In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

Many addicts report similar improvements in their social abilities under the influence, in contrast to the intolerable aloneness they experience when sober. “It makes me talk, it opens me up; I can be friendly,” says one young man wired on crystal meth. “I’m never like this normally.” 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.

Another powerful dynamic perpetuates addiction despite the abundance of disastrous consequences: the addict sees no other possible existence for himself. His outlook on the future is restricted by his entrenched self-image as an addict. No matter how much he may acknowledge the costs of his addiction, he fears a loss of self if it were absent from his life. In his own mind, he would cease to exist as he knows himself.

As many crystal meth users see it, this drug offers benefits to young street dwellers. Strange to say, it makes their lives more livable in the short term. It’s hard to get a good night’s sleep on the street: crystal meth keeps you awake and alert. No money for food? No need for hunger: crystal meth is an appetite suppressant. Tired, lacking energy? Crystal meth gives a user boundless energy.

“I know this sounds pretty fucked up, but I like who I am.” “You’re sitting here with your face smashed in by a metal pipe, and you’re telling me you like who you are?” “Yes, but I like who I am. I’m Toecutter. I’m an addict, and I’m a nice guy.”

Jake is so identified with his addiction that he doesn’t dare imagine himself sober. “It feels like everyday life for me,” he says. “It doesn’t seem any different from anyone else’s life. It’s normal for me.”

“Well,” she shrugged, getting up to leave, “they told me she was dead.” I’ve often been struck by the childlike insouciance of my addicted patients when they lie to me. A naive manipulation like the one Serena attempted is simply part of the game, and being caught is no more shameful than being found while playing hide-and-seek.

Even the average citizen finds it difficult to question medical authority, for a host of cultural and psychological reasons. As an authority figure, the doctor triggers deeply ingrained feelings of childhood powerlessness in many of us—I had that experience even years after completing medical training when I needed care for myself.

It occurs to me at times that, in the view of my addicted patients, the roles of detective, prosecutor, and judge are grafted onto my duties as physician. I am there not only as a healer, but also as an enforcer.

In any confrontation with authority, be it nurse, doctor, police officer, or hospital security guard, the addict is virtually helpless. No one will accept her side of the story—or act on it even if they do. Power comes with the territory, and it corrupts. At the Portland I’ve caught myself in behaviors that I would never permit myself in any other context.

Cindy, looking hurt, reproached me quietly. “You shouldn’t say that so loud.” I was aghast. Back in the “respectable” family practice I ran for twenty years before coming to work in the Downtown Eastside, it would have been unthinkable for me to commit such a callous breach of confidentiality, to injure someone’s dignity so brazenly. I closed the door and offered my regrets. “I was loud,” I agreed. “Very stupid of me.” “Yes,

Imprinted in the developing brain circuitry of the child subjected to abuse or neglect is fear and distrust of powerful people, especially of caregivers. In time this ingrained wariness is reinforced by negative experiences with authority figures such as teachers, foster parents, and members of the legal system or the medical profession.

am prone to that human—but inhumane—failing of defining and categorizing people according to our interpretation of their behaviors. Our ideas and feelings about a person congeal around our limited experience of them, and around our judgments. In my eyes, Serena was reduced to an addict who inconvenienced me by wanting more drugs. I didn’t perceive that she was a human being suffering unimaginable pain, soothing it, easing it in the only way she knew how.

Almost uniformly, the greatest anguish confessed by my patients, male or female, concerns not the abuse they suffered but their own abandonment of their children. They can never forgive themselves for it. The very mention of it draws out bitter tears, and much of their continued drug use is intended to dull the impact of such memories.

And here is where I’m humbled. I’m humbled by my feebleness in helping this person. Humbled that I had the arrogance to believe I’d seen and heard it all. You can never see and hear it all because, for all their sordid similarities, each story in the Downtown Eastside unfolded in the particular existence of a unique human being. Each one needs to be heard, witnessed, and acknowledged anew, every time it’s told. And I’m especially humbled because I dared to imagine that Serena was less than the complex and luminous person she is. Who am I to judge her for being driven to the belief that only through drugs will she find respite from her torments?

