The definitive book for understanding addiction
In this timely and profoundly original book, writer and physician Gabor Maté looks at the epidemic of various addictions in our society, tells us why we are so prone to them and outlines what is needed to liberate ourselves from their hold. Starting with a dramatically close view of Maté's drug addicted patients, In the Realm of Hungry Ghosts weaves in stories of real people while providing a bold synthesis of clinical experience, insight and cutting-edge scientific findings. A haunting, compassionate and deeply personal examination of the nature of addiction.
About the author
Born in Budapest, Gabor Maté immigrated to Canada at the age of twelve. He spent some time working as a teacher before returning to university to pursue his lifelong dream of becoming a doctor. He ran a popular family practice for many years, and spent twelve years working in Vancouver's downtown eastside, caring for patients suffering from mental illness, drug addiction, and HIV. In the 1990s, Dr. Maté was a regular medical columnist for the Vancouver Sun and the Globe and Mail. He is also the author of four works of non-fiction. His most recent book, In the Realm of Hungry Ghosts: Close Encounters With Addiction, won a Hubert Evans Award in 2010. In addition to being a physician and bestselling author, Dr. Maté is a highly sought after public speaker. He has three grown children and currently resides in Vancouver, BC, with his wife. Please visit drgabormate.com.
- Winner, BC Book Prize’s Hubert Evans Non-Fiction Prize
Excerpt: In the Realm of Hungry Ghosts: Close Encounters with Addiction (by (author) Gabor Maté)
The mandala, the Buddhist Wheel of Life, revolves through six realms. Each realm is populated by characters representing aspects of human existence–our various ways of being. In the Beast Realm we are driven by basic survival instincts and appetites such as physical hunger and sexuality, what Freud called the id. The denizens of the Hell Realm are trapped in states of unbearable rage and anxiety. In the God Realm we transcend our troubles and our egos through sensual, aesthetic or religious experience, but only temporarily and in ignorance of spiritual truth. Even this enviable state is tinged with loss and suffering.
The inhabitants of the Hungry Ghost Realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects or pursuits we hope will soothe it are not what we really need. We don’t know what we need, and so long as we stay in the hungry ghost mode, we’ll never know. We haunt our lives without being fully present.
Some people dwell much of their lives in one realm or another. Many of us move back and forth between them, perhaps through all of them in the course of a single day.
My medical work with drug addicts in Vancouver’s Downtown Eastside has given me a unique opportunity to know human beings who spend almost all their time as hungry ghosts. It’s their attempt, I believe, to escape the Hell Realm of overwhelming fear, rage and despair. The painful longing in their hearts reflects something of the emptiness that may also be experienced by people with apparently happier lives. Those whom we dismiss as “junkies” are not creatures from a different world, only men and women mired at the extreme end of a continuum on which, here or there, all of us might well locate ourselves. I can personally attest to that. “You slink around your life with a hungry look,” someone close once said to me. Facing the harmful compulsions of my patients, I have had to encounter my own.
No society can understand itself without looking at its shadow side. I believe there is one addiction process, whether it is manifested in the lethal substance dependencies of my Downtown Eastside patients; the frantic self-soothing of overeaters or shopaholics; the obsessions of gamblers, sexaholics and compulsive Internet users; or the socially acceptable and even admired behaviours of the workaholic. Drug addicts are often dismissed and discounted as unworthy of empathy and respect. In telling their stories my intent is twofold: to help their voices to be heard and to shed light on the origins and nature of their ill-fated struggle to overcome suffering through substance abuse. They have much in common with the society that ostracizes them. If they seem to have chosen a path to nowhere, they still have much to teach the rest of us. In the dark mirror of their lives, we can trace outlines of our own.
There is a host of questions to be considered. Among them:
• What are the causes of addictions?
• What is the nature of the addiction-prone personality?
• What happens physiologically in the brains of addicted people?
• How much choice does the addict really have?
• Why is the “War on Drugs” a failure and what might be a humane, evidence-based approach to the treatment of severe drug addiction?
• What are some of the paths for redeeming addicted minds not dependent on powerful substances–that is, how do we approach the healing of the many behaviour addictions fostered by our culture?
The narrative passages in this book are based on my experience as a medical doctor in Vancouver’s drug ghetto and on extensive interviews with my patients–more than I could cite. Many of them volunteered in the generous hope that their life histories might be of assistance to others who struggle with addiction problems or that they could help enlighten society regarding the experience of addiction. I also present information, reflections and insights distilled from many other sources, including my own addictive patterns. And finally, I provide a synthesis of what we can learn from the research literature on addiction and the development of the human brain and personality.
