A Paradigm Shift in Medicine? Gabor Maté’s "The Myth of Normal"

This is a guest blog post by Seiji Yamada, MD

 

 TRAUMA, ILLNESS, AND HEALING IN A TOXIC CULTURE

 

Published by Avery
Sep 13, 2022 | 576 Pages | 6 x 9 | ISBN 9780593083888

In The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture, family physician Gabor Maté presents a new formulation for understanding health and illness. Perhaps it is fair to call it a paradigm shift. Maté’s formulation implies that those of us who work in health care should be practicing differently. What might such a healing practice look like?

Firstly, the healer takes the side of the patient and the family – against the toxic culture that surrounds us. One component of the toxic culture that Maté identifies is capitalism, the valuing of corporate profits over human life, the relentless drive to extract private wealth while killing our ecosystem. Under capitalism, in order to stay financially solvent, pregnant women stay on the job until they go into labor. They return to their workplaces within weeks of giving birth. The stresses of working while pregnant, or the infant’s need for nurturing and attention, receive little attention.

Another component of the toxic culture is patriarchy, the control exerted over women and children’s bodies by men. In its ugliest form, this takes the form of sexual abuse and rape. Maté presents a number of case examples of how such past events become manifest as disease, not just psychological but also physical. The author, activist, and playwright V, who wrote The Vagina Monologues, recounts to Maté how abuse by her biological father led to her endometrial cancer.

Maté reviews the scientific basis for how our toxic culture leads to disease. As manifested by behaviors seemingly as trivial as not picking up a crying infant to crimes such as sexual abuse, the toxic culture of contemporary capitalism, patriarchy, and white supremacy leads to trauma.

What is trauma? As I use the word, “trauma” is an inner injury, a lasting rupture or split within the self due to difficult or hurtful events. By this definition, trauma is primarily what happens within someone as a result of the difficult or hurtful events that befall them; it is not the events themselves. (p. 20)

This trauma then leads to the somatic and psychological dysfunction that becomes manifest as both bodily and psychiatric disease as well as problematic behaviors such as attention deficit and addiction. Of note, this account of disease is dynamic, changing over time. Rather than an entity that one possesses (e.g. “my cancer” or “my bipolar disorder”), Maté views disease as a temporal process with roots in the toxic culture within which we all live, as well as in events that might not even be subject to conscious recall.

Thus Maté seeks to transcend conventional biomedical modes of analysis. The biomedical paradigm is reflected in traditional medical education. Premedical students must take basic science classes such as biology, physics, chemistry, and organic chemistry as prerequisites for medical school. In the conventional medical curriculum, medical students learn basic sciences such as anatomy, physiology, pathology, and pharmacology before they learn clinical medicine. The biomedical paradigm is reductionist in the sense that it seeks explanations in more and more fundamental levels of analysis: Thus, the search for genes that cause this or that disease, or dysregulated neurotransmitters as explaining this or that psychiatric disorder.

The biopsychosocial model was formulated by the psychiatrist George Engel in the 1970s in opposition to the biomedical model. Engel incorporated the atoms, cells, organs, cognitive and emotional factors, and social influences such as family, community, even the nation-state into the model. (See figure.) As such, the biopsychosocial model is all-encompassing and potentially powerful in its explanatory reach, but the details of its workings, i.e. the underlying mechanisms were insufficiently fleshed out by Engel.

Indeed, the role of large-scale social forces on health and illness has long been the concern of social medicine. Social medicine practitioners take a step back and examine the root causes of why the people become sick. The social medicine practitioner continues to ask questions until she gets down to the fundamental causes of illness—the social structure. The late Paul Farmer was a practitioner of social medicine. Howard Waitzkin, Alina Pérez, and Matthew Anderson provide us with a how-to manual on how to become a social medicine practitioner in Social Medicine and the Coming Transformation.

While Maté views himself as working within the biopsychosocial and social medicine paradigms, his contribution is to elucidate the epigenetic, psychological, neurologic, and immunological mechanisms by which oppressive social structures and the toxic culture of “hypermaterialist, consumerist capitalism” (p. 198) become manifest as disease.

As well, Maté critiques the reductionist program of behavioral psychology, originally formulated by B.F. Skinner, who derived his theories of behavior modification via rewards and punishments through experiments with pigeons caged in boxes. Maté is particularly critical of the child-rearing practices based on operant conditioning principles, e.g. advising parents not to comfort crying infants lest they feel “rewarded” for their “bad behavior.”

In discussing contemporary practices relating to the treatment of the young or the treatment of pregnant mothers-to-be, Maté references ethnographic accounts of the practices of cultures more in touch with nature, as well as how other mammals besides humans raise their young.

