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

by Gabor Maté

I have come to believe that behind the entire epidemic of chronic afflictions, mental and physical, that beset our current moment, something is amiss in our culture itself, generating both the rash of ailments we are suffering and, crucially, the ideological blind spots that keep us from seeing our predicament clearly,

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. The phrase “a toxic culture” in this book’s subtitle may suggest things like environmental pollutants, so prevalent since the dawn of the industrial age and so antagonistic to human health.

also understand “toxic” in its more contemporary, pop-psychological sense, as in the spread of negativity, distrust, hostility, and polarization that, no question, typify the present sociopolitical moment.

In the United States, the richest country in history and the epicenter of the globalized economic system, 60 percent of adults have a chronic disorder such as high blood pressure or diabetes, and over 40 percent have two or more such conditions.[4]

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 may seem counterintuitive, but this reflexive rejection of the loving mother is an adaptation: “I was so hurt when you abandoned me,” says the young child’s mind, “that I will not reconnect with you. I don’t dare open myself to that pain again.”

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?

To sum up, then, capital-T trauma occurs when things happen to vulnerable people that should not have happened, as, for example, a child being abused, or violence in the family, or a rancorous divorce, or the loss of a parent. All these are among the criteria for childhood affliction in the well-known adverse childhood experiences (ACE) studies. Once again, the traumatic events themselves are not identical to the trauma—the injury to self—that occurs in their immediate wake within the person. There is another form of trauma—and this is the kind I am calling nearly universal in our culture—that has sometimes been termed “small-t trauma.” I have often witnessed what long-lasting marks seemingly ordinary events—what a seminal researcher poignantly called the “less memorable but hurtful and far more prevalent misfortunes of childhood”—can leave on the psyches of children.[7] These might include bullying by peers, the casual but repeated harsh comments of a well-meaning parent, or even just a lack of sufficient emotional connection with the nurturing adults.

If, despite decades of evidence, “big-T trauma” has barely registered on the medical radar screen, small-t trauma does not even cause a blip.

Although there are dramatic differences in the way the two forms of trauma can affect people’s lives and functioning—the big-T variety, in general, being far more distressing and disabling—there is also much overlap. They both represent a fracturing of the self and of one’s relationship to the world. That fracturing is the essence of trauma. As Peter Levine writes, trauma “is about a loss of connection—to ourselves, our families, and the world around us. This loss is hard to recognize, because it happens slowly, over time. We adapt to these subtle changes; sometimes without noticing them.”[9] As the lost connection gets internalized, it forges our view of reality: we come to believe in the world we see through its cracked lens. It is sobering to realize that who we take ourselves to be and the ways we habitually act, including many of our seeming “strengths”—the least and the most functional aspects of our “normal” selves—are often, in part, the wages of traumatic loss.

Peter Levine aptly points out, “Certainly, all traumatic events are stressful, but not all stressful events are traumatic.”[10]

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.

Blame becomes a meaningless concept the moment one understands how suffering in a family system or even in a community extends back through the generations. “Recognition of this quickly dispels any disposition to see the parent as villain,” wrote John Bowlby, the British psychiatrist who showed the decisive importance of adult-child relationships in shaping the psyche. No matter how far back we look in the chain of consequence—great-grandparents, pre-modern ancestors, Adam and Eve, the first single-celled amoeba—the accusing finger can find no fixed target. That should come as a relief.

Unless we can measure something, science won’t concede it exists, which is why science refuses to deal with such “nonthings” as the emotions, the mind, the soul, or the spirit. —Candace Pert, Ph.D., Molecules of Emotion

“My way was always being the caretaker, being needed, always coming to somebody’s rescue, a lot of the time to my own detriment,” she told me. “I never wanted to have conflict with anyone. And I always had to be in charge, making sure everything was okay.” Caroline had exhibited what has been called “superautonomous self-sufficiency,”[*] which means exactly what it sounds like: an exaggerated and outsize aversion to asking anything of anyone. A quick note: Nobody is born with such traits. They invariably stem from coping reactions to developmental trauma, beginning with self-abnegation in early childhood. Such suppression takes a lasting toll, a process we’ll explore more fully in chapter 7.

Grief, too, has a powerful physiological dimension. An illuminating study from the British journal Lancet Oncology described the impact of psychological factors on the intricate pathways linking the immune system, the hormones, and the nervous system in, for example, bereavement. Among parents who lost an adult son to an accident or military conflict, the authors reported increased occurrence of lymphatic and hematological malignancy—cancers of the blood, bone marrow, and lymph nodes—along with skin and lung cancer.[8] War kills, and so, it seems, can deep emotional loss. As for cancer, so with other illnesses. In a Danish nationwide study, grieving parents had double the risk of multiple sclerosis.

