A Summary of Key Ideas from ‘In the Realm of Hungry Ghosts’ by Gabor Mate

By Richard Devine, Social Worker and Bath and North East Somerset Council

Introduction 

‘Woke up feeling very scared, was very emotional and anxious for over one hour, then I remembered I had a can of beer, drank that and it receded my fears long enough to get to the chemist to pick up Valium’. 

This was an entry from my dad’s journal, written at some point during my childhood. He spent the second half of my childhood misusing Alcohol, Cannabis, Heroin, Methadone, Valium, and Diazepam.

Growing up with my dad, I witnessed my dad purchase, prepare, and consume drugs. Despite this, I didn’t explicitly understand the morality or legality of it. It was simply what my dad did and I didn’t have a judgement about it. However, that isn’t to say that his drug use didn’t affect me.

My dad relapsed and began using drugs and drinking alcohol when I was 8 or 9 years old. My life before his demise into self-sabotage, self-loathing, shame, and addiction was characterised by love, stability, and innocence.

Events following my dad’s relapse would change that.

The love, care, and attention he had showed me up until that point slowly and increasingly withered away as he was swallowed up by the addiction that had plagued him all his adult life, except for the several years he achieved abstinence when I was born.

At 16 years old, my dad, aged 49, died. To me, psychologically at least, my dad died 1000 times before he physically died. Whenever I approached him or sought comfort or attention from ages 8 until 16, and he was unavailable or rejecting our relationship suffered a blow. 

To cope with the rejection and loss of my dad, I closed down emotionally. I sought to suppress all negative feelings, and whilst I had a close relationship with others, I was emotionally distant.

I associated intimacy with pain and rejection.

Because pain and rejection characterised my relationship with my parents (my mum had depression and chronic fatigue), I assumed at an unconscious level that those feelings would be a feature of all intimate relationships.

Soon after my dad died, I began experimenting with drugs and alcohol. I instantly found great relief and solace in taking alcohol or drugs. I had been suppressing all my negative feelings psychologically. Now I had access to a substance that would do a far more effective job than I could.

I didn’t have to suppress or confront the unbearable feelings of rejection, loss, and feelings of worthless or inadequacy that stem from having my feelings consistently dismissed by my parents. I could drink some alcohol or take some drugs and all of that internal psychological distress would disappear into the background.

Some of my friends used the same substances very differently. For them, it was to enhance an experience or a period in their life of experimentation. When my friends did use them, they did so intermittently. In contrast, I used them to define my experience and quickly depended upon them.

In the introduction of ‘In the Realm of Hungry Ghosts’, Mate describes that he begins his conversation with those who misuse substances with a question about what they liked about the substance and what it afforded them. He writes, ‘And universally, the answers are: “It helped me escape pain; helped me deal with stress; gave me peace of mind, a sense of connection with others, a sense of control”‘ (p. XIX).

He further posits that ‘Such responses illuminate that addiction is neither a choice nor primarily a disease. It originates in a human being’s desperate attempt to solve a problem: the problem of emotional pain, of overwhelming stress, of lost connection, of loss of control, of a deep discomfort with the self. In short, it is a forlorn attempt to solve the problem of human pain’.

Therefore, when working with those experiencing addictions issues his mantra has become:

‘The first question is not ‘Why the addiction’, but ‘Why the pain?” (p. XIX). 

However, this perspective runs contrary to the dominant narrative in our culture that those who take drugs problematically are selfish, impulsive, and pleasure seekers. In pursuit of hedonism, drug addicts are consciously and deliberately choosing to sacrifice other areas in their life, such as work, family relationships, health and wellbeing.

The idea of drug addicts being morally bankrupt individuals with poor self-control is lamented by another idea. Drugs are intrinsically addictive. It is assumed to be self-evident that if you take them, you will become addicted. It is evident, therefore, that the solution is never to take them. Or if you are taking them to stop. Decide to stop and then stop.

After all, ‘People take drugs because they enjoy it’.

If individuals continue to indulge themselves with illegal substances, the solution should be to criminalise them; indeed, harsh sentences would deter individuals from ever using drugs and encourage those using them all ready to stop. 

The socially acceptable disdain for drug addicts is therefore supported by a narrative that conceptualises them as weak-willed, law-breaking hedonists. Another factor that contributes to the contemptuous stance adopted to drug addicts is that addiction often causes many issues that can render them unlikeable and challenging to be around. As pointed out by Mate, ‘They lurk on the social periphery as hardened men with ravaged faces; as thieves, robbers, shoplifters; as done-up prostitutes selling backseat sex for drugs or petty cash; as street corner drug pushers or as small-time entrepreneurs distributing cocaine…Scruffy and dirty, shifty and manipulative, they invite distaste. Fearful and contemptuous of authority at the same time, they evoke hostility’ (p. 268).

