“My first year of life was under Nazi occupation,” Maté says. “With the threat of deportation and death hanging over my mother. Terror and fear.” The Hungarian Army had taken his father, Andor, for forced labour. Judith, just twenty-four years old, didn’t know if her husband was alive or dead. Shortly after, her parents were taken to the gas chambers of Auschwitz. Before Germany surrendered in May 1945, some half a million Hungarian Jews were sent to the Nazi death camps, ninety percent of them murdered upon their arrival.
Maté breaks from the story to quote from a book by Hameed Ali, a Kuwaiti-born spiritual teacher and author who writes under the pen name A.H. Almaas. “The child is very open and can feel the pain and suffering going on in its immediate environment,” he reads. “The child is aware of its own body and can also feel the tension, rigidity, and pain in the body of the mother or of anyone else he is with. If the mother is suffering, the baby suffers too. The pain never gets discharged.”
Maté explains how that sort of childhood trauma physically alters the brain. “My mother could barely ensure my survival,” he says. “She could not give me the joyful, playful parenting that might help the brain develop. Then, when I’m a year old, I’m handed over to a stranger in the street, which was my mother’s attempt to save my life,” he continues. Maté’s mother left him with a Gentile woman who took him to live with relatives in an attempt to save his life. It was a logical choice, but it left him feeling abandoned and unwanted. “Under such circumstances, how does a child deal with that much stress?” Maté asks. “You disassociate, which then gets programmed into your brain, because that is when your brain is developing.”
Maté never became addicted to drugs. Of course, not everyone who has a hard childhood does. But he’s spotted other unhealthy tendencies in himself that he explains as coping mechanisms left over from Nazi-occupied Budapest. In his adult life, Maté became a workaholic; that is, he became addicted to work. “If you are a workaholic doctor, you are wanted all the time,” he says. “Your beeper is going off, and so you must be important.” He developed a compulsive shopping habit for classical music, spending thousands of dollars on CDs, many of which he never listened to. Then, in his fifties, he was diagnosed with attention deficit hyperactivity disorder, or ADHD.
“I started looking at personality development and brain development in a scientific way,” Maté says. “That’s when I first found out about how the brain is actually shaped by the environment.”
At the Portland Hotel, Maté was tasked with keeping as healthy as possible a population in which many were literally dying. A majority were diagnosed as multiple-disorder patients. They had an entrenched addiction to drugs (almost all of them using intravenously), a severe mental-health issue, and were living with HIV or AIDS. He also made regular rounds to three other hotels the Portland was running by the time he was hired.
He looked after tenants’ basic medical needs, treating them for symptoms associated with hepatitis, HIV, and frequent infections. Maté also wrote a lot of prescriptions for methadone. But, breaking from the dominant logic of the medical community, he did not see his job as curing an addiction or fixing a mental illness, per se. Instead, his job was to meet his patients where they were at, and then to help them there.
“We had no intention of controlling anybody,” Maté explains. “We had no visions of getting people off their addictions. We would want to help people do that, but we did not have an agenda for them to do that. There was no coercion in any way. If you were going to be an addict, if that is where you are at in life right now, the question was, how can we support you? How can we get you as healthy as possible? How can we, potentially, make other choices available to you?”
He concedes that many people will struggle to understand harm reduction as treatment, and responds with a comparison.
“If somebody has diabetes and their pancreas is not functioning—it doesn’t produce insulin or enough insulin—you balance their sugars as best you can, you provide them with the right dietary advice, and you give them whatever medication they need. You don’t say to them, ‘Don’t be a diabetic.’ You say, ‘You’re a diabetic and here’s what we can do for you.’
“Harm reduction does not rule out the possibility of abstinence, but it does not demand it,” he adds. “It just says, ‘Right now, this is where you’re at, so how can we work with you to make your life better?’”
The nature of the doctor-patient relationship and the psychological trauma that so many of the Portland’s tenants had experienced inevitably meant that Maté also served as a counsellor. Before too long, he began to draw connections between what he’d learned about the brain while researching his own neural development and the stories of childhood trauma that his patients recounted to him in their rooms at the Portland Hotel.
“All of these people were traumatized as children,” Maté says. “In the Downtown Eastside, not a single patient of mine had not been abused as a child. Nobody, not in twelve years.”
He is emphatic. “Every single one of them, horribly neglected and abused—sexually, physically, emotionally.”
In his second-floor office at the Portland Hotel, Maté came to understand that in seeking destructive drugs like cocaine and heroin, his patients’ brains were not functioning abnormally; rather, they were “responding in a very normal way to abnormal circumstances.”
Those abnormal circumstances usually began many years ago, he learned, when the Portland’s tenants were still just children, or even earlier. There might have been a boy who watched his father beat his mother or a girl who was raped by an uncle. Or an infant who, like Maté, was separated from their mother in circumstances beyond anyone’s control. The effect of such adverse experiences is that the child’s brain was altered.
