In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

Suddenly I cannot imagine my life without this Dvorák symphony cycle or that version of Bach’s Mass in B Minor, or this interpretation, on period instruments, of Haydn’s Paris Symphonies. I cannot abide another moment without Rachmaninoff’s Preludes, or Le Nozze di Figaro, Bachianas Brasileiras, a collection of Shostakovich’s chamber music; yet another fourteen-CD version—my fifth—of Wagner’s Ring Cycle; new issues of Bach’s solo violin or solo cello pieces. This very day I must have Locatelli’s L’Arte del Violino, Rautavaara’s Garden of Spaces, the Diabelli Variations, Pierre Hantaï’s

latest rendition of the Goldberg Variations on harpsichord, Schnittke’s or Henze’s or Mozart’s complete violin concertos, my third version.…

“The first time I listened was at an AA meeting in Toronto. A Native man in his sixties was speaking. ‘I’ve been sober for two years now,’ he

said, ‘and six months ago, I got my first job. If I had known how good it felt to work, I would have been done with drinking long ago. Five months ago I got my own place. Had I known how good that was, I would have gone sober long ago. Three months ago I got myself a girlfriend. Boy, if I’d known how great that was, I might never have drank in the first place.’ ” Merriment, chortles, the clapping of appreciative hands. “ ‘Now I’m sixty-four,’ the man said, ‘and I’ve just been told I have cancer. I have six months to live.’ ” Elaine pauses to look around the room as we take in this information. Silently, we wait for her conclusion. “I thought he’s going to announce, ‘I’m off on the biggest six-month drunk you can imagine. So the hell with you all and goodbye.’ That’s what I would have done with a death sentence hanging over me. But not this Native man. ‘I’m just so grateful,’ he said, ‘so thankful that I’m sober, that I’ve had two years of sobriety and that I can look forward to the rest of my life in sobriety.’ “That’s when I got that sobriety is more than just the absence of alcohol. It’s a way of being.

It’s living life in its ...

“Surrender is the key,” says Elaine. “Even now, whenever I try too hard, I mess it all up. Don’t try. Just listen to God’s directions.” Fuck. That God thing again. What God? Ever since I was a child, I’ve been shaking my fist at Heaven. From the moment I had a mind of my own, I knew there was no all-knowing, all-powerful, all-loving God. In Eastern Europe under the Stalinist regimes there used to be a saying: “You can be honest or intelligent or be a member of the Communist Party. In fact, you can be any two of the three, but not all three at the same time.” In the same way, I understood that God could be all-knowing and all-powerful, but not all-loving. How else to explain the murder of my grandparents in the gas chambers of Auschwitz or my own near-death as an infant in the Budapest ghetto? Or God can be all-loving and all-knowing, but not omnipotent. A milksop. A weakling. So what is this God whose directions I’m supposed to obey?

my shoulder. I turn my head. A woman is smiling at me. “Dr. Gabor Maté! I thought that was you! My name is Sophie. You delivered my baby nineteen years ago. You probably don’t remember.” “I don’t, but nice to see you.” Sophie, she reminds me, was twenty-one years old when I attended the delivery of her child. As it turns out, far from feeling embarrassed at encountering a former patient at an AA event, I’m glad to be greeted by a friendly face. “Tell me something. Do I belong here?” I give the one-minute version of my history. “You do belong.” Sophie explains that the meeting is open to everyone. “If you have addictive behaviors, this is the right place for you. Unless it’s marked with a C for ‘Closed’ in the AA schedule, anyone with a problem is welcome. The C meetings are for alcoholics only.” I will come back, I decide. What I’ve witnessed here are humility, gratitude, commitment, acceptance, support, and authenticity. I so desperately want those qualities for myself. “Nowhere do I see such power and grace as at

my AA meetings,” a writer friend has told me. A manic-depressive with a long history of alcoholism, she’s been attending for fifteen years, and she’s been urging me to do so. I finally get what she means. As I walk to my car, I see Sophie approach a group of her friends. “You wouldn’t believe who I just ran into,” I hear her say. I chuckle inwardly: my ego’s yearning to be recognized, and the fear of it, realized at the last possible moment.

