The Myth of Normal: Trauma, Illness and Healing in a Toxic Culture

by Gabor Maté

This Harvard research provided further striking evidence that emotional stresses are inseparable from the physical states of our bodies, in illness and health.

It is exciting to contemplate the preventive and healing potentials, as well as the social implications, of a wellness perspective that treats emotions like the real and relevant “things” they are.

“Now keep your hands up,” I continue, “if these specialists asked you about your childhood stresses or traumas, your relationship with your parents, the quality of your current relationships, your degree of loneliness or companionship, your job satisfaction and how you relate to work, how you feel about your boss or how your boss treats you, your experience of joy or anger, any present stresses, or how you feel about yourself as a person.” In rooms packed with hundreds of people, the number of hands remaining elevated can most often be counted on the fingers of one of them. “And yet,” I add, “those unasked questions had everything to do with why most of you had reason to seek medical help.”

From the cerebral cortex to the brain’s emotional nuclei to the autonomic nervous system, from the solid or fluid aspects of the immune apparatus to the hormonal organs and secretions, from the stress-response system to the viscera … it’s all one.

No matter how sophisticated our minds may be, the fact remains that their basic contents—what we think, believe consciously or unconsciously, feel or are prevented from feeling—powerfully affect our bodies, for better or worse. Conversely, what our bodies experience from conception onward cannot but affect how we think, feel, perceive, and behave. This, in a nutshell, is psychoneuroimmunology’s core lesson.

Stress can show up in two forms: as an immediate reaction to a threat or as a prolonged state induced by external pressures or internal emotional factors. While acute stress is a necessary reaction that helps maintain our physical and mental integrity, chronic stress, ongoing and unrelieved, undermines both.

It doesn’t take a psychoanalyst or a poetry professor to see the image of the “raging” fire as a powerful analogue for the rage and pain Glenda had to bury away in the deepest parts of herself, given her mother’s utter inability to be there for her emotionally.

On closer look, we see that this choreography of psyche and soma involves far more than two “partners” contained within one person: there is also a vital and underappreciated interpersonal component. After all, the mind and body exist inescapably in the context of relationships, social circumstances, history, and culture. If we want a clear and accurate view of human health, we will have to broaden our understanding of “bodymind” to include the myriad roles that other minds and other bodies play in shaping our well-being,

being, indeed our very sense of self. Unity, it turns out, extends well beyond the unitary individual.

“When you look at a leaf or a raindrop, meditate on the conditions, near and distant, that contributed to the presence of that leaf or raindrop. Know that the world is woven of interconnected threads. This is because that is. This is not because that is not. This is born because that is born. This dies because that dies.” The leaf, as the Buddha implied, is both a discrete entity—a thing—and a process that derives from sun, sky, and earth: light, photosynthesis, rain, organic matter, and minerals and perhaps even the activity of humans and animals.

The pioneering U.S. internist and psychiatrist George Engel argued nearly half a century ago that the “crippling flaw” of modern medicine “is that it does not include the patient and his attributes as a person. Yet in the everyday work of the physician the prime object of study is a person.” We must make provision for the whole person in their full “psychological and social nature,”1 he said, calling for a biopsychosocial approach: one that recognizes the unity of emotions and physiology, knowing both to be dynamic processes unfolding in a context of relationships, from the personal to the cultural.

biopsychosocial approach: one that recognizes the unity of emotions and physiology, knowing both to be dynamic processes unfolding in a context of relationships, from the personal to the cultural.2

Although modern medicine’s focus on the individual organism and its internal processes isn’t wrong as such, it misses something vital: the pivotal influence of the mental, emotional, social, and natural environments in which we live. Our biology itself is interpersonal.

“When I was in medical school,” he writes, “many of the fine teachers we had approached their patients, and their students, as if they had no center of inner experience—no subjective internal core we might call our mental life. It was as if we were just bags of chemicals and bodily organs without a self, without a mind.”

Again, it’s all one: emotions affect nerves and vice versa; nerves act on hormones; hormones on the immune system; the immune system on the brain; the brain on the gut; the gut on the brain; and all of these act on the heart, and vice versa. In turn, our bodies influence our brains and minds and, necessarily, the brains, minds, and bodies of others.

Interpersonal biology also accounts for why loneliness can kill, especially in older people separated from pleasures, social connections, or support. A vast review of multiple studies encompassing more than three hundred thousand participants concluded that the lethal effect of deficient interpersonal relationships is comparable to such risk factors as smoking and alcohol, and even exceeds the dangers posed by physical inactivity and obesity.

For letters or words to become language, they must be arranged, enunciated, inflected, punctuated with pauses, EMPHASIZED or softened.

She was unrecognizable to herself—and wholly incongruous with the person one encounters now, her smile quick and responsive.

Such hyperfunctioning on top of hidden inner distress is a recurring theme among the many autoimmune patients I’ve encountered in my years of practice and teaching.

What we call the personality traits, in addition to reflecting genuine inborn temperaments and qualities, also express the ways that people, as children, had to accommodate their emotional environment. They reflect much that is neither inherent nor immutable about a person, no matter how closely identified he or she is with them. Nor are they character faults; though they may cause us difficulty now, they began as modes of survival.

There is wisdom in that view, but I also hear an unwarranted self-accusation and an all-too-characteristic lack of self-compassion. No person is their disease, and no one did it to themselves—not in any conscious, deliberate, or culpable sense. Disease is an outcome of generations of suffering, of social conditions, of cultural conditioning, of childhood trauma, of physiology bearing the brunt of people’s stresses and emotional histories, all interacting with the physical and psychological environment.

