What Ails Us
Gabor Maté Challenges The Way We Think About Chronic Illness, Drug Addiction, And Attention-Deficit Disorder
by TRACY FRISCH
The complete text of this selection is available in our print edition.
Physician Gabor Maté was born in Nazi-occupied Hungary in 1944 to Jewish parents who were primarily concerned with simple survival. His father was interned in a forced-labor battalion, his aunt disappeared, and his maternal grandparents died in Auschwitz.
In 1957 Maté and his mother and father immigrated to Canada, and he went on to get a medical degree from the University of British Columbia in Vancouver. He started a private family practice in East Vancouver that lasted for twenty-seven years. While treating patients, he observed that those who had experienced trauma, stress, and anxiety at a young age tended to repress their emotions and also to have more health problems. He also served as medical coordinator of the palliative-care unit at Vancouver General Hospital for seven years. In the late 1990s he took a job working with hiv-positive drug addicts at several innovative urban rehab programs, including one where addicts are given needles and allowed to inject heroin on-site — the only such supervised-injection program in North America.
With both the chronically ill and addicts, Maté again saw the roots of their problems in “adverse childhood experiences,” such as abuse, neglect, poverty, or parental stress. At a time when medical science was increasingly looking to our dna for the source of many illnesses, Maté was becoming convinced that experiences in our early years play an even greater role in brain development and behavior. The emotional patterns we learn as small children, he says, live on in the cells of our minds and come back to us as adults.
In his fifties Maté diagnosed himself with attention-deficit disorder [add] — a result, he says, of his early childhood in wartime Hungary. Those difficult formative experiences also led him to become a workaholic and a shopaholic, he believes. He credits mindfulness meditation and therapy with helping him cope.
In his first book, Scattered, Maté makes the case that add is not a genetically inherited disorder but rather is caused by the environment in which one is raised. He proposes the same for addiction in his book In the Realm of Hungry Ghosts. His other titles are When the Body Says No: Exploring the Stress-Disease Connection and, with Dr. Gordon Neufeld, Hold On to Your Kids: Why Parents Need to Matter More Than Peers. Protecting and strengthening the parent-child bond is crucial, Maté says, and he identifies the lack of support for struggling families in the U.S. and Canada as the root cause of many social and healthcare crises.
For many years Maté wrote a weekly medical column for The Globe and Mail, Canada’s most widely read newspaper. Recently he gave up practicing medicine to focus on his appearances at seminars and conferences, where he discusses disease, addiction, and human development within a social context. Attributing our maladies to heredity is simplistic and disempowering, he says, a distraction from the problems of economic inequality, bad schools, and a declining sense of community.
I met with Maté over dinner in Albany, New York, following one of his intense all-day presentations, at which he’d developed a powerful rapport with an audience of two hundred. It was his fourth program of the week.
Frisch: Medical science has tried to offer genetic explanations for everything from alcoholism to obesity to breast cancer to depression. Why do you think genes can’t account for all our differences?
Maté: The genetic explanation is comfortable because it means that we don’t have to look at people’s lives or the society in which those lives are led for the source of our problems. If addiction is genetic, we don’t have to worry that it’s connected to child abuse, for example.
But studies actually show that, though certain genes might predispose you to addiction, if you grow up in a nurturing environment, those genes are inactive. Most genetic studies completely ignore the science of epigenetics, which is how the environment actually turns certain genes on or off.
Frisch: What led you to become interested in the connection between illness and environmental pressures?
Maté: As a family physician I began to notice that who got sick and who didn’t wasn’t completely random, that people who got sick more often tended to have more stressful lives. And I began to think that the stress had a lot to do with their illnesses.
I am not the first to arrive at that thought, which has been amply validated by research over the decades. Stress is a significant factor in the onset of diabetes, high blood pressure, heart disease, and cancer. But that research is generally not part of medical education. Doctors are trained to understand disease as a random event usually caused by external agents — bacteria, viruses — or genetics. We’re not taught to look at patients’ formative experiences or multigenerational stress patterns. Yet both my own observations and the research literature clearly indicate that you can’t separate people’s bodies from their environments.
Consider all the stresses of life in a society where people feel little sense of control and lots of uncertainty all the time; where people are expected to behave contrary to their true nature; where relationships are often troubled; where parents are not available for their kids because they’re too busy. Under such conditions, you’re more likely to get sick. Nearly 50 percent of American adults have a chronic illness.
On top of that, the U.S. has an inequitable healthcare system that provides good care to some but minimal care to others, and the debilitating expense of healthcare stresses patients further.