Spiritual teachings of all traditions enjoin us to see the divine in each other. Namaste, the Sanskrit holy greeting, means, “The divine in me salutes the divine in you.” The divine? It’s so hard for us even to see the human. What have I to offer this young Native woman whose three decades of life bear the compressed torment of generations? An antidepressant capsule every morning, to be dispensed with her methadone, and half an hour of my time once or twice a month.

I shudder. After three decades as a doctor I sometimes believe I’ve heard every kind of depravity adults can inflict on the young and the unprotected. But in the Downtown Eastside new childhood horrors are always being revealed. Celia acknowledges my shock with a flicker of her eyelids and a nod and then continues. “Now my old man, Rick, was with the army in Sarajevo and he has post-traumatic stress. There’s me, having sexual abuse dreams and waking up, and I’ve got him waking up screaming about guns and death.”

Celia is expecting. Down here that’s always a mixed blessing at best. It may seem that a physician’s first thought with a newly pregnant, drug-dependent patient would be to counsel abortion. But the doctor’s job—with this or any other population—is to ascertain the woman’s own preferences and, if appropriate, explain the options without exerting any pressure to decide this way or that.

Many addicted women decide to have their babies, rather than choose the route of an early abortion.

Despite my doubts and misgivings, with all my heart I want them to succeed. Pregnancy has helped some addicts break away from their habits, and Celia would not be the first one to make it. Carol, the young woman with a crystal meth and opiate dependence quoted in Chapter Three, has given birth to a healthy infant, given up her addiction, and moved to the interior of British Columbia to live with her grandparents.

Contrary to what Celia expects, we will not only maintain her on this drug but will likely increase the dose as the pregnancy proceeds. A fetus undergoing opiate withdrawal in utero may suffer neurological damage, so it’s better for the baby to come into the world with an opiate dependence and to wean her from it gently postpartum.

Of course, I recalled, she learned something about spitting in her childhood. But finally, she gave birth to a remarkably healthy infant girl who was easily weaned off her opiate dependence. In every other way the baby was fine. Unlike the opiates methadone and heroin, cocaine does not provoke dangerous physiological withdrawal reactions.

I’ll soon come to know Ralph as one of the most intellectually gifted people I have ever met. He is also profoundly sad—a lost poetic soul with a hopeless, unrequited longing for human connection. Although his wide-ranging but undisciplined intellect is captive to whatever thought or emotion happens to possess it in the moment, he also wields a sharp, self-mocking wit. He indulges in highly aggressive and even violent behaviors when he’s under the influence of the uppers he uses.

The greater the number of medical conditions a person has, the greater the monetary support he receives. Addicts, who may spend a hundred dollars or more daily on their illicit drugs and who often miss health-related appointments, rarely fail to come in when it’s time to have their papers filled out for the monthly twenty, forty, or fifty bucks they receive for dietary support.

If as a Jew and infant survivor of genocide I can receive these ravings calmly, it’s because I know they’re not about me or my grandparents or even about World War II or Nazis and Jews. Ralph is showcasing the terrible unrest of his soul. The suffering Germans and rapacious Jews in his narrative are projections of his own phantoms. The erratic mishmash he calls history reflects his inner chaos, confusion, and fear. “I starved in Germany as a kid and I fuckin’ starved in this country, too.… Came here in 1961.” (Ralph arrived as a teenager.) “Fuck Canadians. I hate Canadians.”

“It is,” Ralph confirms triumphantly. “The final eight lines of Faust.” Without missing a beat he recites in English: All things transitory Are but a parable, Earth’s insufficiency Here finds fulfillment. The ineffable Wins life through love. The eternal feminine Leads us above. He presents this poem without his customary hasty intensity; his voice is soft and gentle.

As I read the great German poet’s verses in my comfortable home in an upscale, leafy Vancouver neighborhood, I can’t help thinking that at this very same moment Ralph, supported by his cane, is holding vigil somewhere in the dusky and dirty Hastings Street evening, hustling for his next hit of cocaine. And in his heart he wants beauty no less than I—and, no less than I, needs love.

