardless of achievement, just because the parents are emotionally connected with the child. But your answer had to do with accomplishment. I wonder why that is?”

A 1952 psychoanalytic evaluation of women with breast cancer had come to similar conclusions. These patients were said to demonstrate “an inability to discharge or deal appropriately with anger, agressiveness, or hostility (which, in turn, was masked by a facade of pleasantness).” The researchers felt that patients’ unresolved conflicts were “manifested through denial and unrealistic self-sacrificing behaviours.”

Repression of anger increases the risk for cancer for the very practical reason that it magnifies exposure to physiological stress. If people are not able to recognize intrusion, or are unable to assert themselves even when they do see a violation, they are likely to experience repeatedly the damage brought on by stress. Recall, from chapter 3, that stress is a physiological response to a perceived threat, physical or emotional, whether or not the individual is immediately aware of the perception.

Adults with a history of troubled childhoods may not encounter more serious losses than others do, but their ability to cope will have been impaired by their upbringing. Stress does not occur in a vacuum. The same external event will have greatly varied physiological impact, depending on who is experiencing it. The death of a family member will be processed in a markedly different way by someone who is emotionally well integrated and in a supportive relationship than it will be by a person who is alone or—like Anna prior to her therapy—tormented by chronic guilt due to childhood conditioning.

“The nature of stress is not always the usual stuff that people think of. It’s not the external stress of war or money loss or somebody dying, it is actually the internal stress of having to adjust oneself to somebody else. Cancer and ALS and MS and rheumatoid arthritis and all these other conditions, it seems to me, happen to people who have a poor sense of themselves as independent persons. On the emotional level, that is—they can be highly accomplished in the arts or intellectually—but on an emotional level they have a poorly differentiated sense of self. They live in reaction to others without ever really sensing who they themselves are.

I think her precocious intellectual development is what happens to bright and sensitive kids when the emotional environment isn’t able to hold them enough; they develop this very powerful intellect that holds them instead. Hence their intellectual maturity and their ability to relate to adults. People would tell me as a child how mature I was. I always thought I was, because in that mode you can seem highly mature. But then when I look at myself emotionally, I’ve been very immature. I’m fifty-eight now and still trying to grow up.”

The mind has an experience, and we translate it into an image. There is a deeper sense of something that’s happening, but the mind can only experience it in terms of thoughts and images.”

“Why can’t parents see their children’s pain?” “I’ve had to ask myself the same thing. It’s because we haven’t seen our own.

“Nightmares are about our deepest anxieties. A kid is afraid of monsters under the bed. You turn the light on and you show him that there are no monsters, and the next minute he is afraid of the monster again. What is he actually afraid of? He’s afraid of not being protected, about not being connected enough. Maybe there’s something monster-ish in the parent . . . maybe the parent is angry, so the kid is really scared. The kid has all this fear, so his mind will create the image of a monster.”

Biologic and psychological activity are not independent; each represents the functioning of a super-system whose components can no longer be thought of as separate or autonomous mechanisms. The past quarter century of scientific inquiry has supplanted the traditional Western medical view of a split between body and mind with a truer, more unitary perspective. Candace Pert, a leading American researcher, has written that “the conceptual division between the sciences of immunology, endocrinology, and psychology/neuroscience is a historical artifact.”4 Psychoneuroimmunology—or, more comprehensively and accurately, psychoneuroimmunoendocrinology—is the name of the discipline that studies the interrelated functions of the organs and glands that regulate our behaviour and physiological balance.

Disease, in other words, is not a simple result of some external attack but develops in a vulnerable host in whom the internal environment has become disordered.

The stresses that create the problems with self-nurture are also stresses that predispose to ill health.

Eating patterns are directly connected with emotional issues arising both from childhood and from current stresses. The patterns of how we eat or don’t eat, and how much we eat, are strongly related to the levels of stress we experience and to the coping responses we have developed in face of life’s vicissitudes. In turn, dietary habits intimately affect the functioning of the hormones that influence the female reproductive tract. Anorexics, for example, will often stop menstruating.

