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

by Gabor Maté

Another way of saying it: chronic illness—mental or physical—is to a large extent a function or feature of the way things are and not a glitch; a consequence of how we live, not a mysterious aberration.

We can certainly fold these two meanings into our discussion, but I am using “toxic culture” to characterize something even broader and more deeply rooted: the entire context of social structures, belief systems, assumptions, and values that surround us and necessarily pervade every aspect of our lives.

It is my contention that by its very nature our social and economic culture generates chronic stressors that undermine well-being in the most serious of ways, as they have done with increasing force over the past several decades.

He could have been articulating this book’s thesis. Indeed, the lives, and the deaths, of individual human beings—their quality and in many cases their duration—are intimately bound up with the aspects of modern society that are “hardest to see and talk about”; phenomena that are, like water to fish, both too vast and too near to be appreciated. In other words, those features of daily life that appear to us now as normal are the ones crying out the loudest for our scrutiny. That is my central contention.

My core intention, accordingly, is to offer a new way of seeing and talking about these phenomena, bringing them from the background to the foreground so we might more swiftly find their much-needed remedies.

will make the case that much of what passes for normal in our society is neither healthy nor natural, and that to meet modern society’s criteria for normality is, in many ways, to conform to requirements that are profoundly abnormal in regard to our Nature-given needs—which is to say, un...

If we could begin to see much illness itself not as a cruel twist of fate or some nefarious mystery but rather as an expected and therefore normal consequence of abnormal, unnatural circumstances, it would have revolutionary...

The ailing bodies and minds among us would no longer be regarded as expressions of individual pathology but as living alarms directing our attention toward where our society has gone askew, and where our prevailing certainties and assumptions around health are, in fact, fictions. Seen clearly, they might also gi...

health and illness are not random states in a particular body or body part. They are, in fact, an expression of an entire life lived, one that cannot, in turn, be understood in isolation: it is influenced by—or better yet, it arises from—a web of circumstances, relationships, events, and experiences.

In fact, it is so deeply “underlying” that many of us don’t know it’s there. The meaning of the word “trauma,” in its Greek origin, is “wound.” Whether we realize it or not, it is our woundedness, or how we cope with it, that dictates much of our behavior, shapes our social habits, and informs our ways of thinking about the world.

It was in 1889 that the pioneering French psychologist Pierre Janet first depicted traumatic memory as being held in “automatic actions and reactions, sensations and attitudes . . . replayed and reenacted in visceral sensations.”[1] In the present century, the leading trauma psychologist and healer Peter Levine has written that certain shocks to the organism “can alter a person’s biological, psychological, and social equilibrium to such a degree that the memory of one particular event comes to taint, and dominate, all other experiences, spoiling an appreciation of the present moment.”[2] Levine calls this “the tyranny of the past.”

After twenty-four hours of the silent treatment, Rae had had enough. “Oh, knock it off already,” she said. And so I did—a measure of progress and relative maturation on my part. In times past, it would have taken me days or longer to “knock it off”: to drop my resentment, and for my core to unfreeze, my face to relax, my voice to soften, and my head to turn willingly and with love toward my life partner. “My problem is that I am married to someone who understands me,” I have often grumbled, only partly in jest. Really, of course, my great blessing is to be married to someone with healthy boundaries, who sees me as I am now and who will no longer bear the brunt of my prolonged and unplanned visits to the distant past.

The usual conception of trauma conjures up notions of catastrophic events: hurricanes, abuse, egregious neglect, and war. This has the unintended and misleading effect of relegating trauma to the realm of the abnormal, the unusual, the exceptional. If there exists a class of people we call “traumatized,” that must mean that most of us are not. Here we miss the mark by a wide margin. Trauma pervades our culture, from personal functioning through social relationships, parenting, education, popular culture, economics, and politics. In fact, someone without the marks of trauma would be an outlier in our society. We are closer to the truth when we ask: Where do we each fit on the broad and surprisingly inclusive trauma spectrum?

