Ms An - my massage therapist

The body keeps the invoice

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Your nervous system has been running a tab for decades. The research says you can start paying it down.

I was lying face-down on a massage table in Đà Lạt when it occurred to me that I might be doing something medically significant. Not spiritually significant. Not Instagram-wellness significant. Actually, measurably, physiologically significant.

Now, as I have mentioned before, there are three types of massage in Vietnam: those performed by beautiful young women who move with all the grace and elegance of models and who every weekend soothe the savage beasts that are my wife and I. These are young women who look, to my Western eyes, like they should still be in school. They are in fact in their mid-20s. 

There are those who work in a legally-grey area and with whom we do not dwell.

And there is Ms An.

Three times a week, Ms An—a middle-aged Vietnamese woman with hands like industrial equipment—works through the accumulated wreckage of six decades of chronic stress, misdiagnosis, financial terror, and the particular muscular catastrophe that comes from spending most of your adult life braced against a world that never quite made sense. And three times a week, something in my body unclenches that I didn’t know was clenched until I got to Đà Lạt.

I assumed this was just pleasant. Turns out it might be one of the more important medical interventions available to someone with my history.

What allostatic load actually is

Bruce McEwen coined the term in 1993, and it remains one of the most useful concepts in stress physiology. Allostatic load is the cumulative biological cost of adapting to chronic stress. Not the stress itself. The invoice.

Here’s how it works. Your body is designed to respond to acute threats—the sabre-toothed tiger, the near-miss on the highway, the email from your ex’s lawyer. Cortisol spikes. Adrenaline floods. Blood pressure rises. Inflammatory markers activate. This is allostasis: the body maintaining stability through change. It’s elegant, efficient, and meant to be temporary.

The problem is when it isn’t temporary.

When the stressor is not a tiger but a decades-long pattern of financial precarity, institutional betrayal, undiagnosed neurodivergence, chronic masking, disrupted sleep, and the low-grade hum of never quite fitting the environment you’re in, the system doesn’t switch off. It just keeps running. Cortisol stays elevated. Inflammatory markers remain high. Blood pressure creeps up. Metabolic markers drift. The cardiovascular system remodels. The immune system stays primed for threats that aren’t coming because the threat is the life itself.

McEwen and Stellar described this as ‘wear and tear’—the physiological price of chronic adaptation. The allostatic load index captures it across multiple body systems: neuroendocrine, immune, cardiovascular, metabolic, and anthropometric. It’s not one number that’s wrong. It’s the pattern of many numbers being slightly wrong, all at once, for a very long time.

The damage is real. And it’s measurable.

A 2025 study from the Paris Brain Institute found that higher allostatic load was associated with reduced grey matter volume and compromised white matter integrity in frontal and temporal brain regions—areas critical to attention, executive function, and emotional regulation. The researchers, led by Palix and colleagues, also found that elevated allostatic load was linked to poorer attentional capacity in older adults (Palix et al., 2025).

Chronic cortisol exposure has been associated with hippocampal volume reduction—the hippocampus being the brain structure most directly involved in learning and memory (Sapolsky, 1996). This isn’t abstract. It’s structural. The brain physically changes shape under sustained stress.

A systematic review and meta-analysis by Guidi, Lucente, Sonino, and Fava (2021) documented the breadth of the damage: allostatic load predicts cardiovascular disease, metabolic dysfunction, cognitive decline, and earlier mortality. A 2025 study using data from the All of Us Research Program confirmed that higher perceived stress was significantly associated with elevated allostatic load, even after controlling for socioeconomic and neighbourhood-level health determinants (Morley et al., 2025).

The socioeconomic dimension is particularly brutal. Research consistently shows that low socioeconomic status is associated with higher allostatic load, and the relationship is cumulative—poverty sustained over time produces worse outcomes than intermittent hardship (Graves & Nowakowski, 2017; Szanton et al., 2005). Financial stress doesn’t just feel terrible. It physically degrades your body’s regulatory systems. A 2023 study by French found that repeated negative financial shocks increased the probability of elevated blood pressure by 9.5% and raised cholesterol ratios by 6.1%, consistent with the allostatic load model of cumulative stress producing secondary health outcomes (French, 2023).

If you’ve spent years—decades—carrying financial stress alongside the rest of it, your body has been keeping a very precise and unforgiving ledger.

But here is the part they don’t tell you enough

The load can be reduced.

