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REVIEW: In Realm of Hungry Ghosts by Gabor Maté

In the Realm of Hungry Ghosts was written originally published in 2008 and then updated to include a new introduction by the author, Gabor Maté, in 2010. I read the 2010 version of the book. For context, I read the book as an assignment in a graduate-level substance abuse and addictions course. My assignment was to provide a reaction to the book, rather than a summary.

Summary

In the book, In the Realm of Hungry Ghosts, author Gabor Maté shares his multifaceted perspective of the underlying processes that drive addiction, based his personal experiences as a doctor at North America’s first supervised injection site: the Portland Clinic in Vancouver’s Downtown Eastside. The time that he spent in this clinic exposed him to the deep complexities of addiction and he shares the harrowing stories of the people who struggle with it. Most of these stories end tragically and Maté’s argument is that they don’t have to, if we as a society begin to see addiction for what it truly is and begin showing greater compassion and empathy toward those who are afflicted, especially given that we are all likely in the throes of it ourselves.

Maté suggests that we are all prone to some form of addiction. To drive this point home, Maté shared his own addictions to work, music, and the need for admiration. He openly discussed the power that these addictions had over him and the shame that he felt, knowing how his behaviors affected his relationships with his wife and son. Through his self-reflection, he connects the biology of addiction to the psychology and sociology of addiction, arguing that an effective solution will require a cultural shift around societal views and language about the nature and cause of addiction. Namely, society should stop stigmatizing and punishing addiction, which only serve to worsen the issue. Maté argues that the only way to design effective policies is by demonstrating compassion. The only way we demonstrate compassion is by holding a mirror up to ourselves.

Reaction

Maté’s proposal is novel because his explanation of the biology of addiction breaks from traditional medical understandings that assume that drugs themselves cause dependency. For example, the idea that someone can become addicted to a substance (e.g., heroin; methamphetamine) through a single exposure, alone. Maté suggests that these definitions are narrowly focused on biological mechanisms (e.g., genes; neurobiology) and ignore environmental contributors, particularly those that cause repeated traumas. Breaking from this traditional view, Maté adopts an integrative approach that is informed by evolutionary psychology, neuroscience, socioecological theories, and psychodynamic perspectives of trauma which highlight the role of family in producing self-perpetuating, intergenerational cycles of trauma and addiction. In other words, an individual is born with a unique genetic predisposition that determines their risk for addiction, but the expression of these genes occur within an environment that has the capacity to affect this process from the moment of conception. Within this framework, infancy and early childhood experiences are especially important for determining one’s risk for addiction later on in life, particularly traumatic ones such as emotional neglect and abuse, because of our heightened vulnerability and sensitivity at the molecular biological level, which is consistent with existing theories of health and development (e.g., Barker, 2004). Maté then suggests that all people are vulnerable to addiction and that our addictions are a natural way to cope with these past and current traumas. One persons trauma often inflicts trauma onto to others, which is how this self-perpetuating cycle becomes locked into place.

In many ways, my conceptualization of addiction is consistent with Maté’s. I also view addiction as the outcome of complex interactions between biological and environmental factors. Similar to Maté, my understanding is also grounded within a life course perspective that integrates interdisciplinary explanations of health-related behaviors and outcomes (e.g., Ben-Shlomo & Kuh, 2002; Elder Jr., 1994) such as substance use. However, one difference between my and Maté’s perspective is that I am less privy to his focus on trauma.

Tautological Arguments

Maté’s conceptualization of, what I will call, the “long-arm of trauma” is often tautological and unsatisfying in explaining why some individuals become addicted to substances whereas others form behavioral addictions. For example, Maté suggests that his son, Daniel, did not develop a chemical addiction, despite his “neglectful or abusive” parenting (p. 248), because he must have mirrored and attended to Daniel’s emotions in a way that his son interpreted as loving—through a process that Maté refers to as attunement (pp. 249-254). In other words, if a person is addicted, they must have experienced what they perceived as traumatic. No addiction means no perception of trauma. What predicts the perception of trauma? The parent’s own experience with trauma, of course. Evolutionary explanations tend to follow the same logic. Notice the circularity. These tautological explanations cannot be tested nor disproved. Consequently, they do not lend to well predictive modeling or proactive intervention, which are necessary for both effective policy and clinical solutions.

