Dr. Gabor Mate is renowned in Canada for his work in treating people with the worst addictions, most notably at Vancouver’s controversial Insite facility, which provides users with clean needles, medical support and a safe space to inject drugs.
Canada’s Conservative government has tried to shut Insite down, but the country’s Supreme Court ruled late last year that doing so would contravene human rights laws because the program has been shown to save lives.
In Mate’s book In the Realm of Hungry Ghosts: Close Encounters with Addiction, which was a No. 1 bestseller in Canada, he advocates for the compassionate treatment of addiction, a position that is increasingly receiving international attention. Healthland recently spoke with Mate about the causes and consequences of addiction and what to do about the problem.
How do you define addiction?
Any behavior that is associated with craving and temporary relief, and with long-term negative consequences, that a person is not able to give up. Note that I said nothing about substances — it’s any behavior that has temporary relief and negative consequences and loss of control.
When you look at process or behavior — sex, gambling, shopping or work or substances — they engage the same brain circuitry, the same reward system, the same psychological dynamic and the same spiritual emptiness. People go from one to the other. The issue for me is not whether you’re using something or not; it’s, Are you craving, are you needing it for relief and does it have negative consequences?
Do you believe all addiction results from trauma?
I think childhood trauma or emotional loss is the universal template for addiction. It also depends on how you want to define trauma: if you want to define it as something bad happening, then it’s true that not every addict [has experienced trauma], in the sense of a death of a parent or violence in the family or child abuse, or any of the usual markers of trauma.
But there’s another [way to define it]. D.W. Winnicott [the late British child psychiatrist] said that there are two things that can go wrong in childhood: things that happen that shouldn’t happen — that’s trauma — and things that should happen that don’t happen. Children are equally hurt by things that should happen and don’t as they are by things that shouldn’t happen but do. If the parents aren’t emotionally available, [for example], no one will define that as trauma, but it will be for the child. If a mother has postpartum depression, that’s not defined as trauma but it can lead to emotional neglect and that interferes with child brain development.
It’s impossible for a parent to be emotionally available all of the time, however.
The parent doesn’t have to be perfect. In our society, it’s not [just] a question of whether parents are doing their best or love their kids or not, it’s that parents are often isolated and stressed or too economically worried to be there. What I’m saying is that early emotional loss is the universal template for all addictions. All addictions are about self-soothing. And when do children need to sooth themselves? When they are not being soothed.
You practice a harm-reduction approach to addiction, in which you provide clean needles and safe spaces for addicts to inject drugs. Americans have long tended to see this as “enabling” and typically view it as a bad thing because it doesn’t require addicts to be abstinent to receive care.
The question is, Is it better for people to inject drugs with puddle water or sterile water? Is it better to use clean needles or share so that you pass on HIV and hepatitis C? This is what harm reduction is. It doesn’t treat addiction, it just reduces harm. In medicine, we do this all the time. People smoke but we still give them inhalers to open airways, so what’s different? You’re not enabling anything they’re not already using.
Some critics claim that it prevents addicts from “hitting bottom” and getting off drugs entirely.
I worked for 12 years in the Americas’ most concentrated area of drug use, the Downtown Eastside of Vancouver. People live there in the street with HIV and hepatitis and festering wounds: what more of a bottom can they hit? If hitting bottom helped people, there would be no addicts at all in the Downtown Eastside. ‘Bottom’ is very relative, so it’s a meaningless concept. For me as a doctor, rockbottom might be losing my medical license, but what is a bottom for a person who has been abused all her life and lives on the street? It’s meaningless and false. People don’t need more negative things to happen to them to give it up. They need more positive things to happen. In 12 years of work on the Downtown Eastside, I didn’t meet an [addicted] woman who was not sexually abused as a child.
[Addicts] relationship to authority figures is one of fear and suspicion. How will it help if I punish them more? They need the very opposite. We end up punishing them for self-soothing. It makes no sense at all. Harm reduction is not an end in itself. Ideally, what it is is a first step towardsa more thorough-going [recovery], but you have to begin with where people are at.
When I’ve visited harm-reduction programs, it seemed that the clean needles and other tools weren’t the most important thing they provided. Rather, it was the message that ‘I believe you are worth saving, even though you are still using drugs.’ That touches people and opens doors.
That’s the key. Quite apart from clean needles and sterile water, the most important factor is for the first time saying to someone who has been rejected all their life, ‘We’re not going to judge you based on how you present your needs at the present moment.’ Harm reduction is much more than set of practices; it’s a way of relating to people. We’re not requiring you to stop using or do anything, we’re just trying to help you get healthier. At least you’re not going to suffer an infection of the bone marrow because you’re using a clean needle: is that not worth something? We’re here to reduce suffering. They may not get better in the sense of giving up the addiction, but that’s not a limit of harm reduction — that’s a limit of the treatment system.
[There are a lot of things] we can’t do in the context of a war on drugs. When people are attacked and stressed, we can’t hope to rehabilitate them [well]. That’s not a valid criticism of harm reduction; it’s a failure of the medico-legal approach we have right now to addiction.
People describe addicts as behaving compulsively in the face of negative consequences, but the same could be said of our drug policy.
It’s almost an addiction because we keep doing something with negative consequences and don’t give it up, and it gives a kind of emotional relief because people feel a lot of hostility towards addicts. Seeing someone jailed certainly provides some satisfaction and relief, but it’s not an evidence-based [treatment for addiction]. There are also a lot of other consequences we experience as a society by avoiding the connections between trauma and illness. Trauma is the basis for not just mental illnesses and addiction specifically, but also often for cancer and all kinds of other conditions [due to the effects of early childhood stress on the brain and immune system]. Society doesn’t look at it. We look at the effects and blame people for the effects but we don’t look at causes.
Because we live in a culture that promotes addiction, left, right and center. Addiction essentially is trying to get something from the outside to fill a gap and soothe pain. The entire economy is based on people seeking soothing from outside. The addict symbolizes all of our self-loathing.
The expression “the scapegoat” is very specific. The term in the Bible means a goat on whom the community symbolically imposed all its sins and then chases it into the desert. That’s what we’re doing with addiction. All the desperation to soothe pain and fill in emptiness from the outside that characterizes our culture, the addict represents. We hate to see that so we scapegoat them and think that way we are getting rid of our own sins.
So what can we do?
First of all, I would recommend that prevention has to begin at the first prenatal visit. Stress during pregnancy — contrary to the genetic view — has a large impact. Second, in the U.S., [you need] yearlong paid maternity leave. In other words, I would provide support and emotional nourishment for the child — and that comes from support for parents.
In term of addictions, first of all recognize that these people are traumatized and what they need is not more trauma and punishment but more compassion.
What most surprised you in working with some of the most severely addicted people?
What’s most astonishing is just how people survive, no matter what. Even amid drug dealing and mutual ripoffs, there’s still a tremendous amount of caring. The same people who rip each other off would sometimes also go to great lengths to help each other. Despite all the pressure and suffering, to see people reach out to each other like that was the most astonishing thing I saw. When someone was sick, how people gathered around and helped, how they would share food with each other and some would volunteer and go at night and look after the young sex trade workers to make sure they were not getting hurt. There is that acceptance and community, and people need community. Especially for people who have not had emotional support, that community is very powerful.