Frisch: We all experience stress, but we don’t all get sick. What makes some people more prone to illness than others?
Maté: People who have a chronic illness of any kind — cancer, multiple sclerosis, rheumatoid arthritis, fibromyalgia, inflammatory bowel disease, chronic neurological and skin disorders — often fit certain personality profiles. For example, they tend to pay a lot more attention to the needs of others than to their own. They get caught up in their job or their role as a caregiver rather than looking after themselves. They also tend to suppress the so-called negative emotions, such as sadness and anger. They try not to acknowledge these emotions even to themselves. And, finally, they tend to think they are responsible for how other people feel and to be terrified of disappointing others who are important to them.
So an overwhelming sense of responsibility and self-suppression is what tends to characterize the chronically ill.
Frisch: Have there been studies that support this?
Maté: Yes. In some studies of women who are having breast biopsies, psychologists could predict with relative certainty who would be diagnosed with cancer based purely on personality profiles. They were right as much as 90 percent of the time. The so-called cancer personality has been studied particularly in relationship to multiple melanoma, a type of skin cancer. Of course the personality doesn’t cause the disease, but it does increase your risk of getting it.
Frisch: Are there different personalities for people who have cancer and people who have, say, heart disease?
Maté: Well, there are two kinds of people who are prone to heart disease. One type is the rageful Type A workaholic. After a fit of rage, your chance of having a heart attack or stroke doubles for the next two hours, because your blood pressure is up, your adrenaline is up, clotting factors are increased, and your blood vessels have narrowed. In the long term you’ll suffer high blood pressure, constriction of the arteries, and so on.
The other type of person who gets heart disease is the emotional suppressor. They express no anger at all, not even healthy anger. They tend to get diseases of the heart muscle. Instead of the coronary arteries being damaged by high blood pressure, the cardiac muscle is weakened.
Frisch: Why shouldn’t we make an effort to stay calm? Doesn’t anger hurt relationships?
Maté: To say that we shouldn’t have anger is like saying that we shouldn’t have rain: we may not like getting wet, but without it there’s no irrigation. Healthy anger is a necessary response to a boundary invasion. It’s our way of saying: You’re in my space. Get out. You see this behavior in animals, too. It’s not a question of should or shouldn’t; it’s a part of our makeup. The role of emotion is to keep out that which is dangerous or unhealthy and allow in that which is helpful and healing. So we have anger and revulsion, and we have love and attraction.
Now, rage is always unhealthy. Rage is anger that is disproportionate to the situation. It usually arises from past experiences, not present boundary issues, and it keeps going on and on. It’s not discharged once you’ve protected your boundaries. It’s the result of frustration that’s built up for many years, like a pressure cooker that explodes.
Anger that is repressed can also turn inward. People who repress their anger can actually suppress their immune system, making it turn against itself. When that happens, you’re going to get autoimmune disease. Anger and the immune system have the same purpose: to protect boundaries. The immune system does its job of attacking foreign particles, and anger does its job of keeping out human invasions.
When you suppress your response to a boundary invasion, you’re going to become stressed. If I started rifling through your purse, for instance, and you didn’t object but instead repressed your anger, you’d feel very stressed, because you’d be worried I’d take your money. It takes tremendous energy to suppress emotions. The act itself is stress producing. Self-suppression is not innate. It’s a learned coping style. When you’re a child and your parents can’t handle your feelings, you learn to suppress them to maintain your relationship with your parents. But what was a coping response in the child becomes a source of illness in the adult.
Frisch: Does positive thinking protect people from illness?
Maté: A genuinely positive attitude that’s based on real experience and authentic power does protect people. If you realistically see the world as a place where you can get your needs met most of the time, you’ll be healthier.
The compulsive positive thinker is in trouble, however, because he or she is in denial of reality. Some people are not comfortable with their own pain, so they cover it up with positive thoughts in a desperate attempt to avoid what’s there.
Frisch: Does low social status or oppression make people less healthy?
Maté: Yes. The major triggers for stress include uncertainty, lack of information, and loss of control. The more you are not in charge of the circumstances of your life and the decisions that affect you, the more stress you will be under. In a study of the British civil service, lower-ranking civil servants had a greater risk of heart disease than their superiors. Low socioeconomic status makes it more likely that you will be exploited and that your needs won’t be met. Of course, other factors such as poor nutrition and housing conditions can also contribute to ill health.