When a wound doesn’t mend on its own, one of two things will happen: it can either remain raw or, more commonly, be replaced by a thick layer of scar tissue. As an open sore, it is an ongoing source of pain and a place where we can be hurt over and over again by even the slightest stimulus. It compels us to be ever vigilant—always nursing our wounds, as it were—and leaves us limited in our capacity to move flexibly and act confidently lest we be harmed again. The scar is preferable, providing protection and holding tissues together, but it has its drawbacks: it is tight, hard, inflexible, unable to grow, a zone of numbness. The original healthy, alive flesh is not regenerated.

maintained. What the two types share is succinctly summarized by Bessel van der Kolk: “Trauma is when we are not seen and known.” Although

An event is traumatizing, or retraumatizing, only if it renders one diminished, which is to say psychically (or physically) more limited than before in a way that persists.

What causes such a disconnect? In my case, the answer requires no speculation. As an infant in wartime Hungary, I endured chronic hunger and dysentery, states of acute discomfort threatening and distressing to adults, let alone to a one-year-old. I also absorbed the terrors and unrelenting emotional distress of my mother. In the absence of relief, a young person’s natural response—their only response, really—is to repress and disconnect from the feeling-states associated with suffering. One no longer knows one’s body. Oddly, this self-estrangement can show up later in life in the form of an apparent strength, such as my ability to perform at a high level when hungry or stressed or fatigued, pushing on without awareness of my need for pause, nutrition, or rest. Alternatively,

This suppression would seem to be akin to the freeze response that creatures often display when fight and flight are both impossible. The crucial difference is this: once the hawk is gone, the possum is free to go about his business, his survival strategy having succeeded. A traumatized nervous system, on the other hand, never gets to unfreeze.

I would have thus exhibited what is called response flexibility: the ability to choose how we address life’s inevitable ups and downs, its disappointments, triumphs, and challenges. “Human freedom involves our capacity to pause between stimulus and response and, in that pause, to choose the one response toward which we wish to throw our weight,” wrote the psychologist Rollo May.[12] Trauma robs us of that freedom.

Here’s what the Buddha left out, if I may be so bold: before the mind can create the world, the world creates our minds. Trauma, especially severe trauma, imposes a worldview tinged with pain, fear, and suspicion: a lens that both distorts and determines our view of how things are. Or it may, through the sheer force of denial, engender a naively rosy perspective that blinds us to real and present dangers—a veneer concealing fears we dare not acknowledge. One may also come to dismiss painful realities by habitually lying to oneself and others.

Work pressures, multitasking, social media, news updates, multiplicities of entertainment sources—these all induce us to become lost in thoughts, frantic activities, gadgets, meaningless conversations. We are caught up in pursuits of all kinds that draw us on not because they are necessary or inspiring or uplifting, or because they enrich or add meaning to our lives, but simply because they obliterate the present. In an absurd twist, we save up to buy the latest “time-saving” devices, the better to “kill” time. Awareness of the moment has become something to fear. Late-stage capitalism is expert in catering to this sense of present-moment dread—in fact, much of its success depends on the chasm between us and the present, our greatest gift, getting ever wider, the false products and artificial distractions of consumer culture designed to fill in the gap.

What is lost is well described by the Polish-born writer[*] Eva Hoffman as “nothing more or less than the experience of experience itself. And what is that? Perhaps something like the capacity to enter into the textures or sensations of the moment; to relax enough so as to give oneself over to the rhythms of an episode or a personal encounter, to follow the thread of feeling or thought without knowing where it leads, or to pause long enough for reflection or contemplation.”[16] Ultimately, what we are distracted from is living.

Note, too, the absence of self-judgment in Jessica’s description of the situation: she speaks of “understanding” rather than castigating herself for what she didn’t—nay, couldn’t—understand way back when. The act of blaming herself, its gravitational center planted permanently in the past, would only divert her from showing up for her loved one in the here and now.

