The myth of normal, p.11
The Myth of Normal, page 11
Sontag’s acerbic rejection of the mind-body connection resonated not only in intellectual circles but also in some of the most hallowed centers of medical thinking. A few years later, the New England Journal of Medicine’s future first woman editor, Dr. Marcia Angell, cited it approvingly, deriding as “folklore” the idea that “mental state is a factor in the causing and curing of specific diseases,” a “myth” for which the evidence is at best “anecdotal.” Like Sontag, Dr. Angell espied in this line of thinking an insidious patient-blaming tendency: “At a time when patients are already burdened by disease, they should not be further burdened by having to accept responsibility for the outcome.”[3]
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.
My intent in reframing Sontag’s perspective, then, is to offer a more helpful view. I empathize with her apprehension about being blamed for becoming ill, even as I see her refutation of the mind-body confluence as misguided and scientifically untenable. A clear and honest look at the biographical factors that can disrupt our biological well-being helps us respond intelligently and effectively to illness—or preferably, to mitigate the risks in the first place. This is as true for individuals as for society.
There is nothing radical about the idea that certain personality traits can pose risks for illness; in fact, it is a restatement in modern scientific terms of insights that date far back. The physiological pathways connecting an irascible temper and heart disease, for instance, have long been well understood: they include increased blood pressure and heart rate, intensified clotting, and tightening of blood vessels, among others.[4], [5], [6] Already in ancient times Hippocrates spoke of the “choleric” temperament, believed to result from an excess of choler (yellow bile). In English we still speak of people who are habitually grumpy as “bilious.” And in traditional Chinese medicine, the liver—the source of bile—is associated with anger, bitterness, and resentment. In 1896, the renowned internist and medical teacher Sir William Osler, often called the father of modern medicine, asserted to graduate students at Baltimore’s Johns Hopkins Hospital that “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.” He was foreshadowing the modern concept of the driven, compulsively preoccupied, impatient, readily upset, and heart-disease-prone type A personality—a biopsychosocial dynamic, which, both scientifically and “anecdotally,” is easy to grasp.
In 1987 the psychologist Dr. Lydia Temoshok[*] proposed what became known as the “type C personality,” referring to traits strongly associated with the onset of malignancy.[*] These couldn’t have been further from the type A traits on the temperamental spectrum; they included being “cooperative and appeasing, unassertive, patient, unexpressive of negative emotions (particularly anger) and compliant with external authorities.” She had interviewed 150 people with melanoma and found these patients to be “excessively nice, pleasant to a fault, uncomplaining and unassertive.” They were identified “pleasers”: while anxious about their disease progression, their worries were focused in a specifically outward direction, away from themselves and toward the effect that their illness was having on their families. Such self-abnegation was too well typified in an article I once read in the Globe and Mail, written by a woman just diagnosed with breast cancer. “I’m worried about my husband,” she immediately told her physician. “I won’t have the strength to support him.”[7]
Around the same time, about ten years into my medical practice, I was beginning to notice similar patterns in the lives of many of my patients, folks with all manner of illnesses. This, despite my lack of familiarity at the time with the voluminous research that in the past half century has shed light on how stress, including the stress of self-suppression, may disturb our physiology, including the immune system. Not knowing then of Dr. Temoshok’s work, I came to alike conclusions because they virtually urged themselves upon me: 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. 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]
Some years later, psychologists at the University of California, Berkeley, investigated the physiological effects not of repression, a largely unconscious process, but of suppression, defined as “the conscious inhibition of one’s own emotional expressive behavior while emotionally aroused.” If I know I’m afraid but choose to conceal that from a rabid dog who can “smell fear,” I am suppressing my feelings—as opposed to repressing them, as in compulsively pretending to agree with opinions one finds repellent and not realizing it until later. In the Berkeley study, participants were shown films normally expected to elicit disgust, such as burn patients being treated or an arm being surgically amputated. Some participants were specifically instructed not to reveal emotions when watching, while the control group was free to express emotion by means of facial or body movements. On a number of physiological measurements, the suppression group showed heightened activation of their sympathetic, or fight-or-flight, nervous system: in other words, a stress response.[9] There may be certain situations where a person, for perfectly valid reasons, deliberately chooses not to express how he feels; if one does it habitually or under compulsion, the impact is more than likely to be toxic.
