Gabor Mate

The Myth of Normal

Trauma, Illness & Healing in a Toxic Culture

Vermilion, London (2022)

Chapter 26

Four A's and Five Compassions: Some Healing Principles

Everything in nature grows and struggles in its own way, establishing its own identity, insisting on it at all costs, against all resistance.

-Rainer Maria Rilke, Letters to a Young Poet

No one can plot somebody else's course of healing, because that's not how healing works. There are no road maps for something that must find its own individual arc. We can, however, sketch out the territory, describe it, familiarize ourselves with it, prepare to meet its challenges. We can learn what natural laws seem to govern healing, specifically what attitudes and attributes it both awakens and responds to in us. Like natural childbirth, healing cannot be mandated or hastened, but it can certainly be helped along. As the poet and musician Jewel eloquently puts it, "You cannot force nature / only nurture it." That had been her personal experience of healing, she told me in an interview.

The following four A's are not how-to steps or rigid injunctions. They represent healing principles that have proved useful guideposts for many people. I originally devised them while writing When the Body Says No and have since amended them, condensing them from seven to four. (In a later chapter I will propose two new A's that harmonize individual and social healing, of which justice is a core tenet.) Each of these represents a healthy quality corresponding to a human need, often stunted or forced underground early in life by emotionally or physically inimical conditions or, in this confused and repressed culture of ours, just by environments that could not support its development. An essential aspect of healing is welcoming each of these qualities back into our life and letting it teach us its ways.

1. Authenticity

To put it bluntly, authenticity is a quality more often marketed than manifested in our culture. Even Coca-Cola is sold as "the real thing." We find ourselves surrounded by the rampant phenomenon of ersatz authenticity: someone is performing "realness" for the crowd or the camera, but it doesn't convince; maybe the words don't match the cadences, or there's too much defiance and bluster in the delivery.

Authenticity is hard to pin down. While synonyms like "genuineness," "truthfulness," "originality," and so on come to mind. authenticity itself eludes any precise definition that could fully capture its essence. Like its fellow natural state, love, authenticity is not a concept but something lived, experienced, basked in. Most of the time you know it when it's there. Have you ever tried explaining to anyone what love is in purely intellectual terms? As with love, so with authenticity.

The pursuit of authenticity is rife with pitfalls. For starters, we have the paradox that authenticity can't be pursued, only embodied. By definition, striving for some idealized self-image is incompatible with being authentically who one is. We have to begin with accepting ourselves fully, as Anita Moorjani discovered in her encounter with fatal illness. "Even the slightest little resistance from the opposite person... like if I had displeased someone even slightly -this was me before- I would be the one to back down," she told me. "Today, I'm not afraid of being disliked, of disappointing someone. I'm not afraid of what I used to think of as my negative qualities. I realized that they are just the other side of being who I am."

One of the most direct approaches to authenticity is noticing when it isn't there, then applying some curiosity and gentle skepticism to the limiting self-beliefs that stand in for it, or just stand in its way.

The lack of authenticity makes itself known through tension or anxiety, irritability or regret, depression or fatigue. When of these disturbances surface, we can inquire of ourselves: Is there an inner guidance I am defying, resisting, ignoring, or avoiding? Are there truths I'm withholding from expression or even contemplation, out of fear of losing security or belonging? In a recent encounter with others, is there some way I abandoned myself, my needs, my values? What fears, rationalizations, or familiar narratives kept me from being myself? Do I even know what my own values are?

The growing capacity to admit to oneself, "Ouch, that hurts," or "You know, I didn't really mean what I just said," or "I'm really scared to be myself in this situation" is the impulse toward authenticity becoming stronger. After enough noticing, actual opportunities for choice begin to appear before we betray our true wants and needs. Whereas earlier, such awareness would have been clocked only after the fact, we might now find ourselves able to pause in the moment and say, "Hmm, I can tell I'm about to stuff down this feeling or thought -is that what I want to do? Is there another option?" The emergence of new choices in place of old, preprogrammed dynamics is a sure sign of our authentic selves coming back online.

