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Saturday,
March 8, 2003
The
Woman Who Never Got Mad
by Gabor Maté
Bottling
up your anger can be fatal, writes GABOR MATÉ,
who believes that suppressing such an emotion can trigger
malignancy and immune mutiny. Take the case of Caitlin,
a 'pretty gentle soul' who died of scleroderma at 42
A patient of mine, Caitlin, died within a year of her
diagnosis with scleroderma, an autoimmune disease. In
scleroderma, from the Greek word meaning "hardened
skin," the immune system turns against the body,
damaging the connective tissues. There is stiffening of
the skin, esophagus, heart and tissues in the lungs and
elsewhere.
I came to know Caitlin well only in her final months.
Although I had delivered her children and remained their
doctor, until her diagnosis with scleroderma Caitlin attended
a female physician.
Caitlin was a kind and quiet woman with concern for everyone
but herself. When she was asked how she was, her response
was always accompanied by a warm, self-effacing smile
that served to protect her listener from the physical
and emotional pain she was experiencing.
I will not forget my last conversation with Caitlin, at
her hospital bedside. Her lungs and heart were barely
functioning; she was less than 24 hours from her death.
I asked how she felt. She immediately turned her attention
to me, inquiring what was happening in my life. I related,
with some disappointment, that a weekly medical column
I had been writing for a local newspaper had been, just
that morning, cancelled by the editors. "Oh,"
she whispered, her face saddened with empathy, "how
terrible that must be for you. You love writing so much."
On the threshold of death from a disabling disease at
the age of 42, leaving four children and a husband, she
uttered not a word about how terrible she may have been
feeling herself.
"It was a long-standing part of her nature to be
cheerful and always welcoming regardless of whether she
was sick or well," her husband, Randy, told me in
the course of a recent interview. According to Randy,
Caitlin "bottled up a lot of emotion," particularly
when she was upset. There were two items she would rarely
talk about: her terminal illness and her childhood.
From Randy's perspective, the good times in his wife's
childhood had been few and far between. Her father, a
successful businessman, was a harsh and arbitrary taskmaster
whose word was law. He was highly critical of Caitlin,
the elder of the two children. "It seemed to me that
she felt that when her parents conceived her, it was a
great inconvenience. That she had come too soon and they
really didn't want her."
That struck a chord with me. Caitlin had been a committed
anti-abortion advocate, but not the hostile or embittered
kind. She knew that I supported women's right to decide
whether to abort their pregnancies. She once wrote me
to urge that I stop referring patients to abortion clinics.
She wrote, "If abortion had been legal at the time
when I was a fetus, I would have been aborted." She
had, said Randy, a deep feeling of not having been wanted.
Scleroderma is one of the rheumatoid diseases, along with
rheumatoid arthritis, systemic lupus and many other conditions
in which the chief targets of immune mutiny are the joints
and connective tissues. In other autoimmune diseases,
the bowels or the nerves or the liver or the brain may
be the points of attack, resulting in inflammation in
almost any part of the body. The immune cells run wild,
as if an army ransacked and devastated the country it
was meant to defend.
What induces the immune system's suicidal rebellion? In
the first edition of his classic Principles and Practice
of Medicine,published in 1892, the great Canadian physician
William Osler suggested that rheumatoid arthritis has
"a nervous origin." He was referring to emotional
stress. He noted "the association of the disease
with shock, worry, and grief." No obscure theoretician,
Dr. Osler was the best-known medical doctor in the English-speaking
world.
Now, at the beginning of the 21st century, one may search
in vain through the mainstream medical texts for mention
of stress in relationship to rheumatoid arthritis or to
its fellow autoimmune conditions. The almost willful failure
of mainstream medical practice to recognize the role stress
plays in the initiation of autoimmunity is tragic for
millions of sufferers.
It is now known that the immune system does not function
in isolation. It is part and parcel of a super-system
to which also belong the brain centres that process emotion,
the nervous system and the hormone-secreting glands. Whatever
happens in one part of the super-system also affects the
other parts.
For this reason, people who in childhood had to develop
the emotional coping style of suppressing their emotions,
particularly anger, are at increased risk for immune system
failures, including malignancy or immune mutiny.
This is not surprising, given that anger and the immune
system have the same function in animal life -- to defend
the organism's boundaries against invasion.
A trait common to many people with rheumatoid illness,
for example, is a stoicism carried to an extreme, a deeply
ingrained reticence about seeking help. Researchers have
called this trait a compensating hyperindependence. It
is a pseudo-independence, a pretense. It is the coping
mechanism of a child who feels emotionally alone and survives
by telling herself, and the world, that she has no needs
that she cannot take care of herself.
Such patients, for no fault of their own, are also characterized
by perfectionism, a fear of their own anger impulses and
strong feelings of inadequacy.
Research has found that the childhoods of people with
autoimmune illness are often marked by loss -- either
the departure or the death of a parent, or a profound
sense of emotional abandonment.
Late in Caitlin's illness, an incident occurred that,
in the telling, brought tears to Randy's eyes. "We
were sitting here in the kitchen with all those pills
she was supposed to be taking. She was feeling miserable.