I have distilled my own list of the personality features most often present in people with chronic illness, as observed by myself and many others. They may remind you of some of the personal stories I’ve included thus far. Whether a person exhibits one, a few, or every one of these features, they all, each in their own way, speak to self-suppression and/or repression. 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 them, develop and grow to prominence in some people are both fascinating and sobering. At root they are coping patterns, adaptations originally formed to preserve something essential and nonnegotiable.
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. True compassion, for example, is an equal-opportunity offering, granted to others precisely because we know and honor what we ourselves feel. We might well admire someone who puts another’s needs before their own in a crisis, or the leader of a struggle for the rights of many, but such sacrifices are undertaken in a conscious and time-bound manner, appropriate to the situation at hand and with full awareness of the risks.
I have a rather unusual habit when it comes to reading the newspaper: I’ve long been taken with reading obituaries in which friends and relatives pay homage to deceased loved ones. I frequently note in these a certain poignant paradox. Composed with affection and sorrow, these moving tributes often reveal and unwittingly celebrate their dearly departed’s self-abnegating traits, without recognizing that these may have played a central role in the illness that ended the life being remembered. Consider, for instance, the case of an Ontario physician—we’ll call him Stanley—who died of cancer. Stanley’s closeness with his mother was approvingly lauded in his obituary in Canada’s national newspaper, the Globe and Mail, in its daily “Lives Lived” section:[*] “Stanley and his mother had an incredibly special relationship, a bond that was apparent in all aspects of their lives until her death. As a married man with young children, Stanley made a point to have dinner with his parents every day, as his wife Lisa and their four kids waited for him at home. He would walk in, greeted by yet another dinner to eat and to enjoy. Never wanting to disappoint either woman in his life, Stanley kept having two dinners a day for years, until gradual weight gain began to raise suspicions.”[*]
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.
Where does such forsaking of the self come from? “Type C,” Lydia Temoshok pointed out, “is not a personality, but rather a behavior pattern that can be modified.”[10] I completely agree with her view. Precisely because no one is born with such traits ingrained, we can unlearn them. That’s a pathway toward healing—not an easy road by any means, and one we will take up later in detail. But first, let’s see if we can trace the origins of these patterns.
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.
Attachment, as defined by my colleague and previous co-author, the psychologist Dr. Gordon Neufeld, is the drive for closeness—proximity to others, in not only the physical but the emotional sense as well. Its primary purpose is to facilitate either caretaking or being taken care of. For mammals and even birds, it is indispensable for life. For the human infant especially—at birth among the most immature, dependent, and helpless animals, and remaining that way for by far the longest period of time—the need for attachment is mandatory. Without reliable adults moved to take care of us, and without our impulse to be close to these caregivers, we simply could not survive—not for a day. As we’ll see in the next chapter, we each arrive in the world “expecting” attachment, just as our lungs expect oxygen. Hardwired into our brains, our drive for attachment is mediated by vast and complex neural circuits governing and promoting behaviors designed to keep us close to those without whom we cannot live. For many people, these attachment circuits powerfully override the ones that grant us rationality, objective decision-making, or conscious will—a fact that explains much about our behavior across multiple realms.
In infancy our dependence is an obligatory and long-haul proposition. Everything from crying to cuteness—two unignorable cues babies transmit—is an inbuilt behavior tailored by Nature to keep our caregivers giving and caring. But the need for attachment does not expire once we’re out of diapers: it continues to motivate us throughout our lifespan. As we saw in chapter 3, unsatisfactory attachments can wreak havoc even with adult physiology. What distinguishes our earliest attachment relationships—and, crucially, the coping styles we develop to maintain them—is that they form the template for how we approach all our significant relationships, long after we have grown out of the do-or-die phase. We carry them into interactions with spouses, partners, employers, friends, colleagues: into all aspects of our personal, professional, social, and even political lives. It follows that attachment is a major concern of the culture—as we see, in a trivial form, in popular media gossip about who loves, leaves, or lies to whom. Attachment—along with attachment frustration, as in the “satisfaction” that we, along with Mick Jagger, can’t get none of—is never far from our minds.
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. Imagine our African ancestor on the savanna, sensing the presence of some natural predator: Just how long will she survive if her gut feelings warning of danger are suppressed?
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.
