Letter from the Publisher

Diane Keaton. I don’t blame you for being furious with me.

Woody Allen. I’m too stunned to be furious.

Keaton. Well then I wish you would. I wish you’d get angry, so that we could have it out, so that we could get it out in the open.

Allen. I don’t get angry, okay? I mean, I have a tendency to internalize. I can’t express anger. That’s one of the problems I have. I, I grow a tumour instead.

from the 1979 movie Manhattan

As in most of Allen’s movies, the dialogue is hilarious. But while the screenwriters created a big laugh, Allen’s quip is hardly laughable. A great many cancer patients have terrible difficulty in expressing, emotions especially anger. Controlled emotions make for a loving homemaker and mother, a respected and successful businessman, a popular and admired adolescent. Too often there is no way to vent emotions appropriately, and anger has only one outlet – to be internalized. A script that plays out from infancy, as a toddler, teen-ager, and adult with resentment hidden under a friendly, helpful visage too often eats away inside and fuels the incipient tumor mass to become full-blown cancer. It is difficult to think of lung cancer, breast cancer, malignant melanoma, colon cancer, and other tumors promoted by our emotions. Oncology certainly gives little credence for repressed anger’s engendering tumor growth and metastasis. However, Dr. Gabor Maté’s 2003 book, When the Body Says No, cites study after study that demonstrates exactly that suppressed anger underlies many cancers. Furthermore, survival rates increased in those patients who were able to express their anger. The quiet, docile patients accepting their cancer diagnosis and treatment, unable to vent, had poorer outcomes. Of course, excess emoting of anger is also a bad thing – too much anger fosters cardiovascular disease, hypertension, and vascular events. Maté makes the case that individuals need to be able to express anger “moderately” without raging; the balance between repressing emotions and screaming is a difficult but worthwhile psychological work.

When the Body Says No, a best-selling book printed in more than 12 languages, is not a “fun” read. I read the book twice, and the first time I found myself becoming angry with the author and his text. How could our emotional state, stress, and our dysfunctional relationships play such a pivotal role in fostering disease? I understood well that the harassed wife (or husband), the mistreated child, the sexually abused woman would experience emotional problems. However, how could the abuse and dysfunctionality lead to cancer, autoimmune illness, neurologic disorders, GI problems, and inflammatory disease? Could it really be that inability to express grief, depression, anxiety, anger could encourage disease development? It just didn’t make sense. Yes, Maté offers compelling scientific evidence that disease initiation, promotion, and progression is underlaid by emotions repressed, enmeshed dysfunctional relationships, and inability to accept oneself as a valued human being. Of course, nobody makes the choice to repress and control emotions. Maté makes the case that we learn these behaviors at infancy and as toddlers and adolescents. Unfortunately, it is very difficult to let go of these behaviors as we get older. In fact, much of the behavior has become scripted in our unconsciousness. We look for mates who enable us to continue the same behaviors that enabled us to survive childhood. The workplace is a great venue to escape the dysfunctional family and to become workaholics avoiding our emotional needs.

I know that this sounds like psychological mumbo-jumbo. As I said, I found myself not able to objectively read Maté because he challenges our rational state of being. How could our emotional state play such an important role in our health? Maté interviews nearly 100 individuals who have chronic illness. He is a practicing physician in Vancouver, B.C., and he has spent nearly a decade working with palliative care. Most physicians do not want to explore a patient’s social situation or emotional state. Maté worked like most physicians carrying out a general medical practice, running tests, and then prescribing treatments or arranging surgery. In the past two decades he began to explore that emotional-neurological-immunological-hormonal connection (psychoneuroimmunoendocrinology) in patient histories. He was particularly impressed by Hans Selye’s work. Maté found that nearly all patients have a story of emotional repression and control and dysfunctionality and stress. However, patients do not generally disclose their social/emotional histories. In fact, some patients cannot recall their difficulties from growing up and others deny such difficulties. Maté claims that illness remains very difficult to treat unless patients are willing to explore their emotional state. Could it be that every patient we have needs counseling work?

Maté does not accept the notion that one can have a chronic illness and have had a loving upbringing and wonderful marriage and stress-free life. He would judge such a characterization as imbued with denial. In Maté’s experience, there are always incidents and situations which are abusive and threatening that the patient has hidden away and forgotten. Regrettably, the psyche has not forgotten. Maté attributes autoimmune illness to a failure of our immune, endocrine, and neurologic systems to be able to distinguish self from nonself. This is not a new concept. What is the new concept is that the roots for that failure to distinguish self from nonself derive from behavioral patterns that we acquire as we grow up and bring into our adulthood. While we focus on medications and herbals and hormones to control autoimmune disease, Matte argues that the patient needs to explore the emotional state and become aware of how personal boundaries are being violated in relationships and at work.

Woody Allen’s character enjoys a laugh but the man he plays admits that he is not whole when he cannot express anger. Maté would argue that he is poised to develop a chronic illness.

Jonathan Collin, MD