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

by Gabor Maté

Contrary to what I, too, used to believe, a diagnosis like ADHD or depression or bipolar illness explains nothing. No diagnosis ever does. Diagnoses are abstractions, or summaries: sometimes helpful, always incomplete. They are professional shorthand for describing constellations of symptoms a person may report, or of other people’s observations of someone’s behavior patterns, thoughts, and emotions. For the individual in question, a diagnosis may seem to account for and validate a lifetime of experiences previously too diffuse or nebulous to put one’s finger on. That can be a first and positive step toward healing. I know this from firsthand experience.

Richard Bentall, a clinical psychologist, academic, and Fellow of the British Academy, summed up the science a few years ago: “The evidence of a link between childhood misfortune and future psychiatric disorder is about as strong statistically as the link between smoking and lung cancer,” he wrote. “There is also now strong evidence that these kinds of experiences affect brain structure, explaining many of the abnormal neuro-imaging findings that have been reported for psychiatric patients.”[12] This mirrored a Harvard study that concluded, “These brain changes may be best understood as adaptive responses to facilitate survival and reproduction in the face of adversity. Their relationship to psychopathology is complex.”

“Popular depictions of depression as a ‘chemical imbalance’ are trivial . . . [All] problems in living, including death, are accompanied by ‘chemical imbalances,’” he pointed out. He, too, saw depression as an adaptation of the brain to the loss of connection, as a physiological “shutdown mechanism” to terminate distress, “which, if sustained, would be dangerous for infant mammals.”

Her crushing belief in her unworthiness revealed itself to be a self-protective strategy gone awry. Odd as it may sound, it was the best worst option. A suffering child, as Leslie was—again, the details matter less than the contours—has two possible options when it comes to processing her experience. She can conclude either that the people she relies on for love are incompetent, malicious, or otherwise ill-suited to the task, and she is all alone in this scary world; or that she herself is to blame for, well, everything. As painful as the latter explanation is, it is far preferable to the other one, which paints a life-threatening picture for a young being with zero power or recourse. The first option is not an option at all. Better to believe “It’s my fault; I’m bad,” which lets you believe there’s the chance that “if I work hard and be good, I will be lovable.”

The incidence of self-cutting is rising, particularly among young people. If we resist the default to “mental illness” as an explanation for such acts, we might ask instead: Why do people harm themselves? As in Leslie’s case, these behaviors play the role, paradoxically enough, of self-soothing. They bring short-term relief. That more and more people are resorting to self-harm is a marker of the growing prevalence of stress and trauma. The comedian Darrell Hammond told me that cutting himself afforded him “a crisis that’s more manageable than the terror inside you, the one that’s going on in your head . . . You look at a cutter’s arms; those aren’t suicide cuts. Those aren’t death cuts. Those are either ‘I want someone to know I’m in distress,’ or ‘When I start patching this arm up, running and finding the Band-Aid, and cleaning myself up, I have a crisis, but it’s manageable, and the one in my head was not.’”

A milder flight from reality is dissociation. Helen Knott, subjected to sexual exploitation when very young, describes it well: “My feelings left my body. My spirit sat outside of me like an unacknowledged apparition. I didn’t know whose life I was living, whose body I inhabited. This wasn’t my story, my life, my reality . . . I was scared that if I tried to lean into my feelings, I would fall off the emotional edge and I didn’t know what I would do to myself.”[10] What we call a disorder is revealed to be an ingenious means for an assaulted psyche to absent itself from agony.

Tuning out is dissociation’s less extreme cousin, part of the same family of escapist adaptations. It is invoked by the organism when the circumstances are stressful and there is no other recourse for relief, when one can neither change the situation nor escape it. Such was the imperative in my own infancy. Such, too, was the situation for my three sensitive children—a trait they may well have inherited, as discussed in the last chapter—in an emotionally chaotic home characterized, amid plenty of love, by parental anxiety, depression, and conflict. This adaptation then becomes wired into the brain, without the brain itself being the original source of the problem.

Today, voluminous research has linked the symptoms of ADHD to trauma or early stress, and has shown that both can impact the dopamine circuits of the brain and that adversity can interfere with a child’s subsequent capacity to focus and to organize tasks.

