Gabor Maté: A new understanding of addiction
A renowned speaker, and bestselling author, Dr. Gabor Maté is highly sought after for his expertise on a range of topics including addiction, stress and childhood development. For twelve years Dr. Maté worked in Vancouver’s Downtown Eastside with patients challenged by hard-core drug addiction, mental illness and HIV, including at Vancouver’s Supervised Injection Site. With over 20 years of family practice and palliative care experience and extensive knowledge of the latest findings of leading-edge research, Dr. Maté is a sought-after speaker and teacher, regularly addressing health professionals, educators, and lay audiences throughout North America.
‘What I am very interested in the mind body unity’ he explains ‘ and I am interested in how childhood stress shows up as adult illness. I am interested in what makes human beings tick. Both my personal and clinical experience have taught me that it is much more useful to look at health and illness as part of expression of human lives, rather than as unfortunate events that strike some people randomly and others escape from it. It is much more of a unity than western medicine likes to acknowledge’.
Dr. Maté is the co-founder of Compassion for Addiction (www.compassion4addiction.org), a new non-profit that focusses on addiction, and he is renowned for promoting a different perspective on how we understand addiction. ‘Society by and large sees addiction as a bad choice that people make’ he says, ‘while other people simply see it as a brain disease. My definition of addiction is: any behaviour in which the individual finds temporary relief or pleasure in - and craves for that reason, despite negative consequences’.
Looking at the process of addiction from the inside out allows Dr. Maté’s definition to be applied universally. ‘That behaviour could be consuming heroin or cocaine or alcohol, but it could also be work, or sex, or shopping, or any number of human activities. So it is not the external activity or substance, but the internal relationship to it. Does it provide temporary relief? Is there craving? Is there short term pleasure at the expense of negative consequences? And an inability to give it up?’
Addiction as a disease
Traditionally, western medicine has treated addiction as a disease, but pathologising the behaviour is unhelpful, Dr. Maté suggests: ‘I think that the disease model is far too narrow to encompass the full experience of addiction. It has features of disease, in that it has symptoms and it causes physical and mental debility. And it is relapsing like many diseases are, but it is much more than a disease. The medical model although it is helpful and useful in some ways, is also limiting and insufficient to explain what addiction is really about’.
‘In the medical model, addiction is defined as a brain disease that is largely determined by genetic factors. I would say that this is a false view. There are some genes that may predispose us, but a predisposition is not the same as a predetermination. And we also know that genes are turned on and off by the environment, so the decisive influence in all cases of addiction is personal trauma, emotional loss in childhood, or experiences of abuse’.
‘It happens in a context of what we might call social or cultural dislocation – so the more dislocation there is, where people lose connection to their culture, to their families, to the land, to their work, and to their spiritual experience then the more addiction you are going to see. That is a on a broad social level. On an individual level, addiction is always a response to pain. The source of that pain is almost inevitably in that person’s childhood experiences, very early on in life’.
Looking at the process of addiction from the inside out challenges the conventional ideas we have about addiction, including where addiction starts – as a biological predisposition within the individual, or within the addictive quality of the substance or behaviour. ‘I have to emphasise that nobody is born with an addictive personality, so we are not talking about genetic diseases. We are not talking about biologically determined events. The personality is our response to our environment. So the addicted personality has a deep sense of its own insufficiency, and a profound emptiness that it tries to fill through the outside. The addictive personality is unable to regulate its own stresses, so when it gets stressed it needs to reach for some external control, such as alcohol, or drugs, or a sexual relationship, in order to make itself feel less stressed. The addicted personality harbours a lot of fear and shame about its own existence – shame is at the heart of the addicted personality. We tend to think that shame is caused by the addiction, but the shame is at the core of the addiction, before the behaviour even was there’.
A new understanding of addiction
‘What is amazingly not being taught in medical schools yet, is that the brain turns out to be a product of the environment. In other words, our brains are not genetically determined. How our brains develop, and which circuits develop depends very much on the rearing environment’.
‘The Journal of Paediatrics points out that the brain develops through an interactive relationship between the environment and our genes, and that the decisive influence on the development of brain circuitry is actually the interactive mutual responsiveness of parent and child. So the brain’s circuits that are implicated in addiction actually develop or don’t develop in response to the environment’.