We need to recall here that the temporary elevation of cortisol that occurs in episodes of acute stress is healthy and necessary. Not healthy are the chronically elevated cortisol levels in chronically stressed persons.

It is customary to conceive of cancer as an invader against whom the body—like a country under foreign attack—must wage war. Such a view, while perhaps comforting in its simplicity, is a distortion of reality. First, even when there is an external carcinogen like tobacco, the cancer itself is partially an outcome of internal processes gone wrong. And, of course, for most cancers there is no such identified carcinogen. Second, it is the internal environment, locally and throughout the entire organism, that plays the major role in deciding whether the malignancy will flourish or be eliminated. The malignant transformation of normal cells, in other words, is a process determined by many factors that have at least as much to do with the biopsychosocial state of the organism as with the type of cancer itself. Once a cancer reaches the stage where its cell surfaces display molecules different from the normal body proteins, it ought to be destroyed by immune responses of many different kinds. T-cells should attack it with noxious chemicals; antibodies should be formed against it; specialized blood cells should chew it up. Under conditions of chronic stress, the immune system may become either too confused to recognize the mutated cell clones that form the cancer or too debilitated to mount an effective attack against them.

The repression of anger is not an abstract emotional trait that mysteriously leads to disease. It is a major risk factor because it increases physiological stress on the organism. It does not act alone but in conjunction with other risk factors that are likely to accompany it, such as hopelessness and lack of social support. The person who does not feel or express “negative” emotion will be isolated even if surrounded by friends, because his real self is not seen. The sense of hopelessness follows from the chronic inability to be true to oneself on the deepest level. And hopelessness leads to helplessness, since nothing one can do is perceived as making any difference.

A holistic approach that places the person at the centre, rather than the blood test or the pathology report, takes into account an individual life history. It encourages people to examine carefully each of the stresses they face, both those in their environment and those generated internally. In this scenario the diagnosis of prostate cancer could serve as a wake-up call rather than simply a threat. In addition to whatever treatment they may choose to receive or not receive, men who are encouraged to respond reflectively, taking into account every aspect of their lives, probably increase their chances of survival.

The child of an unhappy mother will try to take care of her by suppressing his distress so as not to burden her further. His role is to be self-sufficient and not “needy”—recall my reflexive suppression of a limp after minor knee surgery.

For the satisfaction of attachment needs in human beings, more than physical proximity and touching is required. Equally essential is a nourishing emotional connection, in particular the quality of attunement. Attunement, a process in which the parent is “tuned in” to the child’s emotional needs, is a subtle process. It is deeply instinctive but easily subverted when the parent is stressed or distracted emotionally, financially or for any other reason. Attunement may also be absent if the parent never received it in his or her childhood. Strong attachment and love exist in many parent-child relationships but without attunement. Children in non-attuned relationships may feel loved but on a deeper level do not experience themselves as appreciated for who they really are. They learn to present only their “acceptable” side to the parent, repressing emotional responses the parent rejects and learning to reject themselves for even having such responses. Infants whose caregivers were too stressed, for whatever reason, to give them the necessary attunement contact will grow up with a chronic tendency to feel alone with their emotions, to have a sense—rightly or wrongly—that no one can share how they feel, that no one can “understand.” We are speaking here not of a lack of parental love, nor of physical separation between parent and child, but of a void in the child’s perception of being seen, understood, empathized with and “got” on the emotional level. The phenomenon of physical ...

In proximate separations the parents are physically present but emotionally absent. Such parent-child interactions are increasingly the norm in our hyperstressed society. The levels of physiological stress experienced by the child during proximate separation approaches the levels experienced during physical separation. Proximate separation affects the young child on the unconscious physiological levels rather than on the conscious thought-feeling levels. It will not be recalled later as the adult looks back on his childhood experience, but it is entrenched as the biology of loss. Experiences of proximate separation become part of the person’s psychological programming: people “trained” in this way in childhood are likely to choose adult relationships that re-enact repeated proximate separation dynamics. They may, for example, choose partners who do not understand, accept or appreciate them for who they are. Thus the physiological stresses induced by proximal separation will also continue to be repeated in adult life—and, again, often without conscious awareness.