Author: Gabor Mate
This book is a uniquely invaluable insight into the deep roots and dreadful manifestations of addiction, what the author portrays as ‘one of the commonest and most human manifestations of torment’ (page xxix). Whilst the major focus of the book is substance abuse, the author also addressed other addictions such as pathological gambling, food addiction, compulsive shopping, and sex addiction, emphasising that all these are driven by the same brain processes (pages xvii, 215-217 and 232-247). Taking it’s title from the domain of the Buddhist Wheel of Life which encompasses addiction, the book reveals the terrible toll of drug dependence and other forms of addiction on the lives of the author’s patients who live in Downtown Eastside of Vancouver. The book opens a sympathetic window into how they ‘spend almost all their time as hungry ghosts‘ trying to escape ‘overwhelming fear, rage and despair’, at the same time contending with a society which has ‘often dismissed and discounted (them) as unworthy of empathy and respect‘. It is instructive that the author’s motivation for writing the book is his belief that there is much to learn ‘in the dark mirror of their lives’, and in their ‘ill-fated struggle‘ to overcome their tribulations (pages 1 and 2).
In his meticulous depiction of addiction, the author defined it as any behaviour that a person feels compelled to undertake repeatedly ‘regardless of its negative impact on his life and the lives of others’, and he listed its hallmarks as ‘compulsion, impaired control, persistence, irritability, relapse and craving‘ (pages 128-129). He makes it clear that addiction is not merely the pursuit of pleasure but a desperate attempt by the addict to soothe or distract from emotional pain, alienation, emptiness, and the ‘sense of personal inadequacy‘ (page xix and 31-33). In the author’s opinion, addictions very frequently arise from the absence of an ‘attachment relationship‘ in the early years, and this is sadly often the outcome of physical or sexual abuse, and the humiliation, rejection, abandonment, and a ‘deep psychological sense of isolation‘ that follow (pages 34, 42, 138, 180-187, and 205-207). Most addicts therefore never had the opportunity to attain psychological maturation, the knowledge that the self is different from the internal feelings that are dominant at any specified time. Because of this, the author asserted, addicts often never acquired the ability to control their sudden feelings, urges and desires, and they therefore constantly ‘need to fill their minds or bodies with external sources of comfort‘ (pages 226-227).
At the heart of the book is the heartbreaking portrait of the tragic lives of addicts whose existence is full of such overwhelming sorrow that the author declared his prose ‘is unequal to the task of depicting such nearly inconceivable trauma‘ (page 35). He characterised all forms of addictions as harmful because they ‘take a toll on human health and happiness‘, they exact ‘the price of inner peace, harm to relationships, and diminished self-worth‘, and they leave in their wake shame, denial, subterfuge, and dishonesty (page xxv). The author graphically described how addicts, in the ‘relentless pursuit of their cravings, and in the hope of ‘making the moment liveable‘, end up jeopardising their lives. It is telling that under the spell of their urgings, addicts are not only willing to sacrifice their relationships and their dignity, but they will also imperil their lives and livelihoods (page 28). The final outcome of addiction is therefore understandably catastrophic, the author admitting ‘the uncomfortable truth’ that ‘most of our clients will remain addicts who may die from their habit when they ‘do a bad fix one night and die of overdose‘. Equally heartbreaking is that many of them will either acquire infections such as HIV, Hepatitis C, meningitis or septicaemia, or they may develop early age cancer as a result of their ‘stressed and debilitated’ immune systems (pages 12 and 16).
Nothing illustrated the true burden of addiction than the author’s graphic portraits of the grim lives of his addicted patients. One of the such disheartening but insightful anecdotes was that of the ‘complex and luminous’ Serena, his patient who became ‘wired to drugs‘ after she was sexually exploited by her uncle and grandfather from the age of seven, and gave birth at the age fifteen; during most of this time she was looking after her younger siblings and living with a drunken grandmother who couldn’t protect her (pages 45 and 53). The author therefore argued that Serena’s addiction must be viewed in the context of ‘a human being suffering unimaginable pain, soothing it, easing it in the only way she knew’, and she must not be reduced to just ‘an addict…wanting more drugs’. Indeed it is Serena’s life story that taught the author that ‘there is a natural strength and perfection in everyone…even though it is covered up by all kinds of terrors and all kinds of scars‘ (pages 51-55). Another touching case study was Julie; ‘beaten by her foster family from age seven’, she had ‘slashed herself when she was only sixteen’, and has then ‘worked the streets‘ and ‘used a cocktail of painkillers, alcohol, cocaine and heroin‘ (page 22). Another illuminating story was that of Celia whose story of sexual exploitation by her stepfather from the age of five made the author reflect on the kinds of ‘depravity adults can inflict on the young and the unprotected‘. Claire’s similar story of being ‘raped repeatedly by her father…while her mother either didn’t notice or looked away’ explained why her ‘need for endorphins is as insatiable as her need for the dopamine hits she gets from cocaine’ (pages 62, 68, and 172 and 165). The author also wrote openly about his own addiction to buying classical music, a yearning that ‘generates an irresistible gravitational field’ which is ‘relieved only when I succumb‘ (pages 94 and 103-104).