One 2019 study alone in Cancer Research should set every clinician on a fast-track exploration of bodymind medicine. Women with severe post-traumatic stress disorder (PTSD) were found to have twice the risk of ovarian cancer as women with no known trauma exposure.[10] The Daily Gazette, published by Harvard University, where the study was done, reported, “The findings indicate that having higher levels of PTSD symptoms, such as being easily startled by ordinary noises or avoiding reminders of the traumatic experience, can be associated with increased risks of ovarian cancer even decades after women experience a traumatic event.” The more severe the trauma symptoms, the more aggressive the cancer proved to be.

One fascinating example is the demonstrated link between the brain’s fear center, the amygdala, and cardiovascular disease. The more stress someone perceives or experiences, the higher the resting activity of the amygdala and the greater the risk of heart ailments. The pathway from amygdala overactivation to heart problems runs through increased bone-marrow activity and arterial inflammation.[15] Emotional stress affects the heart more generally as well. In 2012, a study from Harvard Medical School showed that women with high job strain are 67 percent more likely to experience a heart attack than women in less stressful jobs.

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. Situational anger, for example, is an instance of acute stress being marshaled for a positive purpose—think self-defense or setting interpersonal boundaries. It makes us more alert of mind, quicker, and stronger of limb. Chronic rage, by contrast, floods the system with stress hormones long past the allotted time. Over the long term, such a hormonal surplus, whatever may have instigated it, can make us anxious or depressed; suppress immunity; promote inflammation; narrow blood vessels, promoting vascular disease throughout the body; encourage cancer growth; thin the bones; make us resistant to our own insulin, inducing diabetes; contribute to abdominal obesity, elevating the risk of cardiovascular and metabolic problems; impair essential cognitive and emotional circuits in the brain; and elevate blood pressure and increase blood clotting, raising the risk of heart attacks or strokes.

Yet for all their dazzling physiological and technical expertise, doctors by and large are not initiated by their training into the ancient wisdom and new science of the bodymind unity. Medical professionals often do little to encourage—and may even resist—people trusting their own hunches, which tend to synthesize signals from both mind and body.

“All my relations.” I have often heard this greeting when visiting Native communities in Canada. These are the places where my country, to its shame, sees the highest levels of physical and mental illness, addictions, and early death—a tragic situation analogous with that of similarly colonized aboriginal populations in the United States and Australia. The phrase, as I understand it, refers to the individual’s multidimensional bond with the entire world, including people—from close relatives to strangers, from the living to ancestors who lived long before—and also the rocks, the plants, the earth, the sky, and all creatures. Ancient cultures have long understood that we exist in relationship to all, are affected by all, and affect all.

Married people have lower rates of mortality than their age-matched single contemporaries, whether the latter were separated, divorced, widowed, or had never married.[6] 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.”

“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] Racism is another risk factor for asthma.

In a British study, unemployed people had higher markers of inflammation in their bodies, and hence were at higher risk for illness; the longer the unemployment, the greater the risk. The most severe inflammation levels were recorded in Scotland, the part of the U.K. where unemployment was most endemic and chronic.

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.

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.[*]

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.

Another study observed higher rates of inflammation in African Americans than in Caucasians, an epigenetic effect that remained even when comparing those of the same socioeconomic level.[10] “We found that experiences with racism and discrimination accounted for more than 50% of the black/white difference in the activity of genes that increase inflammation,” wrote the lead author, Dr. April Thames, in an article titled “Racism Shortens Lives and Hurts Health of Blacks by Promoting Genes That Lead to Inflammation and Illness.”[11]

“For a century we’ve been obsessed with chemical changes, thinking anything that is chemical is true and anything that is not chemical is not true. What epigenetics taught us is that social changes are really not different than chemical changes.” The one is manifested in the other.

Virtually all autoimmune diseases are characterized by inflammation of the afflicted tissues, organs, and body parts—which explains why frontline medical measures often begin with anti-inflammatory drugs. When nonsteroidal anti-inflammatories like ibuprofen or heavier artillery such as steroids themselves prove inadequate, physicians may prescribe medications to suppress the body’s immune activity.

The first mystery is why they are becoming more frequent. Across many Western countries, rates of everything from celiac disease to IBD, from lupus to type 1 diabetes, and even allergies, are steadily rising, stymieing researchers.[2] “In the last half-century, the prevalence of autoimmune disease . . . has increased sharply in the developed world,” a 2016 New York Times article noted. “An estimated one in 13 Americans has one of these often debilitating, generally lifelong conditions.”[3] In the U.K., the diagnosis of Crohn’s disease increased more than threefold between 1994 and 2014,[4] while in Canada the rate of IBD in children grew by over 7 percent a year between 1999 and 2010, giving my country among the highest rates of this disease in the world.[5]

About 70 to 80 percent of sufferers are women, among whom such conditions are a leading cause of disability and death. Rheumatoid arthritis, for example, is three times more likely to strike women than men; lupus affects women by a disproportionate factor of nine.

