In the Realm of Hungry Ghosts by Gabor Maté
Overview
I recently completed listening to an audiobook with the name listed in the title of this blog post. I found it compelling and wanted to provide an overview of what I learned as I kept notes. Keep in mind that my notes are far from thorough, so what I write here isn’t a complete picture of what’s in the book. I’ll provide background re: what the title is about, who the author is, and what to expect. I’ll also try to boil my notes down to a main point and a more thorough breakdown for those interested in reading more in depth. Finally, I’ll offer my critiques/reflections (which should be taken with the biggest grain of salt) based off of my reading experience. Of course, if interested, I suggest people read/listen to the book themselves if they feel up to it. Let’s get started!
Background/Author/Expectations
This book was first published in 2008 and, while it’s dated, I think it still holds immense value. Addiction is front and center throughout and topics targeted range from addiction’s social impact, addiction’s physical origins, and much more. The book focuses on Gabor Maté’s medical practice working for Vancouver’s downtown east side’s Portland Hotel Society (I’ll refer to this as PHS). PHS serves the most vulnerable populations that, at the time of the book’s writing, often wouldn’t be eligible for services anywhere else. An internationally renowned physician, Maté provides excerpts from encounters he has with his patients while working in this context in addition to his own experiences with addiction.
A reader can expect vivid encounters with sensitive material while engaging with this book. There are patient stories shared that are unsettling, upsetting, and, at times, unbelievable. The stories aren’t shared for the sake of shock value and the purpose/intent is clear when it happens. So, gauging discomfort, I encourage readers to persevere as Maté threads things together tastefully. Maté references academic, peer reviewed studies at times and people’s mileage may vary on that; however, I think it’s accessible for most people as it doesn’t get too in the weeds. Finally, the book is dated but not so much so that it feels out of touch. Readers can expect relevant, informative content on a matter that’s impacted everyone in some capacity at some point in time. Enjoy!
What is Addiction?
Main Point: Addiction is defined in this book as something that provides temporary relief and long-term, negative consequences; despite these consequences, someone continues the behavior. Based off this definition, anything could technically fall under this continuum and become addictive. Addiction is inclusive of:
behaviors - gambling, sex, overeating, social media, etc.
chemical substances - legal (alcohol, nicotine, marijuana) and illegal (heroine, cocaine, meth, etc.)
Additionally, addiction impacts the body and brain in profound ways that often create cascading, negative effects.
Breakdown: Addiction often starts with a usually pleasurable experience that someone seeks time and again. A misconception some people hold is that people continue to receive that pleasure further into their addiction. While there’s a base level of pleasure after re-engaging in the addictive behavior, the diminishment of returns is immediate. Eventually, people experiencing addiction use their substance/behavior of choice primarily to stave off withdrawal symptoms. Their bodies and brains deteriorate and problems pile up more quickly than they can be addressed. Specific to the brain, people’s white and gray matter depletes in executive functioning centers causing a decreased ability to process, rationalize, and engage in responsible decision making; moreover, people’s dopamine (pleasure neurotransmitter) receptors flame out which results in less pleasure seeking and more withdrawal avoiding. Specific to the body, infections can occur around injection sites, transmittable diseases can spread, and complex medical conditions can develop. Addiction rots the brain and the body and the physiological impact can prove ghastly.
Nature or Nurture?
Main Point: Maté argues that, while genes play a role in addiction, someone’s surroundings dictate addictive behaviors far more. People need a variety of supports as they grow; if they don’t receive an appropriate amount, they’re likely to turn to whatever resources are available to them to help them fill the void.
Breakdown: Maté speaks at length about epigenetics and how our environments, supports, relationships, and much more impact our development and behaviors. He acknowledges genes as playing a role in the potential development of addiction; however, he challenges the stance that they can be the sole cause of it. He also mentions that people growing up in seemingly healthy households can sometimes develop addictive behaviors anyway.
What gives?
The cause is likely nuanced and further reflection can shed light on factors originally perceived as healthy that are actually problematic. Things like lack of love, intimacy, warmth, etc. can become pronounced issues over time when not present even when basic needs are being met. People may also experience trauma they haven’t shared with others that can lead to insecurities and maladaptive behaviors. Ultimately, people don’t seek to fill a void that doesn’t exist. Everything is relative; we never know what people have gone through and their own perceptions of it.