All of a sudden, she burst out crying. She said, 'Oh,
I wish I had a mother.' And her mother lived only a few
blocks away. They were not emotionally close enough that
the mom would come and comfort her and help her or put
her arms around her.
"We had a homemaker at the time. She was there, cleaning
the fridge. She felt so touched that she came over and
hugged Caitlin. I thought, 'What a shame -- this person
who hardly knows her has more empathy for her than her
own mother.'
"But I don't want to blame the parents either,"
Randy continued. "When you look at their family histories
-- well, her mother's dad walked out on his family when
she was a little girl. She didn't have a dad, and her
mom [Caitlin's grandmother] had to struggle on all alone."
Randy's view of Caitlin's childhood was confirmed in a
subsequent interview with her brother. "There was
little emotional support and love in the family,"
the brother said. "Our father was mean to us, and
our mother was afraid. My mother is a very nice person
-- a great person -- but she would never deal with the
issues."
Caitlin, her brother said, was "a pretty gentle soul,"
but to her father "she was just stupid. The very
fact that she went to university ticked him off. He had
no respect for anything she did. She was in the La Leche
League (a group that promotes breast-feeding.) My father
ridiculed that. 'How long is she going to breast-feed
those kids, until they are teenagers?' "
After putting up with years of feeling dominated even
as an adult, this brother finally broke with his father
and refuses to talk to him. "Caitlin was very concerned
that I had got myself out of the family. I tried to tell
her it was the best thing for me, that I was a better
person for it. She didn't get it."
The brother also revealed details of the family history
that once more demonstrated the multigenerational nature
of stress and suffering. It was a shock to Caitlin and
her brother to learn the truth of what had happened with
their grandfather. An uncle who showed up for the funeral
of Caitlin's grandmother informed them that the grandfather
had not died when Caitlin's mother was a young child,
which had been the family story, but had abandoned his
wife and later divorced her.
All their lives, Caitlin and her brother had been told
that their grandfather had passed away suddenly. "But
that's the way it always was. In our family, you don't
talk about difficult issues, you hide them."
Less than a year preceding the onset of her scleroderma,
Caitlin suffered a major rejection at the hands of her
family, having to do with her exclusion from the family
business. "My sister was never in the calculations,"
her brother says. "It didn't seem abnormal at the
time." Caitlin felt deeply hurt by the perceived
rejection. She never brought up the matter to anyone,
except to her brother shortly before her death. And she
kept maintaining that he, the brother, should go back
to the family.
Caitlin had been assigned a certain role in the family
system, a role bequeathed to her by generations of family
history. Her own mother was deprived of attuned parenting
from an early age, since we can surmise that the family's
problems did not begin the moment the grandfather abandoned
his wife and children. We may be equally sure that the
harsh parenting by Caitlin's father originated in his
own troubled childhood.
The combination of her parents' many unmet emotional needs
led to Caitlin's desperation to make herself lovable and
prepared her for the role of the gentle, uncomplaining
caregiver who never became angry or asserted herself.
That is how the child's adaptive responses to parental
demand, if repeated often enough, become character traits.
Caitlin adopted her assigned role successfully, but at
the cost of her own health. The price was a lifetime of
stress, which, finally, helped induce her immune system
to turn against her own body.
Czech-Canadian physician and scientist Hans Selye, the
founder of stress research, developed the concept of adaptation
energy. "It is as though we had hidden reserves of
adaptability, or adaptation energy, throughout the body
. . . Only when all of our adaptability is used up will
irreversible, general exhaustion and death follow."
Aging, of course, is the normal process through which
the reserves of adaptation energy become depleted. But
physiologically stress ages us as well -- as the language
recognizes when people speak of "having aged overnight."
Throughout her lifetime, much of Caitlin's adaptation
energy had been diverted away from self-nurturing toward
taking care of others. Her function had been determined
by family dynamics during her childhood. By the time her
illness struck, she had run out of energy.
The Power of No
People
usually think of stress as external problems -- a bad
boss, financial loss, the illness of a loved one.
Powerful as those factors may be in their harmful effects,
the most important stressors in our lives are generated
from within. They are the hidden stressors embedded in
our habitual coping patterns, in the unconscious and automatic
ways we conduct our relationships with the world at large
and with the ones close to us.
How to cope with stress, then?
Stress reduction is no easy matter in a society that values
human beings according to their productivity above all
else, but it has to begin with recognizing the degree
of self-rejection we are all prone to.
The difficulty so many of us have in setting our boundaries,
in saying no, is a prime marker of that self-rejection.
People need to ask themselves some of the following questions,
and many others: Do I have trouble saying no? Do I take
responsibility for the feelings of others before considering
my own? Am I able to feel anger? Am I able to communicate
anger in healthy, non-destructive way?
Our culture is addicted to simple self-help solutions
and "positive thinking." We need much more "negative
thinking," that is, the courage to look at what does
not work for us and why. That is the first necessary step
in dealing with stress.
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