‘Just to make that point clear - if you take a child with perfectly good eyes at birth and you put him in a dark room for five years, it doesn’t matter what his genes are, and it doesn’t matter how good the eyes are at birth. If the child is the dark room for five years he will become blind for the rest of his life – because the brain circuits for vision require light waves for their development, and without the input of light waves, then even the rudimentary visual circuits present at birth will atrophy and die, and they cannot come back’.
‘The circuitry of stress regulation, and emotional self-regulation involve our internal opiate substances which are called endorphins. Endorphins and dopamines are important in the addiction context because opiates such as heroin and morphine, and stimulants, such as crystal meth, cocaine, nicotine and caffeine all work through the dopamine circuits or the endorphin circuits’.
‘These circuits develop or do not develop in interaction with the environment. And the most important influence on the physiological and biochemical development of the circuitry is actually the quality of parent-child relationships. And that begins in utero, so when women are stressed during pregnancy then that already predisposes their kids toward addiction as adults. It is an ongoing process that begins before birth’.
‘So whenever there is childhood trauma, whenever there is stressed parenting, whenever there is physical or sexual abuse then that is going to interact with the development of the circuitry. So the many children that there are in Ireland who were abused in various religious institutions – those children are at increased risk of addiction. Traumatic experiences interfere with proper brain development, not to mention when you are traumatised you will feel shame – so you assume that if something bad is happening then it is your fault. There is a deep shame at the very core of the child, who is hurt in childhood. Not that they should be, but there is. So the shame, and the pain, and the disordered brain circuitry all originate in childhood experience’.
Dr. Maté suggests that one of the main reasons that we struggle to overcome addictions is because we do not understand them. Addictive behaviour are attempts to solve a deeper feeling, so trying to quash the behaviour does not actually address the problem. ‘If you found a feeling of comfort in cigarettes, then addiction wasn’t your primary problem. The addiction was trying to solve your problem. Your primary problem is a discomfort with life or with yourself’ Dr. Maté explains.
‘Addiction is a secondary problem that comes out of a primary problem. So when we put all the emphasis on the secondary problem but don’t pay any attention to the primary one, then how can we possibly succeed? Most physicians are not going to understand that, we are not trained that way. Even the 12 step groups see addiction as the problem. But the real question is – if you are in addiction, then something happened in your life, and I can guarantee it happened in your childhood, which made you intensely uncomfortable with yourself and with the present moment. So you try to escape from that, temporarily, in an attempt to change the chemistry of your brain – to soothe yourself temporarily through nicotine. So the nicotine was your attempt to solve a problem, it wasn’t a fundamental problem’.
‘So it is difficult to treat because we don’t understand it. And it is so hard to treat because when you ask people what their addiction gives them, they respond – it gave me pain relief, relief from stress, temporary comfort, it gave me a sense of control or power, it connected me more to other people. When you look at all those answers that people provide – these are essentially human qualities, these are things that we all want, so the addiction is like a substitute for genuine human experiences and the real issue is why are so many people so deprived from their authentic experience of themselves? What happened to them?’
‘And unless we are willing to ask that question and go into the deep then we cannot help with issues of addiction very much’.
Trauma and Pain
‘Fundamentally, it all comes down to pain. Opiates like heroin and morphine are the most powerful painkillers that we have. Alcohol is a pain reliever. For me, no matter what the addiction is, it is an attempt to reduce emotional pain. So the mantra that I keep repeating is not ‘why the addiction’, but why the pain? In order to understand addiction we need to look at human pain, and I’m afraid that the medical profession is not great at looking at human pain’.
Psychological trauma, which Dr. Maté suggests is at the heart of addiction, is not some something our medical system has traditionally had a good track record with. ‘At most medical schools students do not hear a single lecture on trauma – aside from physical trauma. There is little focus on the psychic wounds that most people suffer in the process of growing up. Especially in highly stressed societies – I don’t have to tell you about Irish history but it is a very difficult history – colonialism, conflict, oppression, poverty, a very rigid religious hierarchy, the abuse of children in institutions that were supposed to support them – you can expect a lot of addiction in a country like that, you can expect a lot of people attempting to escape from pain’.
