In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

What makes the Portland model unique and controversial among addiction services is the core intention to accept people as they are—no matter how dysfunctional, troubled, and troubling they may be.

We do not expect to cure anyone, only to ameliorate the effects of drug addiction and its attendant ailments and to soften the impact of the legal and social torments our culture uses to punish the drug addict.

Liz Evans began working in the area at the age of twenty-six. “I was overwhelmed,” she recalls. “As a nurse, I thought I had some expertise to share. While that was true, I soon discovered that, in fact, I had very little to give—I could not rescue people from their pain and sadness. All I could offer was to walk beside them as a fellow human being, a kindred spirit.

How powerful the addiction, I think, that not all the physical disease and pain and psychological torment can shake loose its lethal hold on their souls.

What a wonderful world it would be if the simplistic view were accurate: that human beings need only negative consequences to teach them hard lessons.

“Our difficulty or inability to perceive the experience of others … is all the more pronounced the more distant these experiences are from ours in time, space, or quality,” wrote the Auschwitz survivor Primo Levi.

We can be moved by the tragedy of mass starvation on a far continent; after all, we have all known physical hunger, if only temporarily. But it takes a greater effort of emotional imagination to empathize with the addict. We readily feel for a suffering child but cannot see the child in the adult who, his soul fragmented and isolated, hustles for survival a few blocks away from where we shop or work.

We shouldn’t underestimate how desperate a chronically lonely person is to escape the prison of solitude. It’s not a matter here of common shyness but of a deep psychological sense of isolation experienced from early childhood by people who felt rejected by everyone, beginning with their caregivers.

I am prone to that human—but inhumane—failing of defining and categorizing people according to our interpretation of their behaviors.

In writing about a drug ghetto in a desolate corner of the realm of hungry ghosts, it’s difficult to convey the grace that we witness—we who have the privilege of working down here: the courage, the human connection, the tenacious struggle for existence and even for dignity. The misery is extraordinary in the drug gulag, but so is the humanity.

I rarely resort to such threats, as I find them ethically unjustifiable and, for the most part, valueless in practice. I did hospitalize Devon under duress, however, and he’s thanked me for that since, many times over.

I have come to see addiction not as a discrete, solid entity—a case of “Either you got it or you don’t got it”—but as a subtle and extensive continuum.

A multilevel exploration is necessary because it’s impossible to understand addiction fully from any one perspective, no matter how accurate. Addiction is a complex condition, a complex interaction between human beings and their environment. We need to view it simultaneously from many different angles—or, at least, while examining it from one angle, we need to keep the others in mind. Addiction has biological, chemical, neurological, psychological, medical, emotional, social, political, economic, and spiritual underpinnings—and perhaps others I haven’t thought about.

If deprived of the drug, the user goes into withdrawal partly because the diminished number of receptors can no longer generate the required normal dopamine activity: hence the irritability, depressed mood, alienation, and extreme fatigue of the stimulant addict without his drug: this is the physical dependence state discussed in Chapter Eleven. It can take months or longer for the receptor numbers in the brain to rise back to pre-drug use figures.

The very concept of choice appears less clear-cut if we understand that the addict’s ability to choose, if not absent, is certainly impaired.

Brain development in the uterus and during childhood is the single most important biological factor in determining whether or not a person will be predisposed to substance dependence and to addictive behaviors of any sort, whether drug-related or not.

To begin to grasp the matter, all we need to do is picture a child who was never smiled at, never spoken to in a warm and loving way, never touched gently, never played with. Then we can ask ourselves: What sort of person do we envision such a child becoming?

It’s just as many substance addicts say: they self-medicate to soothe their emotional pain—but more than that, their brain development was sabotaged by their traumatic experiences. The systems subverted by addiction—the dopamine and opioid circuits, the limbic or emotional brain, the stress apparatus and the impulse-control areas of the cortex—just cannot develop normally in such circumstances.

Neglect and abuse during early life may cause bonding systems to develop abnormally and compromise capacity for rewarding interpersonal relationships and commitment to societal and cultural values later in life. Other means of stimulating reward pathways in the brain, such as drugs, sex, aggression, and intimidating others, could become relatively more attractive and less constrained by concern about violating trusting relationships. The ability to modify behavior based on negative experiences may be impaired.

There is a psychological fact that, I believe, provides a powerful incentive for people to cling to genetic theories. We human beings don’t like feeling responsible: as individuals for our own actions; as parents for our children’s hurts; or as a society for our many failings.

It serves a deeply conservative function: if a phenomenon like addiction is determined mostly by biological heredity, we are spared from having to look at how our social environment supports, or does not support, the parents of young children and at how social attitudes, prejudices, and policies burden, stress, and exclude certain segments of the population and thereby increase their propensity for addiction.

In the final analysis, it’s not the activity or object itself that defines an addiction but our relationship to whatever is the external focus of our attention or behavior.

Why do we despise, ostracize, and punish the drug addict when as a social collective we share the same blindness and engage in the same rationalizations?

Of any group in North America, whether in the United States or Canada, none can be said to be more psychologically and socially oppressed than Native women.

More fundamentally, the war is doomed because neither the methods of war nor the war metaphor itself is appropriate to a complex social problem that calls for compassion, self-searching insight, and factually researched scientific understanding.

One of the greatest difficulties we human beings seem to have is to relinquish long-held ideas. Many of us are addicted to being right, even if facts do not support us. One fixed image we cling to, as iconic in today’s culture as the devil was in previous ages, is that of the addict as an unsavory and shadowy character given to criminal activity. What we don’t see is how we’ve contributed to making him a criminal.

Inflamed phrases such as “inhumane medical experiment” and “state-assisted slow suicide” are spoken, it seems to me, in the language of people with a higher regard for their own convictions than for the facts.

We teach what we most need to learn—and sometimes give what we most need to receive.

The greatest damage done by neglect, trauma, or emotional loss is not the immediate pain they inflict but the long-term distortions they induce in the way a developing child will continue to interpret the world and her situation in it.

The prevention of substance abuse needs to begin in the crib—and even before then, in the social recognition that nothing is more important for the future of our culture than the way children develop.