Attunement versus Attachment
Main Point: Attachment is critical for healthy development and, when an attachment isn’t secure between a parent and child, it can severely hamper long-term growth.
Adolescents with healthy, secure attachments to their parents, however, can still lack what’s called attunement.
Without attunement, adolescents can feel misunderstood and may seek support from peers. The adolescent perspective, as we all know, tends to lack maturity at times; consequently, it’s critical to find a balance between peer and parental support that helps children feel safe and connected.
Breakdown: Attachment is a primary driver of conversation when it comes to child/adolescent development. It makes sense why it often takes center stage given that a secure attachment is key to providing a safe, healthy environment in which a person can grow. Maté suggests the process of attunement, the awareness and responsiveness of a parent to a child’s emotional needs, as the biggest factor in determining someone’s susceptibility to addiction. If adolescents don’t feel emotionally connected to their support systems, they’re likely to seek that connection from a different source (usually peers).
This is natural!
Without a balance, however, adolescents can receive a whole lot of support from peers who need a whole lot of support themselves. This can exacerbate adolescent tendencies around risk taking and set a shaky foundation in which addiction, among many other things, can potentially plant its roots. Ideally, adolescents can count on their adult support systems for assistance when their peer supports aren’t what they need them to be. Unfortunately, this wasn’t the reality for many people in their formative years and it tends to create a negative feedback loop over time.
The War on Drugs
Main Point: Maté argues that those most likely to use hard drugs are those who’ve experienced extreme trauma in childhood/adolescence. Maté contextualizes the war on drugs, then, as a war on the adult versions of these traumatized children who were victims of their circumstances. Our westernized society accepts and values certain forms of addiction (work, caffeine, exercise, etc.) and condemns behaviors seen as inferior. In reality we all engage in addictive behaviors to some extent. Hypocritically, the war on drugs seeks to punish those who engage in perceived inferior forms of addiction when addiction is omnipresent in the world we live.
Breakdown: Addiction is widespread. People’s addictions, however, are viewed vastly differently depending on the behavior or substance. Two separate examples can look like this:
Someone frequents a local coffee shop daily to get their usual order on a typical workday. Something happens one morning where they must go without that order. That person starts to experience caffeine withdrawal (headaches, irritability) and receives supportive words and maybe a kind gesture from a coworker (grabbing an order of coffee) to help ease the discomfort.
A person grapples with an ongoing addiction to heroine. That person has gone an extended period without using and is experiencing acute withdrawal symptoms (nausea, sweats, etc.). The person is actively trying to stop using but chooses to utilize a safe injection site to receive sterilized paraphernalia for safe use later in the day. The person is making active efforts to change habits and improve their quality of life; however, someone driving by sees the person put the drug supplies away in a bag. Harsh judgments are made instantly with little to no empathy, compassion, or support being offered.
To be clear, caffeine is not the same as heroine. The salient point here is that our society assigns value to one substance/behavior over another. If people choose to use heroine, they are seen as lesser than people who drinks multiple coffees a day despite both substances possessing addictive qualities. Hard drugs are best to be avoided regardless; however, if addiction inundates so many areas of life, Maté argues we ought to avoid engaging in hypocritical attitudes and look in the mirror around what we and society are judging as acceptable versus unacceptable. This point is especially salient when looking at the root causes of use and addictive behaviors.
The War on Drugs: What is it Good for?
Main Point: Maté argues that the United States and complicit partners have perpetuated a War on Drugs that, instead of decreasing use and availability of substances, has succeeded in the opposite. Countless billions of dollars are spent annually and few examples exist of the benefits of this system. Maté suggests that the War on Drugs would actually surpass any efforts made to create a system/policy that would try to increase the availability, use, and lethality of substances. Objectively, it fails miserably and it’s important to reflect on what causes it to continue.
Breakdown: People likely possess a large range of emotions when the topic of The War on Drugs comes up. It’s such an engrained concept in the United States’ perspective towards illicit substances that it can be extremely difficult to pull away and look at things from a different angle. Below is a short YouTube video describing the War on Drugs and its impact.