Not only confined to medical schools, a societal ignorance around emotional and psychological trauma is widespread in society. ‘We add to the pain by ostracising, shaming, criticizing, and rejecting the addicted person for their attempts to escape from their pain. So then we add more suffering onto the primary suffering’.
Addiction and Vulnerability
If Dr. Maté’s perspective is correct, then by ostracizing and punishing addicts, we are actively hindering their recovery. Inevitably a cycle of shame and addiction, which comes from both internal and external voices, can result in people being completely unable to fit into society. ‘Let’s not forget who the homeless are’ Dr. Maté says, ‘If you do the research you will find that most homeless people were also traumatised in childhood – so it is the same source that we are looking it. Why is it that a person cannot find a home? It is because they never had one. The home in which they were born was not really a home – so they are alienated, they are scared, and they are resourceless’.
‘Among the homeless there is a large rate of mental illness, and the source of mental illness is trauma. So mental illness, addiction, and homelessness form part of a continuum. So the question is – what is the best attitude to take towards these people? Well if we are going to be humane about it, we would have an attitude of compassion and not an attitude of punishment’.
In a society that focuses on punitive action, the idea of compassion as the primary response may seem radical. While Dr. Maté points out, it is something enshrined in religious institutions. ’Ireland is large a Christian country. And that is what the central figure at the heart of Christianity taught. He said that you respond to suffering with compassion, and you do not judge people’.
‘That truth is entirely applicable to what we are talking about today. Any approach that includes rejection, judgement or punishment is only going to add to the suffering. So then how do you deal with people that have suffered so much that they cannot make their way in the world?’
Rethinking our policies
‘My answer is that you give them whatever support you can – in Vancouver we have supervised injection sites. I was a physician there for years. People are allowed to bring their illegal drugs (because drugs are not illegalised or decriminalised in Canada) and they are allowed to inject under medical supervision. They are given clean needles and sterile swabs to use, and they are injecting in a space where they are observed so if they overdose they are resuscitated’.
‘Now that is harm reduction – one of the harms of this addiction is infection, but if you can prevent that happening then you are reducing the harm to the individual, and to society as a whole. It doesn’t treat addiction directly, it is not meant to – but it is meant to make the life of the addict more liveable and less unhealthy. It is also meant to give them a sense of acceptance and support that otherwise they wouldn’t have, which is often the first step in them developing trust in treatment programmes. In some circles this is a hugely controversial practice, the former government tried to shut these places down and were prevented from doing so only by a vote of the Canadian Supreme Court who decided that this was an essential medical service that the government had no right to curtail’.
‘There should be such facilities in every major city in the world, including Dublin. But in most places there are not. So harm reduction is not the answer to addiction, or to homelessness, but it is part of the answer. And anybody who wants to answer otherwise needs to explain why it is better to let people inject with contaminated water, rather than sterile water. Why it is better to let people share needles rather than giving them clean needles. Why it is better to let them live in the streets than give them decent housing, despite the fact that they are using. What principle of medicine, or rationality, or humanity would dictate that you make people’s life worse?’
A cure for addiction
While Dr. Maté suggests that there is a common cause for addiction, there are numerous ways to work out of it. ‘Some people heal themselves from addictions using sacred substances and shamanic ceremonies. Within the indigenous population in Canada we have a huge addiction problem, due to massive dislocation, massive historical trauma, massive expropriation of their lands, the destruction of their lives and culture, and then the subsequent sexual abuse of generations of native kids in religious residential homes. So there is a huge addiction problem here’.
‘Native Canadians make up around 4% of the population, but they make up 30% of the jail population, and in some provinces they make up to 80% of the jail population and this is mostly because of addiction issues. These people also have a very rich traditional culture, with healing practices that can be very helpful in the treatment of addiction. I think when it comes to addiction we need everything – we need good psychotherapy, we need care that recognises the centrality of trauma, emotional pain, and loss in the person’s history. We need, for those that are drawn to it, traditional practices like the 12 Step Programmes. We need to stop this insane and tremendously harmful so called war on drugs. You cannot have a war on drugs, you cannot make war on inanimate objects – the war is actually waged against low level drug users for the most part. We need to stop punishing people for trying to deal with their suffering through addictive means. We need to stop pretending that there is something more respectable about being addicted to work, or power, than there is being addicted to heroin’.