2. Agency

Agency is the capacity to freely take responsibility for our existence, exercising "response ability" in all essential decisions that affect our lives, to every extent possible. Being deprived of agency is a source of stress. Such deprivation could arise from social or political conditions: poverty, injustice, marginalization, or the seeming collapse of the world around us. In the case of illness, it's often due to internal constraints.

The exercise of agency is powerfully healing. The psychologist Kelly Turner has studied many cases of so-called spontaneous remission of what had been diagnosed as terminal malignancy. "Having worked as a counselor at various hospitals and oncologists' offices," she reports, "I know firsthand that the patients who listen and follow instructions are considered 'good' patients, while the "annoying' patients are those who ask a lot of questions, bring in their own research, or -worst of all- challenge their doctors' orders." Yet these latter ones, she found, those who find ways to take control of their own healing, are the ones likely to do better in the long term. In hindsight, Dr. Turner notes, all her radical remission survivors wished they'd started much earlier to be active agents of their destinies rather than compliant patients in the hands of physicians.

As with authenticity, capitalism sells a bogus version of agency through personal-power mantras like "Be all you can be" and "Have it your way." Personal choice becomes a brand, with no attention paid to the contexts in which those choices are made. Often the freedom being advertised is the dubious freedom to choose between this or that identity-burnishing product or service that will not, cannot, satisfy us. Nor does agency mean some sort of false omnipotence or ultimate dominion over all happenings and circumstances. Life is so much bigger than us, and we do not forward our own healing by pretending to be in control where we're not.

Agency does mean having some choice around who and how we "be" in life, what parts of ourselves we identify with and act from. This often starts with renegotiating our relationship with the personality traits we have so long taken to be identical with who we really are, the ones that first arose in us to keep us safe but now keep us boxed in. There is no freedom in having to be "good" or the most talented or accomplished, or in the need to agency please or entertain or be "interesting." Nor can we wield when we react with automatic opposition to other people's demands: knee-jerk reactivity leaves no room for "response ability"—or what in our first chapter we called response flexibility, a capacity trauma greatly impairs.

Agency is neither attitude nor affect, neither blind acceptance nor a rejection of authority. It is a self-bestowal of the right to evaluate things freely and fully, and to choose based on authentic gut feelings, deferring to neither the world's expectations nor the dictates of ingrained personal conditioning.

3. Anger

People often ask me to define healthy "anger." Here's what it's not: blind rage, bluster, resentment, spite, venom, or bile. All of these stem from an unhealthy buildup of unexpressed or unintegrated emotions that need to be experienced and understood rather than acted out. Both anger suppressed and anger amplified out of proportion are toxic.

Anger in its natural, healthy form is a boundary defense, a dynamic activated when we perceive a threat to our lives or our physical or emotional integrity. Our brains being wired for it. we can hardly avoid it: this is the self-protective RAGE system identified by Jaak Panksepp. Its full functioning is a standard feature of our wholeness, essential for survival: think of an animal protecting its turf or its young. The movement toward wholeness often involves a reintegration of this oft-banished emotion into our repertoire of available feelings. This is not the same as stoking resentment or nurturing grievance quite the opposite. Healthy anger is a response of the moment, not a beast we keep in the basement, feeding it with shame or self-justifying narratives. It is situational, its duration limited: flashing up when needed, it accomplishes its task of fending off the threat and then subsides. It becomes neither an experience to fear and loathe nor a chronic

irritant.

The fact and some people may need to actively remind themselves of this is that we are talking about a valid, natural feeling that does not in itself intend anyone any harm. Anger in its pure form has no moral content, right or wrong -it just is, its only "desire" a noble one: to maintain integrity and equilibrium. If and when it does morph into a toxic version of itself, we can address the unhelpful stories and interpretations, the self-righteous or self-flagellating thought patterns that keep stoking it, without invalidating the emotion. We can also observe how our inability to say no fuels chronic resentment that leaves us prone to harmful combustions.