Maté encourages the embrace of harm reduction approaches, despite his own hesitations around them, as they have demonstrated the best success in actually lowering substance use and providing sustained support for people experiencing addiction. Drugs have existed as long as humans have been able to use them. As the above video describes, the supply will always meet the demand with illegal substances. Harm reduction aims to lower demand instead of waging a dead-end struggle of lowering supply.
Maté argues that implementing proactive policies that are based on objective data and aren’t rooted in subjective bias is critical in ensuring a sustainable approach in addressing addiction. Harm reduction fits the bill and ultimately helps others help themselves by providing supports that are relevant to them. Maté suggests that providing those experiencing addiction outlets for creativity, fulfillment, and safety allows the opportunity for them to contribute back to society.
He offers the specific example of William Stewart Halsted, one of the founding physicians of Johns Hopkins University who helped modernize surgery to how we know it today. William Stewart Halsted also happened to experience addiction to opiates. Maté paints the picture of a reality where there could be similar successes to Halsted’s on a smaller scale for those experiencing addiction if they receive shame-free, relevant supports. That reality won’t be reached with how things stand today.
The Continuum of Choice
Main Point: Decision making is processed in the executive functioning areas in our brain. Maté argues that Pre-Attentive Analysis, the unconscious evaluation our brain makes of what goals are judged to be valuable versus not valuable, is a key aspect of decision making in our executive functioning that’s skewed in those experiencing addiction. Therefore, to say there’s always a choice to be made around whether to use or not use isn’t always accurate and it’s important to note the objective limitations those experiencing addiction can endure.
Breakdown: Maté compares this section of the book to the “brain lock” those with OCD (Obsessive Compulsive Disorder) can experience. It’s the idea that those with OCD know the behavior they’re compulsively performing is negatively impacting them but they’re unable to stop because of the way their brain circuits are operating. The parallel between this and diminished executive functioning in those experiencing addiction is that deeply addicted brains are often running on autopilot. Deeply addicted brains have already decided that the substance/behavior people are addicted to is prioritized above all else thanks to the concept of Pre-Attentive Analysis. Consequently, those experiencing addiction don’t always possess capacity to halt themselves acting impulsively and can engage in poor decisions despite long-term, negative impacts.
This isn’t to say that there’s no accountability for those making unsavory decisions. People can sometimes take a step back and actively choose healthier alternatives rather than revert back to decisions resulting in poor health. However, people can often make less than ideal choices despite their best efforts to maintain positive habits depending on their relationship with addiction. The continuum of choice, according to Maté, is another piece of the puzzle when evaluating addiction rather than the whole picture.
Treat Yourself as You Would Treat Others
Main Point: Creating autonomy in others is the best way to foster fulfillment and long-term, sustainable progress. Insight is critical in developing that autonomy and navigating the complex medical condition that is addiction. By knowing ourselves we can navigate our areas of struggle more effectively; moreover, it allows us to cultivate curiosity regarding qualities inherent in us, negative/traumatic experiences we’ve endured, and possibly negative/traumatic experiences we’ve perpetrated upon others. We can’t change these things, but they can be approached differently to offer ourselves the grace, compassion, and openness that we can sometimes heap upon others so readily.
Breakdown: Maté offers the acronym C.O.A.L as a roadmap in how to grow in self-insight and self-reflection. It stands for the following:
C - Curiosity
O - Openness
A - Acceptance
L - Love
C.O.A.L is ultimately a sequence in which someone starts from a curious space when reflecting on something perceived negatively. Maybe it’s a specific character trait. Instead of denying that trait or judging harshly, we can be curious (i.e. “I wonder what makes me that way?”, “What makes me so opposed to that part of myself?”). Once we’re curious, can we be open to viewing it differently? Can we then accept it for what it is in a different light? Finally, are we able to learn to tolerate, like, or love that part of us?
It’s not such an easy roadmap with something like a traumatic experience. We wouldn’t ever seek to gaslight ourselves into viewing something traumatic as something other than what it is; however, we can approach our reactions, thoughts, and feelings towards it differently in the same way we may view a character trait. Those experiencing intense addiction almost always engage in such substances/behaviors because of extreme trauma. Using tools like C.O.A.L can prove beneficial in offering a new paradigm in which to view ourselves instead of the typical negative, self-perpetuating trains of thought we can often engage in.
