GHOST-BUSTING ADDICTIONS

In the Realm of Hungry Ghosts: Close Encounters with Addiction Gabor
Mate MD; Knopf Canada; 2008; 480 pp $34.95 ISBN 978-0-676-97740-0

If stigma still shapes the ways we understand and respond to
addictions in contemporary society - and it does - then this book
deserves our attention. Gabor Mate employs both passion and reason in
shaping an ambitious, sprawling book that is engaging and provocative.

The crucible that shapes Mate's views is Vancouver's Downtown
Eastside, where for 8 years he has been staff doctor for the Portland
Hotel Society, a remarkable agency offering "safety and caring to
marginalized and stigmatized people," by housing and supporting the
homeless. It is there that Mate starts and ends the book - with his
patients and himself. But the journey he takes us on passes through
all kinds of rough terrain to show us what addiction is, how it
develops and what can be done about it.

Mate sees addiction as existing along a continuum, and we are all on it.

It's not just about "them" - the marginalized, desperate aliens who
represent our stereotype of addiction - it's about all of us, Mate included.

He offers himself as an index case, revealing his attention-deficit
hyperactivity disorder (the subject of an earlier book), his
workaholism, and his compulsive CD buying. "At heart, I am no
different than my patients - and I sometimes cannot stand seeing how
. little heaven-granted grace separates me from them."

For Mate, there is one basic addiction process that expresses itself
in many ways. It is that process, not the object (which can be drugs,
gambling, sex, eating or whatever), that is the essence of addiction.
A colleague who found recovery in Alcoholics Anonymous liked to say,
"Addiction isn't a drug problem; it's a people problem." Indeed, Mate
suggests that addiction is not just about particular vulnerable
people, but an inherent aspect of contemporary society.

His view of addiction is a big one: "...any repeated behaviour,
substance-related or not, in which a person feels compelled to
persist, regardless of its negative consequences on his life and the
lives of others." While he admits that addiction has profound
biological and psychological aspects, it is a trap to reduce this
complex problem to any 1 or 2 dimensions. "Addictions have
biological, neurological, psychological, medical, emotional, social,
political, economic and spiritual underpinnings - and perhaps others
I haven't thought about." While the addiction process has features of
illness and disease, it needs to be seen as more than that. Reductive
thinking needs to be replaced by "an appreciation of complexity."

Pointing to the evidence that addiction in the extreme is a chronic
brain condition, Mate wonders why we are so hostile to those who
suffer it and why it is treated primarily through brief treatment
episodes. Drugs alone do not produce these problems - stress,
powerlessness, emotional isolation and social dislocation are in play
as well. In addition, he reminds us of Alexander's seminal research
on "Rat Park" and data on Vietnam veterans to make the point that
social and physical environments, not genetic inevitability, evoke
biological vulnerability to addiction. Looking at his patients and
himself, he sees early development, particularly attachment and
trauma, as predicates of risk.

As an evidence-oriented practitioner, he wonders why the war on drugs
persists and the pragmatic practices of harm reduction arouse such
suspicion. He proposes an approach of "compassionate curiosity,"
which encapsulates the wisdom of many of humanistic therapies for
addiction problems.

The last section of the book ("The Ecology of Healing") starts with a
caution: what Mate is about to state is not meant as a replacement
for treatment or mutual aid. You should not be expected to do recover
if your mind is on drugs: "Under the influence of brain-altering
chemicals it's not possible for users to sustain the
self-compassionate stance and conscious mental effort required to
heal their addicted minds." What he, unfortunately leaves unanswered
is how you get there from here. And is there - doing spiritual
healing - where people need to be? To call for a change within that
privileges the spiritual path over the others is to miss the
opportunity to pull his "bio-psycho-social-plus" model together.

Take for example, tobacco use, that most addictive process of all. We
didn't decrease use through inner change, we made it more difficult
for people to find occasions to smoke. We need to look at other
addictive behaviours as much from the outside as from the inside:
what are the factors that could be changed to make the behaviour less
likely to occur? Focusing on "mental force" to overcome "brain lock"
comes close to returning to the will power model that Mate rightly
contests earlier in the book. If addiction has biological,
psychological, social, political, spiritual and other dimensions,
then each of these represents a potential vector for change. For any
particular person, the mix of factors will be different, but to keep
them all in play is more important than deferring ultimately to one
of them, especially the one that is most commonly evoked.

One final concern: if addiction exists on a continuum, does that mean
that more of us should be thinking of ourselves as addicts? Or might
we need a different vocabulary? We know a great deal about mild to
moderate addiction problems. That includes the fact that, while the
people who have them usually recognize that they are having problems,
they tend not to see themselves as addicts. Indeed, general
practitioners in medicine or in any health discipline have close
encounters with this less-severe population all the time, and are in
an ideal position to offer them effective brief interventions. There
is at least as much that can be done to help the crowd in the shallow
waters as those fewer souls in the deep end of the Downtown Eastside.
Is it because he is swimming in the deep end of the pond that Mate
tells us more about the complex nature of addictions than about the
comprehensive treatment of these problems?

Parts of this epistle from the Portland Hotel will surely aggravate
cynics and ideologues. Mate's confessional narratives make him an
easy target. Points of honest discussion emerge all along the way,
from adequacy of his addiction concept to the sufficiency of
compassionate curiosity. Yet it is important to welcome this book and
acknowledge what it accomplishes. If stigma-busting is an unfinished
task, the kind of candid and - yes - compassionate engagement, Mate
achieves here makes the book itself an act of advocacy, a call for
informed health care practices, and an invitation to community
dialogue that leads to better social policies.