57 pages • 1 hour read
Gabor MatéWhen the Body Says No: The Cost of Hidden Stress
Nonfiction | Book | Adult | Published in 2003A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Chapters 1-5Chapter Summaries & Analyses
Chapter 1 Summary: “The Bermuda Triangle”
In a case study, Dr. Gabor Maté remembers a patient, Mary, who punctured her finger with a needle. Due to a preexisting circulation condition, Raynaud’s syndrome, Mary developed gangrene, and the finger needed to be amputated. However, Mary then developed scleroderma, an autoimmune disorder that stiffens tissues in the body, including the skin, heart, and esophagus.
Dr. Maté interviewed Mary about her life and found that she had repressed the details of a very traumatic childhood and continued to prioritize her husband and children over her own needs. Mary died eight years after her diagnosis. Dr. Maté wonders how different her life may have been if she had been able to express her needs as a child.
Inspired by the case study of Mary, Dr. Maté published an article suggesting that people’s emotional coping style affects their physical health. It was criticized by many physicians, but others agreed that the mindbody connection is important in treating disease. Maté suggests the term “mindbody,” as suggesting a connection between mind and body still establishes the two as separate entities, when in fact they can never exist independently of the other.
Dr. Maté finds that most patients’ doctors do not ask about their lives or experiences, as this information is viewed as “anecdotal” and unhelpful, perhaps even inappropriate. He is interested in the hidden stresses that are formed by early programming and how these can contribute to a person’s physical health. In particular, Dr. Maté believes that emotional repression can harm physical health. His work relies on anecdotal evidence, not just scientifically provable and testable data, but he does not believe that this detracts from the power of the findings.
Psychoneuroimmunology is a new discipline whereby the psyche is believed to interact with the immune system, even at a cellular level. This is a frame of thought that used to be accepted but has been lost (until recently) in a medical orthodox that prioritizes verifiable data. Having said this, research evidence has also made the connection between mind and body in some cases; for example, scientific data suggests that loneliness contributes to disease. Dr. Maté suggests further links between emotional repression and ulcerative colitis, Crohn’s disease, chronic fatigue, fibromyalgia, migraine, skin disorders, endometriosis, and many other conditions. Dr. Maté recognizes that victim-blaming is a dangerous possibility of this interpretation, but he instead suggests that it is a question of the patient’s responsibility and autonomy, rather than being blamed for their illness.
Dr. Maté reflects on his own connection to this topic by noting that he intentionally disguises his limp when he goes to see his mother. He reflects on the fact that, as an infant, he lived with his mother in a crowded ghetto in Budapest; his grandparents and aunt were killed in Auschwitz, and his father was in a forced-labor battalion for the German army. He learned in his infancy to suppress any sign of his own discomfort so as to not burden his mother further; he concludes that emotional repression is present in all people to different extents.
Chapter 2 Summary: “The Little Girl Too Good to Be True”
Dr. Maté discusses a family case study. Natalie was diagnosed with multiple sclerosis (MS) at the same time her husband, Bill, was diagnosed with cancer, which began in his bowel and spread to his liver. Their son was expelled from school for drug and alcohol use and was sent to a rehabilitation facility for six months.
Natalie’s MS was labeled as relapsing and remitting; as in the case of many patients with relapsing and remitting MS, it tends to exacerbate in times of stress, or immediately after a high-stress period. She learns that she has to listen to when her body says no, but she cannot suppress the urge to help her husband and children. In another case study, Barbara, a psychotherapist, developed MS after a stressful guest disrupted her home and marriage.
Some physicians posit, including neurologist Dr. Louis J. Rosner, that MS expresses when there is a genetic susceptibility for MS combined with the onset of an autoimmune allergy to one’s own tissue. On the other hand, Dr. Maté sees a link between emotional stress, particularly stress that threatens the patient’s security, and MS. This is supported by numerous studies on MS patients from both Israel and the US, as well as by a study on rats where autoimmune disease worsened when the fight-or-flight stress response was blocked.
Maté cites another example concerning a woman, Véronique, who didn’t report numbing in her legs and chest. Véronique was going through immense life stressors but was conditioned not to bother or worry her adoptive mother.