One consequence of spiritual deprivation is addiction, and not only to drugs. At conferences devoted to science-based addiction medicine, it is more and more common to hear presentations on the spiritual aspect of addictions and their treatment. The object, form, and severity of addictions are shaped by many influences—social, political, and economic status; personal and family history; physiological and genetic predispositions—but at the core of all addictions there lies a spiritual void.

But for now, suffice it to say that if I hadn’t already sensed Ralph’s secret God-thirst from his Goethe recital, Ralph would, a few months hence, confirm it in so many words. In his soul of souls he longs to connect with the very same feminine quality within himself that his bellicosity and unbridled aggression trample so viciously underfoot.

“I’m curious. What’s that all about for you? “It’s just supremacy. I don’t believe it anyway. No race is supreme. All people are supreme to God, or nobody is.… It doesn’t matter anyway. It’s just stuff that goes through a person’s mind. I grew up affected by National Socialism, as you did also, only you grew up on the other side of the table. It was an unfortunate situation. I apologize for everything I said against you and your son. I really wish to be out of here soon so Daniel and I can make more music.”

In Goethe’s epic drama the Homunculus is a little being of fire conceived in a laboratory flask. He is a masculine figure who voluntarily unites with the vast Ocean, the divine feminine aspect of the soul. According to mystical traditions of all faiths and philosophies, without such ego-annihilating submission, it is impossible to attain spiritual enlightenment, “the peace of God, which passeth all understanding.” Ralph yearns for nothing less. “The Homunculus,” he continues, “is the character that represents all I would have been, had it been possible for me to be that way. But it’s not how I turned out. So now I use Xylocaine when I can get it or cocaine when I can’t.” Ralph hopes to inhale peaceful consciousness through a glass pipe. I cannot be the Homunculus, he says, so I must be an addict.

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.

The moments of reprieve at the Portland come not when we aim for dramatic achievements—helping someone kick addiction or curing a disease—but when clients allow us to reach them, when they permit even a slight opening in the hard, prickly shells they’ve built to protect themselves. For that to happen, they must first sense our commitment to accepting them for who they are. That is the essence of harm reduction, but it’s also the essence of any healing or nurturing relationship. In

Unconditional acceptance of each other is one of the greatest challenges we humans face. Few of us have experienced it consistently; the addict has never experienced it—least of all from himself. “What works for me,” says Kim Markel, “is if I practice not looking for the big, shining success but appreciating the small: someone coming in for their appointment who doesn’t usually come in … that’s actually pretty amazing.

try to take my own value system out of it and look at the value something has for them. Even when people are at their worst, feeling really down and out, you can still have those moments with them. So I try to look on every day as a little bit of success.”

The three of us—Susan, Kim, and I—are chatting in my office on a rainy November morning. It’s “Welfare Wednesday,” the second-to-last Wednesday of the month, when income-assistance checks are issued. In the drug ghetto it’s Mardi Gras time. The office is quiet and will be until the money runs out on Thursday and Friday—and then a large group of hungover, drug-withdrawn patients will descend upon the place, complaining, demanding, and picking fights with each other.

He’s fifty years old but, like many people with attention deficit disorder (ADD), looks younger than his age. He knows I’ve also been diagnosed with ADD and laughs uproariously when I tell him my theory that we ADD folk look young because all the time we spend tuning out doesn’t add to our years.

Dean knows that isolation is in the very nature of addiction. Psychological isolation tips people into addiction in the first place, and addiction keeps them isolated because it sets a higher value on their motivations and behaviors around the drug than on anything else—even human contact.

The meaning of all addictions could be defined as endeavors at controlling our life experiences with the help of external remedies.… Unfortunately, all external means of improving our life experiences are double-edged swords: they are always good and bad. No external remedy improves our condition without, at the same time, making it worse. THOMAS HORA, MD Beyond the Dream: Awakening to Reality

Agitating my mind and body are thoughts of a CD of operatic favorites by the tenor Rolando Villazón. I listened to selections yesterday when I went to the store to pay off my latest debt but resisted the urge to purchase. Today it’s clamoring for me to return and pick it up. I must have it and I must have it now. The desire first arises as a thought and rapidly transforms itself into a concrete object in my mind, with a weight and a pull.

