USABP & IBPJ Forum: Integrating Trauma and Addiction Treatment
Treating Addiction, Trauma and Emotional Loss Together:
A Clinical & Historical Perspective by Gabor Maté
“Your addiction was your attempt to solve a problem. That problem was that of emotional pain, and hence my mantra...Ask not why the addiction, ask why the pain.” - Gabor Maté
Gabor Mate is a retired physician who after 20 years of family practice and palliative care experience worked for over a decade in Vancouver's Downtown Eastside with patients challenged by drug addiction and mental illness. The best-selling author of four books published in 30 languages, Gabor is an internationally renowned speaker, highly sought after for his expertise on addiction, trauma, childhood development, and the relationship of stress and illness. His book on addiction, In the Realm of Hungry Ghosts, received the Hubert Evans prize for literary nonfiction. For his groundbreaking medical work and writing, he has been awarded the order of Canada, his country's highest civilian distinction, and the Civic America award from his hometown Vancouver.
I've worked in Vancouver’s Downtown Eastside in British Columbia. In the few square blocks of Downtown Eastside, North America’s most concentrated area of drug use, we have more people injecting, inhaling, ingesting substances of all kinds than anywhere in the Western world. I was the physician at North America's first supervised injection site here in Vancouver. My patients were afflicted with mental illness, HIV, hepatitis, all the complications of addiction. 30% of them were Indigenous Canadians. Indigenous Canadians make up 5% of the general population but 30% of our jail population and 30% of the population in the Downtown Eastside, which already tells you that addiction isn't simply an accidental random event. It has to do with history, personal history, and the history of a culture.
Now, why is it that Indigenous people in Canada suffer so much? Because they happen to be the most traumatized segment of the Canadian population. For hundreds of years, they were subjugated, their culture was extirpated, their children were abducted from them, forced to be in residential schools under church guidance where they were beaten, sexually abused, emotionally abused, starved. Thousands died. They're just discovering the bodies right now. In those communities, there are high rates of suicide, high rates of addiction, high rates of mental illness, high rates of physical illness, and high rates of sexual abuse of children. And again, high rates of addiction.
In other words, historical and personal trauma has everything to do with addiction.
What is addiction?
I define addiction as a complex psycho-physiological process manifested in any behavior in which a person finds pleasure and relief and therefore craves, but suffers negative consequences without being able to give it up. So: craving, pleasure and relief in the short term, negative consequences in the long-term, and the inability or refusal to desist, that’s what addiction is. Note I have said nothing about substances, because clearly people can be addicted to drugs, nicotine, caffeine, crystal meth, heroin, alcohol, but also of course, to sex, pornography, work, power, profit, gambling, the internet, cell phones, and everything else you can think about. The issue is not the external target or the behavior — the issue is one’s internal relationship to it. If there's craving, pleasure and relief in the short term, harm and inability to give it up, that's what addiction is.
And now I simply ask all those of you who recognize that at some time or another, you had some kind of an addictive pattern in your life to please raise your hands. Thank you. Hardly anybody leaves their hand down if they're honest with themselves.
“The assumption is that people are consciously choosing to use certain substances illegally and therefore they deserve to be punished. Complete and utter scientific nonsense.”
Now, this is where the whole cultural bias about what addiction is shown to be totally false. People make two assumptions about addictions. Number one is that it's a choice people make, a failure of will, a character flaw, a deficiency of moral power. That's one assumption. In fact, that's the assumption that drives the legal system. The assumption is that people are consciously choosing to use certain substances illegally and therefore they deserve to be punished. Complete and utter scientific nonsense. I won't spend a moment trying to refute it. (I would if I had time.)
The second assumption is a little bit more interesting, a little bit more accurate, but still misleading. It’s that addiction is a disease of the brain that somehow is generated significantly by genetic factors. That's what the medical belief is. There are some elements of truth to it, but it's fundamentally inaccurate. Addiction is not a process that begins in the brain and there are no addiction genes, never have been, nobody's ever found one. Nobody will ever find any either, contrary to what you're told.
“Therefore, the treatment of addiction needs to be not simply stopping the behavior, which is only a symptom, but dealing with the underlying embodied trauma.”
So, what is the source of addiction then? For those of you who raised your hands, I'll ask you a question: Whatever your addiction process was focused on, behaviors, shopping, gambling, eating, drugs, whatever it was, the question is not what was wrong with it. You already know that. The question is: What was right about it? I'm going to ask you to put into the chat what that addiction temporarily gave you that you were looking for. What did you like about it?
So, let's just see some of these answers. What did the addiction provide for you that you appreciated? Okay. Numbness, relief, distraction. Thank you. Relief, escape, avoidance, sedation. Thank you. That's good enough.
When do people need to be numb? When they're in pain.
What do people need distraction from? Painful internal body states, vagal states, and emotional states.
What do people need to escape from? Distress.
In other words, it gave you self-soothing, it gave you pleasure. The addiction wasn't your primary problem. Your addiction was your attempt to solve a problem—the problem was of emotional pain. And hence my mantra: Ask not why the addiction, ask why the pain.
Of course, that pain is not just mental or emotional, it's also an embodied thing. You can feel it, the tension in your neck, in your shoulders, in your belly, in your intestines, in your throat. And of course, in your mind. So, again, not why the addiction, but why the pain. Now, if you want to understand why the pain, you can't look at people's genes or choices. You have to look at their lives.
And this is where trauma comes in. I don't think I need to review for you the voluminous literature that has linked addictions to trauma, the Adverse Childhood Experiences Study, and so on. What we know without a shadow of a doubt is that addiction is rooted in childhood trauma. I don't have time to go into it, but childhood trauma not only gives you emotional pain, it also affects the body as this group would know. And it also shapes and programs the circuits of the brain that then become more prone to addiction, the natural opiate circuits, the dopamine circuits, the stress regulation circuits, the impulse regulation circuits.
So, to bring this to a close, I‘ll sum up. Addiction is a desperate and forlorn but totally understandable attempt to deal with the impact of trauma. Addictions are far more common in this toxic culture than most of us realize. Therefore, the treatment of addiction needs to be not simply stopping the behavior, which is only a symptom, but dealing with the underlying embodied trauma. And for those of you who would like to read more about this. my book on addiction is called In the Realm of Hungry Ghosts: Close Encounters with Addiction. And the same subject is also taken up in the book to be published this fall, The Myth of Normal.
With that, I will stop. Thank you.
Gabor Maté’s next book, The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture is due to be published Autumn 2022.
The video of the USABP/IBPJ Forum Integrating Trauma and Addiction Treatment: A Paradigm Shift is available at, https://youtu.be/bB1M6J5OQcs