Beyond their soothing properties, endorphins serve other functions essential to life. They’re important regulators of the autonomic nervous system—the part that’s not under our conscious control. They affect many organs in the body, from the brain and the heart to the intestines. They influence mood changes, physical activity, and sleep and regulate blood pressure, heart rate, breathing, bowel movements, and body temperature. They even help modulate our immune system.

brain-wave patterns of two groups of six-month-old infants: one group whose mothers were suffering postpartum depression and one group whose mothers were in normal good spirits. Electroencephalograms (EEGs) showed consistent, marked differences between the two groups: the babies of the depressed mothers had EEG patterns characteristic of depression even during interactions with their mothers that were meant to elicit a joyful response. Significantly, these effects were noted only in the frontal areas of the brain, where the centers for the self-regulation of emotion are located.10 How does this pertain to brain development? Repeatedly firing nerve patterns become wired into the brain and will form part of a person’s habitual responses to the world. In the words of the great Canadian neuroscientist Donald Hebb, “cells that fire together, wire together.” The infants of stressed or depressed parents are likely to encode negative emotional patterns in their brains.

Since the brain governs mood, emotional self-control, and social behavior, we can expect that the neurological consequences of adverse experiences will lead to deficits in the personal and social lives of people who suffer them in childhood, including, Dr. Joseph continues, “a reduced ability to anticipate consequences or to inhibit irrelevant or inappropriate, self-destructive behaviors.”

Another effect of early maternal deprivation appears to be a permanent decrease in the production of oxytocin, which, as mentioned in Chapter Fourteen, is one of our love chemicals.9 (As noted earlier, oxytocin is not an opioid. Therefore, it has no relationship whatsoever with narcotic drugs like Oxycet or OxyContin; only the names are similar.) It is critical to our experience of loving attachments and even to maintaining committed relationships. People who have difficulty forming intimate relationships are at risk for addiction; they may turn to drugs as social lubricants. Not only can early childhood experience lead to a dearth of “good” brain chemicals; it can also result in a dangerous overload of others. Maternal deprivation and other types of adversity during infancy and childhood result in chronically high levels of the stress hormone cortisol. In addition to damaging the midbrain dopamine system, excess cortisol shrinks important brain centers such as the hippocampus—a structure important for memory and for the processing of emotions—and disturbs normal brain development in many other ways, with lifelong repercussions.10 Another major stress chemical that’s permanently overproduced after insufficient early maternal contact is vasopressin, which is implicated in high blood pressure.11 A child’s capacity to handle psychological and physiological stress is completely dependent on the relationship with his parent or parents. Infants have no ability to regulate their ...

Stress also diminishes the activity of dopamine receptors in the emotional circuits of the forebrain, particularly in the nucleus accumbens, where the craving for drugs increases as dopamine function decreases.34 The research literature has identified three factors that universally lead to stress for human beings: uncertainty, lack of information, and loss of control. 35 To these we may add conflict that the organism is unable to handle and isolation from emotionally supportive relationships. Animal studies have demonstrated that isolation leads to changes in brain receptors and increased propensity for drug use in infant animals,36 and in adults isolation reduces the activity of dopamine-dependent nerve cells.37 Unlike rats reared in isolation, rats housed together in stable social groupings resisted cocaine self-administration—in the same way that Bruce Alexander’s tenants in Rat Park were impervious to the charms of heroin.38 Human children do not have to be reared in physical isolation to suffer deprivation: emotional isolation will have the same effect, as does stress on the parent. As we will later see, stress on pregnant mothers has a negative impact on dopamine activity in the brain of the unborn infant, an impact that can last well past birth.