In African American men the death rate from prostate cancer is more than twice the rate among white American males. If you look at men in Africa, they have the same rate of developing cancer in their prostates as men everywhere — it’s fairly universal — but they don’t have a high rate of death from prostate cancer. I credit the Africans’ high-functioning immune systems, which has to do with the fact that they’re not as stressed as African American men, who deal more often with loss of identity, loss of status, loss of control, loss of power.
There has been a dramatic increase over the past several decades in the number of women being diagnosed with multiple sclerosis as compared to the number of men: “an increase in the ratio of women to men of nearly 50 percent per decade,” according to one U.S. expert. Women are now three to four times more likely than men to get ms. Such changes cannot be explained genetically, since genes don’t change in a population over such a short time frame.
There’s a lot of literature connecting ms to stress, and it’s easy to see why women might be more stressed, especially now. They’re still playing their traditional role of stress absorber, soaking up the worries of their spouse and children, as they always have. Now they also have to be out in the workforce, and they are doing so with less support, because the community and the extended family are less available. And traditionally women are trained not to express their so-called negative emotions.
Frisch: When people already have a chronic or degenerative disease, can changing the way they deal with their emotions help them overcome it?
Maté: In some cases. I know people with stage iv cancer who have changed their lifestyle and their emotional patterns and done very well, surviving a decade or more beyond their prognosis. They also changed their relationships and what responsibilities they took on. They started saying no when they didn’t want to do something. And why not? When they wouldn’t say no, the cancer came along to say no for them.
I don’t want to be simplistic about it. Not everyone can be saved. But with many of these illnesses, flare-ups could be avoided, and the inexorable progression and deterioration slowed or even stopped, if people started living differently, not controlling their emotions but changing how they relate to the world based on their emotions.
Frisch: You seem to be careful in your work not to blame people for their illnesses. Still, when you say there’s a connection between illness and emotional behavior, some might think you are holding the patients responsible for their own disease.
Maté: It’s not that I am careful not to blame. It’s that there’s nobody to blame. People don’t develop these behavior patterns deliberately. These are coping mechanisms based on family-of-origin problems. If I suppress my emotions because my parents couldn’t handle my anger when I was two years old, how am I to blame for that? At some point these coping mechanisms helped us survive.
I also don’t blame parents: these are unconsciously transmitted, multigenerational dynamics. Parents do their best, but we live in a highly stressful culture.
Frisch: What about individual responsibility? Where does it come in?
Maté: You have to understand the word responsibility. It implies that one has the ability to respond. Once I understand something, once I’ve thought it through, then I can respond consciously. Only after it makes sense to me can I start taking responsibility.
So is it true that some people bring on their own illnesses? In a certain sense, yes. How they live affects their health. Nobody argues that smoking doesn’t increase the risk of lung cancer. But even in those cases there are people who smoke to soothe some stress or pain that they didn’t create for themselves. It’s not entirely their choice.
Frisch: How should we raise our children to ensure they become healthy adults?
Maté: First we need to do away with the behavioral under standing of children, which dominates parenting in North America. We insist on looking at the behavior of the child and asking, “Do we like this or not?” If we don’t like it, we try to change the behavior. But we rarely ask, “Why is the child behaving this way?” The behavior is a symptom, a secondary issue. The real task is to understand what is actually bothering the kid. The child doesn’t necessarily understand it himself. It’s not his job to understand it. It’s the parent’s job, the teacher’s job, the doctor’s job, the psychologist’s job.
As long as we restrict ourselves to either punishing or curtailing children’s behaviors, it’s like giving an asthmatic cough medicine: it might suppress the symptom, but it does nothing about the inflammation that’s causing it.
If a child’s “acting out” is a result of a disturbed attachment relationship to her parents, to punish the behavior only further wounds the child, who didn’t deliberately choose that behavior and has no idea why she’s being punished for it.
It’s in relationships that people develop the coping mechanisms that may later make them sick. If my relationship with my parents demands that I become their caregiver because they’re alcoholics, then I’ll likely become a chronic caregiver and will ignore my own needs. The children of alcoholics suffer a lot from anxiety, depression, and physical illness because of how they cope. But they had no choice but to cope that way.
Frisch: You say no one is to blame for a poor attachment relationship between parent and child, but don’t the parents still have to change their behavior to break the cycle?
Maté: Absolutely. The older child’s brain, and even the adult’s brain, has the capacity to develop new executive circuits under the right conditions. Since the child’s most important relationship is with the parents, if the mother and father take better care of themselves and of one another and of the child, the child can significantly grow out of add or learn how to handle it better.