Absorbing a parent’s sorrow is not the Nature-given responsibility of a child. “The reversal of roles between child, or adolescent, and parent, unless very temporary, is almost always not only a sign of pathology in the parent but a cause of it in the child,” wrote the great pioneer of attachment research and personality development, the British psychiatrist John Bowlby.

Extensive scientific literature now links disordered relationships to food, as well, with early trauma and family stress. Recall that the seminal Adverse Childhood Experiences (ACE) Study began after the lead investigator, Dr. Vincent Felitti, began to pay heed to the life histories of patients at the obesity clinic where he served as medical director. “We could help them lose weight,” Dr. Felitti told me, “but not to keep it off. I kept wondering why, until I finally got the message. ‘Don’t you get it?’ they said. ‘We’re stuffing down our pain.’”

This desperate drive to seize some command at least of their own body amid turmoil is almost universal among people with anorexia or bulimia that I have interviewed. The psychologist Julie T. Anné, who specializes in treating eating disorders, nails it: with her clients, she says, “three lacks” are typical—lack of control, identity, and self-worth—along with a need to numb pain. “In a relational world . . . the human psyche devises a brilliant means to emotionally survive,” she told me. “In our culture, this becomes the pursuit of perfection vis-à-vis the body and self. Also known as anorexia.” And yet these deeply wounded individuals, like the bearers of every mental-emotional burden we have touched on, are all too rarely asked the key questions: Where did this come from? and What valid problem is it trying to fix?

The history of the world is the history of a ten-thousand-year war of brains between the rich and the poor . . . The poor win a few battles . . . but of course the rich have won the war for ten thousand years. —Aravind Adiga, The White Tiger

Of course, there is no “equality of opportunity” in stress, any more than there is in economic life. The structure of a society based on power and wealth, with built-in disparities along racial and gender lines, leaves some people far more physiologically burdened than others. It is true that in a culture that recruits individuals and groups into a fearful competition against others, the psychological triggers for stress spare no social tier, but the fact remains that their effects are unevenly distributed. And while the personal stresses of a disconnect from the self and the loss of authenticity may cut across class lines, the allostatic strain imposed by imbalances of power falls most onerously on the politically disempowered and economically disenfranchised.

“psychological factors such as uncertainty, conflict, lack of control, and lack of information are considered the most stressful stimuli and strongly activate the HPA axis.”[3] A society that breeds these conditions, as capitalism inevitably does, is a superpowered generator of stressors that tax human health. Capitalism is “far more than just an economic doctrine,” Yuval Noah Harari observes in his influential bestseller Sapiens. “It now encompasses an ethic—a set of teachings about how people should behave, educate their children, and even think. Its principal tenet is that economic growth is the supreme good, or at least a proxy for the supreme good, because justice, freedom, and even happiness all depend on economic growth.”[4] Capitalism’s influence today runs so deep and wide that its values, assumptions, and expectations potently infuse not only culture, politics, and law but also such subsystems as academia, education, science, news, sports, medicine, child-rearing, and popular entertainment. The hegemony of materialist culture is now total, its discontents universal. We explore how it affects our very health in this and the following chapters. —

All stressors represent the absence or threatened loss of something an organism perceives as necessary for survival. An impending loss of food supply, for example, is a major stressor for any creature. So is, for our species, the absence or threatened loss of love, or work, or dignity, or self-esteem, or meaning.

Many people exist at the mercy of forces completely beyond their power to affect, let alone control. Who knows when the next cyclic recession will strike or when yet another megabusiness will downsize, merge, or relocate so that livelihoods are jeopardized with barely a day’s notice. Even prior to COVID-19’s economic ravages, one had become almost inured to news that yet another corporation was declaring masses of employees redundant. “High Street Crisis Deepens as 3,150 Staff Lose Jobs in a Week” was a headline in the Guardian in January 2020, a few weeks before the pandemic arrived in Britain.

Studies in the United States showed that the risk of stroke and heart attacks in people fifty-one to sixty-one years of age more than doubles in the aftermath of prolonged job loss.

It used to be that only people accused of Marxist tendencies would speak of “class war.” In recent years, though, the actuality of elite dominance and the assault on the middle and lower classes has struck home across ideological lines. No less an authority than the multibillionaire investment tycoon Warren Buffett has seen the writing on the wall. “There’s class warfare, all right,” he told the New York Times in 2006, “but it’s my class, the rich class, that’s making war, and we’re winning.”