Some people may think that addicts invent or exaggerate their sad stories to earn sympathy or to excuse their habits. In my experience, the opposite is the case. As a rule, they tell their life histories reluctantly, only when asked and only after trust has been established—a process that may take months, even years. Often they see no link between childhood experiences and their self-harming habits. If they speak of the connection, they do so in a distanced manner that still insulates them against the full emotional impact of what happened.

Research shows that the vast majority of physical and sexual assault victims do not spontaneously reveal their histories to their doctors or therapists.39 If anything, there is a tendency to forget or to deny pain. One study followed up on young girls who had been treated in an emergency ward for proven sexual abuse. When contacted seventeen years later as adult women, 40 percent of these abuse victims either did not recall or denied the event outright. Yet their memory was found to be intact for other incidents in their lives.40

Grasping the powerful impact of the early environment on brain development may leave us feeling hopelessly gloomy about recovery from addiction. It so happens that there are solid reasons not to despair. Our brains are resilient organs: some important circuits continue to develop throughout our entire lives, and they may do so even in the case of a hard-core drug addict whose brain “never had a chance” in childhood. That’s the good news, on the physical level. Even more encouraging, we will find later that we have something in or about us that transcends the firing and wiring of neurons and the actions of chemicals. The mind may reside mostly in the brain, but it is much more than the sum total of the automatic neurological programs rooted in our pasts. And there is something else in us and about us: it is called by many names, spirit being the most democratic and least denominational or divisive in a religious sense. Later in this book, we will also examine its powerful transformational role.

Such high figures are beyond possibility. The logic behind them rests on mistaken assumptions that owe less to science than to an exaggerated belief in the power of genes to determine our lives. In genetic theories of mental disorders, “unscientific beliefs play a major role,” write the authors of a research review.

It has been demonstrated that both animals and humans who experienced the stress of their mothers during pregnancy are more likely to have disturbed stress-control mechanisms long after birth, which creates a risk factor for addiction. Maternal stress during pregnancy can, for example, increase the offspring’s sensitivity to alcohol.23 As mentioned, a relative scarcity of dopamine receptors also elevates the addiction risk. “We’ve done work, and a lot of other people have done work, showing that essentially the number and density of dopamine receptors in these receptive areas is determined in utero,” psychiatric researcher Dr. Bruce Perry told me in an interview.

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.

Many who engage in spiritual bypassing are simply desiring this one to one causation because it feels simple.

Sugar, for example, provides a quick fix of endorphins and also temporarily raises levels of the mood chemical serotonin.11 This effect can be prevented by an injection of the opiate-blocking drug Naloxone, the same substance used to resuscitate addicts who overdose on heroin.

for maturation the child must become unique and separate from other individuals. She has to know her own mind and not be overwhelmed by the thoughts, perspectives, or emotional states of others. The better differentiated she becomes, the more she is able to mix with others without losing her sense of self. The individuated, well-differentiated person can respond from an open acceptance of his own emotions, which are not tailored either to match someone else’s expectations or to resist them. He neither suppresses his emotions nor acts them out impulsively.

In human development the ingestion of food has significance far beyond its obvious dietary role. Following birth the mother’s nipple replaces the umbilical cord as the source of nutrients for the infant, and it is also a point of continued physical contact between mother and child. Proximity to a parent’s body also meets emotional attachment needs that are as basic to the child as is the need for physical sustenance. When infants are anxious or upset, they are offered a human or a plastic nipple—in other words, a relationship with either a natural nurturing object or something that closely resembles it. That’s how emotional nourishment and oral feeding or soothing become closely associated in the mind.

On the other hand, emotional deprivation will trigger a desire for oral stimulation or eating just as surely as hunger will. Children who continue to suck their thumbs past infancy are attempting to soothe themselves; it’s always a sign of emotional distress. Except in rare cases of physical disease, the more obese a person is, the more emotionally starved they have been at some crucial period in their life.

