In the Realm of Hungry Ghosts

“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.” 

Maté’s thought after talking with Ralph. Ralph tells him a story about a Nazi work camp where Jewish prisoners refused to give up their cigarettes, even though if a soldier caught a man smoking the whole barracks would die. Even if the story is apocryphal, Maté sees echoes of its truth in his own compulsive behaviors. He never feels free of it, and is therefore constantly at risk from its consequences. 

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

Much of the book discusses the various voids addicts tend to have. The patients at PHS use drugs as a substitute for the comforts and developmental milestones that denied to them in childhood. In Maté’s opinion, treating addiction as bad behavior and poor choices does not contribute to a real understanding of addiction. Addiction is a process that begun before the user indulged for the first time. 

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

Maté writes that adults often envy a child’s capacity for wonder, because much of adult life is tedium and routine. Children have so much to learn that they do not often experience the intolerable boredom of adulthood. But most children raised in nurturing environments have no reason to experience what Maté calls the fundamental discomfort with themselves. Addicts often use to relief that boredom and feel something like the joy of childhood wonder again. 

“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 out 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, behavioral addictions are also responses to this terror of the void.” 

Maté talks with various addicts who describe emptiness and boredom as the reasons why they keep using. But the addicts are not able to escape into work, or shopping, or TV watching, or other behaviors that are available to people without drug addictions. Maté knows that his own behaviors arise from a similar void. He does not like to spend time with his own thoughts, because his own thoughts punish him for what he sees as his failures. 

“The wondrous power of a drug is to offer the addict protection from pain while at the same time enabling her to engage the world with excitement and meaning.” 

People who experienced childhood trauma often turn to drugs as protection from their memories and emotions. But the drugs also provide a state of childlike excitement. This excitement may be lacking in anyone who experiences the boredom and mundanity of life, described in the previous quote. The temporary meaning that drugs provide—or the rush of giving in to any compulsive behavior—is preferable to a meaningless life, even if the drugs threaten to destroy the user’s existence. 

“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.” 

People typically do not offer each other unconditional acceptance or love. There are usually expectations involved. Addicts also face being unable to accept themselves as they are. Society reinforces this view that places them on the outside of normal life, and treats them as an afterthought, or something one should avoid. Even Maté has moments in his practice when he realizes that he is placing expectations on his patients that they cannot meet. 

“Addictions, even as they resemble normal human yearnings, are more about desire than attainment. In the addicted mode, the emotional charge is 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.” 

Maté describes the feelings that lead him to a CD-buying binge. He buys the music in order to make the accumulating (or sudden) feeling of yearning stop. The pleasure comes from the momentary suppression of the urge, not from actually obtaining the music. This is the plight of those who live in the Hungry Ghost Realm—they are always desiring, and cannot satiate the desire. 

“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.” 

Maté writes of his buying urges and how unsatisfied he is after giving in to his compulsive music shopping. Not only does his addiction not make him happy, it causes problems in his relationships with others. He hides his purchases from his wife, and worries about the amount of money he spends. He cannot enjoy his new purchases for long, but soon begins wondering when he’ll need to stop again. 

“In the cloudy swirl of misleading ideas surrounding public discussion of addiction, there’s one that stands out: the misconception that drug taking by itself will lead to addiction—in other words, that the cause of addiction resides in the power of the drug over the human brain. It is one of the bedrock fables sustaining the so-called War on Drugs.” 

After the Vietnam War, many American soldiers who had used heroin overseas stopped after returning home. Politicians supporting the War on Drugs often claim that using a drug can make someone an addict instantly, and so the removal of drugs from society is the key to making sure no one gets addicted. But Maté’s clients, research, and anecdotes show that circumstances create addicts, not the mere presence of a substance. 

“‘The evidence for addiction as a different state of the brain has important treatment implications,’ writes Dr. Charles O’Brien. ‘Unfortunately, most health care systems continue to treat addiction as an acute disorder, if not all.’” 

The brain determines the way we act. O’Brien’s data shows that nearly all relevant scientific literature treats addiction as a chronic brain condition, largely caused by inordinate childhood stressors. Maté compares blaming someone for their addiction as similar to blaming someone for having rheumatoid arthritis. Treating addiction as a choice puts the responsibility squarely on the addicts, and absolves medical professionals from pursuing other avenues of treatment. 

“A child’s capacity to handle psychological and physiological stress is completely dependent on the relationship with the parent or parents.” 

Children raised in nurturing homes where parents foster their emotional, developmental milestones are less likely to become addicts. Their ability to handle stress is dependent on their relationship with their parent or parents. If parents do not provide a healthy environment, the child may be more susceptible later in life to the stresses that drugs can temporarily alleviate. 

“I’ve been as willing to sell my soul as they, only I charge a higher price. They settle for bug-infested room on Hastings; my workaholism has bought me a lovely home. Their object of addiction goes up their veins to be excreted by their kidneys or permeates their lungs and vanishes into the air; my shelves are lined with CDs, many of them unheard, and with books, many unread.” 

Maté does not see a huge difference between the urges that drive him, and those that fuel the substance addictions of his patients. He has more to show for his urges, such as his home and career. However, he does not feel free, despite his professional successes. His compulsive shopping distances him from his family, makes his financial situation more complicated than it should be, and leads him into self-loathing. 

“Self-esteem is not what the individual consciously thinks about himself; it’s the quality of self-respect manifested in his emotional life and behaviors.” 

Maté’s writing on awareness and mindfulness states that most people are not self-aware. They are unaccustomed to dedicated self-scrutiny and feel little curiosity about themselves. They may not pay enough attention to themselves to even think of themselves in terms that would reflect low self-esteem. However, regardless of their thoughts, their self-esteem appears in the way they act and treat themselves. Maté believes that people often put themselves—or keep themselves—in situations they think they deserve. 