Although the closing chapters offer thoughts and suggestions concerning the healing of the addicted mind, this book is not a prescription. I can say only what I have learned as a person and describe what I have seen and understood as a physician. Not every story has a happy ending, as the reader will find out, but the discoveries of science, the teachings of the heart and the revelations of the soul all assure us that no human being is ever beyond redemption. The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate question.
I dedicate this work to all my fellow hungry ghosts, be they inner-city street dwellers with HIV, inmates of prisons or their more fortunate counterparts with homes, families, jobs and successful careers. May we all find peace.
As I pass through the grated metal door into the sunshine, a setting from a Fellini film reveals itself. It is a scene both familiar and outlandish, dreamlike and authentic.
On the Hastings Street sidewalk Eva, in her thirties but still waif-like, with dark hair and olive complexion, taps out a bizarre cocaine flamenco. Jutting her hips, torso and pelvis this way and that, bending now at the waist and thrusting one or both arms in the air, she shifts her feet about in a clumsy but concerted pirouette. All the while she tracks me with her large, black eyes.
In the Downtown Eastside this piece of crack-driven improvisational ballet is known as “the Hastings shuffle,” and it’s a familiar sight. During my medical rounds in the neighbourhood one day, I saw a young woman perform it high above the Hastings traffic. She was balanced on the narrow edge of a neon sign two storeys up. A crowd had gathered to watch, the users among them more amused than horrified. The ballerina would turn about, her arms horizontal like a tightrope walker’s, or do deep knee bends–an aerial Cossack dancer, one leg kicked in front. Before the top of the firemen’s ladder could reach her cruising altitude, the stoned acrobat had ducked back inside her window.
Eva weaves her way among her companions, who crowd around me. Sometimes she disappears behind Randall–a wheelchair-bound, heavy-set, serious-looking fellow, whose unorthodox thought patterns do not mask a profound intelligence. He recites an ode of autistic praise to his indispensable motorized chariot. “Isn’t it amazing, Doc, isn’t it, that Napoleon’s cannon was pulled by horses and oxen in the Russian mud and snow. And now I have this!” With an innocent smile and earnest expression, Randall pours out a recursive stream of facts, historical data, memories, interpretations, loose associations, imaginings, and paranoia that almost sound sane–almost. “That’s the Napoleonic Code, Doc, which altered the transportational mediums of the lower rank and file, you know, in those days when such pleasant smorgasboredom was still well fathomed.” Poking her head above Randall’s left shoulder, Eva plays peek-a-boo.
Beside Randall stands Arlene, her hands on her hips and a reproachful look on her face, clad in skimpy jean shorts and blouse–a sign, down here, of a mode of earning drug money and, more often than not, of having been sexually exploited early in life by male predators. Over the steady murmur of Randall’s oration comes her complaint: “You shouldn’t have reduced my pills.” Arlene’s arms bear dozens of horizontal scars, parallel, like railway ties. The older ones white, the more recent red, each mark a souvenir of a razor slash she has inflicted on herself. The pain of self-laceration obliterates, if only momentarily, the pain of a larger hurt deep in the psyche. One of Arlene’s medications controls this compulsive self-wounding, and she’s always afraid I’m reducing her dose. I never do.
Close to us, in the shadow of the Portland Hotel, two cops have Jenkins in handcuffs. Jenkins, a lanky Native man with black, scraggly hair falling to below his shoulders, is quiet and compliant as one of the officers empties his pockets. He arches his back against the wall, not a hint of protest on his face. “They should leave him alone,” Arlene opines loudly. “That guy doesn’t deal. They keep grabbing him and never find a thing.” At least in the broad daylight of Hastings Street, the cops go about their search with exemplary politeness–not, according to my patients, a consistent police attitude. After a minute or two Jenkins is set free and lopes silently into the hotel with his long stride.
Meanwhile, within the span of a few minutes, the resident poet laureate of absurdity has reviewed European history from the Hundred Years’ War to Bosnia and has pronounced on religion from Moses to Mohammed. “Doc,” Randall goes on, “the First World War was supposed to end all wars. If that was true, how come we have the war on cancer or the war on drugs? The Germans had this gun Big Bertha that spoke to the Allies but not in a language the French or the Brits liked. Guns get a bad rap, a bad reputation–a bad raputation, Doc–but they move history forward, if we can speak of history moving forward or moving at all. Do you think history moves, Doc?”
Leaning on his crutches, paunchy, one-legged, smiling Matthew–bald, and irrepressibly jovial–interrupts Randall’s discourse. “Poor Dr. Maté is trying to get home,” he says in his characteristic tone: at once sarcastic and sweetly genuine. Matthew grins at us as if the joke is on everyone but himself. The chain of rings piercing his left ear glimmers in the bronzed gold of the late afternoon sun.
Eva prances out from behind Randall’s back. I turn away. I’ve had enough street theatre and now I want to escape. The good doctor no longer wants to be good.