A landmark scoping review by Beckie (2012), published in Stress, was the first to synthesise interventions specifically targeting allostatic load as a composite outcome. Four of the six interventions studied showed significant decreases in allostatic load scores, with improvements appearing in as little as seven weeks. The review concluded that allostatic load is ‘amenable to change and responsive to interventions’—a finding with enormous clinical implications.

Pfaltz and Schnyder (2023) noted that cognitive behavioural therapy, Tai Chi Chih for insomnia, and group resilience training have all shown promising results in reducing allostatic load parameters. They emphasised that individually tailored interventions addressing both psychological and physiological stress could modulate the vulnerabilities induced by allostatic overload.

The body’s stress-response systems—neuroendocrine, immune, cardiovascular, metabolic—are not fixed. They are dynamic. They respond to environmental change. The trajectory can bend.

This matters because the dominant cultural narrative around chronic stress damage tends toward fatalism. You’ve been stressed for forty years, the story goes, and now you’re damaged. Live with it. Manage it. Accept the diminished version.

The research says something more interesting than that.

What I’m actually doing (and why the science supports it)

I did not design my current life as a clinical intervention. I designed it as an escape. But it turns out that what I stumbled into maps remarkably well onto what the research says works.

Regular massage

Three times a week. Not a spa treat. A clinical intervention.

Field, Hernandez-Reif, Diego, Schanberg, and Kuhn (2005) reviewed the biochemical effects of massage therapy and found that cortisol levels decreased by an average of 31% in studies using saliva or urine assays, while serotonin and dopamine—the activating neurotransmitters—increased significantly. A comprehensive 2025 review of 32 studies confirmed significant reductions in stress biomarkers including cortisol and blood pressure across diverse populations (Virmani, 2025).

Now, here’s where honesty matters. A rigorous meta-analysis by Moyer, Rounds, and Hannum (2011) found that when measured using between-groups methodology, massage therapy’s effect on cortisol was generally small and often not statistically distinguishable from zero. They concluded that cortisol reduction could not be the primary mechanism behind massage therapy’s well-established benefits for anxiety, depression, and pain. Something else is happening—something the research hasn’t fully identified yet.

What’s not in dispute is that regular massage therapy produces reliable, measurable improvements in anxiety, mood, and perceived stress. The mechanism may not be cortisol. It may be parasympathetic nervous system activation—the shift from sympathetic ‘fight-or-flight’ to parasympathetic ‘rest-and-digest.’ It may be something about sustained, intentional human touch. It may be the simple act of lying still for an hour in a body that has spent decades braced for impact.

Whatever the mechanism, three sessions a week means my nervous system gets regular, reliable signals that the emergency is over. For someone whose body has been running an emergency protocol for most of their adult life, that signal is not trivial.

Riding through the hills

Ever since I got my driver’s licence at sixteen in Adelaide, I have been going for long drives in the country on my own. Just the car, some music on the stereo, and the road. I didn’t have the language for it then, but I know now what I was doing: giving my AuDHD brain exactly enough stimulation—the road, the steering, the music, the landscape sliding past—to keep it occupied while the rest of my nervous system stood down from high alert. It has worked for me for fifty years.

I don’t have a car in Vietnam. I have a motor scooter. And once I get outside of Đà Lạt central and into the countryside around it, I am blown away by how beautiful it is. Hills and trees and sunlight. Coffee plantations rolling down into valleys. Pine forests that smell like the world was built five minutes ago. I ride out to an upmarket café bistro tucked into those hills, where nobody is in a hurry and the quiet is so thick you can almost lean on it.

I don’t walk. I’ve tried. My brain will chew itself apart if it’s not given something to focus on. Walking with podcasts, walking with music—none of it provides enough operational demand to keep the AuDHD machinery from turning inward and eating the furniture. Mindfulness and meditation have proved the same: my brain will destroy itself, and my peace of mind along with it, if I don’t give it something to chew on. The scooter gives it exactly the right amount. Enough attention to ride safely. Not so much that it becomes stressful. The sweet spot where the nervous system can actually rest while the conscious mind stays usefully occupied.

A meta-analysis by Wen, Zhang, Harris, Holtge, and Song (2020), synthesising 31 studies across 12 countries, found that direct exposure to natural environments was associated with decreased salivary cortisol, reduced blood pressure, and improved heart rate variability—all markers directly relevant to allostatic load.

