The question is never “Why the addiction?” but “Why the pain?” – Gabor Maté

It has been over ten years since ‘In the Realm of Hungry Ghosts’ was first published, but it remains fiercely relevant in the discussion about how addiction is handled in society. Gabor Maté has written several books since then and has become the expert du jour on the compassionate approach to treating addiction, appearing on television internationally and on many high profile internet podcasts.

The book’s main themes are concerned with his ideas about how addiction develops and how it can be treated in a holistic and compassionate way. Narratives of his conversations with the addicted people he has worked with, mainly in Vancouver’s Downtown Eastside area, are interspersed throughout, providing a humanizing counterpoint to the science and social commentary.

The horrific abuse described by the people in his care, presents an emotional and humanizing backdrop to his explanations of how addiction develops. The stories demonstrate the hold addiction can have on people and the lengths they will go to for their high, often disregarding their health, relationships and in many cases paying the ultimate price.

Maté describes addiction as a phenomenon whereby a person indulges in a habit which relieves their pain in the moment, but leads to longer-term detriments in their life. He says addictive behaviours are much more likely to develop in people with a pre-existing vulnerability to it. In most cases this will be a person who has experienced trauma in their formative years. These ideas do not only apply to those with the most damaging drug addictions however, Maté also places compulsive shoppers and internet addicts on the scale of addictive behaviours which can be detrimental – “Not all addictions are rooted in abuse or trauma,” he writes, “But I do believe they can be traced to painful experience.”

Theories about the development of the brain and how childhood experiences can make a person vulnerable to addiction are discussed at length within social and neuroscience contexts. Deprivation of affection, neglect and abuse in childhood, lead to increased stress responses and disruption in oxytocin and dopamine, the neurotransmitters responsible for emotional bonding and incentive-reward systems, respectively. Emotional processing in the brain is compromised following abuse and exacerbated during prolonged drug use, leading to reduced control of the behaviours associated with habitual drug use. Genetic explanations for the development of addiction are also discussed – Maté reports that addiction is more of an epigenetic expression of genes brought on by environment, rather than outright determinism.

He describes his own early years as an infant in the Jewish ghetto of Budapest, during the tail-end of World War Two. The stress with which parents present to their child, as his mother did in such anxiety-provoking conditions is encoded into the infants brain, he says, in their parents’ facial expressions and the tension in their arms. Maté is careful however to state that he does not endorse parent-blaming and rather that parents are also victims of their own ‘unconscious or unresolved trauma’.

His musings on his habit of compulsively buying music and working too hard (which he links to the trauma he experienced as an infant) may seem a world away from the people injecting heroin on the street, but these stories do demonstrate the common humanity present in addictive behaviours and the continuum on which, he suggests, we all reside to some degree.

His methods of treatment centre on the harm reduction approach, which relies on supporting people even while they continue with their harmful behaviours. Maté takes the view that we should not abandon these people “who suffer because of their own persistent behaviours, mindful that these behaviours stem from early life misfortunes they had no hand in creating.” He does not concede defeat in making abstinence a goal, rather that this can only done as part of a complex process where the addicted person is supported into a more conducive environment for recovery and is allowed the autonomy to work towards abstinence as their own choice.

Politics and addiction treatment is another important thread in the book. Maté is involved in the controversial Insite injection clinic, where users are supervised by healthcare professionals while injecting (mainly) heroin. There have been many positive outcomes reported such as a reduction in overdoses and infection transmission from needle sharing. It has also drawn fierce criticism from many sources, including the Bush Government and former Canadian Prime Minister Stephen Harper. Variously described as ‘state-assisted slow suicide’ and an ‘inhumane medical experiment’, Maté counters that this condemnation is more a question of ideology than anything else, spoken ‘in the language of people with a higher regard for their own convictions than for the facts’.

In such a complex field there are understandably conflicts and questions about whether Maté ‘s harm reduction approach is the most effective or ethical in terms of treating addiction, even within the addiction treatment community. Science is an ever-evolving field of course, so who knows which theories and methods will prove to be most successful in their aims?

We can however, Maté says, look into what does not seem to work and it appears in the case of addiction on a national scale, the tough-love approach comes up lacking. The ‘War on Drugs’ paradigm does not appear to be significantly improving the addiction situation in North America. ‘Recall that uncertainty, isolation, loss of control and conflict are major triggers for stress and that stress is the most predictable factor in triggering relapse,” he says. “These are also precisely the conditions that the demonization of addiction and the War on Drugs (deliberately!) impose on hardcore substance users.”

On the opposite end of the scale, less iron-fisted approaches like the decriminalization of drugs in Portugal have been shown to have decreased both the social and health outcome costs of drug use since commencement. Portugal is a very different country to both the USA and Canada of course and such a massively complex problem as addiction does not have easy answers and those solutions may not be applicable in a different social environment.

The strength of ‘In the Realm of Hungry Ghosts’, for me, lies in its possible political impact on the future of addiction treatment. Perhaps this book with its mixture of emotional vignettes, science and new ways of thinking about addiction and recovery, can inspire people to reconsider the outdated ideas about addiction that are ingrained in society. The heavy handed approach has not been efficacious and Maté, whether or not you accept his individual philosophy and theories about addiction, makes a compelling argument that the compassionate approach is a better way forward for both society and addicted people than judgement and punishment-based ideologies.