“It’s those adversities that open up your mind and your curiosity to see if there are new ways of doing things,” Bessel van der Kolk told me. He then cited Socrates: “An unexamined life is not worth living. As long as one doesn’t examine oneself, one is completely subject to whatever one is wired to do, but once you become aware that you have choices, you can exercise those choices.” Notice that he didn’t say “once you spend decades in therapy.”

There is nothing novel about the notion of the mind and body being intricately linked; if anything, what is new is the belief, tacitly held and overtly enacted by many well-meaning doctors, that they are separable.

A 1982 German study presented at the fourth international Symposium on the Prevention and Detection of Cancer in London found certain personality traits to have a strong association with breast cancer. Fifty-six women admitted to hospital for biopsy were evaluated for characteristics such as emotional suppression, rationalization, altruistic behavior, the avoidance of conflict, and the superautonomous self-sufficiency we saw embodied by Caroline. Based on the interview results alone, both the interviewers and “blind” raters who had no direct contact with the women were able to predict the correct diagnosis in up to 94 percent of all cancer patients, and in about 70 percent of the benign cases.[2] In a previous British study at King’s College Hospital in London, it had also been shown that women with cancerous breast lumps characteristically exhibited “extreme suppression of anger and of other feelings” in “a significantly higher proportion” than the control group, which was made up of women admitted for biopsy at the same time but found to have benign breast tumors.[3]

At Harvard Medical School, Weiss’s memory is kept alive by a yearly research day in his honor, yet his integrative perspective, and the extensive scientific literature now supporting it, still elude conventional medical thinking. “The mind-body stuff is historically something that one pursues at great peril to their career at Harvard,” a leading physician and academic at that hallowed institution told me recently. “That’s starting to change, but it’s a very difficult thing.”[14]

A (relatively) new science, psychoneuroimmunology maps the myriad pathways of the bodymind unity; its field of study includes the connections between emotions and our nervous and immune systems, and how stress might instigate disease. Even “connection” is a misleading word: only entities distinct from each other can be connected, whereas reality knows only oneness.

Sometimes referred to even more tongue-twistingly as psychoneuroimmunoendocrinology, this new discipline is predicated on the unity between all our constituent parts: mind, brain, nervous and immune systems, and the hormonal apparatus (that’s the “endocrine” part). The pieces can be studied separately, but we cannot fully understand any of them without grasping the whole picture. 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.

We cannot do without it, and so our bodies will go to great lengths to maintain it—even to the point of long-term wear and tear if stresses do not abate. Such strain on our body’s regulatory mechanisms, which McEwen dubs “allostatic load,” leads to an excessive and prolonged release of the stress hormones adrenaline and cortisol, nervous tension, immune dysfunction, and, in many cases, exhaustion of the stress apparatus itself. We now know that the infrastructure

Single people showed an elevated risk for heart disease and cancer, for infectious diseases such as pneumonia and influenza, and for such life-habit-related conditions as cirrhosis of the liver and lung disease. Tellingly, the degree of protection offered by married status was five times as great for men as for women, a finding that speaks to the relative roles of the genders in this culture, with profound implications for health—a topic I will circle back to in chapter 23. Interestingly, “unhappily married persons are worse off in well-being than unmarried persons.”[7]

Given their vulnerability and dependence, children’s physiology is especially susceptible to the emotional states of their caregivers. Young kids’ stress hormone levels, for example, are heavily influenced by the emotional atmosphere in the home, whether outright conflict or bristling tension.[9] Asthma is a well-studied example: the inflammation of the child’s lungs is directly affected by the mother’s or father’s emotions.[10] In the words of a recent review: “It has been consistently shown that parents in an unfavorable mental health state such as ‘depression,’ ‘anxiety,’ ‘stress,’ or ‘chronic irritation’ may predict a poorer status for the child’s asthma.”[11]

The recently deceased Buddhist monk and renowned spiritual leader Thich Nhat Hanh long taught the concept of “interbeing.” It’s not merely that we are, he said: we “inter-are.” “There are no separate entities,” he wrote, “only manifestations that rely on each other to be possible.”[17] Again, we would be quite mistaken to relegate these observations to the realm of mystical belief. A scientist lacking a spiritual bone in his body, yet conversant with the growing body of evidence, would nod in agreement: “Yup, that about covers it.”

