Expression of Hidden Stress: Shaping the Biopsychosocial Triads

Abstract

Background

When the Body Says No: The Cost of Hidden Stress, written by Dr Gabor Maté, is an influential book illuminating the mind-body relationship. The book reflects upon the precarious role of prolonged stress, adverse childhood experiences and emotional repression in producing neurodegenerative and chronic diseases.

Summary

Based on the author’s clinical case studies, autobiographies and empirical evidence, this book review critically opines on the prominent themes—childhood trauma, parentification, emotional repression, people-pleasing, lack of assertiveness and repression of anger—signifying the biopsychosocial milieu from an Indian experience through existing knowledge. Further, the importance of the biopsychosocial model of health in illness prevention has been emphasised. Strengths and practical implications have also been presented.

Key Message

This book review implicates the effects of the holistic healing and wellness framework through the process of upholding one’s own needs and wants before others. Nevertheless, the applicability of the insights is immensely relevant in the field of psychology, medicine, psychotherapy and healthcare.

Introduction

The present book, written by Dr Gabor Maté, a Canadian physician, is a powerful work that emphasises the intricacies of the mind-body connection. Maté concludes that psychological forces can equally contribute to physiological illnesses. This is a book with a plethora of practical insights. With expertise in trauma, stress and childhood development, he put forth the outcomes of modern science that reconfirm this psychosomatic link. Though originally published in 2003, it was later republished in 2019 with recent changes. The present review focuses on the current edition, where the author enlightens the readers with his rich qualitative and scientific experiences and insights from a Western lens.

The core theme of the book revolves around how the author’s clinical case studies revealed that adverse childhood experiences, emotional suppression, repressed anger and prolonged stress contributed to neurodegenerative and chronic physical illnesses. Throughout his chapters, he probed several questions: How are our body and mind connected? Is our illness stemming from something more psychic? Is our body paying the price of prolonged stress and emotional suppression? Is disease the body’s way of saying ‘no’ when we cannot? Moreover, he offered a holistic framework for healing.

The present review critically examines the central themes—childhood trauma, parentification, emotional repression, people-pleasing, lack of assertiveness and repression of anger—based on the interactions of the biopsychosocial perspective in general and cultural relevance per se through the Indian lens. As there has been no evidence of reviews done previously from the Indian experience, the present review draws attention based on the author’s core themes. Thus, referring to India’s vast social landscape of idealisation of silent endurance, emotional restraint and conformity, Maté’s work raises significant and culturally rooted experiences of global human suffering.

The review is organised in four sections: Summary of the argument, cultural resonance, strengths and practical implications.

Summary of the Argument

Maté conveys the journey of a human being from an illness to wellness continuum. He emphasised that his book serves as a ‘catalyst for personal transformation’ and not merely as a ‘book of prescriptions’.

The book comprises nineteen chapters, with relevant titles and a total of 320 pages. It captures real-life examples from his clinical experiences, published biographies, interviews, autobiographies of famous people and previous research. The style of writing is lucid, keeping the tone light for lay readers. Highlighting the importance of hidden stresses and their impact on health, Maté not only explained from his clinical settings but also validated from his traumatic childhood experiences. The summary of all 19 chapters is provided in this section.

The author sets the foundation with the first chapter, titled ‘The Bermuda Triangle’, a metaphor to compare our body’s way of mysterious rejections of recognising bodily alarms under life circumstances. The case of ‘Mary’ was introduced. She was diagnosed with scleroderma (an autoimmune disease), which took her life. Her case history was filled with experiences of abusive childhood, parentification and neglect from foster parents. Being a mother of three children, she never expressed her vulnerabilities but rather repressed her trauma and negative experiences. This led to ignoring her illness before the needs of her children. The author reflectively questions: ‘Was the scleroderma her body’s way of finally rejecting this all-encompassing dutifulness’?^{1(p. 10)} Thus, inferring that when we do not learn when to say no, our body ends up saying it. This becomes a recurring theme as he later introduces more cases and interviews in the following chapters.