Later, in researching his seminal book on the subject, In the Realm of Hungry Ghosts: Close Encounters with Addiction (2009), Maté combined the observations he made working at the Portland Hotel with exhaustive research on the subject. People addicted to drugs were not criminals, he concluded. They were victims.
“I didn’t study the individual brain chemistry of any of my patients, but looking at the scientific literature, it was clear to me what happened,” Maté says.
There is no one area of the human brain responsible for addictive tendencies. An addiction primarily plays out in four brain systems, each one of which is vital in shaping human behaviour. This is why an addiction is such a difficult problem to solve. If, in an attempt to address an addiction, we could flip a switch that eliminates any of these networks, doing so would simultaneously terminate a system required for human survival.
Maté lists them off: the dopamine incentive-motivation apparatus, the opioid pain-relief and pleasure-reward apparatus, the impulse-regulation apparatus, and the stress-regulation apparatus.
Each one responds to the external stimuli of childhood abuse and neglect, he continues. These changes can have positive effects in the short term. For example, in situations of abuse or neglect, the brain adjusts to help a child tune out reality and soften the emotional blows of those experiences. But in the long term, the outcome of those adjustments is a development of the brain that makes it significantly more susceptible to addiction.
The dopamine incentive-motivation apparatus
When a child is abused, its brain develops with fewer dopamine receptors. In the long-term, what happens is a person develops a need for an external supply of dopamine; cocaine, for example.
A vicious cycle begins. An addict snorts a line of coke and their brain is flooded with dopamine. Seeking to restore balance, the brain reduces the number of receptors this artificial and unusually plentiful source of dopamine has to latch onto. The addict’s sense of pleasure subsides, leaving them with a greater desire for more cocaine.
Dopamine is also crucial to the brain’s processing of incentives and motivation. This is part of the reason why an individual addicted to cocaine will prioritize drug abuse over relationships with friends and fami
ly. More generally, when the brain lacks dopamine, it feels less motivated to do anything.
The opioid pain-relief and pleasure-reward apparatus
The human brain’s natural opioid system also plays a crucial role in addiction. It has three functions vital to human survival: it regulates feelings of pain, both physical and emotional; it allows us to experience pleasure and related feelings of reward; and it is largely with the opioid system that we feel attachments to other humans.
For example, without an opioid system, a mother would feel less of a bond to her infant. Caring for a newborn baby is one of the most demanding tasks there is. Without the opioid system creating feelings of love and ultimate responsibility for a young child, the task could be abandoned and the infant would die. That is, when we talk about heroin’s effect on the brain, we are discussing a fundamental system crucial to survival—both for the individual and for the human species—and of the chemicals responsible for the very strongest of human emotions: love.
Ask a heroin addict what if feels like to inject the drug. “It’s like a warm hug,” will be among the most common responses one hears.
The relevant chemicals in these processes are called endorphins, a direct contraction of the words “endo,” meaning “within,” and “rphine,” from “morphine.” They are part of the body’s natural pain-management system, attaching to opioid receptors in order to blunt feelings of physical and emotional discomfort.
If, as a child, an individual is abused, or even if they don’t receive adequate attention, their brain’s endorphin activity will decline. Over a sustained period of abuse or neglect, a reduction in supply can become the norm. The individual is therefore more vulnerable to feelings of pain. In such cases, the person becomes more likely to seek external sources of opioids—an organic one like the opium poppy, which we process into heroin, or a chemical one like Purdue Pharma’s popular painkiller, OxyContin.
The impulse-regulation apparatus
The effects that narcotics have on the dopamine and opioid systems have profound consequences for impulse control.
One section of the brain where receptors for those chemicals are concentrated is the orbitofrontal cortex, which is located just behind our eye sockets. It is the orbitofrontal cortex where we rapidly process potential decision outcomes on the basis of short and long-term results; that is, whether or not we should act on an impulse and what consequences any action might bring. The orbitofrontal cortex is also strongly connected to the brain’s limbic centres, the primary home of emotions, which makes it susceptible to responding inappropriately because of past traumatic experiences. The area of the brain that influences decisions about the potential pros and cons of a considered action can be impaired by early childhood adversity in ways that make us more susceptible to addiction.
Take the example of a woman who sells her body for money. The idea was once likely unconscionable, given the high emotional cost versus the relatively low material gain. But trauma and addiction can change the outcome of that equation. In the woman’s limbic system, she feels emotional pain related to childhood memories of sexual abuse. In the orbitofrontal cortex, she subconsciously recalls the power of heroin to dull those feelings. The impulse to acquire the drug becomes difficult to control—almost impossible, for many addicts. The woman finds she can tolerate the shame and disgust that many people associate with sex work in exchange for a few hours numbed on heroin.
The stress-regulation apparatus
Finally, childhood trauma will affect how a brain feels and responds to stress.
In manageable doses, stress is good. It helps us complete work assignments on time and study for tests in university. But prolonged periods of elevated stress can adversely affect our health.
Humans address feelings of emotional discomfort caused by stress with different methods. Often, these are external. A warm bath works for some people but not everyone. What does relieve stress for just about all humans are narcotics like cocaine and heroin, at least in the short term. The extent to which an individual seeks external comforts is affected by how well internal stress regulators are functioning.
