Pubdate: Tue, 06 May 2008
Source: Canadian Medical Association Journal (Canada)
Copyright: 2008 Canadian Medical Association
Author: W.J. Wayne Skinner, MSW RSW, Deputy Clinical Director, 
Addictions Program, Centre for Addiction and Mental Health, Toronto, Ont.


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.
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MAP posted-by: Jay Bergstrom