“When I am sharply judgmental of any other person, it's because I sense or see reflected in them some aspect of myself that I don't want to acknowledge.” 

Maté often views addicts harshly, frequently repulsed by their appearances, willingness to manipulate and steal, and by their inability to focus on anything but their own appetites. But he suspects that he judges them more harshly because he knows that he shares the same addictive tendencies. When he sees an addict at rock bottom, he knows that he could have gone to the same nadir, if his urges had manifested as substance addictions. The principle of an addict reflecting negative associates can extend to the society that treats addicts as separate from normal people, even though all people have compulsions, secrets, and a degree of self-obsession. 

“The War on Drugs fails—and is doomed to perpetual failure—because it is directed not against the root causes of drug addiction or of the international black market in drugs, but only against some drug producers, traffickers, and users.” 

The government fights the War on Drugs according to metrics that are easy to measure. For instance, if authorities arrest a drug producer, there will temporarily be a reduction in drugs. If police take a dealer off the streets, he can no longer deal while in custody. If drug users go to jail, they can no longer cause harm to public society. But none of the measures used by proponents of the War on Drugs even pretend to deal with the causes of addiction, because those causes are harder to quantify, and require greater insight and compassion. 

“It’s a subtle thing, freedom. It takes effort; it takes attention and focus to not act something like an automaton. Although we do have freedom, we exercise it only when we strive for awareness, when we are conscious not just of the content of the mind but also of the mind itself as a process.” 

Maté describes freedom as being a process, just as addiction—which results in the loss of freedom—is a process. In order to be free, in Maté’s view, a person must be aware of their mind, its patterns, and devise strategies to interrupt its compulsions. The choice to observe oneself with curiosity is the critical step towards a mind with access to more freedom. 

“Free choice only comes from thinking; it doesn’t come from emotions. It emerges from the capacity to think about your emotions.” 

While the human mind is a fallible tool, it is the only tool with which the mind can observe and study itself. The mind—and awareness—is what allows a person to learn about himself and his habits to the point where he can identify triggers leading to addictive behaviors. Thinking about emotions is what allows the gap between the input of a stimulus and the output of an addictive act to widen. 

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

Because people with addiction are less likely to have received appropriate psychological comfort and nurturing as children, they use drugs to cope. The drugs provide a temporary sense of stability, and can even lead to a sense of community among users. It is irrational to imagine that taking away one’s primary source of comfort and coping would fix the deeper problems of addiction. It would be akin to removing everything a non-addict uses as support and then asking him to continue to be productive, stable, and to benefit society. 

“If a cure is possible and probably 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.” 

Maté does not pretend that every addict can recover, or that all of their stories will end in triumph. As a physician, he believes that he (and society) still has a duty to chronic cases of addiction that will lead to death. Focusing on harm reduction—such as the existence of a supervised injection site—is politically inconvenient for anyone who supports the traditional War on Drugs. By insisting that people can recover, and that addiction is a sequence of bad behavior and choices, proponents of the War on Drugs, and of traditional methods of drug rehabilitation, they do not have to employ the insight or compassion that harm reduction requires. 

“If people are addicted to self-soothing behaviours, it's only because in their formative years they did not receive the soothing they needed. Such understanding helps delete toxic self-judgment on the past and supports responsibility for the now. Hence the need for compassionate self-inquiry.” 

When Maté grapples with his own addictions, he makes little progress until he begins to view himself with more compassion. He is more productive when he views himself as an object of study, rather than as something loathsome that deserves scolding into better behavior. The acknowledgment that one’s past can inform one’s current addiction can be liberating, but self-scrutiny can be painful, and observing one’s thoughts is the very thing many addicts are trying to avoid when using drugs. 

“Your worst enemy cannot hurt you as much as your own thoughts, when you haven’t mastered them,” said the Buddha. “But once mastered, no one can help you as much—not even your father and your mother.” 

One cannot master thoughts unless one constantly observes them. The Buddha compares the constant stream of thoughts to a river. One goal of the practice of awareness is to learn to watch the river go by, instead of the river sweeping one away. The mastery of thoughts refers to the capacity to observe and acknowledge thoughts, without compulsion into immediate action by them. Unobserved thoughts create patterns that the thinker may be unaware of, and the patterns then reinforce without the person’s knowledge. 

“If you want to find liberation in your commitments, your word needs to be freely given or not at all. Don’t make promises to reform out of a sense of duty or to appease someone else. If you don’t know how to say no to other people’s expectations, howsoever well meant or valid those may be, your yes has no authenticity.” 

Maté doesn’t know if he will ever be free of his addictions. But his life improves when he commits to talking honestly about them, and in not hiding his habits from his wife. He encourages addicts—or readers who identify with the compulsive process he describes—to speak openly and truthfully about their inner struggles. At that point, other people have the ability to know the addict’s inner struggles, and can then adapt their expectations accordingly. But trying to bend addiction to meet the expectations of others will lead to broken promises. 

“We may not be responsible for another’s addiction or the life history that preceded it, but many painful situations could be avoided if we recognized that we are responsible for the way we ourselves enter into the interaction. And that, to put it most simply, means dealing with our own stuff.” 

Maté believes that, because people make up societies, societal improvement starts, case by case, at the level of the individual. He is aware that his own harsh judgements, or visible demonstrations of exasperation, may have been setbacks for his patients. Studying his own habits and weaknesses—what he here calls dealing with his own stuff—grants him a greater sense of empathy for his patients; his own self-improvement project makes him less likely to hinder their progress.