We congregate, these Fellini figures and I–or I should say we, this cast of Fellini characters–outside the Portland Hotel, where they live and I work. My clinic is on the first floor of this cement-and-glass building designed by Canadian architect Arthur Erickson, a spacious, modern, utilitarian structure. It’s an impressive facility that serves its residents well, replacing the formerly luxurious turn-of-the-century establishment around the corner that was the first Portland Hotel. The old place, with its wooden balustrades, wide and winding staircases, musty landings and bay windows, had a character and history the new fortress lacks. Although I miss its Old World aura, the atmosphere of faded wealth and decay, the dark and blistered windowsills varnished with memories of elegance, I doubt the residents have any nostalgia for the cramped rooms, the corroded plumbing or the armies of cockroaches. In 1994 there was a fire on the roof of the old hotel. A local newspaper ran a story and a photograph featuring a female resident and her cat. The headline proclaimed, “Hero Cop Saves Fluffy.” Someone phoned the Portland to complain that animals should not be allowed to live in such conditions.
The nonprofit Portland Hotel Society, for whom I am the staff physician, turned the building into housing for the nonhousable. My patients are mostly addicts, although some, like Randall, have enough derangement of their brain chemicals to put them out of touch with reality even without the use of drugs. Many, like Arlene, suffer from both mental illness and addiction. The PHS administers several similar facilities within a radius of a few blocks: the Stanley, Washington, Regal and Sunrise hotels. I am the house doctor for them all.
The new Portland faces the Army and Navy department store across the street, where my parents, as new immigrants in the late 1950s, bought most of our clothing. Back then, the Army and Navy was a popular shopping destination for working people–and for middle-class kids looking for funky military coats or sailor jackets. On the sidewalks outside, university students seeking some slumming fun mixed with alcoholics, pickpockets, shoppers and Friday night Bible preachers.
No longer. The crowds stopped coming many years ago. Now these streets and their back alleys serve as the centre of Canada’s drug capital. One block away stood the abandoned Woodward’s department store, its giant, lighted “W” sign on the roof a long-time Vancouver landmark. For a while squatters and antipoverty activists occupied the building, but it has recently been demolished; the site is to be converted into a mix of chic apartments and social housing. The Winter Olympics are coming to Vancouver in 2010 and with it the likelihood of gentrification in this neighbourhood. The process has already begun. There’s a fear that the politicians, eager to impress the world, will try to displace the addict population.
Eva intertwines her arms, stretches them behind her back and leans forward to examine her shadow on the sidewalk. Matthew chuckles at her crackhead yoga routine. Randall rambles on. I glance out eagerly at the rush-hour traffic flowing by. Finally, rescue arrives. My son Daniel drives up and opens the car door. “Sometimes I don’t believe my life,” I tell him, easing into the passenger’s seat. “Sometimes I don’t believe your life either,” he nods. “It can get pretty intense down here.” We pull away. In the rearview mirror the receding figure of Eva gesticulates, legs splayed, head tilted to the side.
The Portland and the other buildings of the Portland Hotel Society represent a pioneering social model. The purpose of the PHS is to provide a system of safety and caring to marginalized and stigmatized people–the ones who are “the insulted and the injured,” to borrow from Dostoevsky. The PHS attempts to rescue such people from what a local poet has called the “streets of displacement and the buildings of exclusion.”
“People just need a space to be,” says Liz Evans, a former community nurse, whose upper-tier social background might seem incongruous with her present role as a founder and director of the PHS. “They need a space where they can exist without being judged and hounded and harassed. These are people who are frequently viewed as liabilities, blamed for crime and social ills, and . . . seen as a waste of time and energy. They are regarded harshly even by people who make compassion their careers.”
"A harrowingly honest, compassionate, sometimes angry look at addiction and the people whose lives have been disordered by it."
"Maté does a great service by forcing us to confront the us-and-them mentality that drives the get-tough responses to addiction.... I highly recommend Hungry Ghosts to everyone seeking insight into addiction."
—The Vancouver Sun
"Excellent.... One of the book's strengths is Maté's detailed and compassionate characterization of the afflicted addicts he treats, but this is not just a memoir. Rather, using his own experience as well as the most advanced recent research, he attempts to delineate the closely interrelated psychological, social, and neurological dimensions of addiction.... A calm, unjudging, compassionate attentiveness to what is happening within."
"An insightful, multilayered discussion of the nature of addiction generally, and our society's epidemic of addictions in particular."
—The Globe and Mail
"Enormously compelling and Maté, as noted, is admirably, sometimes inexplicably, empathetic to all who cross his path."
"It's compulsively readable and packed with new scientific discoveries about addiction."