In the subsequent chapters, cases of multiple sclerosis, Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis (ALS), cancer and rheumatoid arthritis have been presented. In each of the cases, emotional repression due to childhood loss and emotional isolation, anger repression and prolonged unhappiness contributed. Maté underlines ‘emotional states are of great potential significance in the prevention or encouragement of cancer metastasis’.^{1(p. 113)} Moreover, prolonged emotional suppression, self-sacrifice, anger suppression and a sense of helplessness are portrayed as potential traits in cancer patients.

Undeniably, two prominent factors—physiological balance and emotional boundaries are the essence of stress regulation. Further, hyper-sensitivity to emotional cues and unexpressed grief are also linked with the development of neurodegenerative diseases and functional illness. Unhealthy bonds, intergenerational trauma, abusive histories and parents’ childhood trauma disrupt the biology of relationships, coping styles and illness susceptibility. Final, he represented ‘Seven A’s of Healing’, from the above chronic conditions that can lead to the growth of emotional competence. The Seven A’s include: Acceptance of our current situation, awareness of symptoms of stress in our body, the capacity to express our anger effectively, develop our sense of autonomy, establish attachment or authentic emotional support, assertion of self-acknowledgement and self-worth affirmation.

Cultural Resonance

Based on Maté’s approach, six common themes have been identified: Childhood trauma, parentification, emotional repression, repression of anger, people-pleasing and lack of assertiveness. This section elaborates on each theme, citing relevant illustrations from the chapters and contrasting them with the Indian experiences using existing literature.

Childhood Trauma

Childhood trauma is characterised by feelings of severe unhappiness and stress due to any event or situation and significantly contributes towards adverse developmental outcomes and psychological consequences.^2–4

Maté further clarified childhood trauma in a broader sense, encompassing abuse, neglect, overburdening of responsibilities and conditional love. In the case of ‘Mary’, who succumbed to autoimmune disease, she recalls, ‘I was so scared all the times’.^{1(p. 9)} While she took care of her younger siblings, her drunken foster parents fought and yelled at each other. In the case of ‘Alexa’, who suffered from ALS, Maté describes how the fear of abandonment froze her. Ever since her biological parents abandoned her, she has failed to establish a relationship with her adoptive mother. Maté writes, ‘The adoptive mother had another child whom she favoured and there was nothing Alexa could do, try as she might’.^{1(p. 52)}

The lifelong culmination of such adversities leads to chronic conditions such as cancer, rheumatoid arthritis, multiple sclerosis and many more. When we compare these illustrations to the Indian culture, childhood abuse can be traced to cultural and parenting styles. Also, greater economic hardships are associated with a greater likelihood of childhood abuse and neglect. ⁵ Poor living conditions, lower incomes and living with domestic violence often lead to maltreatment of children, making parents indifferent to their child’s needs and well-being. ⁶ Childhood maltreatment in the form of physical abuse is more common in India because corporal punishment and child labour are culturally accepted. ⁷ Being a highly patriarchal country, punishing, spanking and reprimanding the child is a cultural norm. ⁸ Frequent forms of maltreatment among Indian adolescents include physical and emotional abuse and neglect. ⁹ Maté shares a case of a male suffering from prostate cancer and his experiences of physical abuse by his stepfather. The patient recalls, ‘The paddle was his preferred method of discipline. If I came home late, out would come the paddle—whack. If I smarted off, I got the paddle—whack. It did not hurt physically, but emotionally’.^{1(p. 133)}

Most of the patients that Maté had interviewed confirmed having an emotionally unsatisfying child-parent interaction or an early loss of parental relationships. Intergenerational transmission of childhood trauma also serves as a significant factor. He writes, ‘And these parents, too, were suffering and carrying the burden of generations. There are generations of generations who had lived to bear a part in the genesis of Barbara Ellen’s breast cancer’.^{1(p 99)} He further mentions, ‘If a parent’s loving feelings are constricted, it is only because that parent has himself or herself suffered deep hurt’.^{1(p. 233)}

Similarly, India is equally loaded by intergenerational trauma stemming from partition, caste-based discrimination and gender inequalities.^10–12 Such deep-rooted, longstanding trauma trickles down to the masses, influencing the whole cultural scenario of the country. Parents who have themselves experienced significant childhood trauma exhibit less warmth, unclear expectations and reduced open communication with their children. ¹³

Therefore, childhood trauma is a universal reality and culturally sensitive. Maté’s illustrations are extremely powerful and deeply embedded. This highlights the cultural shades and adaptations, validating the paths of Indian experiences of childhood trauma.