Reflective questions: What ideas, labels, and images spring to mind when you think of a drug addict or alcoholic? How similar do you see yourself to someone who misuses drugs or alcohol? 

Mate explores the validity of these claims in the Realm of Hungry Ghosts, and I will summarise some of the key ideas from his book, including: 

1. Defining addiction 
2. What causes addiction
3. A bio-pyscho-social model of addiction
4. Response to addiction a) Current approach, b) Proposed approach

Defining addiction 

‘Addiction is any repeated behaviour, substance-related or not, in which a person feels compelled to persist, regardless of Its negative impact on his life and the lives of others.

Addiction involves:

Mate’s definition of addiction moves beyond the use of drugs and alcohol and can be applied to addictions with gambling, shopping, social media, work, sex, and food, to name a few. The mechanisms of addiction to these various external sources is more or less the same, even though the consequences might be vastly different.

For example, I stopped using drugs when I went to university to study Social Work. But, the same internal processes that drove me to misuse drugs also propelled me into workaholism throughout my 20s. This had the advantage of being socially acceptable and even celebrated and rewarded with some positive effects. But it didn’t alter the fact that it was a compulsion I felt unable to regulate and, despite its benefits, it negatively affected my overall wellbeing and essential relationships.

Not only can the object of addiction be different, but there is also a continuum. Uninhibited enslavement to destructive habits on the one end and complete self-awareness and Buddhist-like nonattachment on the other.

Most of us exist somewhere in-between.

And if you are like me, your place on the continuum can change from day to day, week to week. I can go several days health eating, then have a few days of binge eating sweets, chocolate or my favourite late-night snack, cereal.

Reflective questions: What behaviour do you engage in repeatedly even though you know it’s bad for you? Why do you continue to engage in that behaviour? What relief does it offer you, and how is it bad for you (think short and long term)?

What causes addiction?

Addiction has biological, chemical, neurological, psychological, medical, emotional, social, political, economic and spiritual underpinnings…to get anywhere near a complete picture we must keep shaking the kaleidoscope to see what other patterns emerge. (p. 130)

It is a commonly held view that addiction is caused by consuming certain substances that have chemicals that make them addictive. The argument goes that if you or I were to take an illegal substance, such heroin or cocaine for several days consecutively, the chemical hooks would render us powerless to the addictive force of the substance. We would experience unimaginable and unbearable withdrawal in the absence of the substance.

However, Mate draws on multiple lines of evidence to disprove this argument. 

Mate recalls his experience as a doctor prescribing patients morphine (pure, medical Heroin). His patients would take high amounts of morphine as pain relief until an alternative to the pain was found. The patient would no longer be administered the substance with minimal ill-effect, highlighting that it is not just the substance that makes individuals addicted. As quipped by Johann Hari in his TED talk, when your grandmother had a hip replacement and was administered morphine, ‘she didn’t come out a junkie’. 

Mate described a study by Canadian Psychologist Dr Bruce Alexander referred to as the Rat Park Experiment. In one study, rats were placed into a cage with water and Heroin. The rats compulsively devoured Heroin and eventually died. This initial study concluded that drugs are inherently chemically addictive, and anyone who consumes them will follow a linear, unidirectional pathway to addiction. In a subsequent study, rats were placed in a cage again with water and Heroin. However, this time, the rats were provided food, a hamster wheel and toys, a comfortable bed, friends, and sexual mates. They did consume the drugs, but only intermittently, and none of the rats died. 

To further illustrate his point, Mate referred to the Vietnam war. Up to 20% of American Troops used Heroin regularly during their duties in Vietnam. It was anticipated that hundreds of thousands of troops were going to return to America with problematic and severe drug addictions. Instead, all the evidence indicated that the vast majority stopped using Heroin once they returned home. When the troops were no longer in a dangerous and deprived social context, they were no longer compelled to use drugs to cope; it’s the human equivalent of the Rat Park Experiment. 

This leads Mate to conclude that ‘Drugs, in short, do not make anyone into an addict, any more than food makes a person into compulsive eater. There has to be a pre-existing vulnerability’ (p.138). Therefore, it is not simply the case that drugs and alcohol cause the addiction; there have to be other factors.

