The Deepest Well: Healing the Long-Term Effects of Childhood Adversity

“I wonder…What if…It seems like…These questions kept popping up, but part of the problem in putting the pieces together was that they would emerge from situations occurring months or sometimes years apart. Because they didn’t fit logically or neatly into my worldview at those discrete moments in time, it was difficult to see the story behind the story. Later it would feel obvious that all of these questions were simply clues pointing to a deeper truth, but like a soap-opera wife whose husband was stepping out with the nanny, I would understand it only in hindsight.”

Just as Burke Harris pushes back against American cultural idealism, she consistently intervenes in popular representations of science and scientists. Her description of scientific insight as a nonlinear process and the importance of persistent questions allows her to show that science and research can be driven by uncertainty and asking questions rather than by certainty and hard facts.

“There is a widely known parable that students all learn on day one in public-health school, and it happens to be based on a true story. In late August 1854, there was a severe cholera outbreak in London [...]Back then the dominant theory was that diseases like cholera and bubonic plague were spread through unhealthy air. John Snow, a London physician, was skeptical of this “miasma theory” of disease. By canvassing the residents of the Broad Street neighborhood, he was able to deduce the pattern of the disease. Incidences were all clustered around a water source: a public well with a hand pump. When Snow convinced local officials to disable the well by removing the pump’s handle, the outbreak subsided.”

This passage is the source of the work’s title. In addition, Burke Harris’s inclusion of a key episode from the start of epidemiology and public health as medical disciplines allows her to convey important scientific and medical concepts. This quote is a typical effort by Burke Harris to make science and medicine comprehensible by using stories from scientific history.

“As budding public-health crusaders, my classmates and I focused on the sexy part of the parable of the well, the bit where Snow topples the miasma theory. But I also took away a larger lesson: If one hundred people all drink from the same well and ninety-eight of them develop diarrhea, I can write prescription after prescription for antibiotics, or I can stop and ask, ‘What the hell is in this well?’”

The diction—“sexy” in particular—is informal. Burke Harris uses such word choices to create a relatable persona for those who may be intimidated by the scientific content of her book. In addition, she once again highlights the importance of asking good questions in scientific inquiry.

“These babies came into the world no different than the ones born in Laurel Heights, yet as I did newborn exams in Bayview, I knew that these human beings’ lives would, according to the statistics, be twelve years shorter than the lives of the children in Laurel Heights [...] because somewhere in the future, something in their bodies would change—something that would alter the trajectory of their health for the rest of their lives. At the beginning, they are equal, these beautiful bundles of potential, and knowing that they won’t always be is enough to break your heart.”

Burke Harris insists throughout the book that health disparities, ACEs, and toxic stress aren’t problems we can afford to ignore or see just as problems of poor people and people of color. In this passage, she appeals to emotion to help make her topic relatable—and reveals that emotion, as much as reason, drives her work on this topic. This self-representation disrupts the common perception of scientists and doctors as cold, completely rational thinkers who are disconnected from human concerns.

“If you approach your experiments simply as plug and play—either they work or they don’t—then you’re missing the potential for a happy accident. Day to day, good scientists actively engineer the conditions for discovery by making the most of accidents.”

Burke Harris further illuminates what real science looks like by highlighting the importance of poor results and chance as parts of the scientific method and inquiry. In addition, she posits that passion and curiosity are central to good science. Such descriptions of what doing science looks like are designed to get those not in the medical and scientific community to see her research with the same excitement that she does.

“Could my colleagues and I create a standing order for patients like Diego? What would that look like? I didn’t know, but the thought was enough to fill me with the same kind of electricity that I felt as a kid when I was working on a problem with my dad and could sense I was on the right track.”

Burke Harris returns to Diego’s story throughout the book as one of many narrative hooks she uses to show the implications of her research. In this case, she’s emphasizing the importance of providing ongoing resources for patients living with the consequences of ACEs.

“Dr. Felitti’s initial insight about the link between childhood adversity and health outcomes led to the landmark ACE Study. This was a prime example of doctors thinking like detectives, following a hunch and then putting it through its scientific paces. Beginning with just two patients, this research would eventually become both the foundation and the inspiration for ongoing work giving medical professionals critical insight into the lives of so many others.”

