The myth of normal, p.27
The Myth of Normal, page 27
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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.’”
As with other people with “genetic” mental health problems, which anorexia is often considered to be, the personal histories of individuals always reveal meaning. A medical colleague who suffered from anorexia as a teenager, for example, is a self-described perfectionist, a trait that nobody is born with. Rather, it arises as an adaptation to fit in with an environment where one perceives no welcome for being just who one is, with all one’s “imperfections.”
Much as with addictions or self-harming behaviors, or conditions like obsessive-compulsive disorder, there is always a “payoff” with disordered eating patterns. At age seventeen, Andrea, now twenty-seven, became “super, super meticulous” about what she would eat. “I would cook for other people, and I would never eat it. But everything that I would eat for myself was always weighed out, measured out. When I was in university, I remember eating Greek yogurt and granola or muesli for breakfast, and I would measure out absolutely everything in measuring cups. Everything would go into a tracker so I knew what I was eating. It was the ultimate form of control.” At five feet seven, Andrea went down to 106 pounds.[*] She did not menstruate for seven years.
When asked what she “got” from her self-denial, she said: “It’s that sense of control, and also self-acceptance. It made me feel better about myself, because I had control of what I was doing, essentially.” Although she recalled a “not bad” childhood, her mother, Cathy—who participated in our interview—was able to correct the record. She and her husband divorced when Andrea was six, after years of intense marital stress. A child in such circumstances is prone to lack self-acceptance and yearn for agency in an emotionally unstable environment.
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?
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One of Robin Williams’s most beloved performances, for which he won an Academy Award, is in Good Will Hunting, where he appears in the role of a kindly psychologist tasked with helping an angry Boston janitor after the latter assaults a cop. Played by Matt Damon, this gifted man—he turns out to be an intellectual diamond in the rough—has stuffed his vulnerability underneath a layer of ossified rage and defiance. The most iconic scene from the movie features Williams’s therapist getting right in Damon’s face and repeating a simple but powerful statement, “It’s not your fault,” until the latter finally collapses, sobbing, into his embrace. That message, “It’s not your fault,” conveys not just undaunted compassion, for which Damon’s character was starving inside, but wisdom, too. From behavioral problems to full-blown mental illness, it’s not anyone’s fault—nor, as we’ve seen, the fault of their brains or their genes. It is an expression of untended wounds, and it is meaningful.
The meaning extends beyond people’s individual lives, their families of origin, and their childhoods. If we are going to address the myriad afflictions to which this book has devoted its attention so far, we need to look through a wider lens at the bigger story. If I could distill my message and insert it into that beautiful cinematic moment, I would have Robin Williams look all of us in the eye—including himself—and say with assurance: “It’s not your fault . . . and it’s not personal.” It’s about our hurting world, manifesting the illusions and myths of a culture alienated from our essence.
We turn to that bigger picture next.
Part IV
The Toxicities of Our Culture
Making an injury visible and public is often the first step in remedying it, and political change often follows culture, as what was tolerated is seen to be intolerable, or what was overlooked becomes obvious.
—Rebecca Solnit, Hope in the Dark
Chapter 19
From Society to Cell: Uncertainty, Conflict, and Loss of Control
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
We know that chronic stress, whatever its source, puts the nervous system on edge, distorts the hormonal apparatus, impairs immunity, promotes inflammation, and undermines physical and mental well-being. I see it on a daily basis, and I agree with János Selye, the father of stress research, who “without hesitation” asserted “that for man the most important stressors are emotional.”[1] At this stage in our exploration of trauma, illness, and healing I would only add that the main determinants of human emotional stress extend from the personal to the cultural. We are, in effect, biopsychosocietal beings.
