In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

The question of control is a touchy one. No segment of the population feels powerlessness more acutely than Downtown Eastside drug addicts. 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. But in the case of the drug addict, the disempowerment is real, palpable, and quite in the present. Engaged in illegal activities to support her habit—her very habit being illegal—she is on all sides hemmed in by laws, rules, and regulations. 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. Coming most commonly from a socially deprived background and having passed through courts and prisons repeatedly, the Downtown Eastside addict is unaccustomed to challenging authority directly. Dependent on the physician for her lifeline methadone prescription, she is in no position to assert herself. If she doesn’t like her doctor, she has little latitude to seek care elsewhere: downtown clinics are not eager to accept each other’s “problem” clients. Many addicts speak bitterly about medical personnel who, they find, impose their “my-way-or-the-high-way” autho...

So this was the perfect home Serena grew up in, under the care of a grandmother who, no doubt, loved her grandchild but was utterly unable to defend her from the predatory males in the household or from her own alcoholism. And that grandmother, now deceased, was Serena’s sole connection to the possibility of sustaining, consoling love in this world. “Have you ever talked with anyone about this?” In the Downtown Eastside this is almost always a rhetorical question. “No. Can’t trust anybody.… Can’t talk to my mom. Me and my mom don’t have a mother-and-daughter life. We live in the same building; we don’t even see each other. She walks right by me. That hurts me large. I’ve tried everything. There’s no point. I’ve tried so many years to see if my mom would get close to me. And the only time she gets close to me is if I have some dope or money in my pocket. It’s the only time she’ll say, ‘Daughter, I love you.’ ” I wince. “The only time, Maté. The only time.” I have no doubt that if Serena’s mother spoke about her life, an equally painful narrative would emerge. The suffering down here is multigenerational. 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. Serena herself, speaking here as the w...

If our society were truly to appreciate the significance of children’s emotional ties throughout the first years of life, it would no longer tolerate children growing up, or parents having to struggle, in situations that cannot possibly nourish healthy growth. STANLEY GREENSPAN, MD Child psychiatrist and former director, Clinical Infant Development Program, U.S. National Institute Of Mental Health

Why, then, are narrow genetic assumptions so widely accepted and, in particular, so enthusiastically embraced by the media? The neglect of developmental science is one factor. Our preference for a simple and quickly understood explanation is another, as is our tendency to look for one-to-one causations for almost everything. Life in its wondrous complexity does not conform to such easy reductions. 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. More daunting for those who hope for scientific and social progress, the genetic argument is easily used to justify all kinds of inequalities and injustices that are otherwise hard to defend. 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 yo...

Self-regulation does not refer to “good behavior” but to the capacity of an individual to maintain a reasonably even internal emotional environment. A person with good self-regulation will not experience rapidly shifting extremes of emotional highs and lows in the face of life’s challenges, difficulties, disappointments, and satisfactions. She does not depend on other people’s responses or external activities or substances in order to feel okay. The person with poor self-regulation is more likely to look outside herself for emotional soothing, which is why the lack of attunement in infancy increases addiction risk. It’s what Stephen Reid meant when he said, “I’ve spent too much time on external things, bouncing off other people.” The importance of consistent, nonstressed parent–infant interactions was demonstrated in a primate experiment involving three groups of mother–infant pairs. The investigators set up three sets of conditions under which the mothers had to forage for food: a situation of high but predictable difficulty, one of consistently low difficulty, and the third of unpredictably varying difficulty (easy one time, difficult the next). They then observed the nature of mother–infant relationships during the test period, the “personality” traits that evolved as the three groups of infants matured, and the biochemical status of the young monkeys’ stress systems throughout their lifetimes. It was not the high-difficulty foraging conditions that created stress for m...

Biologically, this group of monkeys had lifelong elevated levels of a major stress hormone in their spinal fluid, indicating an abnormality in their stress apparatus.5 That also adds to the propensity for addiction, since both animals and humans use substances or other behaviors to modulate their experience of stress.6 Obviously it’s not a question of the mothers in the other two groups having been “better” parents but of the stresses afflicting the variable-foraging mothers as they were nursing their infants—uncertainty being a trigger for physiological and emotional stress.

The question is not why the War on Drugs is being lost, but why it continues to be waged in the face of all the evidence against it. Many factors are in play, some psychological, some broadly political, others economic, and yet others driven by the natural if unfortunate moralizing tendencies we human beings share. Fundamentalist religious beliefs especially engender judgmental attitudes toward perceived sinners. We may also consider that this war provided a cause to marshal people around at a time in the 1980s when the Soviet ogre had left the stage and the Muslim terrorist had yet to become the leading villain.

a punitive legal stance on drugs may also be seen as a form of imposing heavy-handed social control over disenfranchised and disaffected populations.

“an unfortunate confluence of ignorance, fear, prejudice, and profit.”

And profit? “If you have fear, prejudice, and ignorance, there will be profit,” says Nadelmann. “Private prisons, politicians wanting private prisons operating, prison guard unions—it’s all about people making money. Too, we have a treatment industry that relies on the justice apparatus to keep feeding a treatment system that is less about good medical care and rehabilitation than about enforced abstinence.” To this list we may add entire professions in the law enforcement and legal fields who rely on the drug war for their incomes and, indeed, for their very raison d’être.