Maté further cites the example of cellist Jacqueline du Pre, who died at the age of 42 from MS. Du Pre had an unhealthy relationship with her controlling mother. She was deeply depressed as both a child and an adult. When she married, du Pre seemed to take on the accent of her new husband, illustrating her complete merging of her personality with her husband and mirroring her childhood relationship with her mother. She masked her developing MS symptoms from her husband. Later, she came to believe that her marriage and her music were masking her true self, and she left her marriage and her career for a time, before returning to both and dying soon after. Du Pre’s sister believed that, despite the way that many people connected to her music, that no one every truly heard her sister and that this was du Pre’s downfall.
Chapter 3 Summary: “Stress and Emotional Competence”
Part of the problem in understanding the significance of stress, Maté suggests, is that people’s understanding of stress is limited. Stress is not merely a concrete event, such as the loss of a loved one or being fired from a job; rather, people can become habituated to high levels of internal stress. Stress, rather than being merely a subjective experience, is correctly measured via a set of objective physiological events in the body.
Maté cites the case study of Alan, a healthy and driven engineer who was diagnosed with cancer of the esophagus. His life was defined by never saying no, especially at work. He thrived under the challenge of what he termed as “good stresses” and enjoyed taking things on. He also was experiencing “bad stress” in his unhappy marriage. Regardless of how Alan attributed these different kinds of stresses, both contributed to chronic reflux, which predisposed him to esophageal cancer. Alan began saying no when he was diagnosed, believing that this played a big role in his recovery.
Hans Selye, author of The Stress of Life (1956), articulated that stress has three components: the stressful event, the processing of that event (whereby an interpretation is formed), and the response, which consists of “physiological and behavioral adjustments made as a reaction to a perceived threat” (Maté 31). Processing is affected by the personality and current psychological state of the individual. In terms of the response, Selye articulates that stress generates a central nervous system response as well as a hormonal response that affects the adrenal glands, the lining of the digestive system, and the immune system in terms of the spleen, the thymus, and the lymph glands.
In terms of the hormonal response, cortisol acts to dampen the stress reaction, decreasing immune activity. Meanwhile, the hypothalamus, pituitary gland, and adrenal glands (the HPA axis) also directly affect the immune system and other organs. This wide-ranging response is triggered by any perceived threat. The body tries to reach a state to deal with the threat while also maintaining homeostasis. Selye points out that “for man the most important stressors are emotional” (34).
A study of spousal caregivers whose partners had Alzheimer’s disease versus controls revealed significant immune suppression in the group of caregivers; this was exacerbated in those caregivers who were socially isolated. Research has also revealed inhibited uptake of immunization against influenza and depleted tissue repair ability in the caregivers. Similarly, dental students recovered faster from deliberately inflicted mouth wounds over the summer compared to during their exams.
According to Maté, people often remain trapped in stressful situations, such as unhealthy lifestyles or emotional patterns that cause chronic stress, because they have become inept at understanding and communicating their emotional experiences.
Drawing upon the work of psychologist Ross Buck, Maté notes three levels of emotion: Emotion III (the inner experience of emotion), Emotion II (the outward expression of emotion), and Emotion I (the physiological response to emotion). He notes that parents often struggle to accept displays of Emotion II, which causes those children to become conditioned to repress emotions and emotional expression, causing a helplessness in adulthood that may lead individuals to be trapped in dysfunctional or unhealthy situations.
Emotional competence requires the capacity to feel one’s emotions, the ability to express emotions and maintain emotional boundaries, the capacity to recognize whether psychological reactions are pertinent to the present or whether they are actually rooted in the past (which will lead individuals to perceive loss or the threat of loss where none exists), and the awareness of which needs require satisfaction rather than repression. Stress occurs in the absence of these skills or awarenesses.
Chapter 4 Summary: “Buried Alive”
Maté examines the medical evidence as well as anecdotal findings surrounding those diagnosed with amyotrophic lateral sclerosis (ALS). Through a number of case studies, Maté suggests that the disease is caused by emotional suppression, which is rooted in childhood isolation and loss. These upbringings tend to result in people who, as adults, lead highly driven lives (likely in order to be perceived as acceptable or admirable), are loath to ask for help, and are perceived, by medical professionals as well as friends and families, as very “nice.”