It is important to note that Mate isn’t claiming that drugs or alcohol don’t have an addictive capacity; instead, there have to be other and arguably more important factors. For example, a relatively small percentage of those that take drugs and alcohol become addicted.  

Reflective questions? If addictive chemicals don’t cause addiction, what other factors do you think contribute to addiction? 

A bio-pyscho-social perspective

Addiction is always a poor substitute for love (p.247)

Brain development in the uterus and during childhood is the single most important biological factor in determining whether or not a person will be predisposed to substance dependence and to addictive behaviours of any sort, whether drug-related or not (p. 180)

Mate identifies three essential environmental conditions necessary for human brain development, (i) nutrition, (ii) physical security, and (iii) attachment. For the most part, in modern westernised societies, the former two are met, and therefore it is the latter that tends to be disrupted.

Attachment is an instinctual drive programmed into an infant’s brain that facilitates proximity to an attachment figure.

The human infant is born prematurely compared with other mammals (due to the large size of the human brain), rendering a newborn child ill-equipped, physiologically and physically, to survive without a parent (or parent figure).

Attachment relationships are essential for survival and also the primary vehicle for healthy brain development.

When infants experience reliable, predictable, and attuned caregiving, then the areas in the brain that mediate these relational processes – the opioid attachment-reward system, the dopamine-based incentive system and the self-regulation area of the pre-frontal cortex – develop healthily.

For example, Mate points out that ‘Opiates…are the chemical linchpins of the emotional apparatus in the brain that is responsible for protecting and nurturing infant life. Thus addiction to opiates like morphine and Heroin arises in a brain system that governs the most powerful emotional dynamic in human existence: the attachment instinct. Love. (p. 154). 

In the context of safe, nurturing care, a child learns that the attachment relationship can be a resource for protection and comfort. Over time, a child will develop the capacity to regulate emotions, using relationships as an effective means to do so.

However, in the absence of protective and comforting caregiving, a child will experience high-stress levels. This will disrupt healthy brain development, altering the way a child relates to his inner world and the value that can be derived from relationships with others.

Many drugs are effective because they artificially create satisfying emotional states that typically derive from being well connected to others. Or because they numb the psychological distress caused by fractured or abusive relationships.

Mate quotes Dr Bruce Perry to illustrate this point:

“A child who is stressed early in life will be more overactive and reactive. He is triggered more easily, is more anxious and distressed. Now, compare a person child, adolescent or adult whose baseline arousal is normal with another whose baseline state of arousal is at a higher level. Give them both alcohol: both may experience the same intoxicating effect, but the one who has this higher physiological arousal will have the added effect of feeling pleasure from the relief of that stress. It’s similar to when with a parched throat you drink some cool water: the pleasure effect is much heightened by the relief of thirst’ (p. 197)

My dad and I had vastly different experiences, and the extent of our drug use was significantly different (the intensity arguably related to the severity of adversity we endured). Yet we both used them to deal with our internal landscape in the absence of relational support that could mitigate the psychological malaise. 

Not only did my experiences cause me sadness and emotional pain, but they also led to the development of a strategy that closed me off emotionally, especially within close relationships.

This deprived me of access to genuine connections with others, even when they were available.

Mate eloquently captures this when he writes, ‘The greatest damage done by neglect, trauma or emotional loss is not the immediate pain they inflict but the long-term distortions they induce in the way a developing child will continue to interpret the world and her situation in it’ (p.350)

I had limited access, therefore, to the biochemical and emotional sustenance that is available through relationships.

I entirely related to Mate when he wrote, ‘I’ve had a lifelong resistance to receiving love–not to being loved or even to knowing intellectually that am loved, but to accepting love vulnerably and openly on a visceral, emotional level. People who cannot find or receive love need to find substitutes-and that’s where addictions come in’.

When I used alcohol and drugs, I was not ignorant of the adverse effects of substance misuse and was reasonably educated about the risks and harms associated with various substances.

Nevertheless, it was a trade-off I was willing to make.

It is the case that I chose to take drugs, but I chose them in the context of unbearable psychological distress, a lack of relational support that would support the resolution of that distress and a lack of hope for the future. In other words, it was the most effective, albeit short term solution available to me.

In addition to the biological, psychological and childhood factors, Mate also highlights the impact of society on the emergence of addiction in individuals. Dr Bruce Alexander, the scientist behind the Rat Park Experiment, argues that ‘the precursor of addiction is dislocation’ and ‘only chronically and severely dislocated people are vulnerable to addiction’ (p.261). Mate posits that the rise of industrial societies has ushered in revolutionary life enhancing technologies. But it has also resulted in multiple forms of dislocation. Such as the destabilising of the nuclear family and the erosion of local communities.

