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

Bayview-Hunters Point (also referred to as “Bayview” in the book) is a predominantly Black community in San Francisco, California. Bayview became a majority Black neighborhood during the 1940s when the US naval shipyard Hunter’s Point was active and provided jobs for many Black shipyard workers. During the years that The Deepest Well covers, the community suffers from lack of access to healthy food, poor health care, and issues with street violence. In The Deepest Well, Burke Harris represents Bayview as a typical working-class community of Black people. The residents of Bayview, including Burke Harris’s patients, struggle because of the lack of resources in their community, but they also exhibit resilience and a willingness to help each other.

Burke Harris’s complex relationship with the community colors her representation of it. She takes great care to treat the residents and her patients with respect, especially by listening to them to figure out what the community needs to thrive; still, she acknowledges the tension arising from her status as outsider, especially in the initial years of her work at the pediatric clinic. These tensions are particularly present in Part 3, Chapter 8: “Stop the Massacre,” when community activists slow down the approval process for additions to the clinic and center. Burke Harris speculates that this opposition is rooted in self-interest among community activists and anti-immigrant bias based on her Jamaican American roots. Retrograde forces like these don’t predominate in Burke Harris’s account of Bayview. The community shows up in force to support the clinic, leading Burke to see herself as part of that community and to her insight that resilience and helping each other are the most essential traits of Bayview.

Caroline appears in Part 3, Chapter 10: “Maximum-Strength Bufferin’”—in which Burke Harris describes Caroline as an attractive, white, affluent woman who made her money as a technology entrepreneur. Despite these accomplishments, Caroline and her child (Karl) are survivors of severe verbal and emotional abuse; Caroline, in contrast to the clients Burke Harris was seeing at Bayview at the time, had access to many resources but still had no idea about the effect of ACEs on her and her son—or about the importance of removing her son from the damage that her husband’s behavior did to their family.

Caroline is an important figure in the book because her story allows Burke Harris to make the point that everyone is subject to the negative effect of ACEs and trauma in their lives; Caroline’s healing and that of her son happens through therapy, self-care, and education about how ACEs continue to shape Karl’s life, underscoring for Burke Harris that the universality of ACEs and treatment for toxic stress responses offers a chance for people to unite around this one issue.

Charlene is the young parent of Nia, a toddler who suffers from a failure to thrive under her mother’s care. Burke Harris circles around Charlene’s story multiple times. Initially, Charlene exemplifies a parent who’s incapable of providing care to her daughter. Burke Harris involves Child Protective Services (CPS) when it becomes clear that Charlene’s emotional disconnect from her daughter plays a role in her daughter’s poor health.

Charlene engages with the clinic staff; the intervention that eventually allows her to be a present parent in her daughter’s life is what Burke Harris recommends for families dealing with ACEs. It includes a multidisciplinary team to deal with the complexities of ACEs, parent-child therapy that strengthens relationships and helps parents become better buffers for their children, and addressing multigenerational ACEs. Charlene and Nia’s story are a sort of “happy ending” that shows the real effect of applying insights about how best to treat patients struggling with adversity.

Diego is one of Burke Harris’s patients, and his story is an additional framing anecdote that bookends her narrative, appearing close to the start and the end of the book. At the start of the book, Burke Harris describes Diego as an adorable seven-year-old who has the bones and body of a four-year-old. The fact that his development ceased in the same year that a lodger sexually abused him in his parents’ house is a data point that inspires Burke Harris’s research on the connection between ACEs and health problems later in life.

Burke Harris returns to Diego’s story 10 years later and finds that he’s had several successes but still encounters setbacks. The continuing need to support Diego in managing his stress response is evidence that the solution to helping survivors like him is clear yet complicated to implement. In addition, Diego is a figure who typifies many of Burke Harris’s patients in Bayview: He’s vulnerable to violence in his home and his community, but through his own resilience and the help of a buffering parent/caretaker, he can move forward with his life.

Evan is a sibling of Burke Harris. He appears four times in The Deepest Well: as the subject of an anecdote about a seemingly healthy 43-year-old man who has a stroke despite having no risk factors except a hidden one (adversity in childhood); as a sibling who takes care of Burke Harris when she suffers a breakdown in the aftermath of a pregnancy loss; as a brother who responds to their ACE (having a parent with untreated paranoid schizophrenia) by becoming a charmer; and once again as a patient whose life is saved after a stroke.

Burke Harris’s decision to dramatically detail her brother’s story in the book’s introduction helps anchor the urgency of addressing the ACE-health connection. Her disclosure later in the book that he’s her brother helps show that even a doctor like Burke Harris can benefit from understanding that connection. Evan’s charm and brotherly support exemplify the other side of ACEs—the superpowers of resilience and empathy that those who survive adversity often have.

The short narrative about Louis, a third Burke sibling, is a cautionary tale about the other possible outcome even in seemingly stable and financially comfortable families like the Burkes. Louis is missing and has been since he was 17. His story also explains why Burke Harris has a personal stake in making sure people know about the importance of the ACE lens.

Felitti is the first author of “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” published in 1998 in the American Journal of Preventive Medicine. The work of Felitti and his co-authors serves as the first indication for Burke that a toxic stress response might be the biological mechanism that explains how ACEs lead to poor health outcomes later in life. In Burke Harris’s book, Felitti is a scientist and doctor whose work exemplifies how inquiry-driven research, happy accidents, and a willingness to listen to the stories of patients can lead to breakthroughs.

Burke Harris also points out that Felitti and his co-authors didn’t gain much traction in their work; Burke Harris didn’t even know about the work during her medical school education just a few years later. Her account of the rejection of Felitti and his co-authors’ research is an important example of the power of lenses or paradigms to shape the tools that doctors can bring to bear in their treatment of patients. The study and Felitti are central elements of The Deepest Well because one of Burke Harris’s main motivations for authoring the book was to make the ACE-health connection that Felitti explored more widely known.