The notion that capitalism is meant to provide equality and opportunity for all must be taken on faith, since history and material reality provide no evidence for it. In the realm of political decision-making, a widely circulated U.S. study showed that the views of ordinary people make no difference to public policy: a lack of control on a mass scale.[*] “When a majority of citizens disagree with economic elites or with organized interests, they generally lose,” the authors concluded, adding that “even when fairly large majorities favor policy change, they generally do not get it.”

A society that fails to value communality—our need to belong, to care for one another, and to feel caring energy flowing toward us—is a society facing away from the essence of what it means to be human.

If a gene or virus were found that caused the same impacts on the population’s well-being as disconnection does, news of it would bellow from front-page headlines. Because it transpires on so many levels and so pervasively, we almost take it for granted; it is the water we swim in.

Among psychologists there is wide-ranging consensus about what our core needs consist of, some of which we have already explored. These have been variously listed as: belonging, relatedness, or connectedness; autonomy: a sense of control in one’s life; mastery or competence; genuine self-esteem, not dependent on achievement, attainment, acquisition, or valuation by others; trust: a sense of having the personal and social resources needed to sustain one through life; and purpose, meaning, transcendence: knowing oneself as part of something larger than isolated, self-centered concerns, whether that something is overtly spiritual or simply universal/humanistic, or, given our evolutionary origins, Nature. “The statement that the physical and mental life of man, and nature, are interdependent means simply that nature is interdependent with itself, for man is a part of nature.” So wrote a twenty-six-year-old Karl Marx in 1844.

Dislocation, in Bruce’s formulation, describes a loss of connection to self, to others, and to a sense of meaning and purpose—all of which appear on the roster of essential needs above. Lest the word “dislocation” conjure something hazy like “being lost,” he is quick with a graphic metaphor. “Think of a dislocated shoulder,” he said, “a shoulder disarticulated, out of joint. You didn’t cut off the arm, but it’s just hanging there and not working anymore. Useless. That’s how dislocated people experience themselves. It’s excruciatingly painful.” More than an individual experience, the same intense pain often occurs at the social level when large groups of people find themselves cut off from autonomy, relatedness, trust, and meaning. This is social dislocation, which, along with personal trauma, is a potent source of mental dysfunction, despair, addictions, and physical illness.[*] Abnormal from the perspective of human needs, such dislocation is now an entrenched facet of “normality” in our culture. Extreme examples include the physical and psychic dislocation forced upon North America’s Indigenous populations by colonialism and, more recently, the globalization-induced economic hollowing out of entire regions in the United States, from the Rust Belt to the mining towns of the Appalachians—which has resulted in a vast increase in suicides and overdose deaths among the working class. The latter have been called “deaths of despair” by the Princeton economists Anne Case and Ang...

“For most of us,” wrote two leading economic consultants in the New York Times, “work is a depleting, dispiriting experience, and in some obvious ways, it’s getting worse.”[4]

When do you feel happier, more fulfilled, more viscerally at ease: when you extend yourself to help and connect with others, or when you are focused on burnishing the importance of your little egoic self? We all know the answer, and yet somehow what we know doesn’t always carry the day.

Not only does our individual and societal sanity depend on connection; so does our physical health. Because we are biopsychosocial creatures, the rising loneliness epidemic in Western culture is much more than just a psychological phenomenon: it is a public health crisis.

We now know without doubt that chronic loneliness is associated with an elevated risk of illness and early death. It has been shown to increase mortality from cancer and other diseases and has been compared to the harm of smoking fifteen cigarettes a day.

Alarmed by the health ravages, Britain has even found it necessary to appoint a minister of loneliness.

“Research consistently shows,” he told me, “that the more people value materialistic aspirations as goals, the lower their happiness and life satisfaction and the fewer pleasant emotions they experience day to day. Depression, anxiety, and substance abuse also tend to be higher among people who value the aims encouraged by consumer society.” He points to four central principles of what he calls ACC—American corporate capitalism: it “fosters and encourages a set of values based on self-interest, a strong desire for financial success, high levels of consumption, and interpersonal styles based on competition.”[13]

the more insecure people feel, the more they focus on material things. As materialism promises satisfaction but, instead, yields hollow dissatisfaction, it creates more craving.