She hated me for how much he adored me.” Toxic self-blame is one of the torments imposed on the traumatized child.

Was it not enough boundaries? Was it too many walls?”

“But I think that if there were one underlying reason why I got sick, it was unreckoned—I hadn’t gone deep enough in processing my trauma.”

What if, rather than being cast out and defined by some terminal category, you were identified as someone in the middle of a transformation that could deepen your soul, open your heart?”

“What happens in the body is a matter of flow—there is input and there is output,” she said, “and you can’t control every aspect of it. We need to understand that flow, know there are things you can influence and things you can’t. It’s not a battle, it’s a push-pull phenomenon of finding balance and harmony, of kneading the conflicting forces into one dough.”

Here is my life, and over there is the disease that has encroached upon it. Seen this way, disease is something external with its own nature, existing independently of the person in whom it shows up. Given where that perspective has gotten us, it is time to consider a new one. We have already glimpsed the countless hormonal, neurological, molecular, immunologic, intracellular, and epigenetic pathways that make our physiology inseparable from our emotional, psychological, spiritual, and social lives.

Rather than treating disease as a solid entity that imposes its ill will on the body, we would be dealing with a process, one that can’t be extricated from our personal histories and the context and culture in which we live.

After all, if disease is a manifestation of something in our lives rather than merely their cruel disruptor, we have options: we can pursue new understandings, ask new questions, perhaps make new choices. We can take our rightful place as active participants in the process, rather than remain its victims, helpless but for our reliance on medical miracle workers.

Our emotional dynamics, including our relationship to ourselves, can be among the powerful determinants of that future. An attitude of helplessness and hopelessness at the time of diagnosis, for example, has been shown to exert a marked adverse effect on survival in women with breast cancer even ten years later.

“I got sick,” the author writes with a pained humor, “the way Hemingway says you go broke: ‘gradually and then suddenly.’

He explored cancer as process: not a disease of individual cells gone rogue but as a manifestation of an imbalanced environment, “merely the terminal [event] in a much longer progressive chain of circumstances with no distinctive starting-point.”

Her key insight was to recognize her entire life as the ground for her several illnesses, physical and mental; not separate entities but dynamic processes expressing her interactions with her world.

“it is not the delicate, neurotic person who is prone to angina [a cardinal symptom of coronary artery disease], but the robust, the vigorous in mind and body, the keen and ambitious man … whose engine is always at full speed ahead.”

This cannot help affecting the body: after all, if you go through life being stressed while not knowing you are stressed, there is little you can do to protect yourself from the long-term physiological consequences. Accordingly, the scientists concluded that repressiveness ought to be seen “as a mind-body, rather than as just a mental, construct.”

“the conscious inhibition of one’s own emotional expressive behavior while emotionally aroused.”

Note that the qualities on the latter list, while perhaps superficially resembling those of the first, do not imply or require that a person overstep, ignore, or suppress who they are and what they feel and need.

A healthy ego—not in the sense of superiority, but as in a stable identity, the ground of self-respect, self-regulation, capacity for good decision making, a working memory, and more—is a vital asset of a thriving human being.

Our other core need is authenticity. Definitions vary, but here’s one that I think applies best to this discussion: the quality of being true to oneself, and the capacity to shape one’s own life from a deep knowledge of that self.

the quality of being true to oneself, and the capacity to shape one’s own life from a deep knowledge of that self.

At its most concrete and pragmatic, it means simply this: knowing our gut feelings when they arise and honoring them.

The elemental root of “authenticity” is the Greek autos, or “self,” closely related to “author” and “authority.” To be authentic is to be true to a sense of self arising from one’s own unique and genuine essence, to be plugged into this inner GPS and to navigate from it. A healthy sense of self does not preclude caring for others, or being affected or influenced by them. It is not rigid but expansive and inclusive. Authenticity’s only dictate is that we, not externally imposed expectations, be the true author of and authority on our own life.

What happens if our needs for attachment are imperiled by our authenticity, our connection to what we truly feel?

Thus our real selves are leveraged bit by bit in a tragic transaction where we secure our physical or emotional survival by relinquishing who we are and how we feel. The fact that we don’t consciously choose such coping mechanisms makes them all the more tenacious. We cannot will them away when they no longer serve us precisely because we have no memory of them not being there, no notion of ourselves without them.

As these patterns get wired into our nervous system, the perceived need to be what the world demands becomes entangled with our sense of who we are and how to seek love.

After all, most adaptations are meant for specific situations, not as eternally applicable responses in every possible case.

The internal adaptations we make to our own personalities in order to survive adversity early in life carry the same risks as conditions shift, but we are far less wise to the danger. No matter how the weather changes, the protective gear, welded as it is onto the personality, never comes off. It is sobering to realize that many of the personality traits we have come to believe are us, and perhaps even take pride in, actually bear the scars of where we lost connection to ourselves, way back when. The sources of these scars are most often evident in their shape, so to speak: in many cases, specific traits can be traced to particular kinds of wounding.

In fact, the analogy is entirely appropriate physiologically, since among the brain chemicals released when we have moments of feeling loved or valued or accepted are our own internal opiates, or endorphins.

For most of us it may require a crisis of some kind before we question the veracity and solidity of the self-concept we act from, before it even occurs to us that it might conceal something truer about us.

Strikingly, in her private musings Susan Sontag unwittingly pinpointed the emotional dynamics for which her cancer stood as a perfect metaphor. “I’m being wasted by self-pity and self-contempt,” she wrote in her journal.