Parentification

The term ‘parentification’ signifies the lack of boundaries within the family sub-systems, leading the child to assume adult-like positions and obligations, emerging from childhood neglect, which thwarts the psychological growth of a child by disregarding their desires and personal experiences.^14–16 Parentification is commonly noted in families with a history of addiction, sexual assault, parental separation or divorce, poor living conditions, diseases and single-parent run households.^{17, 18}

Maté explains parentification as role reversal in childhood, where children have to take over practical and emotional responsibilities that are age-inappropriate. Such roles are undertaken to satisfy the unmet emotional and psychological needs and deficits of their parents. This phenomenon is called emotional parentification. ¹⁹

Maté gives multiple instances where his patients showed signs of childhood emotional parentification. A patient recalls, ‘I knew boundaries, but my mother did not. That’s what most of our fights were about—about her inability to recognise where she ended and I began’.^{1(p. 27)} Another case of abuse and abandonment by foster parents is given. She states, ‘But as a seven-year-old, I had to protect my sisters. And no one protected me’. ^{1(p. 9)} Blurred boundaries and role reversals are the key components of parentification.

Cultural values shape the process of parentification. ²⁰ In India, the cultural milieu emphasises women taking over familial responsibilities from a young age, failing which leads to judgement within society. ²¹ According to Maté, women are susceptible to internalising the burden of caregiving, leading to chronic illness and stress in adulthood. Such ideology mirrors parentification in the Indian context. India, being a collectivistic society, has normalised parentification. ²¹ The act of the elder sibling taking care of younger siblings is also a common parentified role in Indian families. ²¹ Collectivistic societies, on the other hand, deem not giving parental responsibilities to children as detrimental to their development.^22–24 Therefore, the present theme goes well with the Indian cultural setup, as parentification is likely to be cultivated.

Emotional Repression

Emotional repression is a striking theme of the book. It refers to the masking of facial and bodily expressions to hide the current emotional status. ²⁵ However, Maté conceptualises it beyond the conscious suppression of feelings. To him, emotional repression is a form of defence mechanism that originates from adverse childhood experiences. When the expression of childhood feelings and vulnerabilities is faced with threat, rejection and abandonment from the parental figures, the child starts subduing his or her emotional needs. In most of Maté’s patients, emotional repression was an underlying contributing factor to their illness. Hence, it is a learned response to childhood trauma and a form of coping style. Early adverse wounds make the individual vulnerable to persistent stress, poor coping styles, emotional dysregulation and chronic physiological illnesses.

It was observed that individuals who repress or deny their feelings suffer the most because repressing emotions leads to immunosuppression, increasing their vulnerability to illnesses ranging from common colds to cancer.^{25, 26} Maté mentions,‘Patients with lung cancer were frequently characterised by a tendency to “bottle up” emotions.’^{1(p. 100)}

Prolonged emotional repression manifests as survival tendencies such as becoming adjusted, good and compliant children, meeting the emotional needs of the parent. Maté writes, ‘The “niceness” of most ALS patients represents more than the innate goodness and sweetness of some human beings; it is an emotion in extremis. It is magnified out of healthy proportion by a powerful suppression of assertiveness’.^{1(p. 69)}

Most of his female patients had hidden emotional repression. They were socialised into calm, adjusting, accommodating figures even in situations of abuse and neglect. Gila, diagnosed with rheumatoid arthritis, was in an abusive marriage. Upon consulting with a psychiatrist, she was advised not to be so upset with her husband’s behaviour but to treat him like her oldest son. She recalls, ‘I did not want a third son. I wanted a husband’.^{1(p. 201)}

Historically, Indian women were conditioned to be modest, emotionally restrained and submissive. ²⁷ Expressing emotions in women is associated with motherhood, caregiving and wifehood, where it is expected of them to prioritise the emotional needs of others over their own. ²⁸ This mirrors Maté’s idea of good girl or good mother. He writes, ‘Mother is taken for granted. Mother is like the world-she’s just supposed to be there and provide’.^{1(p. 82)} However, prolonged emotional availability, nurturing and emotional suppression can lead to burnout and mental health challenges among women. ²⁹ In non-Western countries built on collectivism and social harmony, emotional expression is often constrained to maintain group cohesion, where both men and women suppress emotions to avoid disrupting harmony. ³⁰ The present theme culturally resonates with the trend of India, showcasing how culturally sanctioned emotional repression can contribute to psychosomatic illnesses.