An hour later, I leave Sikora’s with the Villazón disc and several others. Hello, my name is Gabor, and I am a compulsive classical music shopper.

A word before I continue: I do not equate my music obsession with the life-threatening habits of my Portland patients. Far from it. My addiction, though I call it that, wears dainty white gloves compared to theirs. I’ve also had far more opportunity to make free choices in my life, and I still do. But if the differences between my behaviors and the self-annihilating life patterns of my clients are obvious, the similarities are illuminating—and humbling. 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.

I’ve been to Sikora’s several times a week in the past two months—not to mention brief forays to the Magic Flute on Fourth Avenue and lightning visits to Sam the Record Man and HMV in Toronto during a recent speaking tour, to say nothing of the closing-out sale at Tower Records in New York. As of now, mid-February, I’ve blown two thousand dollars on classical CDs since the New Year. I’ve broken my word to stop bingeing, pledged with maximal contrition to my wife, Rae, after my thousand-dollar pre-Christmas and Boxing Day splurge.

Rae is suspicious. “Have you been obsessing and buying?” she’s asked me a number of times in the past few weeks. I look directly at my life partner of thirty-nine years, and I lie. I tell myself I don’t want to hurt her. Nonsense. I fear losing her affection. I don’t want to look bad in her eyes. I’m afraid of her anger. That’s what I don’t want. I’ve given hints—almost as if I wanted to be caught. “You look stressed,” Rae remarks one evening in early January. “Yes, it’s all these CDs,” I begin to reply. She eyes me: my embarrassment is instant and palpable. “I mean, all these CVs I have to e-mail for my speaking engagements.”

“Don Giovanni,” Rae muses. “I don’t know that one. What’s it about?” “The Don Juan story. The obsessive womanizer. He’s this creative, charming, and energetic man. A daring adventurer, but a coward morally, who never finds peace within. His erotic passion is insatiable: no matter how often it’s consummated, it leaves him restless and dissatisfied. And his poetic talent and his drive for mastery only serve his relentless need to possess. It’s always about the next acquisition—he even keeps a notebook listing his amorous conquests. He has many, many opportunities for salvation, but he spurns them all. He torments others and sacrifices his own mortal soul. He scorns repentance, and in the end, he’s dragged down to Hell.” Rae glances at me with something like surprise—or is it a knowing smirk? “You described that so eloquently,” she says. “You brought the character alive. He’s obviously close to your heart.” True, he is—I’ve purchased four versions of this Mozart masterpiece in the last month, adding to the two already in my collection. I’ve never listened to any of them from start to finish. And I’ve been lying, withholding all this from Rae. Actually, I’m a small-time, far less glamorous Don Giovanni—I cheat with operas, not women.

Addictions, even as they resemble normal human yearnings, are more about desire than attainment. In the addicted mode, the emotional charge is in the pursuit and the acquisition of the desired object, not in the possession and enjoyment of it. The greatest pleasure is in the momentary satisfaction of yearning.

The fundamental addiction is to the fleeting experience of not being addicted. The addict craves the absence of the craving state. For a brief moment he’s liberated from emptiness, from boredom, from lack of meaning, from yearning, from being driven or from pain. He is free. His enslavement to the external—the substance, the object, or the activity—consists of the impossibility, in his mind, of finding within himself the freedom from longing or irritability. “I want nothing and fear nothing,” said Zorba the Greek. “I’m free.” There are not many Zorbas among us.

When you get right down to it, it’s the adrenaline I’m after, along with the precious reward chemicals that will flood my brain when I hold the new CD in hand, providing an-all-too temporary reprieve from the stress of my driven state.

Anyone who’s addicted to any kind of pursuit—whether it’s sex or gambling or shopping—is after that same fix of homegrown chemicals.

This behavior has been recurring for decades, since my children were— Wait. “The behavior has been recurring?” What a neat way to put it outside of myself, as if it lived as an independent entity. No, I have been doing this for decades, since my children were small.

was cushioned from economic disaster by the income I earned as one of the self-sacrificing—read workaholic—physicians much admired by the world at large. As I’ve written elsewhere, it was easy for me to justify all the spending as compensation for the hard work I was doing: one addiction providing an alibi for the other.