Two decades later, we know that little of the sort has happened.[1] And for good reason: genes are not, in fact, life’s language, any more than a scrambled alphabet or a randomly arranged dictionary is a Shakespeare play, or a musical scale is equivalent to a John Coltrane solo. For letters or words to become language, they must be arranged, enunciated, inflected, punctuated with pauses, EMPHASIZED or softened. Like all building blocks, genes help make up the language of existence, but it is through the workings of epigenetics that they are activated, accented, or quieted. The mechanisms of epigenetics include, among myriad others, adding certain molecules to DNA sequences so as to change gene function, modifying the numbers of receptors for certain messenger chemicals, and influencing the interactions between genes.[*]

It isn’t that genes don’t matter—they certainly do—only that they cannot dictate even the simplest behaviors, let alone account for most illnesses or address possible cures for them. Far from being the autonomous arbiters of our destinies, genes answer to their environment; without environmental signals, they could not function. In fact, life for us would be impossible if not for the epigenetic mechanisms that “turn” genes “on” or “off” in response to signals from within and from outside the body.[*]

alone in transmitting chronic disturbances of the body’s stress apparatus to their young. In one experiment, healthy male mice were vexed by a series of stressors: frequent cage changes, constant light or white noise, exposure to fox odor, being restrained in a small tube, and so on. They were then mated with non-stressed females who provided their pups with perfectly good mothering. Their young showed impaired stress-response behaviors and blunted stress hormone patterns. In other words, despite the mothers’ best efforts, the fathers had transmitted the disturbing effects through their sperm.[7] In humans, paternal stress early in a child’s life can also have long-term effects, into adolescence at the least.

If even doctors who stray beyond medical orthodoxy can feel intimidated and misunderstood, what do patients experience? Another lamentable feature of Western medical practice—not universal, but all too often seen—is a power hierarchy that casts physicians as the exalted experts and patients as the passive recipients of care.

Upon the emotional graveyard of what she could not afford to feel, Mee Ok erected an impressive edifice: a positive, can-do persona that not only kept her from experiencing her despair and impelled her to ignore her own needs, but also helped her achieve success beyond what she really believed was her due. In her job as assistant to the world-renowned professor, the grown-up Mee Ok found her work stressful and would habitually bear the tensions and pressures of everyone around her. “I was really not myself while I was there,” she said. “I was always having to operate as a more highly functioning person than I really was.” 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.

To restate a question essential to our theme: What if we saw illness as an imbalance in the entire organism, not just as a manifestation of molecules, cells, or organs invaded or denatured by pathology? What if we applied the findings of Western research and medical science in a systems framework, seeking all the connections and conditions that contribute to illness and health? Such a reframing would revolutionize how we practice medicine. 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. This change in approach has much to recommend it, and not only because it takes interpersonal biology into account. When we cease to view illness as a concrete, autonomous thing with a predetermined trajectory—and when we have the proper help and a willingness to look both within and without—we can start to exercise agency in the matter.

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.

The more we understand about disease, the less clear it becomes when you have it and when you don’t.” Within the myth of normal, of course, this kind of nuance is barely comprehensible: you’re either “sick” or you’re “well,” and it should be obvious which camp you’re in. But really, there are no clear dividing lines between illness and health. Nobody all of a sudden “gets” an autoimmune disease, or “gets” cancer—though it may, perhaps, make itself known suddenly and with tremendous impact.