Maté reviews many cases to illustrate his points, but he also references his own failings. He attributes his touchiness about his wife not picking him up at the airport to fears of abandonment stemming from being placed under the care of strangers when he was an infant when the Nazis occupied Hungary. He regrets how his workaholism led to his absence from his children’s lives when they were small. By pointing to his own flaws and sharing how he is still trying to overcome them -  he holds out hope for the rest of us to heal ourselves also.

In the Structure of Scientific Revolutions (1962), Thomas Kuhn described how paradigm shifts work in science. Normal science under the old paradigm, e.g. the Aristotelian view of the cosmos with the earth at its center, seems to work well enough, but there are just a few anomalies that cannot be accounted for. Over time, these anomalies and contradictions accumulate – until somebody, e.g. Copernicus, comes up with a new way of looking at the data. The new way of looking at things works much better, of course, and has much better explanatory and predictive power.

When I introduce medical students to family medicine, I often reference chapter five, “Philosophical and Scientific Foundations of Family Medicine,” from the 2009 edition of McWhinney’s Textbook of Family Medicine, the last edition before Ian McWhinney’s death in 2012. In chapter five, McWhinney discusses the paradigm shift in medicine  - from the biomedical model to the biopsychosocial model – in the Kuhnian sense. Of course, the reductionist, biomedical paradigm continues to advance medicine. Take a look at the studies reported in any issue of the New England Journal of Medicine. In the clinical setting, however, we need to do a better job of understanding our patients’ pasts, their emotional lives. Organized medicine needs to do a better job of ending the hypermaterialist, consumerist capitalism that is making our patients sick.

I have advocated for the biopsychosocial model during my own medical and teaching career, though I will admit to (following Farmer) emphasizing “structural violence” sometimes and (following Waitzkin) “social medicine” at other times. (Farmer actually left out the “psycho” part and called his own approach “biosocial,” Pathologies of Power, p. 19.) Maté puts the “psycho” back into the biopsychosocial.

What does the practice of biopsychosocial medicine, informed by The Myth of Normal look like? How do I envision practicing medicine within the new paradigm?

Firstly, I will need to examine my own faults and shortcomings – similarly to how Maté subjects himself to self-scrutiny. In order to be an effective instrument of healing, I must first work on healing myself. Maté suggests how one might engage in “compassionate self-inquiry” (p. 431).

Secondly, I will pay more attention to the social lives of children. Are they given the opportunity to play freely? Do their parents have the wherewithal to bond with them? Do I encourage parents to respond meaningfully to their children’s emotional needs?

Thirdly, I will work on adopting a trauma-informed stance with patients. A first approximation will be to ask about adverse childhood experiences (ACEs). Many of those who share their illness narratives with Maté tell him, “None of my doctors ever asked me about that.” I hope to help patients recognize the roles that their illness plays in their life trajectories. I hope to help them heal.

The Education of Health Professionals and Prospects for Transformation

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This is a guest blog post by Seiji Yamada, MD, University of Hawaii.

The Commission on the Education of Health Professionals for the 21st Century, chaired by Julio Frenk (Dean of the Harvard School of Public Health) and Lincoln Chen (President of the China Medical Board), published its report in the December 4, 2010 issue of the Lancet. Titled “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world,” the report was released in the centennial year of the Flexner Report of 1910. In contrast to the Flexner Report, however, the current report broadens its focus from medicine alone to include nursing and public health education. In addition, instead of focusing on the U.S., the report takes global health to be within its purview.

As noted by Richard Horton, the editor of the Lancet, "A strong case is made that the present content, organisation, and delivery of health professionals' education have failed to serve the needs and interests of patients and populations."

The commission reviews a century of reforms in health professional education, identifying the Flexner Report as a key document of the first generation. The Flexner report is widely credited with placing American medical education on a scientific basis and leading to the closure of institutions that did not meet its standards. (A critical view of the Flexner Report, that it was a means for allopathic medicine to enhance its dominance over competing philosophies of health and healing might be gleaned from Paul Starr’s The Social Transformation of American Medicine.)

The Commission associates the second generation of reforms with the “instructional breakthroughs” of problem-based learning (PBL) and disciplinarily integrated curricula. Identifying McMaster University as its pioneer, the key aspects of PBL are identified as its learner-centered philosophy and small groups. Newcastle and Case Western are identified as the pioneers of disciplinarily integrated curricula. Other second generation instructional innovations include the use of standardized patients, a focus on the patient-doctor relationship, earlier introduction to patients, and expanding clinical sites to include community settings. (p. 1932)

My own medical school experience (University of Illinois at Chicago, 1983-1987) was singularly uninspired and had none of these elements. I’m assuming (hoping) that UIC is doing better now. It was not until residency (family practice at Cook County Hospital, where Josh Freeman was one of my teachers) that I was introduced to training in the community setting (the South Lawndale Health Center). But it does make me wonder to what extent these “second generation” reforms have been instituted in U.S. medical schools.