The Four (Plus One) Step Method
Main Point: Maté offers what he has adapted from a colleague as the Four Step Method. Maté adds a fifth step and states clearly that this method should be used as an adjunct to other forms of primary programming: things like Alcoholics Anonymous, Narcotics Anonymous, etc. He mentions that it’s critical people acknowledge the impact of their conditions on their bodies and minds in order to engage effectively in the steps as they’re laid out. Additionally, he encourages using tools for self-reflection (journal, etc.) and practicing the steps daily so that they can become more naturally engrained.
Breakdown: I’ll outline the method below with brief detail on how each should be approached.
Step 1 - Relabel addictive urges for what they are. Urges can prove nearly impossible to shake and the perceived urgency around them often reinforces this. Ultimately, urges are not needs, and consistent, conscious relabeling can redistribute the power imbalance that urges can hang over our heads.
Step 2 - Reattribute urges and/or problematic thinking patterns to the proper source(s). Am I thinking this way because my Pre-Attentive Analysis has my brain mixed up? Is this something I’ve thought for a long time and is hard-wired? Reattributing doesn’t dissolve urges or thinking patterns; however, it can whittle away at the power they possess over time.
Step 3 - Refocus: Maté offers the quote, “It’s not what you feel that matters; it’s what you do.” Knowing that practicing refocusing takes time, the goal is to create strategies that can work short-term (creative acts, mindfulness, etc.) that can build incrementally towards long-term abatement of addictive urges and thinking.
Step 4 - Revalue how addiction actually impacts us. Instead of persecuting ourselves, conduct an investigation to engage in non-judgmental thinking. Gauge honestly how addiction has impacted life and how to best avoid re-engagement in urges/problematic thinking patterns. Maté offers two A’s in this step. Anticipate is meant to acknowledge that addictive urges will return, so to be shocked or disappointed by this only succeeds in setting ourselves up for failure. The second A, Acceptance, is meant to acknowledge urges as existing not because of some fundamental flaw in character but instead because of the natural process of addiction. This subverts shameful thinking and frames addictive urges for what they are.
Step 5 - Recreate our lives. Reshape our lives to fit what we strive for and to embrace the creative qualities we possess. Foster longevity through intentionality and live/grow into the best versions of ourselves.
Sobriety and Abstinence
Main Point: Maté suggests that evaluating external circumstances is crucial in determining a successful path towards sobriety. Maté doesn’t discount that abstinence can work for some people; however, he suggests that, for most, complete abstinence is unrealistic. Addictive urges can permeate all areas of life; Maté offers the idea that sobriety can perform a similar function if people focus on positive, incremental steps while practicing self-compassion and forgiveness. Rather than assigning shame and experiencing guilt for enduring or indulging addictive urges, it’s best to acknowledge their severity and approach them accordingly.
Breakdown: According to Maté, sobriety is defined as feeling free of internal compulsions and living according to principles we believe in. Additionally, sobriety is when we prioritize ourselves over addictive urges/behaviors in favor of engaging in self-sustaining activities.
Maté offers the example of his own compulsion of arriving to work late. He admits that this caused undue stress to his support staff and that they often covered for him in ways that unnecessarily added more to their plates. Maté admits that, despite countless promises and apologies, his attempts rang hollow in addressing the issue. He eventually created a system of writing undated checks and providing them to his staff to cash in any instant where he ran late in the future. He acknowledges that this isn’t feasible for most people but that this was the only way he could muster for him to foster accountability at that time.
Staff cashed several checks on Maté’s dime despite the system being implemented; however, Maté did improve on tardiness over time. He mentions that, embarrassing as it can be to admit faults, it’s better to worsen people’s opinions of ourselves while being transparent about faults versus wallowing in shame and self-pity. This is where the rubber hits the road in terms of progress being made.
Maté argues that change must come from ourselves in order for it to feel authentic. Attempting to enact change to please or assuage others places the onus of that process on a faulty foundation.
Put simply: if we don’t want it, then it won’t happen.
Maté also mentions the concept of relapse and how it’s present in all addiction. Maté says that stress and unmet emotional needs are the primary drivers for someone relapsing, so, if people don’t feel properly supported or are inundated with intense stress, they're more likely to resort to unhealthy, damaging behaviors. Maté offers the importance of identifying powers outside of ourselves, whether that be spiritual, religious, or whatever, as it can help provide a source of strength we may not have access to in our natural supports and strategies. It’s critical people feel empowered to utilize supports that are relevant to them.
