In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

That is the paradox: the United States leads the world in scientific knowledge in many areas but trails in applying that knowledge to social and human realities.

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,”

“What is addiction, really?” the Swiss psychologist Alice Miller asks. “It is a sign, a signal, a symptom of distress. It is a language that tells us about a plight that must be understood.”

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.

Those whom we dismiss as “junkies” are not creatures from a different world, only men and women mired at the extreme end of a continuum on which, here or there, all of us might well locate ourselves.

No society can understand itself without looking at its shadow side.

Not every story has a happy ending, as the reader will find out, 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.

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.”

At the Portland Hotel there is no chimera of redemption or any expectation of socially respectable outcomes, only an unsentimental recognition of the real needs of real human beings in the dingy present, based on a uniformly tragic past.

We may (and do) hope that people can be liberated from the demons that haunt them and work to encourage them in that direction, but we don’t fantasize that such psychological exorcism can be forced on anyone. 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.

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.

In a real sense, addiction medicine with this population is also palliative work. We do not expect to cure anyone, only to ameliorate the effects of drug addiction and its attendant ailments and to soften the impact of the legal and social torments our culture uses to punish the drug addict.

For many of Vancouver’s chronic, hard-core addicts, it’s as if an invisible barbed-wire barrier surrounds the area extending a few blocks from Main and Hastings in all directions. There is a world beyond, but to them it’s largely inaccessible. It fears and rejects them; and they, in turn, do not understand its rules and cannot survive in it.

I am reminded of an escapee from a Soviet gulag camp who, after starving on the outside, voluntarily turned himself back in. “Freedom isn’t for us,” he told his fellow prisoners. “We’re chained to this place for the rest of our lives, even though we aren’t wearing chains. We can escape, we can wander about, but in the end we’ll come back.”

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.

Amidst the unrest of irritable drug seekers hustling and scamming for their next high, there also occur frequent moments of humanity and mutual support.

“People here are very raw, so what comes out is the violence and ugliness that often gets highlighted in the media. But that rawness also brings out raw feelings of joy and tears of joy—looking at a flower I hadn’t noticed but someone living in a one-room at the Washington Hotel has noticed because he’s down here every day. This is his world and he pays attention to different details than I do.”

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.

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.

Nothing records the effects of a sad life so graphically as the human body.

people jeopardize their lives for the sake of making the moment livable. Nothing sways them from the habit—not illness, not the sacrifice of love and relationship, not the loss of all earthly goods, not the crushing of their dignity, not the fear of dying. The drive is that relentless.

Far more than a quest for pleasure, chronic substance use is the addict’s attempt to escape distress. From a medical point of view, addicts are self-medicating conditions like depression, anxiety, post-traumatic stress, or even attention deficit/hyperactivity disorder (ADHD). Addictions always originate in pain, whether felt openly or hidden in the unconscious. They are emotional anesthetics. Heroin and cocaine, both powerful physical painkillers, also ease psychological discomfort. Infant animals separated from their mothers can be soothed readily by low doses of narcotics,2 just as if it were actual physical pain they were enduring.3

The pain pathways in humans are no different. 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.

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. The wound may not be as deep and the ache not as excruciating, and it may even be entirely hidden—but it’s there. As we’ll see, the effects of early stress or adverse experiences directly shape both the psychology and the neurobiology of addiction in the brain.

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. They stop functioning at anywhere near full capacity, relying on the artificial boosters instead. 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.

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.

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. Whenever I adopt a sharp tone with one of my clients, display indifference, or attempt some well-meant coercion for her benefit, I unwittingly take on the features of the powerful ones who first wounded and frightened her decades ago. Whatever my intentions, I end up evoking pain and fear.

What will happen to this infant, this being of infinite possibility? Given her dire beginnings, she may well lead a life of limitless sorrow—but she does not need to be defined by those beginnings. It depends on how well our world can nurture her. Perhaps our world will provide just enough loving refuge—enough “shelter from the storm” as Dylan has sung—so the baby, unlike her mother, can come to know herself as something other than her own worst enemy.

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.

try not to measure things as good or bad, just to look at things from the client’s point of view. ‘Okay, you went to detox for two days … was that a good thing for you?’ Not, ‘How come you didn’t stay longer?’ I 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.”

“Cynicism is rife down here, but at the same time most of us want to see that we’re looking after each other. We have the feeling that no one else is going to look after us—for most people down here, no one ever has—and so we have to care for each other. It’s done at the most basic level—just, ‘How are you, how are you getting along?’ And then you leave the person alone. We somehow balance all the ripping each other off with the caring. There’s a lot of warmth, a lot of support.”

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. “Rip-offs happen, but being part of the community is important. Even if it’s the poorest postal code in the country, this is the last club. ‘If you can’t belong to this club,’ I say, ‘you can’t belong to any club.’ ”

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.

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.

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 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.”

‘Just one more’ is the binding factor in the circle of suffering,”

I’ve barely left the store before the adrenaline starts pumping through my circulation again, my mind fixated on the next purchase. 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.

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.3

Any passion can become an addiction; but then how to distinguish between the two? The central question is: who’s in charge, the individual or their behavior? It’s possible to rule a passion, but an obsessive passion that a person is unable to rule is an addiction. And the addiction is the repeated behavior in which a person keeps engaging, even though he knows it harms himself or others. How it looks externally is irrelevant. The key issue is a person’s internal relationship to the passion and its related behaviors.

Passion is divine fire: it enlivens and makes holy; it gives light and yields inspiration. Passion is generous because it’s not ego-driven; addiction is self-centered. Passion gives and enriches; addiction is a thief. Passion is a source of truth and enlightenment; addictive behaviors lead you into darkness. You’re more alive when you are passionate, and you triumph whether or not you attain your goal. But an addiction requires a specific outcome that feeds the ego; without that outcome, the ego feels empty and deprived. A consuming passion that you are helpless to resist, no matter what the consequences, is an addiction.

When we’re preoccupied with serving our own false needs, we can’t endure seeing the genuine needs of other people—least of all those of our children.

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 fullness.”

“Now my goal is only that each day I should become closer to the God that I understand.” The God I understand? Not the willful old man in the sky I’ve resented all my life. Truth. Essence. The inner voice I keep running away from. That’s the God I’ve been resisting. If, Jonah-like, I’d rather hide in the stinking belly of a whale than face the truth I know so well, it’s not because of intelligence but because of the refusal to surrender. To surrender, you have to give something up. I’ve been unwilling to do that. And YHWH said to Moshe: “I see this people—and here, it is a stiff-necked people!”

drug addiction is a disease of the brain, and the associated abnormal behavior is the result of dysfunction of brain tissue, just as cardiac insufficiency is a disease of the heart.

Addiction is any repeated behavior, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others. Addiction involves: compulsive engagement with the behavior, a preoccupation with it; impaired control over the behavior; persistence or relapse despite evidence of harm; and dissatisfaction, irritability, or intense craving when the object—be it a drug, activity, or other goal—is not immediately available.

all addictions—whether to drugs or to non-drug behaviors—share the same brain circuits and brain chemicals. On the biochemical level the purpose of all addictions is to create an altered physiological state in the brain. This can be achieved in many ways, drug taking being the most direct. So an addiction is never purely “psychological”; all addictions have a biological dimension.