In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

“If it is irrational and hypocritical to hold a minor to the same standard of behavioral control as a mature adult, it is equally unjust to hold a traumatized and neurologically impaired adult to the same standard as one not so afflicted,”

Thus, the addict comes to make his choice with a brain that overvalues the addictive substance or behavior and undervalues the healthy alternatives. Impulses favoring the addiction process arise. The cortex, whose job it is to censor inappropriate actions—to exercise the “free won’t”—is hobbled. Brain lock sets in: the milliseconds that afford the possibility of “just saying no” flash by.

“The more we dehumanize and vilify substance abusers, the more it is impossible to put in place the kind of interventions that will help them.”

It’s not the particulars of this or that social policy that matter most deeply, but the relationship between those who influence policy and those who are affected by it.

If we are to help addicts, we must strive to change not them but their environments. These are the only things we can change. Transformation of the addict must come from within, and the best we can do is to encourage it. Fortunately, there is much that we can do.

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.

The findings of stress research suggest that the issue is not control over others, but whether one is free to exercise control in one’s own life. Yet the practices of the social welfare, legal, and medical systems subject the addict to domination in many ways and deprive her of control, even if unwittingly. In relegating the addict to the bottom of the social and moral scales and in our contemptuous rejection of him as a person, we have created the exact circumstances that are most likely to keep him trapped in pathological dependence on drugs.

The War on Drugs expresses a split mind-set in two ways: we want to eradicate or limit addiction, yet our social policies are best suited to promote it, and we condemn the addict for qualities we dare not acknowledge in ourselves.

the complete elimination of drug trafficking and use, is no option at all—only a chimera that even the most draconian measures have failed to conjure into reality anywhere in the world. Unless we are willing to see our society metamorphose into a brutal police state, no coercive policy will come close to even limiting drug use, let alone eliminating it.

The indispensable foundation of a rational stance toward drug addiction would be the decriminalization of all substance dependence and the provision of such substances to confirmed users under safely controlled conditions. It’s important to note that decriminalization does not mean legalization.

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.

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.

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.

consider that the street products currently available are full of impurities, mixed with noxious chemicals that magnify the damage from the stimulant itself. By bringing the crystal meth addict into a therapeutic interaction with the health care system, we would be fostering the possibility of use and gradual detoxification and withdrawal under relatively safe circumstances—relatively, because there is no safe way to use crystal meth. 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. And, very much to the point, most young people who become hooked on crystal meth are self-medicating other conditions: most commonly attention deficit/hyperactivity disorder (ADHD), but also depression, post-traumatic stress disorder, or the effects of emotional and social dislocation. As we discussed in Chapter Three, some young street people who use crystal meth see it as a way of survival. If the necessary physical, psychological, and social supports were provided, I believe it would not take long to diminish the appeal of methamphetamine and...

for many decades in the United Kingdom, heroin has been dispensed, under legal supervision, to addicts. The same type of program has been offered on a limited basis in other countries as well, and nowhere has it been found that this measure served in any way to entice unaddicted people into addiction. That is not surprising, given that addiction is a response to life experience, not simply to a drug.

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.

It may be thought that the cost of such a drug rehabilitation and treatment system would be exorbitant. No doubt the financial expenses would be great—but surely less than the funds now freely squandered on the War on Drugs, to say nothing of the savings from the cessation of drug-related criminal activity and the diminished burden on the health care system.

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.”

There is nothing more intrinsically criminal in the average drug user than in the average cigarette smoker or alcohol addict. The drugs they inject or inhale do not themselves induce criminal activity by their pharmacological effect,

The criminality associated with addiction follows directly from the need to raise money to purchase drugs at prices that are artificially inflated owing to their illegality.

Sam Sullivan, Vancouver’s quadriplegic mayor, told a conference on drug addiction once that if wheelchairs were illegal, he would do anything to get one, no matter what laws he had to break. It was an apt comparison: the hard-core addict feels equally handicapped without his substances.

Halsted’s story is revealing not only because it shows that with a morphine addiction the proper maintenance dose can be productive. It also illustrates the incredible power of the drug in question. Here was a man with almost unlimited resources—moral, physical, financial, medical—who tried everything he could think of and he was hooked until the day he died. Today we would send a man like that to prison. Instead he became the father of modern surgery.9

“You can fall into communities around alcohol or cocaine and whatever. Everyone has a need to belong. Unless people have another community, an alternative community that provides them with more belonging, being wanted, and purpose, the so-called treatment always fails. What seems to work here for aboriginal people is to switch their allegiance to an alternative community, modern but honoring traditional values. As long as they can maintain their position in that nonusing community, they are not using substances.”

Few harm reductionists who know their stuff recommend a market-led free-for-all in drugs like heroin and cocaine and the amphetamine stimulants. But there is now an undisputable body of evidence that demonstrates that developing mechanisms to make safer forms of these drugs available to those with an intractable need brings enormous benefits to both the drug user and the society around them. Thus both Holland and Switzerland and parts of Germany have changed policies and seen an enormous drop in the levels of drug-related crime. The average age of hard-drug users is rising there, indicated that fewer young people are taking up such an activity. The real obscenity here is the shocking lack of funding for treatment and care and harm-reduction initiatives that have been shown to work. The U.K. National Treatment Outcome Survey (known as NTROS) showed that for every one pound invested in treatment and care, three pounds came back in health care and enforcement savings. If such a return was available in the financial markets, we’d all rush to take advantage.

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.

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.