Many of us have learned to minimize our anger to the point that we don't even know what it looks like. In this case it's best not to idealize or exaggerate: picturing a bombastic eruption of ire or some righteous, curse-encrusted monologue will not help us. Like authenticity, genuine anger is not a performance. Anger's core message is a concise and potent no, said as forcefully as the moment demands. Wherever we find ourselves tolerating or explaining away situations that persistently stress us, insisting that "it's not so bad" or "I can handle it" or "I don't want to make a fuss about it," there is likely an opportunity to practice giving anger some space to emerge. Even the plainspoken admission that "I don't like this" or "I don't want this" can be a step forward.

Research suggests that anger expression could support physical health, for example in those with amyotrophic lateral sclerosis (ALS) or fibromyalgia, two conditions that baffle the conventional medical mind. We have already reported (in chapter 2) that ALS patients are perceived by their physicians as extraordinarily nice. Tellingly, in another ALS study, the most "agreeable" ones-the ones least likely to be in touch with anger, that isalso had the most rapid deterioration of their condition and of their quality of life.' The same is true with fibromyalgia, which many studies have linked to childhood trauma. A 2010 study in the European Journal of Pain concluded that "anger and a general tendency to inhibit anger predicts heightened pain in the everyday life of female patients with fibromyalgia. Psychological intervention could focus on healthy anger expression to try to mitigate the symptoms of fibromyalgia."

The question for most of us is not whether to be angry but how to relate in a wholesome way to the feelings that naturally ebb and flow with life's tide, anger included.

4. Acceptance

Acceptance begins with allowing things to be as they are, however they are. It has nothing to do with complacency or resignation, though sometimes these can pose as acceptance-think of the shrugging expression "It is what it is" -just as stubborn egotism can moonlight as authenticity. Rather, acceptance is the recognition, ever accurate, that in this moment things cannot be other than how they are. We abstain from rejecting or condoning. Instead of resisting the truth or denying or fantasizing our way out of it, we endeavor to just be with it. In doing so, we foster an aligned relationship with the actual, present moment.

Acceptance also means accepting how downright difficult it can be to accept. It may seem paradoxical, but true acceptance denies or excludes no aspect of how it is, not even our impulse to reject how it is. Anger, sadness, trepidation, resistance, even hatred within an accepting attitude, these all have room to say their piece. Sometimes accepting ourselves starts with facing that we don't know how we feel, or that our feelings are mixed. Rejection of any part of our experience is an unnatural self-rejection, one that nonetheless feels normal to many of us. You've made some serious mistakes? You find yourself filled with hatred, or resentment, or confusion? These, too, are candidates for acceptance; underneath them there is always pain. In fact, hatred, resentment, and even confusion can be the psyche's attempts not to feel pain or sadness. Healthy grief-the jewel so often hidden within ossified grievance-frequently waits on the other side of accepting how things are and have been. That, too, can be hard to embrace, but when we forestall the energy of mourning that wants to move through us, we only cause it to build up. As Gordon Neufeld puts it, "We shall be saved in an ocean of tears."

A distinction must be made between accepting and tolerating. Being with something and putting up with something have precious little to do with each other. Acceptance is vitalizing because it makes room for the other three A's-it grants admission to anger if such is present, increases our sense of free agency, and makes room for whatever our authentic experience might be. Tolerating the intolerable, on the other hand, is deadening. For example, resigning oneself bleakly to conditions such as abuse or neglect involves rejecting crucial parts of one's self, needs, and values that deserve to be respected and integrity that needs to be safeguarded. That is far from true acceptance.

