In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

One fact suffices to demonstrate the imbalance: Americans make up 5 percent of the world’s population but 25 percent of the world’s prison population. A main cause of this shocking discrepancy is the antiquated social and legal approach to addiction. “We pay dearly for a vindictive system that often serves to make matters worse—much worse,” in the words of another former Seattle police chief, Norm Stamper. In Canada my book has been praised as “humanizing” the hard-core addicted people I work with. I find that a revealing overstatement—how can human beings be “humanized,” and who says that addicts aren’t human to begin with?

The mandala, the Buddhist wheel of life, revolves through six realms. Each realm is populated by characters representing aspects of human existence—our various ways of being. In the beast realm we are driven by basic survival instincts and appetites such as physical hunger and sexuality, what Freud called the id. The denizens of the hell realm are trapped in states of unbearable rage and anxiety. In the god realm we transcend our troubles and our egos through sensual, aesthetic, or religious experience, but only temporarily and in ignorance of spiritual truth.

The inhabitants of the hungry ghost realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs, and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects, or pursuits we hope will soothe it are not what we really need. We don’t know what we need, and so long as we stay in the hungry ghost mode, we’ll never know. We haunt our lives without being fully present.

My medical work with drug addicts in Vancouver’s Downtown Eastside has given me a unique opportunity to know human beings who spend almost all their time as hungry ghosts. It’s their attempt, I believe, to escape the hell realm of overwhelming fear, rage, and despair.

No society can understand itself without looking at its shadow side. I believe there is one addiction process, whether it is manifested in the lethal substance dependencies of my Downtown Eastside patients; the frantic self-soothing of overeaters or shopaholics; the obsessions of gamblers, sexaholics, and compulsive Internet users; or the socially acceptable and even admired behaviors of the workaholic.

There is a host of questions to be considered. Among them: • What are the causes of addictions? • What is the nature of the addiction-prone personality? • What happens physiologically in the brains of addicted people? • How much choice does the addict really have? • Why is the War on Drugs a failure, and what might be a humane, evidence-based approach to the treatment of severe drug addiction? • What are some of the paths for redeeming addicted minds not dependent on powerful substances—that is, how do we approach the healing of the many behavior addictions fostered by our culture?

but the discoveries of science, the teachings of the heart, and the revelations of the soul all assure us that no human being is ever beyond redemption. The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate question. I dedicate this work to all my fellow hungry ghosts, be they innercity street dwellers with HIV, inmates of prisons, or their more fortunate counterparts with homes, families, jobs, and successful careers. May we all find peace.

Beside Randall stands Arlene, her hands on her hips and a reproachful look on her face, clad in skimpy jean shorts and blouse—a sign, down here, of a mode of earning drug money and, more often than not, of having been sexually exploited early in life by male predators.

The Portland and the other buildings of the PHS represent a pioneering social model. The purpose of the PHS is to provide a system of safety and caring to marginalized and stigmatized people—the ones who are “the insulted and the injured,” to borrow from Dostoyevsky. The PHS attempts to rescue such people from what a local poet has called the “streets of displacement and the buildings of exclusion.”

From very modest beginnings in 1991, the PHS has grown to participate in activities such as a neighborhood bank; an art gallery for Downtown Eastside artists; North America’s first supervised injection site; a community hospital ward, where deep-tissue infections are treated with intravenous antibiotics; a free dental clinic; and the Portland Clinic, where I have worked for the past eight years. The core mandate of the PHS is to provide domiciles for people who would otherwise be homeless. The statistics are stark.

The proportion of Native Canadians among Portland residents is five times their ratio in the general population.

Our clients are not the “deserving poor”; they are just poor—undeserving in their own eyes and in those of society.

The uncomfortable truth is that most of our clients will remain addicts who are on the wrong side of the law as it now stands. Kerstin Stuerzbecher, a former nurse with two liberal arts degrees, is another PHS director.

My patients’ addictions make every medical treatment encounter a challenge. Where else do you find people in such poor health and yet so averse to taking care of themselves or even to allowing others to take care of them? At times, one literally has to coax them into a hospital. Take Kai, who has an immobilizing infection of his hip that could leave him crippled, or Hobo, whose breastbone osteomyelitis could penetrate into his lungs. Both men are so focused on their next hit of cocaine or heroin or “jib”—crystal methamphetamine—that self-preservation pales into insignificance.