In Lost Connections, Johann Hari (2018) identified several forms of dislocation, which he argues to be the underpinning components of unprecedented high levels of depression. Disconnection from meaningful work, other people, meaningful values, childhood trauma, status and respect, the natural world, and a hopeful and secure future. I think that these could apply equally well to drug and alcohol use.

I don’t think it’s a coincidence that when I moved out of the council estate I grew up on and lived on a University Campus and did a degree that gave me status, meaningful values, and a future that the drugs I was taken became far less appealing.

Reflective questions? Do you have any bad habits or behaviours that you can link to your experiences growing up? Have you ever felt lonely – how did you manage that? Looking at Johann Hari’s seven types of dislocation, do you experience any of them? If so, what do you think is the impact is? 

Our current approach to addiction 

‘If one set out deliberately to fashion a legal system designed to maximise and sustain the wealth of international drug criminals and their abettors, one could never dream up anything to improve upon the present one’ (p.276)

‘If the goal of the War on Drugs is discourage or prevent drug use, it has failed…if the Wars purpose is to protect people and communities or to improve their quality of life it has failed disastrously…if the Wars aim is to end or even curtail the international drug trade it has failed there too’ (p.275) 

The current approach to addressing the issue of drug consumption depends on pathologising any drug use. This happens mainly by making it illegal so that legal consequences will deter anyone tempted to use a drug. Anyone who continues to take drugs will be criminalised, thus eventually deciding that it isn’t worth it. The fundamental premise of this approach is underpinned by the false idea that those who take drugs are freely choosing to for enjoyment, and should the consequences be severe enough, they will be deterred from taking them.

This perspective assumes that choices are made in a social and political vacuum by individuals without developmental experiences that have indelibly shaped their psychological and neuro-physiological functioning.

In other words, we have a punishment orientated system that ‘rests on a bedrock of personal volition and blame’ (Eagleman, 2011 p.178).

However, Mate points out that the decisions that we believe our freely made are often manifestations of unconscious emotions or beliefs, usually determined by mechanisms programmed early in childhood.

Returning to Eagleman and his brilliant book Incognito (2011).

‘You choose neither your nature nor your nurture, much less their entangled interaction. You inherit a genetic blueprint and are born into a world which you have no choice throughout most your formative years. This is reason people come to the table with quite different ways of seeing the world, dissimilar personalities, and varied capacities for decision making. These are not choices’ (p.216) 

The War on Drugs is evidentially ineffective. It also creates conditions that contribute or exasperate the likelihood of drug use. Mate quotes affective Neuroscientist Panksepp describing the War on Drugs as ‘cultural schizophrenia’ because Mate writes ‘we want to eradicate or limit addiction, yet our social policies are best suited to promote it’ (p.301).

When we criminalise, stigmatise, and morally condemn the most vulnerable and traumatised members of our society for self-medicating, we decrease the possibility of connection and create the conditions that are most likely to keep them trapped on drug dependency. 

Neil Wood is an ex-policeman who worked undercover infiltrating drug gangs documents his experiences in his captivating book Good Cop, Bad War (2016). He originally began his career motivated by a well-intentioned and idealistic notion to capture and punish drug addicts and dealers. After several years, however, he realised that the drug dealers became adept at responding to the police’s tactics, which drove it further underground. To avoid infiltration, drug dealers become more professional, ruthless, and violent to maintain secrecy and their business. Even when Woods caught big-time dealers, usually following a lengthy and costly investigation, they were quickly replaced by another one willing to capitalise on the financial opportunities. He argued that it was failing to address the underlying issues. Woods also observed that many drug users, without any other means to fund their addiction, resorted to anti-social behaviours, including stealing or prostituting themselves. He concluded that drugs should be decriminalised, taking the trade out of the hands of criminals and that we should provide remedial, instead of punitive, support for drug users.   

Reflective questions: What are your immediate thoughts about decriminalising drug use? What concerns or fears might you have about it as an approach? 