Children whose emotionally nourishing relationships with adults give them a strong sense of themselves do not need to soothe themselves by passively taking in either food or entertainment.

Stressed parents have difficulty offering their children a specific quality required for the development of the brain’s self-regulation circuits: the quality of attunement. Attunement is, literally, being “in tune” with someone else’s emotional states. It’s not a question of parental love but of the parent’s ability to be present emotionally in such a way that the infant or child feels understood, accepted, and mirrored. Attunement is the real language of love, the conduit by which a preverbal child can realize that she is loved.

Although the cracks in his argument are easy to discern, perhaps it would be more worthwhile to consider what realities the drug-dependent Ralph might be articulating and what we might learn about ourselves in the dark mirror he holds up for us. Though we pretend otherwise, in our materialist culture many of us conduct ourselves as if Ralph’s cynicism reflected the truth—that it’s each man for himself, that the world offers nothing other than brief, illusory satisfactions. But from his pinched and narrow perch at the edge of society, the drug addict sees who we are—or more exactly, who we are choosing to be. He sees that we resemble him in our frantic material pursuits and our delusions and that we exceed him in our hypocrisies.

“At heart, I am not that different from my patients—and sometimes I cannot stand seeing how little psychological space, how little heaven-granted grace separates me from them”—so I wrote in the first chapter. There are moments when I’m revolted by my patients’ disheveled appearances, their stained and decayed teeth, the look of insatiable hunger in their eyes, their demands, complaints, and neediness. Those are times when I would do well to examine myself for irresponsibility in my own life, for self-neglect—in my case not so much physical as spiritual—and for placing false needs above real ones.

When I am sharply judgmental of any other person, it’s because I sense or see reflected in them some aspect of myself that I don’t want to acknowledge. I’m speaking here not of my critique of another person’s behavior in objective terms but of the self-righteous tone of personal judgment that colors my opinion. If, for example, I resent some person close to me as “controlling,” it may be owing to my own inability to assert myself. Or I may react against another person because he or she has a trait that I myself have—and dislike—but don’t wish to acknowledge: for example, a tendency to want to control others. As I mentioned in a previous chapter, some mornings I vituperate about right-wing political columnists. My opinion remains more or less constant: their views are based on a highly selective reading of the facts and are rooted in a denial of reality. What does vary from day to day is the emotional charge that infuses my opinion. Some days I dismiss them with intense hostility; at other times I see their perspective as one possible way of looking at things, as an interpretation of their experience of life.

Moral judgments, however, are never about the obvious: they always speak to the underlying similarities between the judge and the condemned. My judgments of others are an accurate gauge of how, beneath the surface, I feel about myself. It’s only the willful blindness in me that condemns others for deluding themselves; my own selfishness that excoriates others for being self-serving; my lack of authenticity that judges falsehood in others. It is the same, I believe, for all moral judgments people cast on each other and for all vehemently held communal judgments a society visits upon its members. So it is with the harsh social attitudes toward addicts, especially hard-core drug addicts.

How can we compare the misdemeanors of my patients—petty dealers thrown against the wall and frisked by police in the back alleys of the Downtown Eastside—with those of their respectable counterparts in corporate boardrooms? In May 2007, Purdue Pharma, a giant drug manufacturer, pleaded guilty to criminal charges that the firm had “misled doctors and patients” in claiming that their product, OxyContin, was less addictive than other opiate medications. “That claim,” said the New York Times, “became the linchpin of an aggressive marketing campaign that helped the company sell over $1 billion of OxyContin a year.… But both experienced drug abusers and novices, including teenagers, soon discovered that chewing an OxyContin tablet—or crushing one and then snorting the powder, or injecting it with a needle—produced a high as powerful as heroin.”9 There have been hundreds of overdose deaths on OxyContin across the United States, devastating entire villages in Appalachia, for example, where the drug became known as “hillbilly heroin” and was illicitly marketed for $40 for a 40-milligram tablet. We see that substance addictions are only one specific form of blind attachment to harmful ways of being. Yet we condemn the addict’s stubborn refusal to give up something deleterious to his life or to the lives of others. 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?