A recurring theme in the book, which deeply concerned the author, is society’s negative social view of addicts. Describing this unjustifiable attitude as ‘intolerant and self-defeating‘, and the ‘public discourse concerning drug policies’ as uninformed, the author noted that these misconceptions sadly manifest as social ostracism and as institutionalised contempt for addicts (pages 17 and 285). The author particularly condemned the practice of blaming and punishing addicts for their behaviour, arguing stridently that they suffer from a brain disease which impairs their ability to make rational decisions (pages 146-147). Whilst he disapproved of ‘their refusal to take responsibility’ and their ‘compulsive deceit‘, the author nevertheless highlighted their positive attributes, for example their refreshing authenticity (pages 22 and 24). The book therefore appealed to society to recognise addicts ‘as human beings who are legitimately part of the social fabric, deserving compassion and respect‘; he urged people to ‘give up any hint of moral superiority and judgment toward the addict’, and society to consider their ‘reintegration…into the larger community’ (pages xxii and 295-297).
The care of people with addiction was a major topic the book addressed, the author particularly keen to redress the disadvantaged status of addicts within healthcare. The author noted that many medical personnel treat addicts ‘with arrogance and insensitivity‘ because they have received ‘little, if any, training on the subject of addiction’; they are therefore unaware of how addiction impacts the addict’s ‘physical and mental health, longevity, productivity and family life‘ (page xxvi). Admitting that it takes great ‘emotional imagination to empathize with the addict’, the author nevertheless encouraged carers to envisage the addict as ‘the child in the adult‘, and see ‘his soul fragmented and isolated’ as he ‘hustles for survival‘ (page 35). The author makes it clear that ‘our only choice is between compassion and indifference‘, emphasising that there is no justification to turn addicts away on the assumption that their predicaments are self-invoked, and the notion that their habits are difficult to break. Stressing that the only way to ‘reach‘ drug addicts is to accept them unconditionally for who they are, the book advised physicians to ‘open up a healing space‘ in themselves so that they can find it in the addict. The author therefore urged healthcare practitioners to patiently identify the source of the the addict’s pain, and to liberally implement harm reduction policies such as methadone prescription and needle exchange programmes (pages xxiii-xxiv, 49, 87, 385 and 315-319). He specifically advocated against government policies which criminalise drug use and punish addicts, people who ‘historically have suffered the most enduring trauma and dislocation‘ (page xxi).
This is an all human book which reveals the real lives of addicts which the author has managed during the course of his career as a psychiatrist. Whilst the book discusses the academic and theoretical dimensions of addiction, the book’s main themes are the real sources and the lived consequences of dependence. It depicts the spiralling endless life cycle of the addict, pointing out that addiction is as much the product of circumstances beyond the addict’s control as it is a result of the biological mechanisms that makes the addict almost powerlessness to resist their cravings. The author’s narrative style counterpoises academic facts with illustrative anecdotes in such a way that it enlightens and infuses empathy at the same time. It is difficult to come away from reading the book without a more compassionate and less condemnatory perspective of addiction.
Addiction is a ubiquitous and growing problem, with ramifications in society generally, and healthcare specifically. A largely ignored subject, commensurate with the disdain the victims endure, this book is a worthy attempt at reversing the situation. By painting the truly distressing lives of addicts, noting the brutalising triggers that are not of the addicts making, the author invokes the empathy that is required to address the problem at the social and clinical spheres. The book offers practical recommendations for managing all aspects of addiction, and I highly recommend it to all doctors.
Publisher, Place, Year: Vermillion, London, 2018
Number of chapters: 34
Number of pages: 465
Star rating: 5