This brand of niceness typical of people with ALS goes beyond a predisposition to be sweet or thoughtful; rather, it is a brand of niceness that is formed through the complete suppression of one’s needs and emotional expression. In 1970, two Yale University psychiatrists published a paper on the phenomenon and documented that ALS patients tended to be exceptionally hard workers who habitually suppress negative feelings of anxiety, anger, and sadness, preferring to present as uniformly cheerful. Neurologists from the Cleveland Clinic discuss this phenomenon in another paper, finding that those with ALS seemed to “cluster at the MOST PLEASANT end of the personality spectrum” (42).
Alexa, an elementary school teacher diagnosed with ALS, was totally unable to express her emotional experience. She recalls being unloved by her adoptive mother despite her best efforts. Later, she is dominated by her opinionated husband, whose thoughts and ideas she inherits entirely.
Lou Gehrig, a baseball player who died from ALS (ALS is sometimes called “Lou Gehrig’s disease”) famously played with broken fingers so as not to let his teammates down. Gehrig made immense allowances to others and was known for being kind and considerate. Conforming with Maté’s theory about childhood wounds, Gehrig had an extremely interdependent relationship with his mother.
Dennis Kaye wrote his memoir about battling ALS using a stick fastened to his forehead, having lost the use of his hands and fingers. He confirmed that, adhering to the “ALS personality,” he lived a life of constant activity and seemed drawn to hard work, as illustrated by the manner in which he wrote his book.
Stephen Hawking, a scientist who was well-known for his ALS diagnosis, came from a family to whom emotional vulnerability and expression were taboo; the family was totally devoid of warmth. Hawking refused help from friends when he was moving around university as his disease worsened, often experiencing bad falls. Hawking was reluctant to discuss the stress or strain caused by his developing illness, preferring his wife, Jane, to silently shoulder his care.
Dana Johnson, a nurse and researcher, decided to adopt a maxim of complete bodily self-love in her final stages of ALS. Through focusing her loving attention on different body parts and choosing to love them unconditionally, Johnson “unfroze” each part of her body.
Chapter 5 Summary: “Never Good Enough”
Maté considers the impact of stress on developing cancerous cells. Many experts, including Dr. Donna Stewart, a University of Toronto professor, disagree with the perspective that stress is causational in cancer: “The evidence for stress is pretty low” (60). However, Maté finds the evidence (both anecdotal and data-driven) from many patients with cancer to be highly suggestive of an interplay between genetic tendency and environmental factors (namely, stress). In particular, Maté calls on evidence that suggests that women are more prone to breast cancer if they come from families characterized by emotional disconnection, if they repress anger, if they lack nurturing relationships in adulthood, and if they are “compulsively caregiving types” (62).
Michelle, a patient of Maté’s who developed breast cancer, came from a family of parents with alcoholism. Similarly, David, who has had four different cancers, recalls his parents’ unhappy marriage and emotional distance from their children. Anna, a breast cancer patient, needed to continue caring for her emotionally abusive father through her chemotherapy treatment. She recalls being abandoned by her mother and being unable to articulate her discomfort to her father when he discussed his sex life with her. Betty Ford, a former first lady, came from an unloving family, which shaped her coping style in a way that fostered chronic stress. Her self-concept was low; she felt that she became a “doormat” for her husband and her children. She developed both alcoholism and breast cancer.
One male patient, Melvin, developed breast cancer after a public and humiliating legal process. Furthermore, his life conforms with Maté’s construct of chronic stress: His mother was not warm or loving, and his father’s love was conditional and based on his children’s achievements. Melvin tends to suppress his own emotional needs and truths in favor of being viewed positively; he picks up colleagues’ slack at work instead of delegating that they should complete their own tasks. Tellingly, he avoids expressing anger.
Chapters 1-5 Analysis
In the exposition, Maté introduces the pivotal theme, The Shortcomings of Western Medicine: Mindbody Dichotomizing and Rejection of Anecdotal Evidence, through Mary’s case study. Maté problematizes the original approach to Mary’s complex presentation, an approach that is normalized in modern medicine: “We simply treated each of her physical symptoms as they presented themselves” (2). Specifically, Maté problematizes the narrow focus of medical specialists who deal only in their own specialty: “The more specialized doctors become, the more they know about a body part or organ and the less they tend to understand the human being in whom that part or organ resides” (4). Maté suggests that in only treating the specific complaint that comes under their remit, specialists are unable to look at health in a more holistic sense; this discourages them from considering the interrelation of physical complaints as well as removing them from the lived experience of the patient, which Maté believes is integral in understanding disease presentation.