‘We need to stop pretending that alcohol is more acceptable than heroin – alcohol is much more harmful than heroin is, in the long term, to the body and the spirit. What sense does it make that people can buy cigarettes in their local shop and kill themselves with it, but the heroin addict is jailed for the possession of their substance? I’m not recommending that we sell heroin, I’m talking about the insanity, irrationality, and inconsistency that makes the job of treating addiction on the social level all the more difficult. We need to get rational about this whole thing. All addiction, no matter what, corresponds to human pain. And my question is: what humane practice can we institute that help people deal with their pain, without adding further pain? You cannot help people escape from addiction when you are adding to their pain, which is what the war on drugs does. So the whole conversation has to change’.
A Western Problem
‘I was diagnosed myself with ADHD, my first book was written on that subject. Again we have this belief that it is an inherited disease. The hallmark of attention deficit disorder, which is a tuning-out, a kind of absent-mindedness, is not a disease. When you look at the function of tuning-out, you can see it is a protective mechanism. So when people are stressed too much and they cannot escape the situation, and they cannot change it, and they cannot seek help within in, then they tune-out as a way of enduring the stress. So the question is: what is happening in western society that more and more kids are starting to tune-out?’
‘When I looked at my own history, being a Jewish infant in Budapest, Hungary in 1944, I was two months of age when the Nazis occupied Hungary and the genocide that had already exterminated the Jewry of all Eastern Europe now came to my home. So you can imagine the terrified state of my mother during the first year of my life. You can imagine the grief and distress she was dealing with following the death of her parents in Auschwitz. What emotional circumstances did I live under as an infant? They were terribly stressed conditions. How did I cope with that? Well I couldn’t – so my brain coped with it by tuning-out. And that was happening as my brain was being developed, in that first year of life, when every second there may be millions of connections being made’.
‘So when I put together what is happening in Western society – which is an increasing stress on parents, because of economic factors, because of both parents having to work, because of the high divorce rate, because of cultural disconnection and alienation, and the loss of community – these just some of the accepted stresses that people experience under the system of globalisation. When you look at that situation, and look at what we now know about brain development, then it is stands to reason that you are going to have more and more kids diagnosed with this problem. It is not a genetic disorder, it is a disorder of a society that no longer provides the right conditions for childhood development. And that is why we are seeing more and more of it’.
‘Look at my children, who have also been diagnosed with the same condition – that would seem to prove that it is a genetic problem, but it doesn’t. My children grew up in a home where their father was a workaholic and their mother was highly stressed. And children are very sensitive, so they respond to that stress by their own defensive mechanism which then gets programmed into their brains. So we do pass this our trauma on, but we don’t necessarily pass it on genetically, we pass it on by recreating conditions, from one generation to the next, in which there is disconnection and stress and trauma’.
‘In western society, and through globalisation, we are increasingly seeing it elsewhere too, we are seeing a socially engineered problem of stress that is affecting the development of children and it is showing up in more and more medical diagnoses’.
A way to wholeness
‘We need to remember that the essence of trauma is not actually in the external event. The fact that the trauma is not in the external event is good, because if it was in the external event then it is irreparable because it happened in the past. So the actual trauma is in the impact of that event. And the impact of trauma is a deep disconnection from the self. The good news is that the disconnect can be repaired at any time’.
‘Repairing that disconnect involves work. It can involve psychological work, emotional work, physical work, and spiritual work but the key to remember is that it is available at any time, and that is good news’.
‘If you look at the etymology of the word heal, it comes from the Anglo-Saxon word for wholeness. Wholeness means reconnection to yourself. So all of us, no matter what stage of our lives, and no matter what happened to us – we have this healing capacity that is internal, and that very much part of our nature. If we can remember that then there is no reason ever to give up - on anybody else or on ourselves’.
This piece is based on a conversation between Gabor Maté and Micheál O'Mathúna, presenter of The Health Zone. The Health Zone is a free online radio show dedicated to empowering your health. To listen to the full interview, as well as many other great guests visit www.thehealthzoneshow.com or www.mixcloud.com/thehealthzone
28/12/2017 to 12/01/2018