Shallow Considerations of Inequality and Discrimination

A more comprehensive framework would allow for testable hypotheses while also providing explanations for observed differences in individual propensities for addiction. For example, Maté could explicitly point to social inequities as the fundamental causes (e.g., Phelan, Link, & Tehranifar, 2010; Mezuk et al., 2013) of addiction, where trauma is simply one of many risk factors, particularly among those who are socioeconomically disadvantaged. The social inequities perspective would provide more potential mechanisms for explaining why some individuals do or do not develop an addiction to substances despite experiencing early-life disadvantages and traumatic events (e.g., culture; religion; access to healthcare), while preserving the emphasis on our collective responsibility in enacting policies that improve the lives of those who are suffering from addiction.

I generally felt disappointed that Maté did not more explicitly address the issue of systemic inequalities such as racism or sexism anywhere in his book. He made some overtures to these social inequalities when he discussed the concept of dislocation, the drug war, and the idea of freedom of choice, but his coverage was inadequate, especially given the amount of scholarly literature he easily could have referenced. I believe that social inequities are critical for understanding disparate outcomes such as differences in the risk of forming substance addictions and the consequences that may ensue. For example, Maté discusses the expensive failure of the War on Drugs (WoD) in achieving its objective of curbing substance use but he failed to truly give credence to the traumatic consequences that result from the unequal enforcement of drug policies—I would argue the lack of acknowledgement of unequal law enforcement, in general. Consider that in the U.S., Black men are five times more likely than their White counterparts to be incarcerated (Nellis, 2016). These men of color are also more likely to be directly targeted under the name of the WoD (Cooper, 2015), and severely injured or killed during the process of arrest despite being unarmed (e.g., Eric Garner; Jacob Blake; Rayshard Brooks). Thus, with respect to the WoD, the likelihood of trauma is unevenly distributed across the population due to discriminatory practices. Maté’s failure to address this point opens the possibility that addiction could mostly be the outcome of structural issues, rather than traumatic experiences. To be clear, I don’t necessarily endorse this belief. I’m simply pointing out the weaknesses of his framework.

Ignoring the Diversity of Human Motivations

The long-arm of trauma approach also ignores other characteristics that I believe are generally a core and common part of human behavior. For example, the role of curiosity in motivating our behaviors and/or the desire for acceptance. Humans are generally very naturally curious creatures and there are plenty of qualitative accounts that suggest that individuals will try a certain drug because they are inquisitive about its effects on their mind and body, rather than for self-medicating purposes to alleviate trauma. Humans may also develop a substance habit through social motivations such as drinking at parties to fit in with their friends or smoking during breaks at work to bond with their co-workers. If these behaviors were repeated on a consistent basis and within a common social setting, an individual could easily form a habit around these substances because of their addictive chemical properties combined with environmental reinforcers, regardless of whether or not they experienced trauma. This is especially true for children and adolescents, whose brains are actively developing and are therefore less able to consider the potential long-term ramifications of their behaviors, relative to an adult. The narrow focus on sad and traumatic stories overshadowed these alternative explanations.

Base Rate Fallacy

Maté’s tendency to ignore potential alternative explanations may have been due to a common fallacy known as the base rate fallacy. Maté suggested that there was a dearth of evidence to support his trauma hypothesis but he appeared to reach this conclusion based on his observations that largely concentrated only on those with substance addictions, rather than a randomly distributed population. In other words, Maté looked backwards at evidence among those with substance addictions, ignoring the possibility that this may lead him to overestimate the prevalence of trauma. Consider the statistic that he sited stating that 50% to 100% of female substance abusers reported victimization (p. 202). We should not assume that 100% of women who are victimized will develop a substance use disorder in the future. The application of Bayes’ theorem would be useful here. To understand the probability of forming an addiction in relation to trauma, we must consider the conditional probability of addiction given that a traumatic event occurred.

Basically, we need to consider the likelihood of falsely concluding that trauma predicts addiction.

Strengths of Máte’s Approach & Conclusion

Regardless of my arguments about the shortcomings of Maté’s framework for understanding addiction, I admit that his eloquent writing and masterful storytelling was a powerful method for evoking empathy from the reader. Whereas more nuanced arguments would likely have failed, his emphasis on trauma is highly relatable for any reader and enables them to engage in critical self-reflection. Maté’s transparency and vulnerability around his own struggles made this framing all the more compelling and invites the reader to evaluate their own life and behaviors with him. I certainly found myself repeatedly and critically considering how my experiences may have manifested as addictions. Particularly in Part III and Part IV of his book, where he explained the neurological processes that underlie our behaviors, I found myself at times despairing over what may amount to permanent defects rooted in painful personal experiences. I am certain that I am not alone in feeling this way when reading his book and I think it is this emotional intensity that intimately connects the reader to anyone who suffers from an addiction, regardless of type and severity. Through this lens, Maté powerfully demonstrates that the best way to address the issue of addiction is to take a good hard look at oneself, which represents the first and most important step toward effectively helping others.

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