Rob Lustig calls the United States “the drug capital of the world,” and he isn’t talking about cocaine, heroin, or methamphetamine, nor even mass-marketed opioids like OxyContin. He is referring to sugar, a substance that, in 2013, the chief health officer of the Netherlands declared to be “addictive and the most dangerous drug of all times.” “Addictive” is not too strong a term. A Harvard Medical School study found that people ingesting foods with a high glycemic index—meaning, in practice, junk foods that rapidly elevate blood sugar levels—got hungrier faster. On fMRI scans, they showed activation of the same brain regions stimulated by drugs such as cocaine or heroin.[2] Never missing a profitable beat, multinational corporations vigorously market sugar-laden concoctions to children, and prey on people who, owing to trauma, penury, and grinding oppression, are especially vulnerable to addictive substances. The latter include poor Black people in the United States and the denizens of Brazil’s makeshift villages, the favelas. In many “developing” countries—a term that manages to be both condescending and euphemistic—troops of impoverished women are recruited to go door-to-door, selling such junk products to already

Mexico now vies with the United States for world leadership in obesity and its related diseases. “About 73% of the Mexican population is overweight, compared to one-fifth of the population in 1996,

In China, the adult obesity rate doubled in the two decades between 1991 and 2011, from 20.5 to 42.3 percent. There, too, Coca-Cola has wielded major influence in shaping government policy to enhance its profits.

The worldwide obesity epidemic is a marker of the international stress epidemic discussed in our previous chapters, and of the attendant lifestyle challenges endemic to our modern era: lack of time, lack of exercise, growing insecurity, lack of family connection, loss of community, and erosion of the social network. There are many aspects of life that drive people to follow unhealthy diets and engage in self-harming habits, the main culprits being emotional pain, stress, and social dislocation.

Tobacco kills about forty-five thousand Canadians annually, ten times as many as die from opioid overdoses—not to mention the hundreds of thousands who suffer smoking-related illness and debility. The worldwide death toll due to tobacco use exceeds seven million each year.[12] For every person who dies, thirty live with chronic illness.

“Viewed from such a vantage,” he told me, “many corporations meet the criteria of ‘sociopaths,’ acting without a conscience: not caring about what happens to other people as a consequence of their actions, having no compulsion to comply with social or legal norms, not feeling guilt or remorse.”

It was in the year 1800 that the great German naturalist and geographer Alexander von Humboldt first sounded the alarm about the impact of human activity on the climate, having seen the environmental damage wreaked by colonial plantations in Venezuela. He prophesized that our interference with the ecology could have “unforeseeable impact on future generations.”[16] Over two centuries later, more than eleven thousand leading scientists from 153 nations found it necessary to endorse an urgent warning. “We declare clearly and unequivocally that planet Earth is facing a climate emergency,” they wrote. “To secure a sustainable future, we must change how we live. [This] entails major transformations in the ways our global society functions and interacts with natural ecosystems.”

In the logic of profit, greed is creed, and health nothing but collateral damage. “It’s not that they want you to die,” the endocrinologist Rob Lustig told me in a tone of mock reassurance. “They only want your money. They just don’t care if it kills you.”

It’s all too easy for the privileged among us to assume we walk the same streets as everyone else. Though a satellite view of Earth may suggest we do, that’s not how it plays out at ground level. Do Indigenous people in Canada or Black people in America tread the same ground as their Caucasian counterparts, face the same daily obstacles, navigate the same sorts of adversity? Surely not.

Malcolm’s withering questions probe far beyond mental or emotional self-concept. Self-rejection has powerful physiological dimensions that pertain to every aspect of well-being. From an early age it is one of racism’s sharpest and most intimate harms.

It is no outcome of genetic destiny, for example, that in Canada Indigenous people suffer more illness and die earlier than others. Racism and poverty do get under the skin, in so many ways.

