Why Do People Become Addicts?
Gabor Mate M.D. has been for over ten years the staff physician at the Portland Hotel, North America’s only supervised safe-injection site in Vancouver's Downtown Eastside, home to one of the world’s densest areas of drug users. Mate advocates for and practices a holistic view of reality, its challenges and potential solutions. Mate’s books include When the Body Says No: Understanding The Stress-Disease Connection; Scattered: How Attention Deficit Disorder Originates And What You Can Do About It, and his latest, In The Realm of Hungry Ghosts: Close Encounters with Addiction.
McNally: Can you tell us a bit about your path to the work that you do today?
Mate: I’m a medical doctor. I’ve worked for 20 years in family practice in Vancouver, BC. For seven years I worked in palliative care looking after old people and for 12 years I’ve worked in the downtown eastside.
My own journey involves not just my observations and experiences as a physician, but also dealing with my own mental health issues and emotional problems and imbalances. In the process of coming to terms with my own issues, I began to understand that the medical training I’d received, although valuable and a great benefit in many ways, was also hopelessly too narrow and shallow in its approach to human beings.
The medical approach still separates the mind from the body, and still looks at individuals as discrete entities rather than seeing us as manifestations of cultural, physical and emotional alignment. I’ve come to understand that whether we’re talking about addiction or any dysfunction of human mind, body or spirit, we have to understand that we’re all connected; that people are not separate from their environment; and that we’re very much shaped by what happens to us in early childhood. Disease in the end is not the source of our problems, but a manifestation of a lifelong disconnection from ourselves.
At the same time, when disease arises it presents an opportunity for healing, which actually means wholeness; an opportunity to get back to what we actually are. I approach illness from the perspective of asking what is it telling us about the individual at that particular time in their life. This is not to say that I would therefore reject conventional medical treatment. Often that can be very helpful, but it’s not the ultimate answer.
McNally: Am I correct in saying that your work embodies these principles of holistic treatment: Deal with the whole situation – mind, body, emotions, spirit, and environment; look for root causes rather than symptoms; and treat as naturally and safely as possible?
Mate: I’m a medical doctor, but I’m also very open to alternative therapies. Western medicine has very limited responses to most chronic conditions, whether physical conditions like multiple sclerosis or mental health conditions like depression or addiction. Certainly when it comes to understanding causes, we have to look at people’s lives and the social milieu where these lives are lived.
McNally: What does it mean to say that yours is the only legal injection site in North America?
Mate: You’re referring to Insite, which is administered by the Portland Hotel Society in Vancouver. It’s a facility where people who are addicted can bring their illegal drugs like heroin or cocaine without the fear of being arrested. They’re provided with sterile swabs, clean water and clean needles, and with lights and a mirror and a sink where they can wash themselves. There they can inject their substances under the supervision of a nurse.
As a result, there’s less injection in the streets and fewer crack vials and drug needles strewn around the neighborhood. Among the benefits demonstrated by many medical studies are that people don’t transmit HIV or hepatitis-C or other infectious diseases to one another, and that saves a lot of money.
Childhood trauma is the universal template for severe addiction. These drug addicts all began life as abused children. Finally they have a place where they feel accepted and safe for the first time in their lives, so it’s a beginning of the possibility of treatment.
McNally: What is the situation in Vancouver, the city, British Columbia, the province, and Canada, the country, in terms of implementing a philosophy of harm reduction rather than criminalization with regard to drugs?
Mate: On a civic level in Vancouver and a provincial level in BC, harm reduction is well accepted in the government. But the federal government in Canada has shaped itself very much to the right of the George Bush conservatives. They claim that somehow we’re supporting or condoning addiction, a completely false and demonstrably baseless idea. And, for purely ideological reasons, they’re trying to shut the place down despite the demonstrated evidence of economic and health benefits.
I’m told the Obama administration prevented the American federal government from funding HIV programs that involve needle exchange, even though, of course, clean needle exchange is one of the best ways to prevent HIV transmission. In both cases, such actions have nothing to do with health, humanity or compassion, and everything to do with a right wing agenda.
McNally: When I look at the perpetuation of the war on drugs here in the US, I see on one side the correctional unions and what I would call the prison industrial complex, and on the other, millions of people who know better. But the issue is not high enough on their agenda to overcome the money and influence of those institutions who benefit from it.
Your latest book has a provocative title, In The Realm of Hungry Ghosts. What does it refer to?