To review what we’ve seen about stress so far: First, its physiology and consequences include the acute or chronic activation, potential overactivation, and even exhaustion of the hypothalamic-pituitary-adrenal (HPA) axis that connects our brain’s emotional centers and the body’s entire physiological apparatus.[*] Then there’s what Bruce McEwen has called “allostatic load”: the wear and tear on the body of having to maintain its internal equilibrium in the face of changing and challenging circumstances, trauma salient among them. In this culture many people are fated to be bearers of heavy allostatic loads, to the detriment of their mental and physical health, as demonstrated, if more proof were needed, by a recent Yale study showing the cumulative impact of stress on accelerated biological aging. “Our society is experiencing more stress than ever before, leading to both negative psychiatric and physical outcomes,” the researchers noted.[2]
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.
What, in our society, are the most widespread emotional triggers for stress? My own observations of self and others have led me to endorse fully what a review of the stress literature concluded, namely that “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.
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In medical school I was trained to think of life and health in purely individualistic terms. That we have a hard time not seeing things this way is, itself, a quintessential feature of the “normal” worldview engendered by capitalism.
In this, as in much else, the medical system mirrors and reinforces the prevailing ethic. In an atomized, materialistic culture people are induced to take everything personally, to see their own mental and physical distress as misfortunes or even failures belonging to them alone. Take the picture painted by the former British prime minister Tony Blair, to this day a sought-after, well-remunerated spokesperson for the desocializing ethic—that is, for bleaching the “social” out of society. Many health problems, he said, are “not, strictly speaking, public health problems at all. They are questions of lifestyle: obesity, smoking, alcohol abuse, diabetes, sexually transmitted diseases . . . These are not epidemics in the epidemiological sense—they are the result of millions of individual decisions, at millions of points in time.”[5] This perspective denotes a blithe unawareness of the many studies linking all these “millions of decisions” to trauma and stress, including the stresses imposed by low socioeconomic or occupational status, and poverty—a festering sore in British society since the dismantling of the “welfare state” and communal institutions, along with the disempowering of labor unions. That underlying such “individual decisions” is the social milieu fostered by late-stage capitalism seems not to have occurred to Mr. Blair, despite considerable evidence. This is no surprise: a refusal to recognize broad economic and political conditions as relevant to individual health and happiness is a core feature of materialistic ideology. No one inclined to connect those dots would ever be entrusted with the keys to the kingdom.
Culture acts on our well-being via all manner of biopsychosocial pathways, including epigenetic causes; stress-induced inflammation; impairment of telomeres and premature aging; how and what we eat; toxins we ingest or inhale. It exerts its influences through many other outside-in mechanisms, too: through effects passed on from parents to children; from one person to another; from social, political, and economic conditions to individual bodies—“from society to cell,” in the words of the molecular scientist and researcher Michael Kobor. Contra the Blairite view, it also powerfully influences and constrains nearly all the “individual decisions” most of us make with regard to our well-being.
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.
In 2020, a few weeks before the novel coronavirus metastasized to devastate the world economy, no less a figure than Kristalina Georgieva—head of the International Monetary Fund, that executive planning committee of international capital—was already warning that the global economy risked returning to the woeful conditions of the Great Depression, owing to inequality and financial-sector instability. “If I had to identify a theme at the outset of the new decade,” she said, “it would be increasing uncertainty.”[6] The majority of the population in my own country, for one, did not require this alarming forecast to know that things were not looking up. Just a month before the IMF head issued her prediction, nearly 90 percent of Canadians expressed the concern that food prices were rising faster than their incomes. About one in eight Canadian households experienced food insecurity in the previous year.[7] In my home province of British Columbia in 2017, 52 percent of women reported “extreme emotional stress” regarding their financial situation.[8] Such trends are international and have been growing for decades.