Darlene, a thirty-eight-year-old family therapist in San Jose, California, began to accept that the realities of her marriage were intolerable only when she developed an autoimmune disease. Based on her fundamentalist Christian upbringing, she had truly believed her God-given duty was to "accept"-read endure-the miseries her husband's own traumatic imprints visited upon her. "As the connection between my stress and my illness dawned on me," she related, "at one point I remember going, 'Holy shit-I've been in this kind of martyr-honoring-God position of staying in this abusive marriage, and there's just no way: this is going to kill me!"

The same applies to injustice or oppression on the social level. To accept that whatever is currently happening is happeningthe simple fact of the matter-does not mean conceding that it should happen. To deal with racism, poverty, or any other societal ill, we must first recognize that they are realities of life in this culture. They exist, and we must acknowledge our pain and grief that they do. Now we can ask ourselves how we might effectively work to eliminate not only their expressions but their root causes. We can move on to healthy anger, to agency, to autonomy in action.

The Five Compassions

The acclaimed neurosurgeon James Doty heads Stanford University's Center for Compassion and Altruism Research and Education. "There is a subset of people who believe that compassion is soft, that it's not worthy of scientific study," he told me during a public conversation we held at the California retreat center 1440 Multiversity. "Yet, I assure you, the science we have today demonstrates these practices of mindfulness, self-compassion, and

+ Author of the bestseller Into the Magic Shop A Neurosurgeon's Quest to Discover the

Mysteries of the Brain and the Secrets of the Heart.

A brief segment of this conversation can be viewed here: "A Neurosurgeon Talks of Vulnerability: Gabor Maté and James Doty" July 12, 2019 https://www.youtube.com /watch?v=WiAXbZmadu.

compassion are some of the most powerful that exist to change your physiology and to benefit you in your own health, mental and physical, and in terms of your longevity." Compassion, as both salve and salvation, is not limited to the realm of the individual. If we are to dream of a healthier, less fractured world, we will have to harness and amplify compassion's healing power.

In my work with clients and in training thousands of therapists, I have distinguished five levels of compassion that build on and reinforce one another nonhierarchically. Together, they encourage, guide, and orient us on the pathway to wholeness. As the playwright (and physician) Anton Chekhov wrote, "It is compassion that moves us beyond numbness toward healing."

I. Ordinary Human Compassion

The word "compassion" comes from the Latin, meaning "to suffer with." Whether or not we experience another's pain so vividly, entry-level compassion does mean the ability to be with suffering. It also means being moved by the awareness that someone is struggling; it does not register as a neutral fact.

Interpersonal compassion necessarily involves empathy, the ability to get and relate to the feelings of another. Our experience of it may fluctuate depending on who we are looking at and even on how we are feeling at any given moment. Certainly, it can be worn down or depleted, as anyone who has ever experienced workrelated "compassion fatigue" can attest. For most of us it bounces back once we get the rest and replenishment we need. Its absence in anyone, glaring in sociopaths and psychopaths, is always a marker of a wound to the soul, or, in A. H. Almaas's words, "the suppression of hurt." When we notice such an empathy gap in ourselves, instead of self-judgment-itself a lack of compassion-we could well ask what pain we have not yet fully felt and metabolized. We can learn a lot about our own emotional-injury history by observing in what situations, and toward whom, our naturally open and supple hearts tend to harden and shut down.

Compassion is not the same as pity, which on some level always buys into a preexisting story about oneself or another. While compassion guides the best social policies, pity empowers no one. To take pity on you, I have to first cast us in unequal roles, looking down on your misfortune from some imagined perch. Even if there is an actual power gap between us in the worldsay, one born of a racial or economic hierarchy-treating it as if it is a permanent, essential fact about us does neither one of us any favors. Self-compassion, equally necessary, also has its unhealthy analogue: "to wallow in self-pity" conveys the comfy but muddy trap of feeling perennially sorry for oneself. Self-pity takes a kind of solace in seeing oneself as an unfortunate character, beleaguered by fate. It undermines healing by reinforcing the stories that keep us ensconced in a world of hurt, and by discouraging responsibility for our own point of view. Self-compassion, by contrast, doesn't resist how things are, nor swaddle the pain in layers of narrative gauze; it just says, "I am hurting."