Through Maté’s discussions with Mary, he increasingly comes to problematize the interpretation of Mary’s symptoms in isolation from each other, and more broadly, the interpretation of her “body in isolation from the mind” (3). His fascination with the mindbody construct is illustrated in his seeking out anecdotal evidence about Mary’s life, believing that this might have a bearing on her chronic and multifaceted illness. The semantics of the word “mindbody” are important in Maté’s work; this term illustrates his belief in the absolute interconnectedness of these systems, rather than discussing them as inherently separate systems that are perhaps somewhat interrelated.
Through his discussions with Mary, Maté’s interest in The Power of Early Conditioning in Forming Coping Mechanisms is illustrated. Mary’s traumatic childhood caused her to learn to repress her needs and feelings: “She had learned not to express her feelings to anyone, not even herself” (2). Maté reflects on his own deeply ingrained repression, somewhat similar to Mary’s, that was formed by wanting to reduce stress for his mother: “I learned early that I had to work for attention, to burden my mother as little as possible and that my anxiety and pain were best suppressed” (11). Maté forms the belief that the repression of emotions in childhood has immense impacts on these individuals as adults, in terms of forming maladaptive coping mechanisms that encourage dissociation from emotions, especially from distress and anger, rather than feeling and expressing these emotions. This can be caused both by under-involved, absent, or unloving parents, or parents who are overinvolved, controlling, and overly anxious. Either of these maladaptive parenting strategies can result in adults who repress negative emotional expressions and who “spend their entire lives as if under the gaze of a powerful and judgmental examiner whom they must please at all costs” (7). This perception of omnipotent judgment mirrors the parental presence that the adult experienced as a child—or perhaps, ongoingly as an adult, depending on the parents’ presence or absence in the adult’s life.
Maté perceives maladaptive coping mechanisms, namely repression, as a cause of chronic stress, as “people with indistinct personal boundaries live with stress” (19). This leads to the next of Maté’s themes: The Relationship Between Chronic Stress and Disease. Over and over, Maté encounters cases that elucidate the connection between chronic stress (caused by childhood conditioning that leads to repression) and autoimmune illness or other diseases. Maté’s stated aim is to articulate “the effects of stress on health, particularly of the hidden stress we all generate from our early programming” (4).
Maté suggests that acute and chronic stress through childhood conditioning inhibits the ability of individuals to engage in necessary fight-or-flight behavior, instead encouraging them to live in a constant state of stress and vigilance while repressing their present needs and emotions. He calls this state “environmentally conditioned helplessness” (20). This helplessness leads these individuals to remain in stressful work, life, or relationship situations, which only exacerbates chronic stress, because these individuals are unable to connect with their present needs and make decisive change as they are “anesthetized to emotional realities” (36). This is the case for Mary, who had a “meek and diffident manner” that masked a “vast store of repressed emotion” (20); Mary continued to subjugate herself to her husband and her children’s needs, rather than her own, mirroring patterns learned in childhood. This expressed itself in multifaceted physical maladies that eventually led to Mary’s death. Maté believes that Mary’s body “said no” when her conditioning inhibited her from doing so herself, hence the title of his work.
Maté’s contention with modern medical practices in failing to acknowledge the inherent mindbody interconnectedness is mirrored in his research into ALS, MS, and cancer: “Breast cancer patients often report that their doctors do not express an active interest in them as individuals or in the social and emotional context in which they live” (59). Maté problematizes this; as in the case of Mary, he sees imperative connections between emotional states and cancer, as “emotions directly modulate the immune system” (61). He notes that breast cancer patients are more likely to come from either emotionally distant or overly judgmental homes and therefore are more likely to repress emotions and needs.
Maté’s observation of the link between repression and disease is suggested in the 1977 British study that found that “‘extreme suppression of anger’ was the most commonly identified characteristic of breast cancer patients” (64). A typical profile can be formed for breast cancer patients, who are typically “altruistic, compulsively caregiving types” (62). This mirrors observations of MS patients, who often are preoccupied with “fitting [themselves] in to someone’s expectations” (25), as well as ALS patients, who tend to be extremely nice in a way which suggests abandoning their own needs in favor of the needs and expectations of others.
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