“The reason I do drugs is so I don’t feel the fucking feelings I feel when I don’t do drugs,” Nick, a forty-year-old heroin and crystal meth addict once told me, weeping as he spoke. “When I don’t feel the drugs in me, I get depressed.” His father drilled into his twin sons the notion that they were nothing but “pieces of shit.” Nick’s brother committed suicide as a teenager; Nick became a lifelong addict. The hell realm of painful emotions frightens most of us; drug addicts fear they would be trapped there forever but for their substances. This urge to escape exacts a fearful price.

Marcia had been in my office just the week before, in good cheer, asking for help with some medical forms she needed to fill out to get back on welfare. It was the first time I’d seen her in six months. During that period, as she explained with nonchalant resignation, she had helped her boyfriend, Kyle, blow through a $130,000 inheritance—a process selflessly aided by many other user friends and hangers-on. For

Except for the rare fortunate ones who escape the Downtown Eastside drug colony, very few of my patients will live to old age. Most will die of some complication of their HIV or hepatitis C or of meningitis or a massive septicemia contracted through multiple self-injections during a prolonged cocaine run. Some will succumb to cancer at a relatively young age, their stressed and debilitated immune systems unable to keep malignancy in check.

And how to offer them comfort when their suffering is made worse every day by social ostracism—by what the scholar and writer Elliot Leyton has described as “the bland, racist, sexist, and ‘classist’ prejudices buried in Canadian society: an institutionalized contempt for the poor, for sex-trade workers, for drug addicts and alcoholics, for aboriginal people.”2

don’t know who he is or the path that led him to Vancouver’s skid row, where he pushes cocaine and slaps around the emaciated women who steal, deal, cheat, or sell cheap oral sex to pay him. Where was he born? What war, what deprivation forced his parents out of their slum or their mountain village to seek a life so far north of the equator? Poverty in Honduras, paramilitaries in Guatemala, death squads in El Salvador? How did he become the Spic, a villain in a story told by the rake-thin, distraught woman in my office who,

community originate? In my case, I know it is rooted in my beginnings as a Jewish infant in Nazi-occupied Budapest in 1944. I’ve grown up with the awareness of how terrible and difficult life can be for some people—through no fault of their own. But if the empathy I feel for my patients can be traced to my childhood, so can the reactively intense scorn, disdain, and judgment that sometimes erupt from me, often toward these same pain-driven individuals.

Some people are attracted to painful places because they hope to resolve their own pain there. Others offer themselves because their compassionate hearts know that here is where love is most needed. Yet others come out of professional interest: this work is ever challenging. Those with low self-esteem may be attracted because it feeds their egos to work with such powerless individuals. Some are lured by the magnetic force of addictions because they haven’t resolved, or even recognized, their own addictive tendencies. My guess is that most of us physicians, nurses, and other professional helpers who work in the Downtown Eastside are impelled by some mixture of these motives.

their

“Where I live,” Kerstin says, “I don’t know the person two houses down from me. I vaguely know what they look like, but I certainly don’t know their name. Not down here. Here people know each other, and that has its pros and its cons. It means that people rail at each other and rage at each other, and it also means that people will share their last five pennies with each other.

The witticisms are often fearlessly self-mocking. “Used to bench press two hundred pounds, Doc,” Tony, emaciated, shriveled, and dying of AIDS, cracked during one of his last office visits. “Now I can’t even bench press my own dick.” When my addict patients look at me, they are seeking the real me. Like children, they are unimpressed with titles, achievements, worldly credentials. Their concerns are too immediate, too urgent.

Nothing records the effects of a sad life so graphically as the human body. NAGUIB MAHFOUZ Palace of Desire

people jeopardize their lives for the sake of making the moment livable.

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.

On the physiological level, drug addiction is a matter of brain chemistry gone askew under the influence of a substance and, as we will see, even before the use of mind-altering substances begins. But we cannot reduce human beings to their neurochemistry; and even if we could, people’s brain physiology doesn’t develop separately from their life events and their emotions.

Beyond the addict’s immediate orgasmic release of the moment, drugs have the power to make the painful tolerable and the humdrum worth living for.

Like patterns in a tapestry, recurring themes emerge in my interviews with addicts: the drug as emotional anesthetic; as an antidote to a frightful feeling of emptiness; as a tonic against fatigue, boredom, alienation, and a sense of personal inadequacy; as stress reliever and social lubricant. And, as in Stephen Reid’s description, the drug may—if only for a brief instant—open the portals of spiritual transcendence.