Rather than simply summarizing the outcome of the ACEs study in dry detail, Burke Harris chooses to narrate how Felitti’s accidental discovery of his patient’s ACE and following up on a hunch allowed him to contribute breakthrough research to medicine. Her decision to emphasize narrative over factual presentation is one of many instances in which she uses storytelling to make science more interesting.

“I’d have to jump back into those journals and hit up some medical conferences, but now I had the ACE Study to guide me. I could use its language in my searches, interrogate its authors for clues, and even start collecting my own ACE data at the clinic. The realization that this was bigger than my patients, bigger than Bayview, made my heart pound. Adversity’s detrimental impact on health had all the hallmarks of a public-health crisis hidden in plain sight.”

Burke Harris’s description of her next step after coming up with a research question—doing background research and engaging in collaboration and conversation with others—illustrates another important stage of scientific inquiry. In focusing on her motivation for the research, she reveals that science can indeed be driven by the personal stakes of scientists and that science is a team sport.

“[T]he body remembers.”

This statement, which the author placed within a long discussion of how past trauma and the stress response have a persistent effect on the present, packs a stylistic punch and drives home a central point. Burke Harris uses such statements to help important ideas stand out in dense discussions. In addition, this statement highlights the important theme of the link between the past and the present—this time in terms of the biological reality of what trauma does to the body.

“Flipping through a magazine in the checkout line or circling the Internet vortex, you’ve probably come upon stories of superhuman strength: the father who lifts the car that was pinning his child (maybe an urban legend?) or the woman who fought off the mountain lion that was mauling her husband […] If you’ve ever wondered what makes a person able to achieve such feats, I can tell you it’s not the daily bowl of Wheaties—it’s the elegantly designed, evolutionarily imperative stress-response system. Essentially, it works like this: Imagine you’re walking in the forest and you see a bear.”

Burke Harris inserts references to popular narratives to help explain a scientific phenomenon. This rhetorical choice, coupled with an extended comparison between stressors and bears, helps her break down complex scientific concepts in a relatable way.

“Vegas Baby! (aka the Ventral Tegmental Area, VTA). If the locus coeruleus is a Raiders fan, then the VTA region of the brain is Las Vegas. Responsible for things like rewards, motivation, and addiction, this part of your brain is the one you really don’t want running away with your credit card. Basically it all boils down to dopamine, which is the feel-good (or feel-amazing) neurotransmitter that peppers your brain with rewards when you have sex, shoot heroin, or say yes to that piece of triple chocolate cake at the end of the day.”

Like some section and chapter titles, Burke Harris’s descriptions are often witty. They help Burke Harris clearly convey important concepts during deep dives into the science of stress responses. Here, she relies on everyday pleasurable experiences and comparison to help illustrate scientific mechanisms that operate in everyone’s lives. These choices help show that her book is for everyone.

“‘Go on an’ call ‘em,’ Cora responded. ‘CPS don’t got to raise that baby, I do. He need to get some act-right in him. Otherwise, he goin’ to end up in the pen just like his mama.’ It was obvious to me that Cora believed that she was doing the right thing. After watching two generations lose their way, Cora was relying on the tools she had learned in her own upbringing to keep Tiny on the straight and narrow. The irony was that, despite Cora’s intentions, the beating was undoubtedly unleashing a neurochemical cascade that made Tiny more likely to end up like his mom and his grandparents.”

This passage includes the voice of a caretaker of a Bayview child. Burke Harris preserves the diction of the caretaker (a grandmother who strikes a misbehaving child in Burke Harris’s clinic) and her rationale for hitting the child, as the author tries to accurately represent the people she serves in the community. The diction and frame of reference here of a grandmother’s lived experience contrasts sharply with those of a scientist-doctor’s voice explaining why the grandmother is wrong. This passage reflects a tension between Burke Harris and the people on whose behalf she speaks and advocates. She gains authority and credibility in this instance and others by using emotional appeals to focus on how adaptive strategies like this grandmother’s response can further traumatize a child.