Repression of Anger

The emotional and physiological manifestations of rage are seen to be universal and evolutionary in terms of development. ³¹ Due to the disruptive nature of anger, various cultural strategies, urbanisation and social position are implemented to regulate it.^32–34 Maté, however, considers anger as a significant and adaptive emotion that facilitates boundary-setting and self-protection. Repressing anger increases psychological stress, which adversely affects our bodies. Childhood trauma sets the foundation for repressed anger, which results in the form of rejection, internalised people-pleasing tendencies and fear of guilt. He delineates how he repeatedly found a pattern of prolonged anger suppression in his patients who suffered from autoimmune diseases, cancer, ALS and multiple sclerosis. He writes, ‘Repression of anger—increases the amount of stress in an individual’s life’.^{1(p. 245)}

He links anger repression with psychoneuroimmunology, stating that anger triggers a stress response, which gradually accumulates and sabotages physiological functioning. Especially in autoimmune disorders, the self-mutilation is metaphorically linked with self-directed anger. Previous research has inferred that anger repression could be a contributing factor in the development of pathological syndromes, such as cardiovascular dysfunctions, oncological disorders and gastrointestinal disorders. ³⁵

Considering the Indian culture, the collectivistic setting inhibits the expression of negative emotions such as anger and sadness, as it is not socially approved. ³⁶ With a strong traditional foundation, children are taught to maintain social harmony and relationships. ³⁷ Anger is a gender-specific emotion. Indian culture values traditional gender roles. Therefore, women might avoid expressing anger as it contradicts the conventional prescriptions of them being kind, compassionate and gentle. ³⁸ Angry men are deemed to be strong, whereas angry women are labelled as domineering, confrontational or nasty. ³⁸ Maté has also mentioned how his women patients were conditioned to be more adjusting, compliant and self-sacrificing. Though his viewpoints were based on a Western lens, the theme matches well with the Eastern perspective of India.

People-pleasing and Lack of Assertiveness

People-pleasers lack assertiveness and therefore harm themselves by following others compulsively without considering their own needs. ³⁹ Individuals with such non-assertiveness face guilt and anxiety for refusing others’ requests, as a result, blame themselves and neglect their well-being, leading to poor quality of life, heightened stress, illness and dissatisfaction. ⁴⁰

These findings support Maté’s observations. He argues that such tendencies are a form of coping mechanism to survive adverse childhood circumstances. When children realise that their parents will accept them only if they are good and non-demanding, they tend to suppress their own needs and pain. In adulthood, such survival mechanisms become a fixed pattern of responding characterised by a lack of assertiveness.

Narrating the case of Mary, he writes, ‘To be self-expressive, vulnerable and questioning in her childhood would have put her at risk. Her security lay in considering other people’s feelings, never her own’. ^{1(p. 10)} Similarly, another patient states, ‘I need to know when to withdraw from my helping mode. But I can’t; if somebody needs help, I have to do it’. ^{1(p. 23)} The title of the book lies in this current theme. When we have been conditioned not to say ‘no’, our body might start saying it for us.

Lack of assertiveness and people-pleasing tendencies can be traced to Indian culture. The patriarchal nature of India promotes avoiding uncertainty in relationships and encourages power-distance.^{41, 42} The vertical collectivist culture of India glorifies submission to authority and conventionalism. ⁴³ Discussion of controversial opinions or personal views is perceived as uncomfortable and conflicting. ⁴³ This viewpoint aligns with Maté’s perspective of suppressing authenticity to promote harmony in interpersonal relationships. Several studies have established that Indians tend to be less assertive. ⁴³ Thus, the present theme aligns well with the cultural viewpoint of India.

