In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

What is addiction, really? 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.

The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate question. I dedicate this work to all my fellow hungry ghosts, be they innercity street dwellers with HIV, inmates of prisons, or their more fortunate counterparts with homes, families, jobs, and successful careers. May we all find peace.

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.

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.

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.

At first all I hear is a litany of funerary clichés, and I am annoyed. Soon, however, I find myself comforted. In the face of untimely death, it occurs to me, there are no clichés. “For always Sharon, that voice, that spirit.… For the peace of eternity, immortal peace.…”

I look at this small cluster of human beings gathered at the funeral of a comrade who met her death in her midthirties. How powerful the addiction, I think, that not all the physical disease and pain and psychological torment can shake loose its lethal hold on their souls.

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.

What a wonderful world it would be if the simplistic view were accurate: that human beings need only negative consequences to teach them hard lessons. Then any number of fast-food franchises would be tickets to bankruptcy, the TV room would be a deserted spot in our homes, and the Portland Hotel could reinvent itself as something more lucrative: perhaps a luxury housing unit with Mediterranean pretensions for downtown yuppies, similar to the sold-out Firenze and España condo developments still under construction around the corner.

“I’m not afraid of dying,” a client told me. “Sometimes I’m more afraid of living.” That fear of life as they have experienced it underlies my patients’ continued drug use. “Nothing bothers me when I’m high. There’s no stress in my life,” one person said—a sentiment echoed by many addicted people. “Makes me just forget,” said Dora, an inveterate cocaine user. “I forget about my problems. Nothing ever seems quite as bad as it really is, until you wake up the next morning, and then it’s worse.”

Beyond the addict’s immediate orgasmic release of the moment, drugs have the power to make the painful tolerable and the humdrum worth living for. “There is a memory so fixed and so perfect that on certain days my brain listens to no other,” writes Stephen Reid—author, incarcerated bank robber, and self-described junkie—of his first hit of narcotics, at age eleven. “I am in profound awe of the ordinary—the pale sky, the blue spruce tree, the rusty barbed-wire fence, those dying yellow leaves. I am high. I am eleven years old and in communion with this world. Wholly innocent, I enter into the heart of unknowing.”2 In a similar vein, Leonard Cohen has written about “the promise, the beauty, the salvation of cigarettes.”

Like patterns in a tapestry, recurring themes emerge in my interviews with addicts: the drug as emotional anesthetic; as an antidote to a frightful feeling of emptiness; as a tonic against fatigue, boredom, alienation, and a sense of personal inadequacy; as stress reliever and social lubricant. And, as in Stephen Reid’s description, the drug may—if only for a brief instant—open the portals of spiritual transcendence. In places high and low these themes blight the lives of hungry ghosts everywhere.

It is impossible to understand addiction without asking what relief the addict finds, or hopes to find, in the drug or the addictive behavior.

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.

Boredom, rooted in a fundamental discomfort with the self, is one of the least tolerable mental states. For the addict the drug provides a route to feeling alive again, if only temporarily. “I am in profound awe of the ordinary,” recalls author and bank robber Stephen Reid of his first hit of morphine. Thomas De Quincey extols opium’s power “to stimulate the capacities of enjoyment.”

From the Latin word vulnerare, “to wound,” vulnerability is our susceptibility to be wounded. This fragility is part of our nature and cannot be escaped. 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.

Imagine how disabled we would be if we could not see or hear or taste or sense heat or cold or physical pain. Emotional shutdown is similar. Our emotions are an indispensable part of our sensory apparatus and an essential part of who we are. They make life worthwhile, exciting, challenging, beautiful, and meaningful.

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.

And here is where I’m humbled. I’m humbled by my feebleness in helping this person. Humbled that I had the arrogance to believe I’d seen and heard it all. You can never see and hear it all because, for all their sordid similarities, each story in the Downtown Eastside unfolded in the particular existence of a unique human being. Each one needs to be heard, witnessed, and acknowledged anew, every time it’s told. And I’m especially humbled because I dared to imagine that Serena was less than the complex and luminous person she is. Who am I to judge her for being driven

For now there is nothing to say. As I await some sign that she’s ready for contact, I read the prayer she’s written on the wall above her cot: “Oh, Great Spirit, whose voice I hear in the Winds and whose breath gives life to all the World around me, hear our cry, for we are small and weak.” It ends with a plea: “Help me make peace with my greatest Enemy—myself.”

“Every person I ever wanted to trust, I’ve been hurt by. I truly am in love with Rick, but for the life of me I can’t bring myself to believe that he will not betray me. It stems right back to my sexual abuse.”

When the music is over, she stirs from her reverie and tells me that she and her boyfriend are making plans for the future. “What about your ongoing addiction? Is it creating a problem for you or him?” “Well, yeah, because the whole me isn’t there.… You don’t get the best of a person when there’s an addiction, right?” “Right,” I concur. “I know something about that myself.”