Mate: The hungry ghost is a Buddhist image. The Buddhist wheel of life cycles through six realms of human existence: the ordinary human realm; the hell realm of unbearable emotions like rage and terror; the animal realm of passions, instincts, and drives; and so on.
The hungry ghost realm depicts creatures with large empty bellies, small scrawny necks and mouths. They’re forever hungry and insatiable, but can never fill that emptiness. So they go around attempting to satisfy this inner void without ever being able to do so. That, of course, is the realm of addiction.
And it’s not that some people are here all the time and other people are there all the time.
With hardcore drug addicts, the hungry ghost dominates their lives, but if we look at ourselves honestly, we can see that we all have that hungry ghost inside of us to one degree or another. I certainly do. The question is, why do people get stuck or why do they gravitate towards the hungry ghost realm. I say it’s because they’re attempting to escape the hell realm of unbearable emotion.
If you look at all the people who are addicted to anything, it’s always based on some degree of loss, emotional loss in childhood, particularly the loss of love. In the case of the extreme addict, it’s trauma. Research clearly shows that people who become addicted are traumatized individuals, either because they’re directly abused, neglected, abandoned, or because they didn’t get their needs met as children because their parents were too distracted or stressed or perhaps addicted themselves.
One way or another, there’s a void, an emptiness that we spend all our lives trying to fill. Hence the hungry ghost image.
McNally: Could you speak about your own challenges?
Mate: Well, addiction is a biopsychosocial continuum and some people are at the extreme end, usually because they suffered more extremely. But in this society many of us find ourselves somewhere on that continuum. My own particular addictions have been expressed in two major areas.
One has been through work. I’ve been a workaholic physician, driving myself too hard. I ignored my own family’s needs; my children didn’t have my presence as an emotionally available father when they were small, and my marriage relationship was affected negatively by my workaholic tendencies.
My other addiction has been the purchasing of compact discs. I love classical music, but it’s not the love of the music I’m talking about. I’m talking about the need to acquire more and more, and the need to have that fix immediately, right now, this very second. The addiction is never to the external product, it’s actually to the process of getting.
With the sex addict, for example, it’s not so much sex that they enjoy, but the need to be validated by being sexually accepted. They have to keep proving to themselves all the time that they’re lovable. They’re addicted to the hunt and to the excitement of the quest for the immediate fix. But then they have to go on to the next one because it never satiates and never satisfies. It’s the same with work and with shopping.
There’s one universal addiction process. Whether you’re addicted to drugs, sex or rock ’n’ roll, the same brain circuits are involved. The same emotional imbalance and the same spiritual emptiness underlies it all. The targets may vary from person to person, but the process is virtually identical.
McNally: Could you talk a little bit about neurotransmitters in terms of addiction, in terms of drug use, and it terms of the wounding that brought that all about?
Mate: The brain circuits involved in addiction are essential for human life. These are the brain’s internal endogenous opiate circuits or pain relieving circuits -- endorphins, endorphin meaning “endogenous morphine-like substance.”
These circuits facilitate pain relief, pleasure and reward, and facilitate our love relationships. A person who lacks endorphins would be desperate for some relief from too much pain and from a lack of love and pleasure in their world.
The brain’s incentive and motivation circuits, which involve the chemical dopamine, are also involved in addiction. Dopamine is essential for human life, without it we have no incentive or motivation, no vitality or curiosity. All stimulant drugs work on the dopamine incentive motivation system, elevating dopamine levels.
These and other essential brain circuits involved in addiction require a nurturing, calm, balanced and consistent parenting environment for their healthy development. To the extent that those conditions are not available to the small child, the brain does not get the environmental input that it requires and will not develop optimally. Therefore people will be prone to try to supplant or supplement those chemicals by outside means, whether through drugs or behaviors. So addiction reflects not just a psychological need but a physiological imbalance, which is the result of early childhood adversity.
McNally: It’s my suspicion that we can become addicted to our own stress. Can people become addicted to the unconscious desire to trigger the stress mechanism?
Mate: Certainly people can become addicted to their own stress hormones. The great Canadian – Hungarian-born like myself -- stress researcher, Hans Selye, who did the pioneering work on stress in the mammalian body, pointed out that people can be adrenalin junkies, addicted to their own adrenalin and cortisol.