Dismissing addictions as “bad habits” or “self-destructive behavior” comfortably hides their functionality in the life of the addict.1 VINCENT FELITTI, MD

Addictions always originate in pain, whether felt openly or hidden in the unconscious.

The very same brain centers that interpret and “feel” physical pain also become activated during the experience of emotional rejection: on brain scans they “light up” in response to social ostracism just as they would when triggered by physically harmful stimuli.4 When people speak of feeling “hurt” or of having emotional “pain,” they are not being abstract or poetic but scientifically quite precise.

The question is never “Why the addiction?” but “Why the pain?”

The research literature is unequivocal: most hard-core substance abusers come from abusive homes.5 The majority of my skid row patients suffered severe neglect and maltreatment early in life.

Another man described the way his mother used a mechanical babysitter when he was three years old. “She went to the bar to drink and pick up men. Her idea of keeping me safe and from getting into trouble was to stick me in the dryer. She put a heavy box on top so I couldn’t get out.” The air vent ensured that the little boy wouldn’t suffocate.

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.

Not all addictions are rooted in abuse or trauma, but I do believe they can all be traced to painful experience. A hurt is at the center of all addictive behaviors. It is present in the gambler, the Internet addict, the compulsive shopper, and the workaholic.

I asked fifty-seven-year-old Richard, an addict since his teens, why he kept using. “I don’t know, I’m just trying to fill a void,” he replied. “Emptiness in my life. Boredom. Lack of direction.” I knew all too well what he meant. “Here I am, in my late fifties,” he said. “I have no wife, no children. I appear to be a failure. Society says you should be married and have children, a job, that kind of stuff. This way, with the cocaine, I can sit there and do some little thing like rewire the toaster that wasn’t working, and not feel like I’ve lost out on life.”

A sense of deficient emptiness pervades our entire culture. The drug addict is more painfully conscious of this void than most people and has limited means of escaping it.

When we have nothing to occupy our minds, bad memories, troubling anxieties, unease, or the nagging mental stupor we call boredom can arise. At all costs, drug addicts want to escape spending “alone time” with their minds. To a lesser degree, behavioral addictions are also responses to this terror of the void.

Boredom, rooted in a fundamental discomfort with the self, is one of the least tolerable mental states.

The addict’s reliance on the drug to reawaken her dulled feelings is no adolescent caprice. The dullness is itself a consequence of an emotional malfunction not of her making: the internal shutdown of vulnerability.

From the Latin word vulnerare, “to wound,” vulnerability is our susceptibility to be wounded. This fragility is part of our nature and cannot be escaped. The best the brain can do is to shut down conscious awareness of it when pain becomes so vast or unbearable that it threatens to overwhelm our capacity to function.

“Everybody knows there is no fineness or accuracy of suppression,” wrote the American novelist Saul Bellow in The Adventures of Augie March; “if you hold down one thing you hold down the adjoining.”8

Emotional shutdown is similar. Our emotions are an indispensable part of our sensory apparatus and an essential part of who we are. They make life worthwhile, exciting, challenging, beautiful, and meaningful. When we flee our vulnerability, we lose our full capacity for feeling emotion. We may even become emotional amnesiacs, not remembering ever having felt truly elated or truly sad. A nagging void opens, and we experience it as alienation, as profound ennui, as the sense of deficient emptiness described earlier.

Emotionally drained people often lack physical energy, as anyone who has experienced depression knows, and this is a prime cause of the bodily weariness that beleaguers many addicts.

These four don’t know it, but beyond illness or the inertia of emotional and physical exhaustion, they are also up against the brain physiology of addiction. Cocaine, as we shall see, exerts its euphoric effect by increasing the availability of the reward chemical dopamine in key brain circuits, and this is necessary for motivation and for mental and physical energy. Flooded with artificially high levels of dopamine triggered by external substances, the brain’s own mechanisms of dopamine secretion become lazy.

Only long months of abstinence allow the intrinsic machinery of dopamine production to regenerate, and in the meantime, the addict will experience extremes of physical and emotional exhaustion.

He feels incomplete and incompetent as a person without the drug, a self-concept that has nothing to do with his real abilities and everything to do with his formative experiences as a child. By