In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

It may seem at first glance that the addict is more culpable, since he “enjoys” his behaviour as compared with the OCD patient, who suffers from it. In reality, the addict’s temporary enjoyment makes it all the more difficult for him to give up his habit, whereas the obsessive-compulsive would be only too glad to do so, if shown how. When it comes to choosing recovery, this momentary but highly enticing pleasure experience puts the addict at a disadvantage—even if what we call “pleasure” is, in addiction, little more than an evanescent sense of relief from mental distress or spiritual emptiness.

It is not helpful, however, to compare any one person with another. Just because one person succeeds doesn’t mean that we’re entitled to judge another for having failed. For all our similarities, from the moment of conception we are each shaped by our own unique makeup and set of life experiences. No two human brains look alike, not even those of identical twins. One person’s pain cannot be compared with anyone else’s, nor can we compare any two people’s capacity to endure suffering. In addition to the visible factors, there are also many subtle, invisible ones that may positively influence our psychic strength and our capacity for choice: a kind word spoken long ago, a fortuitous circumstance, a new relationship, a flash of insight, a memory of love, a sudden opening to faith. People who have overcome severe addictions deserve to be celebrated and they have much to teach, but their example cannot be used to condemn others who have not been able follow in their footsteps.

It’s even more nonsensical to judge addicts by arbitrary criteria derived from the experience of people with relatively normal lives. “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,” says brain researcher Martin Teicher.4

In the words of the seminal researcher Jaak Panksepp, “drug addictions wouldn’t occur unless they were related to natural reward processes of some kind.” Habits and the brain circuits that maintain them form around substances and behaviours that promise instant if only temporary satisfaction.

“Those habit structures are so incredibly robust, and once they form in the nervous system they will guide behaviour without free choice,” Dr. Panksepp said in a personal interview. “Addicts become addicts because they develop these habit structures which become totally focused on non-traditional rewards, drug rewards. They get hooked and they can’t break out of that psychological imprisonment.”

Thus, the addict comes to make his choice with a brain that overvalues the addictive substance or behaviour and undervalues the healthy alternatives. Impulses favouring the addiction process arise. The cortex, whose job it is to censor inappropriate actions—to exercise the “free won’t”—is hobbled. Brain lock s...

The manipulation and dishonesty have been his automatic defences since childhood. He must be terrified that without them he will suffer deprivation.

I’LL START FROM the assumption that we want to redeem people trapped in drug addiction—and that redemption can be something other than an addict’s complete abstinence from addictive chemicals, a goal that’s not always realistic. Under current conditions it hardly ever is for most hardcore substance users, although I believe our success rate could be much higher if we abandoned our present intolerant and self-defeating social attitudes toward addiction and the care of addicted people. Even in cases where abstinence is not achieved, redemption would mean the reintegration of the user into the larger community and the restoration of his value as a person in his own eyes.

In a culture that projects its darkest features onto the addict and makes addicted people into scapegoats for its shortcomings, insight and knowledge are almost entirely absent from public discourse concerning drug policies. Moralizing displaces compassion and prejudice substitutes for inquiry.

I don’t believe that the “vested interests” of medical professionals are, in this case, consciously selfish or motivated by material considerations; they are the investment we have in maintaining that our way of thinking is right, that the principles and methods we have practised are sound and that approaches outside our emotional or intellectual comfort zones are not worth investigating. Institutions such as professional bodies, medical schools and scientific associations tend to be deeply conservative, even if in some ways they are at the forefront of bold exploration. They mistrust new paradigms and resist moving outside the boundaries of a narrowly defined science-ideology that separates mind from body, human beings from their lifetime environments.

Similarly, most political leaders and policymakers seem unaware of the abundance of facts and experience refuting the theory and practices of the War on Drugs or they lack the will to act on the evidence. In the worst-case scenario some may be too blinded by a moralistic and judgment-ridden ideology to act according to the Christian principles they profess.

“first take the plank out of your own eye, and then you will see clearly to take the splinter out of your brother’s eye.”

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.

Addicts are locked into addiction not only by their painful past and distressing present, but equally by their bleak view of the future. 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.

As we have seen, a major factor in addiction that medical and social policies must take into account is stress. If we want to support people’s potential for healthy transformation, we must cease to impose debilitating stress on their already burdened existence. Recall that uncertainty, isolation, loss of control and conflict are the major triggers for stress and that stress is the most predictable factor in maintaining addiction and triggering relapse.

a history of childhood abuse increases physiological stress reactivity for a lifetime, a reactivity “which is further enhanced when additional trauma is experienced in adulthood.”

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. Legalization would make manufacturing and selling drugs legal, acceptable commercial activities. 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 Holland, 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.

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. They would not have to decide between eating or drug use, or to scrounge for food in garbage cans or pick cigarett...

I admit I am ambivalent about the decriminalization of certain drugs, particularly crystal meth, and I understand why some people would resist even discussing the possibility. But if it seems bizarre to suggest that such a potentially brain-toxic drug be legally administered to addicts, 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 curr...

And, very much to the point, most young people who become hooked on crystal meth are self-medicating for other conditions: most commonly ADHD, but also depression, post-traumatic stress disorder or the effects of emotional and social dislocation.

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, counselling, skills training and emotional support.