Just like any addict going through withdrawal, when they’re not stressed, when they’re not in a highly intense situation, they go through withdrawal, listlessness and irritability. So people generate stress just to feel okay about themselves, usually because they were brought up under very stressed and intense circumstances. That strikes them as normal, so when it isn’t available, they just don’t feel like themselves.
McNally: Looking at US society, it seems to me that’s an insight that’s both powerful and helpful…
What is your take on the current habituation -- if not addiction -- to screens, text messages, Facebook accounts, and so on?
Mate: Addiction is always a matter of external focus. Rather than being internally directed, we’re looking outside to be excited and satisfied. So, first of all, the screens provide that.
Number two, amongst young people in this culture, there’s a lack of connection with nurturing adults. Children and young people become connected to one another and this becomes addictive. The addiction to technology is not simply an addiction to technology itself, it’s also an addiction to peer contact.
They have to be in touch with each other all the time. Twittering and texting and the emailing and skyping has to do with a loss of connection to nurturing adults. That’s being replaced by a desperation to belong to the peer group, and now we have technology that keeps you connected to the peer group all the time. Even when they’re not physically in each other’s presence, they can be in virtual contact.
Then there are specific addictions to things on the internet like pornography. There are news junkies, people who just have to have the news all the time. Why? Because they’re empty inside.
McNally: And a bit of news promises novelty, a little moment of stimulation…
Mate: One morning this spring, for example, you could spend hours reading about how Osama bin Laden is dead. Well, there’s only one fact, he’s dead; all the rest of it is simply verbiage. But people have the need to be engaged with it for hours and hours, because they’re lacking something inside. They’re not getting more information that in any way will help them live a better life. They’re simply indulging themselves in order to be externally stimulated.
McNally: How does ADD or ADHD fit into this approach?
Mate: It’s not surprising that the first three letters of the word addiction are A-D-D, because there’s a huge overlap between addictions and ADD. Both ADD and addictions involve a lack of the chemical dopamine in the brain. That’s what we supply to people when we give them Ritalin or Dexadrin. So both conditions are marked by the lack of the incentive chemical.
Number two, both conditions involve poor impulse control. People don’t know how to regulate their impulses so they act things out, even though it’s bad for them. Contrary to the dominant medical perspective, in my view, neither ADD nor addiction represent genetic conditions, but both are the result of childhood stress.
I have ADD and so do my kids, but I don’t think I passed it on to them genetically. I passed it on to them because they had a stressed childhood just like me. This research on brain development is not even controversial any more, but it’s still not taught in medical school. The medical profession still looks on these conditions as inherited diseases, rather than as conditions induced by environmental stress, which can be reversed if we change people’s environment.
McNally: Let’s talk about healing and recovery. You make the point that recovery implies that we’re recovering something essential. Whether we’re talking about a child with ADD or an adult with a severe addiction, what is the path of healing?
Mate: Once we understand that we’re not dealing with genetically determined conditions but with the impact of early experience on brain development and personality and psychological functioning, then we also realize -- again this is not controversial -- that the human brain has the capacity to recreate itself based on new experiences.
The question we should be asking is, not simply how do we control symptoms through medication, but how do we change behaviors to promote new development. Whether you’re dealing with adult addicts or children with ADD, this means not just dealing with symptoms but also providing them with the conditions for healing.
The right conditions can be summed up as that which they didn’t get in the first place -- a tuned, compassionate and emotionally nurturing relationship. The essential point to grasp is that in neither case are we dealing with conditions that are written in genetic stone. Therefore they are reversible. We have to ask ourselves what conditions we need to provide in order for people to develop, whether they are children or adults,
Development is always a matter of conditions. If you’re a gardener and your plant is not developing properly, you ask yourself what condition does that plant require? It’s the same thing with human beings.
McNally: Where can people learn more and what can they do if they want to move on these issues?
Mate: Unfortunately, there are more ideals and ideas than there are realized practicalities, because of society’s emphasis on the war on drugs. All the money is going into fighting something that cannot be fought as opposed to healing something that could be healed.
But there are organizations and facilities all over the place. In San Diego there’s a wonderful organization called Practical Recovery. Another organization is called Smart Recovery, smartrecovery.org. There are groups, therapists, and institutions all over the place, but I don’t have access to them all. Then there are 12-step groups which, though I don’t think they have the whole answer, can provide a lot of help as well. But you have to keep looking. If people understand that the capacity for wholeness and health is inside them, then if they keep looking, they will find the help they need.