I was introduced to PBL (as well as disciplinary integration, discussions about the patient-doctor relationship in the family medicine clerkship, clinical experiences for MS1s, and student rotations in community health centers) when I joined the faculty of the University of Hawaii John A. Burns School of Medicine (UH JABSOM). Initially skeptical, I have become a proselytizer for PBL in a way that only a former unbeliever can be. (My friend Mark Durand prefers to say that he once was a sinner, now he’s a preacher.)

I do know that PBL has become the organizing principle of medical education in only ten or so U.S. medical schools. The institutional barriers to changing over an entire curriculum to PBL are significant. Basic science departments generally have to give up ownership of courses, as disciplinary integration is inherent to PBL. In addition, the faculty resources for conducting small group tutorials are significant. PBL fails without faculty enthusiastic about serving as tutors.

The Commission calls for a third generation of educational reforms. They call for health professional education that is patient-centered and population-centered. By “population” is meant the global population. The goal is that all people around the world have access to health care. “The ultimate purpose is to assure universal coverage of the high-quality comprehensive services that are essential to advance opportunity for health equity within and between countries.” (p. 1924)

This point is what makes this report of interest for the readers of Medicine and Social Justice. Our educational system is charged with creating the next generation of workers who will transform the health care system into one that will serve all of humanity. This cannot be achieved without inculcating an ethic of social justice.

The Commission calls for two educational outcomes in this third generation of reforms: transformative learning and interdependence in education. “Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms.” (p. 1924) Generally, we tend to view our role as educators as informative and formative: we transmit knowledge to our learners (inform) and place them in settings to develop professional attitudes (form), so that they become competent and eligible for licensure. However, if we expect the next generation to lead the reform of the health system so that it delivers health for all, then we must train them to become agents of change, that is, we must inculcate transformative learning.

The second outcome called for by the Commission, interdependence in education, reflects the need for teamwork in the delivery of all health services. Disciplinary boundaries among the health professions can be overcome by interprofessional and transprofessional educational models. [The Commission defines interprofessional as teamwork with other health professional students and transprofessional as teamwork with "basic and ancillary health workers, administrators and managers, policy makers, and leaders of the local community" (pp. 1943-1944).] This will require integration of institutions as well as disciplines. Curricula will need to take more advantage of global flows of information and educational resources.

The University of Hawaii made a foray into community-based interprofessional education in the early 1990s, when the schools of social work, nursing, public health, and medicine collaborated education at community health centers. Initially funded by the Kellogg Foundation, then by the Area Health Education Center (AHEC), this effort petered out after about ten years. With external funding running dry, the various schools involved failed to commit resources to the effort.

With regards to the transprofessional educational model - in a separate piece, Marshall MacLachlan of Trinity College, calls for integrative expertise in research and research training for global health. Noting that global health is a composite field, MacLachlan proposes “integrating research about ‘what’ (content), with research about ‘where’ (context) and ‘how’ (process).” (p.2) As an example, he offers “Paul Farmer’s work on HIV/AIDS (Content), his socio-political analysis of power relations (Context), and his service delivery role in Partners in Health (Process).” (p.3) Of course, Farmer is a neo-polymath (to use MacLachlan’s term), but MacLachlan’s point is that “these people tend to emerge individually, we don’t have an explicit way of producing or encouraging such skills, or encouraging a more integrative orientation in general; and we don’t have a structure for teaching it.” (p.3)

But the fact of the matter is that our learners are demanding such teaching. As Skip Burkle points out (personal communication), young people and second career adults are demanding educational programs in humanitarian assistance. He notes that the majority of people responding to the Haiti earthquake were under thirty years old, and for many, it was their first experience in disaster assistance. Young people recognize that their working years will be spent in a globalized world, and that much of the world is characterized by poor governance and poor social and physical protections. Burkle, Clarke, and VanRooyen point out that humanitarian community inadequately translates humanitarian action into public policy. Young people recognize that they will also need to lead at the policy level.

At UH JABSOM, students formed their own organizations, the Global Health Interest Group (GHIG) and the Partnership for Social Justice (PSJ). Students in the PSJ are organizing their own leadership workshop to learn about how to improve the health system. They are motivated by a moral belief in health as a human right and the need for more social justice in health and medicine. The tasks in store for us as teachers are self-evident. Our students are demonstrating their commitment to globalism, to social justice, and to a conception of health that transcends narrow disciplines. We need to make sure that we can help prepare them to achieve these goals.
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