To pose that question is to answer it. We despise, ostracize, and punish the addict because we don’t wish to see how much we resemble him. In his dark mirror our own features are unmistakable. We shudder at the recognition. This mirror is not for us, we say to the addict. You are different, and you don’t belong with us. Ralph’s critique, for all its flaws, is too close for comfort. Like the hard-core addict’s pursuit of drugs, much of our economic and cultural life caters to people’s craving to escape mental and emotional distress. In an apt phrase, Lewis Lapham10 derides “consumer markets selling promises of instant relief from the pain of thought, loneliness, doubt, experience, envy, and old age.”11

Some of these former children are not pleasant to deal with. Scruffy and dirty, shifty and manipulative, they invite distaste. Fearful and contemptuous of authority at the same time, they evoke hostility. The police often handle them roughly. Cops are not necessarily predisposed to harshness, but a loss of humane interaction inevitably results whenever an entire group of people is delegitimized while another group is granted virtually unrestrained physical authority over them. I’ve had a small taste of it, having been stopped by cops on my Hastings Street rounds—once for jaywalking and once for riding my bicycle on the sidewalk. An officer’s tone shifts instantly from curt and contemptuous to polite when he realizes I’m not a Downtown Eastside resident. How utterly helpless I would feel, I have thought at such times, if I didn’t have a respectable address on my driver’s license; if I lived in a restricted, ghettoized domain where a uniformed and armed force was the omnipresent power; if I depended on substances the police had to suppress and on activities they were obliged to prosecute; if I couldn’t count on reliable friends and family to advocate for me if ever I got into trouble. I have also witnessed officers treat my clients calmly and with kindness, but I know that’s not the face they always turn toward the addict.

The Downtown Eastside addicts are acutely aware of their lack of power in any conflict with authority, be it legal or medical. “Who would believe me; I’m just a junkie” is the refrain I hear over and over again as patients complain of being beaten in jail or on the darkened streets or of being dismissed rudely by nurses or doctors at an emergency ward. Such experiences, for the addict, add more links to the chain of utter powerlessness that began in childhood.

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.

Decriminalization refers only to removing from the penal code the possession of drugs for personal use. It would create the possibility of medically supervised dispensing when necessary. The fear that easier access to drugs would fuel addiction is unfounded: drugs, we have seen, are not the cause of addiction. Despite the fact that cannabis is openly available in the Netherlands, for instance, Dutch per-capita use of marijuana is half that in the United States. And no one is advocating the open availability of hard drugs. 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. The health benefits of such an approach are self-evident: greatly reduced risk of infection and disease transmission, much less risk of overdose, and—very importantly—comfortable and regular access to medical care.

Above all, such an approach would create a basis for gently shepherding the addict toward rehabilitation. It would provide an opportunity to create a healing relationship with users who are currently relegated to streets and back alleys. Further, if many users no longer had to turn to illicit drug labs and dealers for their substance, the underground economy of crystal meth would be deprived of much of its profit and allure. Not an ideal situation, but a vast mitigation of the present dismal scenario.

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.

Many addicts could work at productive jobs if the imperative of seeking illegal drugs did not keep them constantly on the street. It’s interesting to learn that before the War on Drugs mentality took hold in the early twentieth century, a prominent individual such as Dr. William Stewart Halsted, a pioneer of modern surgical practice, was an opiate addict for over forty years. During those decades he did stellar and innovative work at Johns Hopkins University, where he was one of the four founding physicians. He was the first, for example, to insist that members of his surgical team wear rubber gloves—a major advance in eradicating postoperative infections. Throughout his career, however, he never got by with less than 180 milligrams of morphine a day. “On this,” said his colleague, the world-renowned Canadian physician Sir William Osler, “he could do his work comfortably and maintain his excellent vigor.”