Rick, as an alcoholic, has done some twelve-step work. He is quick to understand and, like Celia, is insightful and articulate. “There’s a fine line,” he offers, “between healthy boundaries and codependency, where you’re just getting walked over. In the heat of the moment, it’s so tough for me to discern that.” I momentarily permit myself some optimism. If anyone can make it, it’s these two.

“He’s told me to fuck off.… He made it more than clear he doesn’t want anything to do with me anymore.” I feel dismayed, even irritated, as if Celia owed it to me personally to live out some happy, odds-defying fantasy of redemption. “Were those Rick’s words or your interpretation?”

“I’m devastated. I’ve never felt so unwanted in my whole fucking life.” Yes, you have, I think to myself. You have always felt unwanted. And desperate as you are to offer your baby what you never experienced—a loving welcome into this world—in the end, you’ll give her the same message of rejection.

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.

If I understand him well, above everything Ralph aches for unity with the eternal feminine caritas—blessed, soul-saving divine love. Divine here refers not to a supernatural deity above us but to the immortal essence of existence that lives in us, through us, beyond us. Religions may identify it with a god belief, but a search for the eternal extends far beyond formal religious concepts. One consequence of spiritual deprivation is addiction, and not only to drugs. At conferences devoted to science-based addiction medicine, it is more and more common to hear presentations on the spiritual aspect of addictions and their treatment.

In Goethe’s epic drama the Homunculus is a little being of fire conceived in a laboratory flask. He is a masculine figure who voluntarily unites with the vast Ocean, the divine feminine aspect of the soul. According to mystical traditions of all faiths and philosophies, without such ego-annihilating submission, it is impossible to attain spiritual enlightenment, “the peace of God, which passeth all understanding.” Ralph yearns for nothing less. “The Homunculus,” he continues, “is the character that represents all I would have been, had it been possible for me to be that way. But it’s not how I turned out. So now I use Xylocaine when I can get it or cocaine when I can’t.” Ralph hopes to inhale peaceful consciousness through a glass pipe. I cannot be the Homunculus, he says, so I must be an addict.

In writing about a drug ghetto in a desolate corner of the realm of hungry ghosts, it’s difficult to convey the grace that we witness—we who have the privilege of working down here: the courage, the human connection, the tenacious struggle for existence and even for dignity. The misery is extraordinary in the drug gulag, but so is the humanity.

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.”

Unconditional acceptance of each other is one of the greatest challenges we humans face. Few of us have experienced it consistently; the addict has never experienced it—least of all from himself.

Some authorities see ADHD as an inherited neurophysiological dysfunction, but in my view such psychological agitation has a deeper source. Remy’s wandering speech patterns are attempts to escape an agonizing discomfort with his own self.

seeking absolution

do over

“Can you forgive yourself?” “Yeah, I can. I don’t know how, but I can forgive myself.

“As I purged that shit, I realized I had to bring light back into my life. Otherwise, all the horror I’d seen and done would have been for nothing. There’s got to be some light. I believe there is a truth—for lack of another word,

Dean knows that 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.

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.

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.

“The Don Juan story. The obsessive womanizer. He’s this creative, charming, and energetic man. A daring adventurer, but a coward morally, who never finds peace within. His erotic passion is insatiable: no matter how often it’s consummated, it leaves him restless and dissatisfied. And his poetic talent and his drive for mastery only serve his relentless need to possess. It’s always about the next acquisition—he even keeps a notebook listing his amorous conquests. He has many, many opportunities for salvation, but he spurns them all. He torments others and sacrifices his own mortal soul. He scorns repentance, and in the end, he’s dragged down to Hell.”

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 fundamental addiction is to the fleeting experience of not being addicted. 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.” There are not many Zorbas among us.

When you get right down to it, it’s the adrenaline I’m after, along with the precious reward chemicals that will flood my brain when I hold the new CD in hand, providing an-all-too temporary reprieve from the stress of my driven state. But 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.

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.

Addiction is centrifugal. It sucks energy from you, creating a vacuum of inertia. A passion energizes you and enriches your relationships. It empowers you and gives strength to others. Passion creates; addiction consumes—first the self and then the others within its orbit.

That’s how I am.” Self-deprecating, pessimistic, or negative comments creep into my conversations. Someone on the ward compliments my work. I attempt a joke: “Oh, you can fool some of the people some of the time.” No joke, that. They look at me strangely and protest that they meant it. Of course they did, but in my shame, I don’t believe I deserve any praise. A secret addiction comes equipped with praise deflectors.

I can’t be optimistic and believe in her growth and development when I know I’m sabotaging my own. How can I see the best in her when I’m blind to all but the worst in myself? Our interactions are tense. At age seventeen, she’s at no loss for words or body language to communicate her displeasure.

I hated myself, and this self-loathing manifested itself in the harsh, controlling, and critical ways I’d deal with my sons and my daughter.