As the Black American writer Ta-Nehisi Coates tersely asserts, “Race is the child of racism, not the father.” In other words, the very concept of race emerges from the distorted imagination of the racist. Though racism’s impacts are real, in physiological or genetic terms race does not exist. Superficial differences in skin color, body morphology, or facial features do not create “races.” Historically the idea of race arose from the impulse of European capitalism to enrich itself by subjugating, enslaving, and, if necessary, destroying Indigenous people on other continents, from Africa to Australia to North America. Indeed, the word “race” did not exist in any meaningful way until it was created in the late eighteenth century. Psychologically, on the individual level, the “othering” racism entails is an antidote to self-doubt: if I don’t feel good about myself, at least I can feel superior to somebody and gain a sense of power and status by claiming privilege over them.

words of Ta-Nehisi Coates as he recalls his youth in inner-city Baltimore: “We could not get out. The ground we walked on was trip-wired. The air we breathed was toxic. The water stunted our growth. We could not get out . . . Not being violent enough could cost me my body. Being too violent could cost me my body. We could not get out.”

James Baldwin once said that “to be a Negro in this country and to be relatively conscious, is to be in a rage almost all the time.” Baldwin uttered those words in 1961. They still ring true, decades of civil rights advances and a Black president later. Baldwin also understood that rage on its own, even if come by honestly, could not be the end of the story. In the very next sentence, he described “the first problem” as being “how to control that rage so that it won’t destroy you.”[10]

I was thirteen in 1957 when, along with nearly thirty-eight thousand fellow Hungarians, refugees from a brutal Stalinist dictatorship, my family and I were welcomed with open arms by Canada. The North really seemed true and strong and free, in line with the words of this country’s national anthem. What I didn’t know and what no one was speaking of was that in the same year, even as we were adjusting to the advantages of life in British Columbia, a four-year-old First Nations child, Carlene, had a pin stuck in her tongue on her first day at a federally mandated, church-run residential school not far from where I lived. Her crime had been to speak her Native language in the classroom. For an hour this little girl could not put her tongue back in her mouth for fear of cutting her lips. Soon after, years of sexual abuse began. By age nine Carlene was an alcoholic and later became dependent on opiates to soothe her pain. We met at a healing ceremony not long ago and that was when, sobbing and trembling with emotion, she told me her story. I thought I had heard everything. I had not. Now a grandmother and years sober, she grieves to see her grandchildren suffer the throes of addiction. For her, our national anthem was a cruel hoax: there was no “true North strong and free!” Nor is there yet.

The lifespan of Indigenous people is fifteen years shorter than that of other Canadians, infant mortality two to three times higher, and type 2 diabetes four times more widespread: this among a population that knew no diabetes a little over a century ago.[15]

Elevated blood sugars are the least of it: diabetes is a leading cause of blindness, heart and kidney failure, and limb amputations. First Nations people are developing the disease in their forties, while among other sectors of the populace its onset is mostly in the eighth decade. The rates are rising. “By 2005,” a 2010 study found, “almost 50% of First Nations women and more than 40% of First Nations men aged 60 or older had diabetes, [compared] with less than 25% of non–First Nations men and less than 20% of non–First Nations women aged 80 or older . . . First Nations adults are experiencing a diabetes epidemic that disproportionately affects women during their productive years.”[16] Youth suicide rates in some Indigenous communities in Canada—First Nations, Inuit, Métis—were higher, according to a 1994 paper, than of any other culturally identifiable cohort in the world.[17] That continues to be the case.

While we Canadians like to pride ourselves on our publicly funded health care system—and rightly so, especially as we peer over the 49th parallel at the law-of-the-jungle morass to our south—research shows that, at most, only about 25 percent of population health is attributable to health care. A full 50 percent is determined by social and economic environments.[20]

In 1974 the anthropologist Ashley Montagu, cited earlier in this book, coined the phrase “sociogenic brain damage.” Technologies since available to us confirm that stressed environments, including penury, do interfere with brain development. More recently, one scientist has called poverty a “neurotoxin.” Brain scans of children and young people from deprived backgrounds have shown reduced surface area of the cerebral cortex, as well as smaller hippocampi and amygdalae—the subcortical regions involved in memory formation and emotional processing.[23]

Were health professionals to take to heart information about social determinants, Canadian health expert Dennis Raphael mockingly suggests, they would stop issuing injunctions such as “Stop smoking,” dispensing instead “Don’t be poor” and related prescriptions: “Don’t live in damp, low-quality housing”; “Don’t work in a stressful, low-paying manual job”; “Don’t live next to a busy major road or near a polluting factory”; “Be able to afford to go on a foreign holiday and sunbathe.”[25] In other words, immigrate to a kinder, saner, more equitable parallel universe.