How much actual freedom to choose does any one human being possess? There’s only one answer: We cannot know. We may have our particular beliefs, spiritual or otherwise, about this aspect of human nature—about how it is or how it should be. These beliefs may strengthen our commitment to helping others find freedom, or they may become harmful dogma. Either way, in the end we all have to humble ourselves and admit to a degree of uncertainty. There is no way we can peer into a brain to measure a person’s capacity for awareness and rational choice or to estimate how the relative balance of these brain-mind systems will operate when that person is stressed. There is no gauging the burden of emotional suffering weighing down one person’s psyche against another’s, and there is no way to know what hidden life-enhancing experiences one person may have enjoyed that another has been denied. That is why it’s facile to demand that anyone should be able to “just say no” and to judge them as morally lacking if they can’t.

In a culture that projects its darkest features onto the addict and makes addicted people into scapegoats for its shortcomings, insight and knowledge are almost entirely absent from public discourse concerning drug policies. Moralizing displaces compassion, and prejudice substitutes for inquiry.

We cannot help people when we put ourselves in a position of judgment. Addicts, all but the very few completely sociopathic ones, are deeply self-critical and harsh with themselves. They are keenly sensitive to judgmental tones in others and respond with withdrawal or defensive denial. Worse, morally judging others clouds our eyes not only to their needs, but to our own true needs as well.

Addicts are locked into addiction not only by their painful past and distressing present but equally by their bleak view of the future as well. They cannot envision the real possibility of sobriety, of a life governed by values rather than by immediate survival needs and by desperation to escape physical and mental suffering. They are unable to develop compassion toward themselves and their bodies while they are regarded as outcasts, hunted as enemies, and treated like human refuse.

If we want to support people’s potential for healthy transformation, we must cease to impose debilitating stress on their already-burdened existence. Recall that uncertainty, isolation, loss of control, and conflict are the major triggers for stress and that stress is the most predictable factor in maintaining addiction and triggering relapse. These are also precisely the conditions that the demonization of addiction and the War on Drugs (deliberately!) impose on hard-core substance users.

Once we understand that the current assault on addicts creates greater insecurity for everyone and severe hardship for users, and once we understand that stressing people chronically and mercilessly can in no way promote their capacity for healthy transformation, it becomes a straightforward matter to envision approaches that rely not on moralizing but on science and humane values.

Decriminalization also does not mean that addicts will be able to walk into any pharmacy to get a prescription of cocaine. Their drugs of dependence should be dispensed under public authority and under medical supervision, in pure form, not adulterated by unscrupulous dealers. Addicts also ought to be offered the information, the facilities, and the instruments they need to use drugs as safely as possible.

Not having to spend exorbitant amounts on drugs that, in themselves, are inexpensive to prepare, addicts would not be forced into crime, violence, prostitution, or poverty to pay for their habits. They would not have to decide between eating or drug use or to scrounge for food in garbage cans or pick cigarette butts out of sidewalk puddles. They would no longer need to suffer malnutrition.

Addicts should not be coerced into treatment, since in the long term coercion creates more problems than it solves. On the other hand, for those addicts who opt for treatment, there must be a system of publicly funded recovery facilities with clean rooms, nutritious food, and access to outdoors and nature. Well-trained professional staff need to provide medical care, counseling, skills training, and emotional support. Our current nonsystem is utterly inadequate, with its patchwork of recovery homes run on private contracts and, here and there, a few upscale addiction treatment spas for the wealthy. No matter how committed their staff and how helpful their services may be, they are a drop in comparison to the ocean of vast need. In the absence of a coordinated rehabilitation system, the efforts of individual recovery homes are limited and occur in a vacuum, with no follow-up.

To expect an addict to give up her drug is like asking the average person to imagine living without all his social skills, support networks, emotional stability, and sense of physical and psychological comfort. Those are the qualities that drugs, in their illusory and evanescent way, give the addict. People like Serena and Celia and the others whose portraits have appeared in this book perceive their drugs as their “rock and salvation.” Thus, for all the valid reasons we have for wanting the addict to “just say no,” we first need to offer her something to which she can say “yes.”

We must provide that island of relief.

We have to demonstrate that esteem, acceptance, love, and humane interaction are realities in this world, contrary to what t...

Posed in a tone of compassionate curiosity, “Why?” is transformed from rigid accusation to an open-minded, even scientific question. Instead of hurling an accusatory brick at your own head (e.g., “I’m so stupid; when will I ever learn?” etc.), the question “Why did I do this again, knowing full well the negative consequences?” can become the subject of a fruitful inquiry, a gentle investigation. Taking off the starched uniform of the interrogator, who is determined to try, convict, and punish, we adopt toward ourselves the attitude of the empathic friend, who simply wants to know what’s going on with us.

Justification is another form of judgment every bit as debilitating as condemnation. When we justify, we hope to win the judge’s favor or to hoodwink her. Justification connives to absolve the self of responsibility; understanding helps us assume responsibility. When we don’t have to defend ourselves against others or, what’s more, against ourselves, we are open to seeing how things are.

Being cut off from our own natural self-compassion is one of the greatest impairments we can suffer.

The addict seldom questions the reality of the unpleasant mood or feeling she wants to escape. She rarely examines the perspective from which her mind experiences and understands the world around her and from which she hears and sees the people in her life. She is in a constant state of reactivity—not to the world so much as to her own interpretations of it. The distressing internal state is not examined: the focus is entirely on the outside: What can I receive from the world that will make me feel okay, if only for a moment? Bare attention can show her that these moods and feelings have only the meaning and power that she gives them. Eventually she will realize that there is nothing to run away from. Situations might need to be changed, but there is no internal hell that one must escape by dulling or stimulating the mind.