It’s better to think of it as a multistep causation . . . One of the things many diseases have in common is inflammation, acting as kind of a fertilizer for the development of illness. We’ve discovered that when people feel threatened, insecure—especially over an extended period of time—our bodies are programmed to turn on inflammatory genes.”

I agree wholeheartedly that no one, ever, ought to be made to feel guilty for whatever transpires with or within their body, whether that guilt arises from the self or is imposed from without. As I stated earlier, blame is inappropriate, unmerited, and cruel; it is also unscientific. But we have to take care not to fall into an easy fallacy. Asserting that features of the personality contribute to the onset of illness, and more generally perceiving connections between traits, emotions, developmental histories, and disease is not to lay blame. It is to understand the bigger picture for the purposes of prevention and healing—and ultimately for the sake of self-acceptance and self-forgiveness.

Three groups of participants were assessed in this way: people with melanoma, people with heart disease, and a healthy control group. Among the melanoma group there was a consistently large gap between what they reported—that is, to what degree they consciously felt upset by these scornful and disparaging messages—and the level of bodily stress their skin reactions betrayed. In other words, they had pushed their emotions below conscious awareness. 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.”[8]

I have found them not only present but prominent among people with all manner of chronic illnesses, from cancer to autoimmune disease to persistent skin conditions, through a gamut of maladies including migraine headaches, fibromyalgia, endometriosis, myalgic encephalomyelitis (ME), also known as chronic fatigue syndrome, and many others. In no particular order, these traits are an automatic and compulsive concern for the emotional needs of others, while ignoring one’s own; rigid identification with social role, duty, and responsibility (which is closely related to the next point); overdriven, externally focused multitasking hyper-responsibility, based on the conviction that one must justify one’s existence by doing and giving; repression of healthy, self-protective aggression and anger; and harboring and compulsively acting out two beliefs: “I am responsible for how other people feel” and “I must never disappoint anyone.” These characteristics have nothing to do with will or conscious choice. No one wakes up in the morning and decides, “Today I’ll put the needs of the whole world foremost, disregarding my own,” or “I can’t wait to stuff down my anger and frustration and put on a happy face instead.” Nor is anyone born with such traits: if you’ve ever met a newborn infant, you know they have zero compunction about expressing their feelings, nor do they think twice before crying lest they inconvenience someone else. The reasons these habits of personality, as we might call ...

Another column memorializes a woman who, despite her metastatic cancer, “did not give up any of her roles,” including “several hockey practices, school board, orchestra and other extracurricular activities,” and even took on new ones—all directed toward helping others—as the disease spread throughout her body. I am all for enthusiastic engagement with one’s community. But there is such a thing as a lust for life, and then there is being driven to derive one’s sense of self from constant activity, even to the point of not being able to pause for self-care when disaster strikes.

As a final example, we have a widower remembering his wife (dead of breast cancer at age fifty-five) in these terms: “In her entire life she never got into a fight with anyone . . . She had no ego, she just blended in with the environment in an unassuming manner.” The phrase “no ego” should give us pause. Intended to lovingly convey an admirable lack of arrogance or conceit, those two little words reveal, to me, a deeper story. 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. Unbeknownst to the grieving spouse, what he was describing was the same lifelong repression of one’s feelings—particularly healthy anger—which undermines the immune system and poses a risk for malignancy and other illness.

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. What may not be apparent is that authenticity is not some abstract aspiration, no mere luxury for New Agers dabbling in self-improvement. Like attachment, it is a drive rooted in survival instincts. 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.

“Guilt is awful,” Sontag said, poignantly—and yes, it is. But there is no culpability where there is no choice. No conceivable condition exists under which a human being has less agency or fewer options than in infancy and early childhood. The imperative to survive overrides everything, and that survival depends on the maintenance of attachment, at whatever cost to authenticity. This is why so many childhoods, particularly in a culture that both breeds stress and feeds on it, are marked by a tense standoff between the two, where the outcome is predictable and the consequences are lifelong.