In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

We should be cautious not to confuse the trees for the forest—the manifestation for the underlying process, the symptom for the cause. There are no new disorders here, only new targets for the universal and age-old addiction process, new forms of escape. The mind and brain processes are the same in all addictions, no matter what form, as is the psycho-spiritual emptiness that resides at the core.

“We need to talk about what drives people to take drugs,” the famed trauma researcher Dr. Bessel van der Kolk has said. “People who feel good about themselves don’t do things that endanger their bodies…. Traumatized people feel agitated, restless, tight in the chest. You hate the way you feel. You take drugs in order to stabilize your body.” That is the desperation—the need to regulate one’s body and mind, to escape unbearable distress or unrest.

“I’m not going to ask you what you were addicted to,” I often say to people. “Nor when, nor for how long. Only, whatever your addictive focus; what did it offer you? What did you like about it? What, in the short term, did it give you that you craved or liked so much?” And universally, the answers are: “It helped me escape emotional pain; helped me deal with stress; gave me peace of mind, a sense of connection with others, a sense of control.”

Such responses illuminate that addiction is neither a choice nor primarily a disease. It originates in a human being’s desperate attempt to solve a problem: the problem of emotional pain, of overwhelming stress, of lost connection, of loss of control, of a deep discomfort with the self. In short, it is a forlorn attempt to solve the problem of human pain. All drugs—and all behaviours of addiction, substance-dependent or not, whether to gambling, sex, the internet or cocaine—either soothe pain directly or distract from it. Hence my mantra: The first question is not “Why the addiction?” but “Why the pain?”

Dr. Bruce Alexander in his seminal work The Globalization of Addiction: A Study in the Poverty of the Spirit.

Portugal has seen a reduction in drug habits, less criminality, and more people in treatment. They have halved their rate of injection drug use. There has been no downside. Norway is pondering the same policy. “How I frame it is the decriminalization of people who use drugs, not the decriminalization of the drugs,” says Dr. Henry.

Jeff Sessions, has also called for stricter enforcement and harsher punishment, believing, in the face of all evidence, that crime inevitably follows drug use. What crime inevitably does follow is not drug use as such, but criminalization,

writer Johann Hari brilliantly shows in Chasing the Scream: The First and Last Days of the War on Drugs.

In this book I argue that there is no “war on drugs.” One cannot make war on inanimate objects, only on human beings. And the people the war is mostly waged upon are those who have been the most neglected and oppressed in childhood, for, according to all the science, all the epidemiological data, all the experience, they are the most likely to succumb to substance addiction later in life. In our civilized times we are punishing and tormenting people for having suffered trauma.

“Your book humanizes the addict,” many readers have told me. That acknowledgement reflects a fundamental and common misperception. Addicts are human. What keeps many of us from seeing that? It is only the habit of our egocentric mind that divides the world into “us and them.” More precisely, it is our inability—or refusal—to see the us in “them” and the them in what we take to be “us.” Such failure of imagination is seen in every realm, from personal relationships to international politics. Simply put, it reflects that clinging to identity which is our way of belonging to a group. And if we identify with a group of any dimension narrower than all humanity, there must then be others who, by definition, do not belong and to whom, we may believe at least unconsciously, we are superior. That superiority makes us feel entitled to judge, and to remain indifferent.

Harm reduction has made significant inroads in the U.S. as well. San Francisco will soon be the first American city officially to open a supervised injection site; unofficially such facilities already operate. The idea, as Dr. Henry, British Columbia’s provincial health officer, says, “is to keep people alive until we can actually build a system that can help people with substance use and addiction and mental health [matters]. As your book points out, we don’t have a system that can prevent people from becoming addicted, nor one that can meet them where they are in their journey and can support them through the different phases of recovery, or to try to have a life when they have a mental health issue, or addiction, or both.”

There is only one universal addiction process. Its manifestations are multiple, from the gentler to the life-threatening, but in all addictions it utilizes the same brain circuits of pain relief, reward and motivation; it imposes the same psychological dynamics of shame and denial, the same behaviours of subterfuge and dishonesty. In all cases, it exacts the price of inner peace, harm to relationships, and diminished self-worth. In the case of substance addicts, whether in thrall to nicotine or alcohol or illicit drugs, it also jeopardizes physical health. Only from a broader understanding of addiction and from an appreciation of its sources, not in genes or choices but in human suffering, arise treatment approaches that could truly heal.

Parent-blaming is emotionally unkind and scientifically incorrect. All parents do their best; only our best is limited by our own unresolved or unconscious trauma.

Addictions arise from thwarted love, from our thwarted ability to love children the way they need to be loved, from our thwarted ability to love ourselves and one another in the ways we all need. Opening our hearts is the path to healing addiction—opening our compassion for the pain within ourselves, and the pain all around us.

being. In the Beast Realm we are driven by basic survival instincts and appetites such as physical hunger and sexuality, what Freud called the id.

The inhabitants of the Hungry Ghost Realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs and large, bloated, empty bellies. 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 pain of self-laceration obliterates, if only momentarily, the pain of a larger hurt deep in the psyche.

The work can be intensely satisfying or deeply frustrating, depending on my own state of mind.

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.

“The reason I do drugs is so I don’t feel the fucking feelings I feel when I don’t do drugs,” Nick, a forty-year-old heroin and crystal meth addict once told me, weeping as he spoke. “When I don’t feel the drugs in me, I get depressed.” His father drilled into his twin sons the notion that they were nothing but “pieces of shit.” Nick’s brother committed suicide as a teenager; Nick became a lifelong addict.