—The Georgia Straight
A challenging but rewarding readThe last eighty pages of In the Realm of Hungry Ghosts have taken me three weeks to finish.
I stumbled through the first few chapters. Dr. Gabor Maté, a physician from Vancouver’s DownTown East Side (DTES) wrote the book in what I interpret to be four main overtures. The first section of the book is devoted to bringing the readers up to speed on the narratives and geography. The second provides an overview of what is addiction (biologically, psychologically, in society), which gradually morphs into “how people got to that place” (physically, personally and societally) and then resoundingly (thankfully) the book closes with a section looking at redemption and healing.
This book is by no means easy to read.
The epicenter of the DTES will envelop you in cacophonous laughter, colours and sickly sweet smoke of the intersection. People hawking wares on the sidewalks, people lining the streets so thick it looked like Africa. Shouting, mingling, bartering; the traffic slowed down to the pace of Bamako, where traffic lights suddenly becomes a suggestion, and common sense becomes your safest bet to sound passage through to the other humdrum dreary side.
Regardless of whether or not the reader of Hungry Ghosts has visited the DTES, Dr. Maté does an excellent job of describing the neighbourhood. Dr. Maté writes with a clarity and clinical precision that is almost romantic. He goes on to describe where he works (the Portland Hotel Society), a housing facility that now manages several projects in the DTES.
The book begins with nearly the first 100 pages devoted to shocking the reader into a loose portrait of understanding of the DTES. He is able to evoke us into a place of compassion, where a community emerges out of systemic failure. Dr. Maté brings out our empathy without demanding it; the outpouring of compassion these first chapters extract is almost involuntary and exhausting. Through a series of short case studies he puts faces to the issues of the DTES. This I expected. People who have read this book before me have described it as labourous, reading a chapter at a time, putting it down often because of their tears. Chapter 4, entitled “You wouldn’t believe my life story” is accurately more devastating than any fiction I have ever read. His writing style and the humanity of the stories are addictive, catalyzing an empathy out of the reader that is almost grotesque: how can our social system fail so many people so completely? It is difficult to believe.
Dr. Maté’s book is well referenced, he provides over twenty pages of end-notes to supplement and bolster his arguments. The book is sprinkled with references to classical music and literature. But what is sneaky about the book, is that of course, the average reader, soldiering through 400 dense pages of largely scientific and academic writing will identify here and there with the people interviewed and contributing, but realistically, these same people are far more likely to identify with Dr. Maté himself. I was able to quickly locate the music he refers to, I’ve read many of the authors and thinkers he refers to—I was lulled into identifying with him. His relentless unabashed oversharing of his personal experiences and home life allow you to think of Dr. Maté as an actual person. This is helped along as many of the clients participating in the work also see him as such—they talk back to him, challenge him and manipulate him, in part (I’m guessing) because after a system has failed them so completely, what would the use be in continuing to participate in the staunch hierarchies that exist to protect it. The book’s greatest case study, is in fact, Dr. Maté himself.
Where this tactic become particularly effective is that as Dr. Maté switches to explaining the symptoms and causes of addiction, he uses himself as an example to illustrate the principles. At first, the links and parallels seem tenuous, but by the end of the work (it is impossible to feel as though this is a short book—it’s a veritable tome!), it works. That is why this book is so effective, and imperative to read for change makers, anyone really. It is why this book becomes accessible.
Dr. Maté’s quirky illustration of himself as a learned, compassionate man that suffers from addictions, forces the readers to attempt to assess their own lives and social moralities. Ultimately, as illustrated in Chapter 33 “A Word to Friends, Families and Colleagues”–you can’t sort out other people’s shit unless you are able to objectively try to sort out your own, or at the very least, realize that you (and everyone else) has work to do. This is the deeply humbling and universal message of this book, that there is a need for compassion and a holistic approach to dealing with all social issues, not only is this the most effective way, but also the most efficient because the impacts are on so many levels: support systems in all aspects of life. Holistic approaches are more complicated than the current systems in place, but the problems arising out of the current “silver bullet” solutions are so much more costly and complicated.
I would highly recommend this book to anyone with the emotional capacity and time to process the complex issues it delves into. Although I don’t agree 100% with every argument Dr. Maté brings forward, ultimately I couldn’t agree more with his demands to demonstrate “curious compassion” and constant questioning: from the systems that suspend us to the actions that hold us in it’s grasp, inviting us to a lifelong work of constant redevelopment.
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Other titles by Gabor Maté
Eight Step Recovery
Using the Buddha's Teachings to Overcome Addiction
True Stories from People Who Live with Mental Illness
A Room in the City
Photographs of Gabor Gasztonyi
When the Body Says No
The Cost of Hidden Stress
The Origins and Healing of Attention Deficit Disorder