2. The Compassion of Curiosity and Understanding

The second compassion takes as its first principle that everything exists for a reason, and that the reason matters. We ask, without judgment, why a person or group-any person, any groupwould end up being the way they are and act the way they do, even or especially when we are vexed or perplexed by it. We might also call this the compassion of context. However sincere our desire to help ourselves or someone else, we cannot do so without beholding the suffering being experienced, including knowing its source as best we can. It's not enough, for example, to feel bad for people caught in the coils of addiction without seeking to understand what pain in their lives they've been driven to escape and how that wound was sustained. Absent a clear view of the context, one is left, at best, harboring inert good wishes and engaged in well-meant but ultimately ineffective interventions. We see this limitation in the woefully inadequate addiction-treatment approaches currently in vogue.

The willingness to seek the why before leaping to the how is the compassion of curiosity and understanding in action. Though it is called for in every instance of chronic suffering, whether in the personal or social realm, it can be challenging in practice. In today's society we often default to easy explanations, quick judgments, and knee-jerk solutions. Questing with clear eyes to find the systemic roots of why things are the way they are takes patience, curiosity, and fortitude.

The Métis academic Jesse Thistle, cited in chapter 15, has authored a gripping memoir of his childhood, youth, spiral into addiction and crime, and ultimate recovery, a book suffused with precisely this kind of thoroughgoing compassion. "I wrote From the Ashes," Jesse told me, "mainly so that people could witness what happened to me and my brothers in our family... In a way, I was trying to vindicate my family and make people understand. So with my nation's history, I'm helping re-member. Not just remember, like a memory. Like re-member, reassemble this history that has been disembodied by the state and forgotten." In chronicling the events of his own life, Thistle, along with fellow writers and artists of Indigenous Canada, is reclaiming a compassionate context for his people - in both the familial and national senses of that word - to exist and be seen in the world's eyes, and their own.

3. The Compassion of Recognition

Remember Bruce from chapter 15-the Oregon vascular surgeon arrested at his hospital for forging drug prescriptions to feed his opiate habit? He views the experience, humiliating as it was, with gratitude for the life-changing awakening it sparked in him. "If it hadn't happened to me in the way it happened," he told me, "I would have gone on my merry way as the oblivious, technically proficient but emotionally retarded individual that characterizes so many of us in the surgical profession." In place of his old "self-centered" ways of relating, Bruce describes "a new attitude" characterized by seeing himself in others: "[I can say] 'I am a human being who has flaws, who struggled. You may be in that same category. Let's see how we can fix this problem together.""

Bruce is embodying what I call the compassion of recognition, which allows us to perceive and appreciate that we are all in the same boat, roiled by similar tribulations and contradictions. Until we recognize our commonality, we create more woe for ourselves and others: for ourselves, because we increase our distance from our humanity and get caught up in the tense physiological states of judgment and resistance; for others, because we trigger their shame and further their isolation. If you are not sure what I mean, the next time you feel intense judgment toward anyone, check in with your body states-the sensations in your chest, belly, throat. Does it feel pleasant? Unlikely; nor is it healthy for you.

The lesson is not that you shouldn't judge, since it's not you that's doing it but rather your automatic mind. To judge yourself for judging is itself to keep the wheel of shame spinning. The opportunity is to inquire into your judgmental mind and body state with compassionate curiosity. Healing flows when we are able to view this hurting world as a mirror for our own pain, and to allow others to see themselves reflected in us as well - recognition paving the way for reconnection.