“Drug addiction has to be devilified,” Dr. Bruce Perry said during our interview. “If we create environments that are safe and predictable and relationally enriched, then all of the other factors involved in substance abuse and dependence will be so much easier to dissolve away. Our challenge is to figure out how to create these environments. “We really need … and I know it sounds kind of corny … we need to be very loving, very accepting, and very patient with people who have these problems. And if we are, they will have a much higher probability of getting better.” We need to absorb in our minds and guts the utter futility of what we are doing now. We need to wake to the reality that our present system actively generates misery for users and nonusers alike and places intolerable burdens on society. More of the same will only cause more of the same.

Around drug addiction there are no easy, risk-free solutions to be found. But for every fresh difficulty there would be new benefits that would weigh far more in the balance. No foreseeable risk can to any degree resemble the tremendous harm currently being done.

What is harm reduction? Harm reduction is often perceived as being inimical to the ultimate purpose of “curing” addiction—that is, of helping addicts transcend their habits and heal. People regard it as coddling addicts, as enabling them to continue their destructive ways. It’s also considered to be the opposite of abstinence, which many regard as the only legitimate goal of addiction treatment. Such a distinction is artificial. The issue in medical practice is always how best to help a patient. If a cure is possible and probable without doing greater harm, then cure is the objective. When it isn’t—and in most chronic medical conditions cure is not the expected outcome—the physician’s role is to help the patient with the symptoms and to reduce the harm done by the disease process. In rheumatoid arthritis, for example, one aims to prevent joint inflammation and bone destruction and, in all events, to reduce pain. In incurable cancers we aim to prolong life, if that can be achieved without a loss of life quality, and also to control symptoms. In other words, harm reduction means making the lives of afflicted human beings more bearable, more worth living. That is also the goal of harm reduction in the context of addiction.

Specific harm-reduction practices depend on resources and need. One such practice is the prescription of methadone. These days I write regular methadone scripts for over one hundred patients. The drug is a synthetic narcotic that occupies opiate receptors on brain cells, blocking the access of heroin molecules to the same binding site. When ingested orally, it does not cause a high in chronic narcotic users, but for many addicts it prevents heroin craving and also withdrawal symptoms such as nervousness, pain, diarrhea, and nausea.5 It’s long-acting, so a once-daily dose will see most people through twenty-four hours. It is estimated that there are sixty thousand to ninety thousand illicit opioid abusers in Canada, but only about a quarter are receiving treatment.6 U.S. treatment figures would be much lower given the near impossibility of obtaining this medication in many jurisdictions. We offer methadone maintenance to addicts not to cure them of their narcotic dependence but to transfer that dependence to a narcotic that is legal, that is safe if ingested properly, and that prevents them from having to prostitute themselves, steal, and beg to avoid withdrawal. An addict chooses methadone when he tires of the endless daily scrounging for illicit narcotics and of the consequences of always having to dodge the law. None of my methadone patients would accept abstinence as an alternative to heroin use, and even with methadone the heroin craving remains irresistible for some. ...

Why this hidebound resistance to a simple harm-reduction and disease-prevention method? “People often talk about American’s Puritan origins as the reason for opposition to needle exchange,” says Daniel Wolfe, the deputy director of the New York—based International Harm Reduction Development program at the Open Society Institute, “but it’s actually evangelism that underlies most of the politics against needle exchange. To give someone a needle or methadone is seen as giving up on the idea that they can be ‘saved,’ and as a moral failure for both drug user and care provider. The moral reality of leaving drug users to die of HIV because you refuse to adjust this vision of redemption to reality, or the moral implications of turning our anti-harm-reduction ideology into a global crusade go unexamined.… The ban on federal funds for needle exchange in the United States—the only such restriction in the world—finds further reinforcement in the American hostility to central government assistance to people in need.”7 Unless, one is tempted to add, the people in need—owing to their own poor choices—are shareholders of Freddie Mac or Fannie Mae.