Frisch: Aren’t there cases in which a child’s acting out or add can’t be traced back to a lack of proper attachment to the parents?
Maté: Sometimes the question is not so much of attachment, but of attunement: the capacity of the parent to be emotionally in tune with the child. Many children are well attached to their parents, but the latter are too stressed or too distracted to be attuned to their kids. Stress on parents in this society is why we are seeing so many more kids being diagnosed with disorders.
Frisch: Why is attachment so essential for humans and other animals?
Maté: Attachment is simply the drive to be close to other creatures — to take care of them or be taken care of by them. The attachment drive is what we call “love” in lay terms.
It’s not essential for all animals. Reptiles hatch from the egg, and off they go. There’s nobody to take care of them; the mother turtle is long gone by the time the eggs hatch. Some of the offspring survive, but most of them don’t.
In avian species the infant has to attach to the parent to be nurtured and in order to model behavior and to learn. Mother birds instinctively care for their young and sometimes will risk their own lives in order to save their infants.
The more helpless the infant, the longer the period of attachment. In human beings it goes on longer than in any other creature because of the immaturity of the human infant.
The parent-child bond is our most important relationship; through it we experience the world. The child doesn’t experience poverty in the abstract; the child experiences whether the parents can provide for him or her. When a parent comes home stressed, the child experiences the parent’s emotions and, through them, the world that stresses the parent. The attachment relationship gives us our concept of the world: Is this place hostile? Is it friendly? Is it nurturing? Is it indifferent?
It’s also through the attachment relationship that we learn about relationships in general. Can people be trusted? Can we be vulnerable and express who we are, or are we going to be attacked for it? Do we need to protect ourselves and hide and shut down?
In the attachment relationship we also learn who we are: Are we good? Are we bad? Are we acceptable? Are we worthwhile? All of this depends not on what the parent thinks of us but on how the parent unconsciously acts toward us. If my parents enjoy me, then I’ll have good self-esteem. If my parents are so stressed and worried and depressed that they can’t enjoy me, even if they love me, then I will have low self-esteem, because children invariably make everything about themselves.
Frisch: How do other theories of learning and human development deal with attachment?
Maté: Educational theory tends not to understand it. Educators focus mostly on subject matter and little on the relationship between the teacher and the student, which is actually a strong determinant of how well a child will do in school. A kid who is well connected to adults will learn more easily. And the parents are the primary adult relationship.
In today’s climate teachers are under scrutiny and may themselves be graded by how well their students do on standardized tests. If you want to be a “successful” teacher, all you have to do — it doesn’t matter how inept you are — is teach in a nice middle-class neighborhood with intact families and well-adjusted kids, and you’ll get great scores. But if you take on the job of working with kids in poorer areas, where the families are challenged by poverty or racism and the children are constantly stressed, you might as well give up trying to present yourself as a successful teacher.
Frisch: Why don’t you advocate any particular set of parenting techniques?
Maté: Parenting is not about techniques. Parenting is about a relationship. You may read all the latest books, but if your relationship with your child is not well established because you’re too stressed, too busy, or too involved in your career, even the best techniques will not work.
In the context of a healthy relationship your proper parenting instincts will be triggered. When you’re with a baby, and the baby starts making big eyes at you and smiling, what’s your response? But when we are disconnected from our kids, because we haven’t been present enough in their lives, they don’t trigger our parenting instincts; they trigger our anxieties, our resistance, or our rage, and then we parent from those places.
The main trap parents fall into is thinking that this child is my child just because I am the biological parent. In the emotional sense the child is mine only if he or she is attached to me. In this society we tend to take that attachment for granted, but we can’t afford to do that. In older cultures parents used to be with their young children every hour of the day. In this society we often don’t see our kids for most of the day, so our status as parents is on shaky ground. When we’re not around, our kids tend to connect with people besides us, particularly other kids, who often supplant us as the primary figures in our children’s lives, even though we’re the caregivers and pro viders. Children are looking for an emotional connection. When they find it in other kids, they’re less concerned with what we as parents expect or demand of them.
Frisch: But what about stay-at-home parents who find themselves starting to go stir-crazy when they’re with their child all day long?
Maté: Why do they go stir-crazy? Because they’re alone with the child in an isolated home. That’s not how people are meant to parent. We’re meant to parent in a community. Indigenous women don’t go stir-crazy. They’re out in the village, relating to other adults the whole day.
The complete text of this selection is available in our print edition.
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