Reflections
Several other reflections popped up for me as I listened to the book. I’m going to try and stay cognizant around noting these in addition to the general notes I’ve already taken the next time I pursue an endeavor like this. Otherwise, I get scrambled and don’t address the number of topics actually listed throughout the book. Here are the reflections that came up for me as I wrote this post:
I found this book incredibly interesting. My notes are far from comprehensive so people who don’t read/listen to the book will miss out on the plethora of anecdotes shared throughout that help to accentuate and emphasize several points Maté proposes. Things like actual examples of addiction his patients experience, personal accounts of his own struggles with addiction, and government policies addressing substance use are a few examples of how Maté attempts to make connections.
I find that, despite how dated the book is, the information still feels extremely relevant. Data and approaches have surely changed since the book’s publication; however, things like harm reduction are being discussed, debated, and implemented to this day. It demonstrates how long it can take to change societal attitudes and opinions around sensitive topics like addiction. I also appreciate how the book defines addiction in an inclusive way and brings humanity to the forefront of the topic. I’ve been exposed to addiction in personal and professional contexts. The way Maté describes people’s relationship with addiction rings true from my experiences. His book helped me to clarify what caused certain people to behave the way they did, highlighted barriers they may have faced, and validated my struggles in offering support.
I appreciate that Maté tackles a macro lens when speaking about the topic of addiction as well. My education has proven how ineffective the War on Drugs has been at tackling the public health concern of addiction to the point of ad nauseam. That said, it’s critical others be exposed to the dysfunctional mess that is the War on Drugs that the USA and most of western society continues to perpetrate, continuously yielding miserable results and inflicting avoidable harm. I’ve worked in harm reduction settings and have harbored many of my own hesitations towards it; however, I can put my biases aside and recognize that few other strategies exist that help to humanize and support people in better ways. The War on Drugs achieves little besides perpetuating corruption and further instilling shame into those experiencing addiction. That’s not a recipe for success.
Critiques
It’s been a while since I’ve read the book so I’ve likely forgotten many of my original, hot off the press critiques. Similar to what I wrote previously, I’m going to try and note these in the future. Here are the ones that came up for me while writing this post:
I felt the weight put on attunement and how it impacts the likelihood of people experiencing addiction was potentially lopsided. I appreciate that attunement is discussed since it’s often neglected in conversations related to development; however, it felt to me that more should’ve been highlighted in this area since I think people can be both securely attached and attuned to caregivers and still experience addiction down the line.
I thought it would’ve been helpful to see proposed policy suggestions from Maté on alternatives to the War on Drugs. It’s powerful pointing out the obvious faults in the system that is the War on Drugs, but I think it could’ve proven more powerful to hear perspectives regarding how things could be changed for the better.
I appreciate that programs like AA and NA are mentioned; however, I wanted other alternatives to be discussed as I’ve worked with multitudes of people experiencing addiction who don’t jive with the format and messaging of those programming options. It felt strange to me that Maté would endorse them so strongly as well, especially after only having attended one meeting of AA himself (per the book) at the time of publication. I thought his book would’ve served as a great platform to highlight other community options.
To be clear: I haven’t read the appendix of this book and don’t know the extent to which Maté outlines the number of sources he used while writing. It felt to me, however, that the studies he references as supporting evidence to his points are helpful but he doesn’t mention in the moment if they’ve been corroborated, reviewed, etc. I’m sure this is to accommodate a general audience and the appendix could easily ameliorate this critique, but it’s something that stood out to me while listening.
Many of my critiques felt they fit in the “nitty-gritty” category which says a lot about the book with how much it addresses. This is also one of Maté’s earlier writings, so I’m curious how things may have shifted in future books should I find myself reading them. If you made it this far, thank you for reading!
References:
Maté, G. (2018). In the realm of hungry ghosts: Close encounters with addiction (D. Maté, Narr.). [Audiobook]. Vintage Canada.
Kurzgesagt - In a Nutshell. (2016, March 1). Why the war on drugs is a huge failure [Video]. Youtube. https://www.youtube.com/watch?v=wJUXLqNHCaI