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.”2

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.

“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….”

Like patterns in a tapestry, recurring themes emerge in my interviews with addicts: the drug as emotional anaesthetic; 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.

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 ADHD (attention deficit hyperactivity disorder).

Addictions always originate in pain, whether felt openly or hidden in the unconscious. They are emotional anaesthetics. 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, just as if it was actual physical pain they were enduring.fn1

Or they had to look after younger siblings and defend them from being abused even as they themselves endured the daily violation of their own bodies and souls.

Carl, a thirty-six-year-old Native man, was banished from one foster home after another, had dishwashing liquid poured down his throat at age five for using foul language and was tied to a chair in a dark room in attempts to control his hyperactivity. When he’s angry at himself—as he was one day for having used cocaine—he gouges his foot with a knife as punishment. He confessed his “sin” to me with the look of a terrorized urchin who’d just smashed some family heirloom and dreaded the harshest retribution.

“Anyone who was tortured remains tortured … Anyone who has suffered torture never again will be able to be at ease in the world … Faith in humanity, already cracked by the first slap in the face, then demolished by torture, is never acquired again.”

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 centre of all addictive behaviours. 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.

A sense of deficient emptiness pervades our entire culture. The drug addict is more painfully conscious of this void than most people and has limited means of escaping it. The rest of us find other ways of suppressing our fear of emptiness or of distracting ourselves from it. When we have nothing to occupy our minds, bad memories, troubling anxieties, unease or the nagging mental stupor we call boredom can arise. At all costs, drug addicts want to escape spending “alone time” with their minds. To a lesser degree, behavioural addictions are also responses to this terror of the void.

Boredom, rooted in a fundamental discomfort with the self, is one of the least tolerable mental states.

The addict’s reliance on the drug to reawaken her dulled feelings is no adolescent caprice. The dullness is itself a consequence of an emotional malfunction not of her making: the internal shutdown of vulnerability.

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 defence mechanism and can enable the child to endure trauma that would otherwise be catastrophic. The unfortunate consequence is a wholesale dulling of emotional awareness. “Everybody knows there is no fineness or accuracy of suppressi...

Intuitively, we all know that it’s better to feel ...

dismal nutrition; a debilitating lifestyle; diseases like HIV, hepatitis C and their complications; disturbed sleep patterns that date back, in many cases, to childhood—another consequence of abuse or neglect.

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.

I don’t believe that’s true. I think deep in his heart there must live a desire for a life of wholeness and integrity that may be too painful to acknowledge—painful because, in his eyes, it’s unattainable. Jake is so identified with his addiction that he doesn’t dare imagine himself sober.

Her HIV care has been a source of struggle between us, since she habitually refuses to have her blood counts done. “I can’t know what treatment you need,” I explain, “if I don’t know the state of your immune system.” Once, in utter frustration, I tried to coerce her into having the blood tests by threatening to withhold her methadone. A week later I recanted. “It’s not my right to force you into anything,” I said by way of apology. “The methadone has nothing to do with HIV. Whether you get yourself tested or not is entirely up to you. I can only offer you my best advice. I’m sorry.” “Thank you, Maté,” Serena said. “I just don’t want anybody controlling me.” Soon afterwards she did undergo the required tests voluntarily. And so far her immune counts have been high enough that antiviral medications haven’t been needed.

The question of control is a touchy one. No segment of the population feels powerlessness more acutely than Downtown Eastside drug addicts. Even the average citizen finds it difficult to question medical authority, for a host of cultural and psychological reasons. As an authority figure, the doctor triggers deeply ingrained feelings of childhood powerlessness in many of us—I had that experience even years after completing medical training when I needed care for myself. But in the case of the drug addict, the disempowerment is real, palpable and quite in the present. Engaged in illegal activities to support her habit—her very habit being illegal—she is on all sides hemmed in by laws, rules and regulations.

Imprinted in the developing brain circuitry of the child subjected to abuse or neglect is fear and distrust of powerful people, especially of caregivers.

unwittingly take on the features of the powerful ones who first wounded and frightened

seeker. I am prone to that human—but inhumane—failing of defining and categorizing people according to our interpretation of their behaviours. Our ideas and feelings about a person congeal around our limited experience of them, and around our judgments.

So this was the perfect home Serena grew up in, under the care of a grandmother who, no doubt, loved her grandchild but was utterly unable to defend her from the predatory males in the household or from her own alcoholism. And that grandmother, now deceased, was Serena’s sole connection to the possibility of sustaining, consoling love in this world.

“What happened to you is truly horrible. There is no other word for it and there is nothing I can say that comes even close to acknowledging just how terrible, how unfair it is for any being, any child to be forced to endure all that. But no matter what, I still don’t accept that things are hopeless for any human being. I believe there is a natural strength and innate perfection in everyone. Even though it’s covered up by all kinds of terrors and all kinds of scars, it’s there.”

Spiritual teachings of all traditions enjoin us to see the divine in each other. “Namaste,” the Sanskrit holy greeting, means: “The divine in me salutes the divine in you.” The divine? It’s so hard for us even to see the human.

What have I to offer this young Native woman whose three decades of life bear the compressed torment of generations? An antidepressant capsule every morning, to be dispensed with her methadone, and half an hour of my time once or twice a month.

“Mirror of my inner self, what do others see?”

“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.”