An alternative, humane approach

‘Once we understand that the current assault on addicts creates greater insecurity for everyone and severe hardship for users, once we understand that stressing people chronically and mercilessly can in no way promote their capacity for healthy transformation, it becomes a straightforward matter to envision approaches that rely not on moralising but on science and humane values’ (p.302)

To expect an addict to give up her drug is like asking the average person to imagine living without all her social skills, support networks, emotional stability, and sense of physical and psychological comfort. Those are the qualities that, in their illusory and evanescent way, drugs give the addict (p.305)

Shortly before I was born, my dad attended a Rehabilitation Centre and achieved sobriety for the first time in his adult life. Drug-induced psychosis causing him to be sectioned, outbursts of violence, and the legal consequences of his drug use did little to deter him.

However, once he decided to stop using drugs, he accessed a residential treatment centre that could offer him a highly accepting, supportive, yet challenging support system and programme to help him abstain. Notably, he was offered support to address or at least alleviate the intensity of the psychological distress associated with the rejection from his mother, the unexpected separation from his father and childhood experiences in multiple foster homes.

This experience (‘ an island of relief’, p.305), afforded him the greatest period of stability in his adult life and allowed me to spend several years sober with my dad.

While he relapsed, and this caused considerable difficulties, I do not doubt that those first several years were crucially beneficial for my development and life outcomes. Perhaps it is why I am writing this today and not following his footsteps to a drug and alcohol-induced early grave.  

Mate proposes that drugs are decriminalised and dispensed by the public authorities under legal supervision. He recognises that many people fear that this approach will encourage and/or lead to widespread substance misuse by those currently deterred by legal prohibitions. 

Mate identifies two arguments against this concern.

Firstly, the evidence indicates the opposite happens. For example, he notes that cannabis use in Holland, where it is legal is half the rate than in the United States, where it is illegal (although the law has changed since this book was published).

Secondly, ‘People who do not suffer the searing emotional pain that drives hardcore drug addiction will rarely fall into dependency on chemicals, even if these were more readily available-and, once more, public access to habit-forming substances is not being proposed’. 

After rebuking the arguments against this approach, Mate details several advantages.

Firstly, there would be health benefits, such as the reduced risk of infection and disease transmission, less chance of overdose and access to ongoing medical care, help and information.

In addition, addicts might be less compelled to resort to criminal activity to fund their addiction, which would benefit them and the community.

They also won’t need to conceal their drug use due to the risk of being arrested, which from my experience, can prevent individuals from seeking help.

A final benefit that Mate identifies is that the illegal, underground international market would dramatically shrink, freeing up substantial funds to offer rehabilitative care to drug addicts. The type of treatment available to my dad has become increasingly harder to access over the past several years. 

Despite his advocacy of abstinence-based approaches, Mate has worked long enough with those addicted to drugs and alcohol to realise that it is naïve to expect that even if treatment options were more readily available that all drug users would wish to access it.

In these instances, harm reduction is favoured to ameliorate the pain and suffering caused by those using drugs yet not ready to abstain.

Mate is unsympathetic to the claims that harm reduction squanders resources on the undeserving who consciously choose to misuse drugs and perpetuates addiction by tacitly encouraging their self-destructive habits.

Instead, he considers an ethical and moral duty with practical benefits to all involved to offer ongoing support and methods to reduce the effects of continuing drug use. He notes, ‘in practising harm reduction we do not give up hope on abstinence-on the contrary, we may hope to encourage that possibility by helping people feel better, bringing them into therapeutic relationships with caregivers, offering them a sense of trust, removing judgement from our interactions with them and giving them a sense of acceptance’ (p.317) 

Conclusion 

There’s no question that hard-core addicts are a challenging population to work with, challenging because they trigger our judgments and anxieties and because they threaten the comfortable self-image we’ve worked so hard to establish for ourselves as cool, competent and powerful professionals. They stand quite outside the “nicely-nicely” ethic of respectable middle-class social interaction (P.384)

A central invitation by Mate in his book is that through unabated introspection, we can see that there is an aspect of ourselves that, like the drug addict, battles with the use of external stimuli to address inner discontent.

Recognising this within ourselves is an important, if not crucial pathway to developing an empathic response to those who misuse drugs and alcohol. Drug use is a particularly recognisable form of addiction, partly because of the dire and self-evident consequences. But most, if not all of us, seek disconnection, a temporary numbing out of life through various means, such as alcohol use, food, and social media.

Perhaps the disdain that we sometimes experience when faced with an addict is a disdain for those aspects of ourselves that cannot avoid the allure of whatever coping strategy we resort to. If what we see in the addicted individual is a reflection of that which we are too ashamed to acknowledge in ourselves, perhaps that gives an opportunity to connect and recognise our shared humanity.

Compassion is a manifestation of understanding.

By Richard Devine (06.05.22)

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