Hunter and colleagues (2019) found that nature exposure decreased salivary cortisol by 21% and salivary amylase by 28%, with the most significant stress reduction occurring in exposures between 20 and 30 minutes. Olafsdottir and colleagues (2020) found that active engagement with nature—walking, in their study—produced lower cortisol levels than either passive nature viewing or indoor exercise alone, particularly during high-stress periods. The principle holds regardless of whether you’re walking, cycling, or riding a scooter through it: being immersed in a natural environment while your body is in motion produces measurable physiological benefits.

The combination—nature immersion with light physical engagement and enough cognitive demand to occupy a restless brain—is addressing multiple allostatic load pathways simultaneously. Parasympathetic activation from the natural environment. Reduced sensory load from the absence of urban noise and visual clutter. And a mode of engagement that actually works for a neurodivergent nervous system, which is more than most mindfulness programmes can claim.

Removal of financial stress

This is the one nobody wants to talk about, because it implies that the most effective health intervention for chronically stressed people might be money. Which is awkward for an industry built on selling mindset shifts and gratitude journals.

Allostatic load research has consistently demonstrated that low socioeconomic status is associated with elevated biological stress across multiple systems (Szanton et al., 2005). The relationship is not just correlational. Financial stress activates the same neuroendocrine cascades as any other chronic stressor—cortisol elevation, inflammatory activation, cardiovascular strain—and it does so relentlessly, because you cannot take a holiday from being broke.

The removal of financial pressure from my life has been, I suspect, the single largest contributor to reducing my allostatic load. Not because money buys happiness (a claim so oversimplified it barely deserves a sentence), but because the absence of financial threat allows the stress-response system to stand down. The emergency protocol can finally switch off. The body can begin allocating resources to repair rather than defence.

I mention this because most allostatic load intervention research focuses on things individuals can do—exercise, meditation, therapy, diet. These matter. But the elephant in the consulting room is that the most powerful modifiable risk factor for elevated allostatic load is socioeconomic—and addressing it requires structural change, not better coping strategies.

Sensory environment

Đà Lạt sits at 1,500 metres in the Central Highlands of Vietnam. The temperature rarely exceeds 25°C. The air is clean (well, except during the burning season). The pace is slower than Saigon or Hanoi by several orders of magnitude. For an AuDHD nervous system that spent decades in sensory environments calibrated for neurotypical tolerance, the reduction in baseline sensory load is enormous.

This maps directly onto the allostatic load framework. Every sensory demand that exceeds your processing threshold is a micro-stressor. Fluorescent lights. Background noise. Crowded spaces. Unpredictable social environments. For a neurodivergent person, these are not preferences—they are physiological demands that activate stress-response systems. Reduce them, and you reduce the cumulative load.

I did not move to Đà Lạt because I read a paper on allostatic load and environmental fit. I moved because I could breathe here. The science arrived later and confirmed what my body already knew.

What the research doesn’t promise

I want to be careful here, because the contrarian in me knows how easily this becomes a wellness narrative, and wellness narratives are where nuance goes to die.

The research does not promise a full reset. Structural brain changes from decades of chronic cortisol exposure may not fully reverse. Hippocampal volume reduction, white matter degradation, cardiovascular remodelling—some of this may be permanent. The body keeps a record that cannot be entirely erased.

What the research does promise is that the trajectory can change. Systems that have been running hot can begin to recalibrate. Inflammatory markers can come down. Cortisol patterns can normalise. Blood pressure can improve. Metabolic function can shift. And the earlier you intervene, the more room there is for recovery—though ‘earlier’ is relative, and seven weeks for measurable change suggests that it is never too late to be worth trying.

Pfaltz and Schnyder (2023) put it well: consideration of allostatic load allows clinicians to create individually tailored interventions that address the whole picture—not just the symptoms, but the accumulated biological cost of the life that produced them.

The question nobody asks

The standard question in stress management is: How do I cope better?

I wonder if the better question is: What would it take to remove the things my body is coping with?

For me, the answer turned out to be: leave the country, find an environment that doesn’t assault my nervous system, remove the financial pressure, get regular massage, ride a scooter through pine-forested hills, and stop pretending that willpower and gratitude could fix what was fundamentally an environmental mismatch.

Your answer will be different. But the principle is the same. The body keeps a ledger. It responds to what you actually do, not what you intend to do. And the research is clear: the load can be lightened. The invoice can start being paid down.