To expect an addict to give up her drug is like asking the average person to imagine living without all her social skills, support networks, emotional stability and sense of physical and psychological comfort.

History has demonstrated many times over that people will transgress laws and resist coercion when it comes to struggling for their basic needs—or what they perceive as such.

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 post-operative 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.” As noted at the Common Sense for Drug Policy website: 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.7

“People fall into these communities of substance, centred around drugs,” Dr. Mehl-Madrona pointed out. “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 honouring traditional values. As long as they can maintain their position in that non-using community, they are not using substances.”

If we understood the sources of their dysfunction, we would want to reduce their suffering, whether or not they continue to use.

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 to 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.

There is also no contradiction between harm reduction and abstinence. The two objectives are incompatible only if we imagine that we can set the agenda for someone else’s life regardless of what he or she may choose. We cannot.

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.

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, safe if ingested properly and which 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.

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.

In the United Kingdom opiate maintenance programs were administered from the 1920s to the 1970s but fell into disfavour under heavy U.S. opposition. Since then, despite the War on Drugs—or perhaps, in part, owing to it—the number of British opiate addicts has soared exponentially.

The problem’s not that the truth is harsh but that liberation from ignorance is as painful as being born. Run after truth until you’re breathless. Accept the pain involved in re-creating yourself afresh. These ideas will take a life to comprehend, a hard one interspersed with drunken moments. NAGUIB MAHFOUZ Palace of Desire

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.

“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?”

When I’m reasonably balanced in my personal and spiritual life, I don’t have difficulty finding compassion for my addicted patients. I’m curious about their life histories and self-perceptions and, for the most part, I’m able to avoid imposing judgments on them.

Things are very different when it comes to my own self in the midst of an addicted phase. Suffused with corrosive shame, I attempt to hide the self-loathing from my own sight with feigned joviality or self-justifying combativeness,

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.1

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?”

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 favour or to hoodwink her. Justification connives to absolve the ...

My anxiety clothes itself in concerns about body image or financial security, doubts regarding loveability or the ability to love, self-disparagement and existential pessimism about life’s meaning and purpose—or, on the other hand, it manifests itself as grandiosity, the need to be admired, to be seen as special. At bottom it is nameless and formless. I feel sure it was forged in my chest cavity somewhere between my lungs and heart long before I knew the names of things.

The British psychiatrist R.D. Laing wrote somewhere that there are three things human beings are afraid of: death, other people, and their own minds. Terrified of my mind, I had always dreaded to spend a moment alone with it. There always had to be a book in my pocket as an emergency kit in case I was ever trapped waiting anywhere, even for one minute, be it a bank lineup or supermarket checkout counter. I was forever throwing my mind scraps to feed on, as to a ferocious and malevolent beast that would devour me the moment it was not chewing on something else.2

At that time I ascribed that state of perpetual dissatisfaction to attention deficit disorder. Although a salient mental feature of ADD, the drive to escape the moment is a common, nearly universal human characteristic. In the addicted brain it is magnified to the point of desperation. It becomes the overriding force in directing choices and behaviour.

My workaholism and compact disc shopping have been only the most consistent forms of escape my mind chooses when it’s uncomfortable. There have been other behaviours just as compulsive and just as impulsive. I see now that the underlying anxiety and sense of emptiness have been pervasive. Emotionally they take the shape of chronic, low-grade depression and irritability. On the thought level, they manifest as cynicism—the negative side of the healthy skepticism and independent thinking I’ve always valued. Behaviourally they mask themselves as hypomanic energy or as lethargy, as the constant hankering for activity or for oblivion. When the ordinary, everyday escape mechanisms fail to satisfy, I plunge into my overtly addictive patterns. If I had greater pain and fewer resources, if I had been less fortunate in the circumstances of my nurturing environment, I might well have been impelled to turn to drugs.

Compassionate curiosity directed toward the self leads to the truth of things. Once I see my anxiety and recognize it for what it is, the need to escape dwindles. It is clear to me that the sense of threat and fear of abandonment that make up anxiety were, in my case, programmed in the Budapest ghetto in 1944. Why attempt to escape some old brain pattern laid down when I was a frightened infant during a terrible time in history? It’s there and the circuits in which its wordless stories are embedded are indelibly a part of my brain. It doesn’t need to go away—indeed, it won’t go away, not completely. But I can transform my relationship to it, become more intimately related to it. I can even gain some mastery over it, which means noticing it without allowing it to control my moods or behaviours. Similarly, I don’t have to take on the impossible task of erasing the addictive impulses that arose from early acquired brain patterns—but I can transform my relationship to them, as well. Essential to any such transformations is a letting-go of judgment and self-condemnation.

“I fully acknowledge that my cravings and behaviours 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.”

First, since I pride myself on a strong intellect, I’ve resisted accepting that I’m powerless over any mental process. 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—

Second, in focusing on the most visible compulsive behaviours, such as CD shopping, book bingeing or workaholism, I could still permit myself to ignore how addictive patterns have permeated much of my functioning. Narrowing it down to a few “problematic” issues has allowed me to deny that the addiction process shows up in numerous aspects of my daily existence.

Finally, whenever I have felt wooden or alienated in the intimate areas of life, I’ve seen myself as deprived, rather than owning the reality that I create the sense of deprivation internally.