If a girl or boy is raped as a child, they will be overwhelmed by stress. At chronically elevated levels, their biological systems for the natural regulation of stress hormones will develop improperly.
At birth, humans are completely helpless to regulate stress. A newborn baby can scream for hours in response to even the most minor of discomforts. They depend entirely on their parents to respond and help manage their emotions. The stress-regulation system remains in its early stage of development for some time. If a toddler experiences prolonged periods when stress-hormone levels are elevated, the development of their regulation apparatus will suffer. They will experience difficulty regulating impulse-responses; for example, perhaps they feel anxiety concerning who receives the first piece of a cake, and in response they physically attack another child. Years later, teenagers will shout at their parents and stomp their feet when they feel anxious about a social gathering they are forbidden from attending. It takes humans a very long time to develop appropriate responses to stress.
Faced with stressful circumstances later in life, someone who suffered abuse as a child will have grown more likely to seek external sources of comfort.
“People who use opiates, very often they are medicating post-traumatic stress disorder,” Maté says. “It is a way of reducing the symptoms temporarily.”
There is data supporting Maté’s emphasis on childhood trauma as a determinant of one’s likelihood of developing an addiction to drugs. The landmark Adverse Childhood Experiences Study found that a person who underwent four or more traumatic events as a child was 7.4 times more likely to develop a problem with alcohol compared to someone who experienced no significant trauma as a child. The same group was 10.3 times more likely to use injection drugs.32 A related study found that a child even just witnessing traumatic events (spousal abuse, for example) resulted in a positive-graded risk (the more events, the greater the likelihood) for later developing problems with alcohol and illicit drugs.33
In the under-developed brain of an adult, stress becomes significantly more likely to perpetuate an addiction or prompt an individual to relapse and return to an abusive habit that was previously under control.
Maté recalls that this effect was everywhere he looked during his time as a physician in the Downtown Eastside. The primary source of stress was the prohibition of drugs. “If you had to design a system to stress people, you would design the current legal system,” he argues.
Most people addicted to drugs are engaging in one form or another of self-medication, says Maté. They are attempting to suppress memories of childhood trauma or sooth feelings of lifelong abandonment. But the substances that many of these people chose to use as medication have been made illegal—arbitrarily, Maté insists. And since they are addicted, forced to seek these substances out several times a day, their life becomes one that is as stressful as anyone could imagine. “If they are caught with it, they are jailed,” he says. “If they deal it a little bit to support their habit (which most of them do), they are jailed for longer.”
The first thing prohibition does is create a feeling of anxiety for supply. Where will the next hit come from? When the consequence of failing to obtain the drug is as severe as heroin withdrawal, the associated stress is extreme. Next, like a squirrel in a park, a drug addict is forced to remain vigilant at all times, constantly on the lookout for threats posed by police. Will their dealer cheat them? Forced to buy drugs in an alley, there’s a risk they will be robbed. What would a friend or family member think of what they are doing? It all creates stress, which builds a desire for more of the drug that can relieve them of those feelings.
“You make them afraid, you make them live outside the law, you ostracize them, and you demean them,” Maté says. “That is a great way to create stress in people. It is a great way to keep them mired in addiction.
“I saw it
every day,” he continues. “Their very lives were a reflection of the effects of prohibition. Having to spend all their energy looking for the drugs, having to scrounge around for the next hit, having to shoplift, getting arrested all the time, moving through the revolving door in and out of jail, the experiences they had in jail, their furtiveness, their fear. Everything. Everything I saw in them was a reflection of prohibition.”
In the Portland Hotel, Maté, Evans, and Townsend acknowledged that the majority of their tenants were victims and would be treated as such. They began breaking the rules to free tenants who were addicted to drugs from those stresses caused by prohibition.
Maté would, for example, perform an act he says he never would have imagined engaging in: in a dingy hotel room, he helped an addicted man find a vein in his arm to inject some illegal concoction. “If I hadn’t done so, he was going to inject in his neck, risking a brain abscess,” Maté explains.
“Liz and Mark are the same way,” he says. “It’s not even that they are rule breakers. They created new rules. They saw a necessity and they fashioned what they would do around that necessity.
“Most institutions try and fit the clients and everything into a set of top-down priorities,” Maté continues, “whereas Liz began with a simple question: What do these people need? What’s actually required?”
32Vincent Felitti, Robert Anda, Dale Nordenberg, David Williamson, Alison Spitz, Valerie Edwards, Mary Koss, James Marks, “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” American Journal of Preventive Medicine 14 (4) (1998): 245-258.
33Shanta Dube, Robert Anda, Vincent Felitti, Valerie Edwards, David Williamson, “Exposure to Abuse, Neglect, and Household Dysfunction Among Adults Who Witnessed Intimate Partner Violence as Children: Implications for Integrated Health and Social Services,” Violence and Victims 17 (1) (February 2002): 3-17.
Fighting for Space Page 17