Not perfectly. Not completely. But meaningfully, measurably, and—if the scoping review is right—in as little as seven weeks.

Your nervous system has been waiting for the emergency to end. It might be worth asking what it would take to actually end it.


See also:

References

Beckie, T. M. (2012). A scoping review of interventions targeting allostatic load. Stress15(6), 583–594. https://doi.org/10.1080/10253890.2020.1784136

Sapolsky, R. M. (1996). Why stress is bad for your brain. Science273(5276), 749–750. https://doi.org/10.1126/science.273.5276.749

Field, T., Hernandez-Reif, M., Diego, M., Schanberg, S., & Kuhn, C. (2005). Cortisol decreases and serotonin and dopamine increase following massage therapy. International Journal of Neuroscience115(10), 1397–1413. https://doi.org/10.1080/00207450590956459

French, D. (2023). From financial wealth shocks to ill-health: Allostatic load and overload. Health Economics32(4), 871–890. https://doi.org/10.1002/hec.4648

Graves, K. Y., & Nowakowski, A. C. H. (2017). Childhood socioeconomic status and stress in late adulthood: A longitudinal approach to measuring allostatic load. Global Pediatric Health4, 1–8. https://doi.org/10.1177/2333794X17744950

Guidi, J., Lucente, M., Sonino, N., & Fava, G. A. (2021). Allostatic load and its impact on health: A systematic review. Psychotherapy and Psychosomatics90(1), 11–27. https://doi.org/10.1159/000510696

Hunter, M. R., Gillespie, B. W., & Chen, S. Y.-P. (2019). Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers. Frontiers in Psychology10, 722. https://doi.org/10.3389/fpsyg.2019.00722

McEwen, B. S., & Stellar, E. (1993). Stress and the individual: Mechanisms leading to disease. Archives of Internal Medicine153(18), 2093–2101.

Morley, F., Mount, L., An, A., Phillips, E., Tamimi, R. M., & Kensler, K. H. (2025). Perceived stress and allostatic load: Results from the All of Us Research Program. PLOS ONE20(8), e0330106. https://doi.org/10.1371/journal.pone.0330106

Moyer, C. A., Seefeldt, L., Mann, E. S., & Jackley, L. M. (2011). Does massage therapy reduce cortisol? A comprehensive quantitative review. Journal of Bodywork and Movement Therapies15(1), 3–14. https://doi.org/10.1016/j.jbmt.2010.06.001

Olafsdottir, G., Cloke, P., Schulz, A., van Dyck, Z., Eysteinsson, T., Thorleifsdottir, B., & Vögele, C. (2020). Health benefits of walking in nature: A randomized controlled study under conditions of real-life stress. Environment and Behavior52(3), 248–274. https://doi.org/10.1177/0013916518800798

Palix, C., Chauveau, L., Felisatti, F., Chocat, A., Coulbault, L., Hébert, O., … & Poisnel, G. (2025). Allostatic load, a measure of cumulative physiological stress, impairs brain structure but not β-accumulation in older adults: An exploratory study. Frontiers in Aging Neuroscience17, 1508677. https://doi.org/10.3389/fnagi.2025.1508677

Pfaltz, M. C., & Schnyder, U. (2023). Allostatic load and allostatic overload: Preventive and clinical implications. Psychotherapy and Psychosomatics92(6), 359–362. https://doi.org/10.1159/000535031

Szanton, S. L., Gill, J. M., & Allen, J. K. (2005). Allostatic load: A mechanism of socioeconomic health disparities? Biological Research for Nursing7(1), 7–15. https://doi.org/10.1177/1099800405278216

Virmani, S. (2025). Massage therapy as an effective intervention for stress reduction: A comprehensive review. Indian Journal of Ayurveda & Alternative Medicines2(2), 26–30.

Wen, Y., Zhang, B., Harris, J., Holtge, J., & Song, Q. (2020). The effect of exposure to the natural environment on stress reduction: A meta-analysis. Urban Forestry & Urban Greening57, 126932. https://doi.org/10.1016/j.ufug.2020.126932

Zheng, G., Sheridan, S., & Verstraten, E. (2019). Effect of aerobic exercise on inflammatory markers in healthy middle-aged and older adults: A systematic review and meta-analysis of randomized controlled trials. Frontiers in Aging Neuroscience11, 98. https://doi.org/10.3389/fnagi.2019.00098

Take the next step—contact Lee Hopkins: lee@mindblownpsychology.com

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