The burgeoning of chronic mental and physical health conditions across many countries in the past decades, from depression to diabetes, can be no coincidence. “Neoliberalism[*] has made the world of work far less secure and consequently more stressful and health damaging,” write two British health academics, “. . . resulting in a myriad of chronic diseases including musculoskeletal pain and cardiovascular disease.”[9] I find that unsurprising, living as we do under a system that habitually foments the stress of mass uncertainty. Globalization, with its ruinous policies dictated to so-called developing countries by bodies like the International Monetary Fund and the World Bank—such as cutting back social supports, suppressing workers’ rights, and encouraging privatization—has also permeated the industrialized nations. It’s what the Canadian political philosopher John Ralston Saul called “the crucifixion theory of economics: you had to be killed economically and socially in order to be reborn clean and healthy.”[10]
The health impacts of our economic system are neither hard to understand nor difficult to track. A 2013 study comparing the health and stress status of young Swedes to young Greeks during the financial catastrophe then engulfing Greece found the Athens students to be at a marked disadvantage. They reported higher levels of stress, harbored “lower hope for the future,” and suffered “significantly more widespread symptoms of depression and anxiety,” as well as, ominously, lower cortisol levels.[11] The latter is a marker of long-term stress: a sign that people’s healthy, protective stress-response mechanism was burning out. It often augurs future disease.[*] “One can suspect that the social crisis in Greece is beginning to have biological effects on the residents of the country,” the study warned. Similarly, in Canada it was found that when women are under economic pressure, their children’s stress-hormone levels rise markedly by age six, elevating the risk of illness later in life.[12]
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. Only months earlier, the New York Times had reported on the deepening insecurity of American families: “The costs of housing, health care and education are consuming ever larger shares of household budgets and have risen faster than incomes. Today’s middle-class families are working longer, managing new kinds of stress and shouldering greater financial risks than previous generations did.”[13] As the famed anthropologist, researcher, and author Wade Davis remarked recently in a broadly circulated Rolling Stone piece, “Though living in a nation that celebrates itself as the wealthiest in history, most Americans live on a high wire, with no safety net to brace a fall.”[14] A better blueprint for allostatic overload could not be imagined.
Although the world’s most advanced capitalist country evinces the rawest individualistic ethic, leaving the majority of its people mired in insecurity, we are not speaking of a uniquely American trend. Such is the overweening economic and cultural influence of the U.S. throughout the world that, as Morris Berman has argued, “If the twentieth century was the ‘American century’ the twenty-first will be the ‘Americanized century.’”[15] The Organisation for Economic Co-operation and Development reported that pressures on the middle class around the world have increased since the 1980s.[16] Thus on the very terrain in which capitalism stakes its greatest claims to success—economic achievement—we find many people in a state of chronic uncertainty and loss of control, subject to stress-inducing fears that translate into disturbances of the hormonal apparatus, of the immune system, and of the entire organism.
No wonder, then, that insecurity about work or the loss of it can instigate disease. 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.[17] The results hold even after the expected increase in stress-related behaviors such as smoking, drinking, and eating are taken into account. In fact, multiple job losses have been shown to raise the risk of heart attacks as much as cigarettes, alcohol, and hypertension.[18] Even the fear of losing one’s job is just as strong a predictor of an older person’s health as it actually happening. In the decade and a half between the late 1970s and the mid-1990s, the proportion of American employees of major corporations who professed themselves “frequently concerned about being laid off’’ nearly doubled, from 24 to 46 percent.[19] Jobs with time pressure, fast pace, and high workload, coupled with decreased control over such factors, are also associated with increased stress and ill health.[20]
A signature marker of stress is inflammation. I’ve encountered the links between the two in many of the patients under my care. Inflammation is implicated in an extensive range of pathologies, from autoimmune conditions to vascular disease of heart and brain, from cancer to depression. One of my most penetrating interviews for this book was with the scientist Dr. Steven Cole. “A theme that comes up over and over and again,” Cole said, “is this increase in inflammatory gene activity in people confronting a sense of threat or insecurity for more than a short period of time. We can detect these same in mice, in monkeys. As far down as in fish, you can see that the more stress or threat or uncertainty you’re exposed to, the more the body turns on this defensive program that involves more inflammation.”