“‘What’s your name?’ I asked. ‘Marjorie,’ she said, smiling. Since that day with Marjorie and the hospital council, after every talk and every presentation, I make it a point to go up to the people clearing the tables or breaking down the PA system to ask them what they thought. No matter how well my presentations are received professionally, talking to these folks always gives me additional insight into how the story of ACEs is playing out in people’s day-to-day lives. I walk away understanding that no matter the geographies, ethnicities, and socioeconomic backgrounds, we are all affected by ACEs in similar ways.”

In this passage, Burke Harris addresses the tension of being an apparent outsider—an Ivy League doctor who isn’t from the community she serves. She presents herself as having the resources and access to ensure that stories like that of Marjorie—a working-class woman in recovery from chemical dependency—get told. Burke Harris uses stories like these to enhance her credibility but, more importantly, to highlight the people whose struggles inspire her to continue with the years-long process of raising awareness about the effect of ACEs.

“Dr. Lieberman remembers tensing up and having the realization that stress lives in the body [….] Dr. Lieberman started her professional work from a place of deep personal familiarity and curiosity about trauma and stress [….] After years as a clinician, Dr. Lieberman came to understand that children’s need to create a story or narrative out of confusing events is quite normal. Children are compelled to give meaning to what is happening to them. When there is no clear explanation, they make one up.”

Burke Harris explicitly uses storytelling about the person behind the science (Lieberman) and describes storytelling as one of the main ways that children (and the adults they become) process trauma. The implication is that storytelling is at the heart of understanding ACEs.

“Dr. Renschler took his time building rapport with Charlene, starting off by giving her some choice in how the sessions would proceed, offering her some power in a situation where she felt totally powerless. Instead of diving right into Nia’s health and Charlene’s depression, he started by addressing what Charlene said was her biggest problem, something that every parent of an infant can relate to: serious lack of sleep.”

While medical literature often represents people in need of support as passive recipients of treatment and help, this description of the rapport between Charlene and her therapist underscores Burke Harris’s commitment to representing people like Charlene as partners in healing themselves. The results of Charlene’s assuming more ownership over her mental health and buffering for her daughter make this story a good example of how the book functions as a self-help guide.

“I got to see all the ways these interventions were making my patients’ lives better. I knew that was real, but as a scientist, I also knew it was anecdotal. We didn’t have the manpower or the money to do the kind of systematic data tracking that would translate all those good report cards and bike-giveaway parties into solid research that would stand up to scrutiny in scientific circles. At one point, I even thought to myself, We should be writing all of this up. But our team was stretched thinner than pantyhose. I realized that we could do or we could write, but we didn’t have the bandwidth for both. I decided that, for now, the doing was more important.”

Burke Harris consistently experiences internal and external conflicts in balancing the demands of public health. While her patients need her, spending time on research might allow her to address issues at a community and societal level. Her open discussion of this conflict and her choice to focus on immediate needs shows that she cares about the community where she works—and paints a realistic picture of practicing science and medicine in under-resourced communities.

“It’s one thing to read research papers that talk about prevalence rates and odds ratios. It’s another thing entirely to meet the Marjories of the world and hear their stories. When statistics have faces, they feel a lot heavier. The worst part for me was thinking of the men, women, and children struggling with the effects of ACEs and toxic stress, walking around every day without knowing what the problem was and, harder still, not knowing that there were effective treatments. Their doctors don’t tell them because chances are, their doctors don’t know. To anyone looking at the day-to-day practice in the average doctor’s office—or looking anywhere else in society—it was as if the research didn’t exist. The more I knew, the more intolerable it felt to me that almost no one seemed to have this information.”

Burke Harris approaches raising awareness about ACEs and the stress response with a sense of mission. This passage shows that she grounds her work in the ethical commitment of doctors to do no harm and prevent harm where possible. This rationale also shows how deeply rooted her work is in public health, which focuses on how medicine can help wide swaths of society by preventing illness.

