In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

The work can be intensely satisfying or deeply frustrating, depending on my own state of mind. Often I face the refractory nature of people who value their health and well-being less than the immediate, drug-driven needs of the moment. I also have to confront my own resistance to them as people. Much as I want to accept them, at least in principle, some days I find myself full of disapproval and judgment, rejecting them and wanting them to be other than who they are. That contradiction originates with me, not with my patients. It’s my problem—except that, given the obvious power imbalance between us, it’s all too easy for me to make it their problem.

“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.

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. If they come to like me or to appreciate my work with them, they will spontaneously express pride in having a doctor who is occasionally interviewed on television and is an author. But only then. What they care about is my presence or absence as a human being. They gauge with unerring eyes whether I am grounded enough on any given day to coexist with them, to listen to them as persons with feelings, hopes, and aspirations that are as valid as mine. They can tell instantly whether I’m genuinely committed to their well-being or just trying to get them out of my way. Chronically unable to offer such caring to themselves, they are all the more sensitive to its presence or absence in those charged with caring for them.

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

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. The automatic repression of painful emotion is a helpless child’s prime defense mechanism and can enable the child to endure trauma that would otherwise be catastrophic. The unfortunate consequence is a wholesale dulling of emotional awareness.

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 his book On Becoming a Person, the great American psychologist Carl Rogers described a warm, caring attitude, which he called unconditional positive regard because, he said, “it has no conditions of worth attached to it.” This is a caring, wrote Rogers, “[that] is not possessive, [that] demands no personal gratification. It is an atmosphere [that] simply demonstrates I care; not I care for you if you behave thus and so.”1

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. Its central, defining qualities are active in all addicts, from the honored workaholic at the apex of society to the impoverished and criminalized crack fiend who haunts skid row. Somewhere along that continuum I locate myself.

We can never understand addiction if we look for its sources exclusively in the actions of chemicals, no matter how powerful they are. “Addiction is a human problem that resides in people, not in the drug or in the drug’s capacity to produce physical effects,” writes Lance Dodes, a psychiatrist at the Harvard Medical School Division on Addictions.4 It is true that some people will become hooked on substances after only a few times of using, with potentially tragic consequences, but to understand why, we have to know what about those individuals makes them vulnerable to addiction. Mere exposure to a stimulant or narcotic or to any other mood-altering chemical does not make a person susceptible. If she becomes an addict, it’s because she’s already at risk.

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. Genetics—that neutral, impassive, impersonal handmaiden of Nature—would absolve us of responsibility and of its ominous shadow, guilt. If genetics ruled our fate, we would not need to blame ourselves or anyone else. Genetic explanations get us off the hook. The possibility does not occur to us that we can accept or assign responsibility without taking on the useless baggage of guilt or blame.

The lack of an emotionally attuned and consistently available parenting figure is a major source of stress for the child. Such a lack can occur when the parent is physically present but emotionally distracted—a situation that has been called proximate separation. Proximate separation happens when attuned contact between parent and child is interrupted due to stresses that draw the parent away from the interaction. The levels of physiological stress experienced by the child during proximate separation approach the levels experienced during physical separation.

While it’s true that overt episodes of hostility between the parents may damage the child, so may repressed anger and unhappiness. As a rule, whatever we don’t deal with in our lives, we pass on to our children. Our unfinished emotional business becomes theirs. As a therapist said to me, “Children swim in their parents’ unconscious like fish swim in the sea.” This mother and father were fully committed to their family and still are, but under such circumstances all the parental love in the world could not provide the children with a well-attuned, nonstressed, nurturing environment.

A powerful person’s self-esteem may appear to be high, but it’s a hollow shell if it’s based on externals, on the ability to impress or intimidate others. It’s what psychologist Gordon Neufeld calls conditional or contingent self-esteem: it depends on circumstances. The greater the void within, the more urgent the drive to be noticed and to be “important,” and the more compulsive the need for status. By contrast, genuine self-esteem needs nothing from the outside.

When I’m reasonably balanced in my personal and spiritual life, I don’t have difficulty finding compassion for my addicted patients. I’m curious about their life histories and self-perceptions, and for the most part I’m able to avoid imposing judgments on them. As with Clarissa, my aim is to open their eyes to the possibility of a nonjudgmental, compassionate curiosity toward themselves.