4. The Compassion of Truth

We may believe it an act of kindness to protect people from experiencing pain. While this is so when it comes to pain that is unnecessary and preventable, there is nothing compassionate about shielding people from the inevitable hurts, disappointments, and setbacks life doles out to all of us, from childhood onward. Such a mission is not only futile, it is counterproductive-and may even be inauthentic, the seemingly altruistic impulse arising from our discomfort with our own woundedness.

Whatever our intentions, we do no one any favors by fearing their pain or colluding in their banishment of it. As people work to heal their traumas, hurt will inevitably arise. This is why all of us go into denial, suppression, repression, rationalization, justification, hazy memory, and varying grades of dissociation in the presence of hurt. When we face all the ways we have numbed ourselves, pain will inevitably emerge-in fact, it has been waiting a long time to do so. Of course, the fear of these exiled parts is also natural. "When you have a lifetime of emotions that you have been running from," writes Helen Knott, "it seems like once they catch up they will gang-beat you and leave you crippled in an alleyway." That need not happen. The compassion of truth recognizes that pain is not the enemy. In fact, pain is inherently compassionate, as it tries to alert us to what is amiss. Healing, in a sense, is about unlearning the notion that we need to protect ourselves from our own pain. In this way, compassion is a gateway to another essential quality: courage.

The compassion of truth also recognizes that truth may lead, in the short term, to further pain. Darlene, the San Jose family therapist, found this out once she left her dysfunctional marriage. "My childhood community doesn't understand me, can't see me, doesn't get it," she said. "It breaks my heart because I want to be loved and connected, but I suspect they will never be able to see me or connect with me." That some attachments may not survive the choice for authenticity is one of the most agonizing realizations one can come to; and yet, in that pain, there is freedom. It reverses and vindicates the tragic, mandatory choices we had to make in the opposite direction as we started in life. "It's a journey of ditching people-pleasing and not caring what people think," Darlene told me. "There are times when I go, 'I want that person's approval.' I can't say I've arrived, but it's an onion process: I've gotten lots of the layers off, and more and more freedom in my authenticity. I've had to find my own pockets of community where I am seen and understood. It's been a painful process, but I know it's the right thing."

Truth and compassion have to be reciprocal partners. We are not being compassionate by dumping unwelcome truths in someone's lap, perhaps justifying it on the grounds that "I'm just being honest!" "Only when compassion is present," writes A. H. Almaas, "do people allow themselves to see the truth." And without safety, the truth cannot do its healing work.

5. The Compassion of Possibility

There is more to each of us than the conditioned personalities we present to the world, the suppressed or untrammeled emotions we act out, and the behaviors we exhibit. Understanding this allows for what I call the compassion of possibility. I don't mean possibility in the hypothetical, future-dwelling sense, as in "maybe someday," but as a present, alive, ever-available inherent quality. Possibility is connected to many of humanity's greatest gifts: wonder, awe, mystery, and imagination-the qualities that allow us to remain connected to that which we can't necessarily prove. It's up to us to nurture this connection, because the day-to-day world will not always provide us with reassuring evidence. This deepest aspect of compassion recognizes that the seemingly impossible only seems so, and that whatever we most need and long for can actualize at any moment.

Staying open to possibility doesn't require instant results. It means knowing that there is more to all of us, in the most positive sense, than meets the eye. The same applies to whatever seems the most real, solid, or intractable in us or others. In a famous story, the Buddha saw the universal potential for the humane self to emerge in a notorious criminal who accosted him with murderous intent; the man became his humblest and most gentle follower.

"In order to gain possession of ourselves, we have to have some confidence, some hope of victory," wrote the Catholic mystic Thomas Merton. "And in order to keep that hope alive we must usually have some taste of victory." The compassion of possibility, I would say, is a door we keep open so we can see that victory coming. If we didn't mistake ourselves or one another for whatever personality features and behavioral traits appear on the surface, "good" or "bad," if in each person we could sense the potential for wholeness that can never be lost, that would be, for us all, a victory worth savoring.

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Version: 8.6.2024

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