“Here in front of me was the blueprint for our success—a community of people struggling with a legacy of ACEs, up against obstacles strengthened by historical cycles of marginalization and violence, but nonetheless coming together to advocate for a better life for their kids. These families testified that we were doing something powerful and important for their children. The cycle could be broken [….] Overwhelmed, I was struck yet again by the way that people in our community take care of one another. That moment is what Bayview looks and feels like from the inside, and I have to say, it feels pretty damn good.”

This marks the moment when Burke Harris resolved tensions between herself and the community she serves. She identifies herself as an outsider who enriches the community by providing a service but also by manifesting a positive value—showing up for each other—that she sees as an integral part of Bayview. This characterization of Bayview sidesteps the tendency to represent under-resourced communities as being devoid of strength.

“More good news—there are things that you can actually do yourself to boost your synaptic plasticity; sleep, exercise, nutrition, and meditation all enhance the process.”

The book’s subtitle—Healing the Long-Term Effects of Childhood Adversity—implies that although The Deepest Well may belong to the self-help genre, the book is mostly about changing the paradigm that laypeople and professionals use when they talk about ACEs and health disparities. This chapter details how patients learn to tamp down their toxic stress responses, shifting that focus through practical approaches to addressing the problem.

“We are expected to be perfect. We are supposed to have it all together. The hiding is pervasive because exposure can cost people their careers. By the mere fact that we are hiding it, we are perpetuating it.”

This quote comes from Caroline, a woman whose affluence and professional success weren’t enough to protect her and her son from the effect of ACEs. Burke Harris uses this story as the opening move in her argument that everyone is subject to the effect of toxic stress.

“What I felt Jenee wasn’t seeing was that while my kids and hers might have stress-response-triggering experiences because of their race, poor white kids living in Appalachia also have triggering experiences. Think about it like this: We all live in a forest with different kinds of bears. There is a large group of bears that populate a part of the forest called Poverty, and if you live there, you’re going to see a whole lot of bears. There’s also a part of the forest called Race, where a different cluster of bears hang out.”

Burke Harris further advances her argument that toxic stress is universal by using her personal experience to push back against Ms. Johnson’s argument that the people suffering from ACES (people of color and people without a lot of financial resources) aren’t represented at conferences. Burke Harris returns to the bear story to make this point, a move that emphasizes all the science behind her characterization of the stress response and adds credibility to her argument.

“We need to make dat argument! We mus’ hexplain to ev’ry person dat if dey are in Appalachia, if dey are living in Middle Americah, if dey are living in Kentucky and dey believe dat dey have it hard—we mus’ mek sure dat ev’ry single person knows dat dey cyan get strong solu-shons—for poor white folks and for de peer-ent who brought her child and her syuitcases to you—dat we are in a united struggle about de effects of adversity on de developing brains and bodies of children. And when we all get behind dat, den we will have solu-shons that will lif’ ev’rybody.”

Burke Harris’s primary persona in the book is a passionate scientist following the facts and her heart to find scientific truth. In this passage, however, she code-switches to patois—a marker of her identity as the child of Black Jamaican immigrants—to counter an activist’s criticism that the ACEs lens ignores authentic, lived experiences of people of color. Her use of this voice in a public space exemplifies how Burke Harris increasingly discloses more personal information about the effect of ACEs in her own life. These disclosures and this voice help her shore up both her professional and personal credibility. The implication is that these various parts of her identity together make her a powerful force for good.

“If this were a movie, we could roll the credits right here and all of us could feel pretty good about ourselves. Diego had ‘made it.’ But that’s not how life works. The story doesn’t stop. In real life, Diego lives in a dangerous neighborhood, and things keep happening.”

At the start of the book, Burke Harris is a self-described idealist and slightly naive doctor who believes she can discover and treat the cause of health disparities. After 10 years of work in Bayview, her approach is tempered and pragmatic. She recognizes that the relationship between the past and present that Diego lives can’t be undone but can be shifted by consistent intervention. Even her epilogue—a fantasy of a future in which screening for ACEs is universal in the US and on its way to going global—she keeps this pragmatic focus, showing how much the experience of working on this topic has changed her as a doctor.