“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.

A recent American study found that emotional and physical abuse in childhood more than doubles the risk of systemic lupus erythematosus, with inflammation being one of the likely pathways.

Blood tests found one of the indicators of rheumatoid arthritis highly elevated, clinching the diagnosis. Her emotional profile aligned with the hyper-responsible, anger-suppressing personae described in the literature, traits she developed in a family of origin with an alcoholic father and an emotionally dependent mother to whom she could not divulge her sexual abuse at the hands of a family friend who also victimized the younger sister Julia tried to protect.

Charcot’s pioneering formulation. “A majority of the MS patients had grown up against an unhappy family background,” found a 1958 study at two Montreal hospitals. “Marital discord, broken homes, alcoholism, and lack of parental love and affection were given as reasons for unhappiness.”

The evidence just keeps coming. MS patients experiencing significant life stresses were seen to have a nearly quadrupled incidence of disease flare-ups.[21]

Toxic self-blame is one of the torments imposed on the traumatized child.

“A disease is not like a thing. It is energy flow, it’s a current; it is evolution or devolution that occurs when you’re not awake and connected, and trauma is essentially ruling your life. I think it’s such a mistake to identify it as a thing, because that makes it hard matter when it’s in fact a much more psychological, spiritual, emotional condition.”

In a five-decades-long British study that followed nearly ten thousand people from birth until the age of fifty, it was found that early-life adversity—abuse, socioeconomic disadvantage, family strife, for example—greatly increased the risk of cancer before the mid-century mark. Women who experienced two or more such adversities had a doubled risk by midlife.

The disorganizing impact of stress hormones on the immune system as a risk for cancer is far from a scientific secret. We have also seen how stress and trauma are prime drivers of inflammation, another central gear in the cancer-causing apparatus. Along parallel lines, girls who are sexually and physically abused have far greater risk in adulthood of endometriosis, a painful and often disabling condition that heightens the risk of ovarian cancer and whose origins perplex conventional medical thinking.[4] Considered from the mind-body psychoneuroimmunological perspective, the puzzle becomes rather less puzzling.[*]

We know from autopsies, for example, that many women have breast cancer cells, just as many men have prostate cancer cells, without ever developing the disease of cancer. The question is, What drives the progression of these cells into clinical illness? What keeps the immune system from successfully confronting the internal menace? This is where stress plays its incendiary role: for example, through the release of inflammatory proteins into the circulation—proteins that can instigate damage to DNA and impede DNA repair in the face of malignant transformation.

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.”

Most of our tensions and frustrations stem from compulsive needs to act the role of someone we are not. —János (Hans) Selye, M.D., The Stress of Life

I couldn’t help seeing what I saw. Time after time it was the “nice” people, the ones who compulsively put other’s expectations and needs ahead of their own and who repressed their so-called negative emotions, who showed up with chronic illness in my family practice, or who came under my care at the hospital palliative ward I directed. It struck me that these patients had a higher likelihood of cancer and poorer prognoses. The reason, I believe, is straightforward: repression disarms one’s ability to protect oneself from stress. In one study, the physiological stress responses of participants were measured by how their skin reacted electrically to unpleasant emotional stimuli, while the patients reported how much these stimuli bothered them. Flashed on a screen were insulting or demeaning statements, such as “You deserve to suffer,” “You are ugly,” “No one loves you,” and “You have only yourself to blame.” 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.

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.”

Why these features and their striking prevalence in the personalities of chronically ill people are so often overlooked—or missed entirely—goes to the heart of our theme: they are among the most normalized ways of being in this culture. Normalized how? Largely by being regarded as admirable strengths rather than potential liabilities. These dangerously self-denying traits tend to fly under our radar because they are easily conflated with their healthy analogues: compassion, honor, diligence, loving kindness, generosity, temperance, conscience, and so forth. 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 recurring theme—maybe the core theme—in every talk or workshop I give is the inescapable tension, and for most of us an eventual clash, between two essential needs: attachment and authenticity. This clash is ground zero for the most widespread form of trauma in our society: namely, the “small-t” trauma expressed in a disconnection from the self even in the absence of abuse or overwhelming threat.

in a child’s life, the outcome is well-nigh predetermined. If the choice is between “hiding my feelings, even from myself, and getting the basic care I need” and “being myself and going without,” I’m going to pick that first option every single time. 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.