From this section, it can be inferred that despite the book being grounded in a Western perspective, the inferences and insights are practicable in the Eastern culture as well. The themes drawn from the book match well with the current psychosocial scenario of India. Therefore, the book can be considered relevant to the experiences of the Indian context.

Strengths

The bestselling book uncovers the silent dialogue between the interplay of somatic illness and psychological stress. One of the fundamental strengths of this book is its shift from a biomedical perspective to a biopsychosocial exploration of health and illness. The biomedical model, which has been a historically dominant model of medicine, attributes illness to the deviation from biological variables, ignoring psychosocial factors. ⁴⁴ Through more than 100 clinical interviews, Maté has established that psychological factors and personal histories can profoundly contribute to chronic and neurodegenerative illnesses. Hence, he challenges the reductionist biomedical model, which isolates the body from the mind and emphasises the interpretive paradigm focusing on the subjective and lived experiences of his patients.

He included social, cultural, structural, socio-economic and multigenerational variables in explaining and understanding wellness, which are strong contributors and determinants of health and illness. ⁴⁵ The style of writing is a significant strength. The statements are clear and precise. Maté puts considerable effort into explaining scientific terminologies clearly, making it understandable for both lay readers and professionals.

The rich use of narratives evokes a sense of empathy and relatedness among the readers, making the text enriching and engaging. From an introspective angle, Maté’s disclosure about his own personal history and struggles makes the book more authentic to the readers. The book psycho-educates people about how prolonged and ignored psychological distress can contribute to some of the life-threatening diseases. The main theme, ‘When the Body Says No’, is well explained to the readers. This path-breaking perspective has not yet been reviewed and applied in clinical settings, particularly in India. Hence, it opens a gateway for clinicians, psychotherapists, practising psychologists and healthcare professionals in exploring the biopsychosocial triad.

Practical Implication

Maté’s insights provide significant ramifications in the field of psychology, medicine, psychotherapy and healthcare. The present study has established Engel’s biopsychosocial model in the context of health and illness. Since the early 21st century, the need for a holistic and integrated approach in understanding health and illness has emerged, where the physical, mental and social factors are considered altogether. ⁴⁶ Solely focusing on the observable symptoms of the illness is not sufficient to promote wellness among the masses.

From a clinical implication, Maté emphasises a holistic treatment plan, placing the person at the centre. Maté urges physicians and healthcare professionals to break free from the longstanding tradition of considering the body and mind as distinct and separate entities. He also suggests that healthcare professionals exercise empathetic listening to make patients feel heard and understood, leading to better disclosure. The practical implications through public health officials and policy-makers include a holistic intervention plan and awareness programme from an ecological perspective for early detection of illness and psychological distress. Structural variables such as occupation, class, educational qualifications and employment are crucial in predicting health and must not be ignored. As Maté elaborates, ‘Many processes and factors work together in the formation of disease or in the creation of health’.^{1(p. 267)} Further, psychologists should explore patients’ experiences of childhood neglect, attachment patterns and traumatic roots behind physical illnesses. Using Maté’s framework of ‘seven A’s’, therapists should promote the growth of emotional competence within patients. Promoting healthy emotional expression among parents is also fundamental. Therapy should promote parent-child authentic communication about emotions and commitment to secure their bond. ⁴⁷ Maté explains, ‘The greatest influences on human development, health and behaviour are those of the nurturing environment’. ^{1(p. 252)} This necessitates cultural integration in the therapeutic settings.

Conclusion

The book is a compelling coalescence of biology, psychology and individual experiences. Maté shifts the spotlight to the biopsychosocial model of health and well-being. With his captivating narration and clinical interviews, he challenges the prevailing dualism in medical science. The relevance and significance of the book in the current psychosocial environment of India have also been established. The key concept of the mind-body connection has been proven through this review. Therefore, this book promotes assertiveness, emotional honesty, self-awareness and self-care as the prerequisites for maintaining health and well-being. The book acts as a clarion call to the readers to start learning to say no rather than being complacent suppressors of pain and suffering.