Not all addicts will accept methadone as a substitute (just as for some others whose drug of choice is morphine, neither methadone nor heroin will do). In such cases we can leave the addict to fend for herself in the underworld jungle, or we can offer heroin or morphine unadulterated by who-knows-what impurities, to be self-injected in a clean environment with uncontaminated needles. We are neither condoning nor encouraging addiction: the addiction exists and will continue to savage that person’s life no matter what we believe. Our only choice is between compassion and indifference. By administering heroin in a controlled fashion, we are attempting to minimize harm for the addict, with the social benefit of reducing crime, squalor, and medical expenses.

We teach what we most need to learn—and sometimes give what we most need to receive. It was impossible to study addiction without observing myself closely, and I can say truthfully that I have learned much through this exercise. No matter how hard I try, I have found out that I may never fully defeat my addiction-prone tendencies. And I’ve also learned that this is all right. Triumph and defeat: these are still metaphors of war. If, as the research shows, addictions arise near our emotional core, to defeat them we would have to wage a war against ourselves. And a war against parts of the self—even against nonadaptive, dysfunctional parts, can lead only to inner discord and more distress.

sobriety is the directing of compassionate curiosity at oneself. Many teachings, from spiritual writings to psychological works, tell us that we need to look at ourselves this way. “In cultivating loving-kindness, we learn first to be honest, loving, and compassionate towards ourselves,” writes the American Buddhist nun Pema Chödrön. “Rather than nurturing self-denigration, we begin to cultivate a clear-seeing kindness.” Chödrön also suggests it’s a good idea to lighten up: Being able to lighten up is the key to feeling at home with your body, mind, and emotions, to feeling worthy of living on this planet.… In addition to a sense of humor, a basic support for a joyful mind is curiosity, paying attention.… Happiness is not required, but being curious without a heavy judgmental attitude helps. If you are judgmental, you can even be curious about that.

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. The acronym COAL has been proposed for this attitude of compassionate curiosity: curiosity, openness, acceptance, and love: “Hmm. I wonder what drove me to do this again.”

If I examine my addictive behaviors without judgment and ask “Why?” in the spirit of compassionate curiosity, what do I find? More to the point, whom do I find? What is the full truth of me? Is it that I’m a respected thirty-year veteran of medical practice, spouse and parent, counselor, public speaker, activist, and author? What about the anxious, insecure man who has often felt empty and incomplete and has looked to the outside to allay some insatiable hunger? As fellow addict and author Stephen Reid said during our conversation in the cafeteria of the William Head penitentiary: “… makes my teeth hurt, the work of pulling back from all those outside things and looking inside myself.” In my case, the unconscious tension literally made my teeth hurt—so forcefully have I ground my teeth at night since childhood that by the end of my fifth decade most of them were whittled stubs with the pulp exposed.

On the contrary, it is in the nature of the ego to turn anything to its advantage. Even the public disclosure of my addictive patterns has served to reassure me of my sincerity and honesty and “courage.” Audiences greet such self-disclosure with nods, appreciative smiles, and applause. But real courage does not lie in speaking about addiction; it resides in actively doing something about it—and that, until very recently, I have not been prepared to take on.

From an ecological perspective, the addiction process doesn’t happen accidentally; nor is it preprogrammed by heredity. It is a product of development in a certain context, and it continues to be maintained by factors in the environment. The ecological view sees addiction as a changeable and evolving dynamic that expresses a lifelong interaction with a person’s social and emotional surroundings and with his own internal psychological space. Healing, then, must take into account the internal psychological climate—the beliefs, memories, mind-states, and emotions that feed addictive impulses and behaviors—as well as the external milieu. In an ecological framework recovery from addiction does not mean a “cure” for a disease but the creation of new resources, internal and external, that can support different, healthy ways of satisfying one’s genuine needs. It also involves developing new brain circuits that can facilitate more adaptive responses and behaviors.