There is no evidence from anywhere in the world that harm-reduction measures encourage drug use. Denying addicts humane assistance multiplies their miseries without bringing them one inch closer to recovery.

The harm-reduction approach accepts that some people—many people—are too deeply enmeshed in substance dependence for any realistic “cure” under present circumstances. There is, for now, too much pain in their lives and too few internal and external resources available to them. In practicing harm reduction, we do not give up on abstinence—on the contrary, we may hope to encourage that possibility by helping people feel better, bringing them into therapeutic relationships with caregivers, offering them a sense of trust, removing judgment from our interactions with them, and giving them a sense of acceptance. At the same time, we do not hold out abstinence as the holy grail, and we do not make our valuation of addicts as worthwhile human beings dependent on their making choices that please us.

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.

We teach what we most need to learn—and sometimes give what we most need to receive.

“What you said about hating yourself and feeling sorry for yourself. What if you were to replace your harsh judgments with some genuine curiosity about why you do what you do? What if you use drugs because you’re afraid that you can’t bear the pain without them? You have every reason to feel hurt after all you’ve been through. It’s not a matter of ‘fucking up.’ You just haven’t found any other way to cope. If your child had had the same experiences and ended up on drugs, would you accuse her so harshly?” “No,” Clarissa says. “I’d love her.… I’d give her tough love.” “Forget the tough,” I tell her. “All she’d need is your love. And so do you.”

Among the necessary initial moves toward sobriety is the directing of compassionate curiosity at oneself.

The purpose is not to justify or rationalize but to understand. 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. I become free to acknowledge the addiction the moment the fact of having behaved along addictive patterns no longer means that I’m a failure as a person, unworthy of respect, shallow and valueless. I can own it and see the many ways it sabotages my real goals in life.

Incompleteness is the baseline state of the addict. The addict believes—either with full awareness or unconsciously—that he is “not enough.” As he is, he is inadequate to face life’s demands or to present an acceptable face to the world. He is unable to tolerate his own emotions without artificial supports. He must escape the painful experience of the void within through any activity that fills his mind with even temporary purpose, be it work, gambling, shopping, eating, or sexual seeking.

Twelve-step methods are not for everyone, and they may not be the only route out of addiction, but the principles on which they are based are common to any successful program of recovery.

“I admit I am powerless over my addiction process.” That is, “I fully acknowledge that my cravings and behaviors have been out of control and that my inability to regulate them has led to dysfunction and chaos in important areas of my life. I no longer deny their impact on myself or my coworkers or my loved ones, and I admit my failure to confront them honestly and consistently.”

No organism in nature is separate from the system in which it lives, functions, and dies, and no natural process can be understood in isolation from its physical and biological context.

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 al...

Most encouraging were Dr. Diamond’s findings that even the brains of animals deprived before birth or damaged in infancy were able to compensate through structural changes in response to enriched living conditions. “Thus,” she wrote, “we must not give up on people who begin life under unfavorable conditions. Environmental enrichment has the potential to enhance their brain development too, depending on the degree or severity of the insult.”

the brain remodels itself throughout life, and that it retains the capacity to change itself as the result not only of passively experienced factors such as enriched environments, but also of changes in the ways we behave and the ways we think.… Nor is there any question that every treatment that exploits the power of the mind to change the brain involves arduous effort—by patients afflicted by stroke or depression, by Tourette or OCD—to improve both their functional capacity and their brain function.”8 Arduous effort is also required on the part of any addict—all the more since her compulsions entice her to behaviors that, contrary to other distressing conditions, promise pleasure and reward.

The mind activity that can physically rewire malfunctioning brain circuits and alter our dysfunctional emotional and cerebral responses is conscious mental effort—what Dr. Schwartz calls mental force.

If changing external circumstances can improve brain physiology, so can mental effort. “Intention and attention exert real, physical effects on the brain,” Dr. Schwartz explains.9 Not surprisingly, the brain area activated in studies looking at the effect of self-directed mental effort is the prefrontal cortex, the apex of the brain’s emotional self-regulation system. It’s also an area where, we have learned, the brains of addicts are impaired. The mental activity most critical to the development of emotional self-regulation has been called “dispassionate self-observation” by the authors of an important article on the interface of brain and mind, published in the Philosophical Transactions of the Royal Society (Biological Sciences) in 20...

Mindful awareness involves directing our attention not only to the mental content of our thoughts, but also to the emotions and mind-states that inform those thoughts. It is being aware of the processes of our mind even as we work through its materials. Mindful awareness is the key t...

The teaching of Buddhism is that the way to deal with the mind is not to attempt to change it, but to become an impartial, compassionate observer of it.

By consciously observing the workings of our mind, we are able gradually to let go of its habitual, programmed interpretations and automatic reactions.

Reflection on the addicted brain, not willful resistance to it, is the way to tame it.

Brain research is demonstrating that mindful awareness is able to release the grip of harmful thoughts and also to change positively the physiology of the brain circuits where those thoughts originate. The implications for the healing of addiction are far-reaching.

“when people are influenced by past experience without any awareness that they are remembering.… If we are unaware that something is influencing our behavior, there is little we can do to understand or counteract it. The subtle, virtually undetectable nature of implicit memory is one reason it can have powerful effects on our mental lives.”12 Whenever a person “overreacts”—that is, reacts in a way that seems inappropriately exaggerated to the situation at hand—we can be sure that implicit memory is at work. The reaction is not to the irritant in the present but to some buried hurt in the past.