Treating Addiction: A Top Doc Explains Why Kind Love Beats Tough Love

Using punishment to try to rehabilitate people who have already suffered years of punishment doesn't work

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Drug users at Canada's Insite injection room in Vancouver's Downtown Eastside.

Dr. Gabor Mate is renowned in Canada for his work in treating people with the worst addictions, most notably at Vancouver’s controversial Insite facility, which provides users with clean needles, medical support and a safe space to inject drugs.

Canada’s Conservative government has tried to shut Insite down, but the country’s Supreme Court ruled late last year that doing so would contravene human rights laws because the program has been shown to save lives.

In Mate’s book In the Realm of Hungry Ghosts: Close Encounters with Addiction, which was a No. 1 bestseller in Canada, he advocates for the compassionate treatment of addiction, a position that is increasingly receiving international attention. Healthland recently spoke with Mate about the causes and consequences of addiction and what to do about the problem.

How do you define addiction?
Any behavior that is associated with craving and temporary relief, and with long-term negative consequences, that a person is not able to give up. Note that I said nothing about substances — it’s any behavior that has temporary relief and negative consequences and loss of control.

When you look at process or behavior — sex, gambling, shopping or work or substances — they engage the same brain circuitry, the same reward system, the same psychological dynamic and the same spiritual emptiness. People go from one to the other. The issue for me is not whether you’re using something or not; it’s, Are you craving, are you needing it for relief and does it have negative consequences?

Do you believe all addiction results from trauma?
I think childhood trauma or emotional loss is the universal template for addiction. It also depends on how you want to define trauma: if you want to define it as something bad happening, then it’s true that not every addict [has experienced trauma], in the sense of a death of a parent or violence in the family or child abuse, or any of the usual markers of trauma.

But there’s another [way to define it]. D.W. Winnicott [the late British child psychiatrist] said that there are two things that can go wrong in childhood: things that happen that shouldn’t happen — that’s trauma — and things that should happen that don’t happen. Children are equally hurt by things that should happen and don’t as they are by things that shouldn’t happen but do. If the parents aren’t emotionally available, [for example], no one will define that as trauma, but it will be for the child. If a mother has postpartum depression, that’s not defined as trauma but it can lead to emotional neglect and that interferes with child brain development.

(MORE: How Childhood Trauma Can Cause Adult Obesity)

It’s impossible for a parent to be emotionally available all of the time, however.
The parent doesn’t have to be perfect. In our society, it’s not [just] a question of whether parents are doing their best or love their kids or not, it’s that parents are often isolated and stressed or too economically worried to be there. What I’m saying is that early emotional loss is the universal template for all addictions. All addictions are about self-soothing. And when do children need to sooth themselves? When they are not being soothed.

You practice a harm-reduction approach to addiction, in which you provide clean needles and safe spaces for addicts to inject drugs. Americans have long tended to see this as “enabling” and typically view it as a bad thing because it doesn’t require addicts to be abstinent to receive care.
The question is, Is it better for people to inject drugs with puddle water or sterile water? Is it better to use clean needles or share so that you pass on HIV and hepatitis C? This is what harm reduction is. It doesn’t treat addiction, it just reduces harm. In medicine, we do this all the time. People smoke but we still give them inhalers to open airways, so what’s different? You’re not enabling anything they’re not already using.

Some critics claim that it prevents addicts from “hitting bottom” and getting off drugs entirely.
I worked for 12 years in the Americas’ most concentrated area of drug use, the Downtown Eastside of Vancouver. People live there in the street with HIV and hepatitis and festering wounds: what more of a bottom can they hit? If hitting bottom helped people, there would be no addicts at all in the Downtown Eastside. ‘Bottom’ is very relative, so it’s a meaningless concept. For me as a doctor, rockbottom might be losing my medical license, but what is a bottom for a person who has been abused all her life and lives on the street? It’s meaningless and false. People don’t need more negative things to happen to them to give it up. They need more positive things to happen. In 12 years of work on the Downtown Eastside, I didn’t meet an [addicted] woman who was not sexually abused as a child.

[Addicts] relationship to authority figures is one of fear and suspicion. How will it help if I punish them more? They need the very opposite. We end up punishing them for self-soothing. It makes no sense at all. Harm reduction is not an end in itself. Ideally, what it is is a first step towardsa more thorough-going [recovery], but you have to begin with where people are at.

When I’ve visited harm-reduction programs, it seemed that the clean needles and other tools weren’t the most important thing they provided. Rather, it was the message that ‘I believe you are worth saving, even though you are still using drugs.’ That touches people and opens doors.
That’s the key. Quite apart from clean needles and sterile water, the most important factor is for the first time saying to someone who has been rejected all their life, ‘We’re not going to judge you based on how you present your needs at the present moment.’ Harm reduction is much more than set of practices; it’s a way of relating to people. We’re not requiring you to stop using or do anything, we’re just trying to help you get healthier. At least you’re not going to suffer an infection of the bone marrow because you’re using a clean needle: is that not worth something? We’re here to reduce suffering. They may not get better in the sense of giving up the addiction, but that’s not a limit of harm reduction — that’s a limit of the treatment system.

[There are a lot of things] we can’t do in the context of a war on drugs. When people are attacked and stressed, we can’t hope to rehabilitate them [well]. That’s not a valid criticism of harm reduction; it’s a failure of the medico-legal approach we have right now to addiction.

People describe addicts as behaving compulsively in the face of negative consequences, but the same could be said of our drug policy.
It’s almost an addiction because we keep doing something with negative consequences and don’t give it up, and it gives a kind of emotional relief because people feel a lot of hostility towards addicts. Seeing someone jailed certainly provides some satisfaction and relief, but it’s not an evidence-based [treatment for addiction]. There are also a lot of other consequences we experience as a society by avoiding the connections between trauma and illness. Trauma is the basis for not just mental illnesses and addiction specifically, but also often for cancer and all kinds of other conditions [due to the effects of early childhood stress on the brain and immune system]. Society doesn’t look at it. We look at the effects and blame people for the effects but we don’t look at causes.

Why?
Because we live in a culture that promotes addiction, left, right and center. Addiction essentially is trying to get something from the outside to fill a gap and soothe pain. The entire economy is based on people seeking soothing from outside. The addict symbolizes all of our self-loathing.

The expression “the scapegoat” is very specific. The term in the Bible means a goat on whom the community symbolically imposed all its sins and then chases it into the desert. That’s what we’re doing with addiction. All the desperation to soothe pain and fill in emptiness from the outside that characterizes our culture, the addict represents. We hate to see that so we scapegoat them and think that way we are getting rid of our own sins.

So what can we do?
First of all, I would recommend that prevention has to begin at the first prenatal visit. Stress during pregnancy — contrary to the genetic view — has a large impact. Second, in the U.S., [you need] yearlong paid maternity leave. In other words, I would provide support and emotional nourishment for the child — and that comes from support for parents.

In term of addictions, first of all recognize that these people are traumatized and what they need is not more trauma and punishment but more compassion.

(MORE: 10 Reasons to Revisit Marijuana Policy Now)

What most surprised you in working with some of the most severely addicted people?
What’s most astonishing is just how people survive, no matter what. Even amid drug dealing and mutual ripoffs, there’s still a tremendous amount of caring. The same people who rip each other off would sometimes also go to great lengths to help each other. Despite all the pressure and suffering, to see people reach out to each other like that was the most astonishing thing I saw. When someone was sick, how people gathered around and helped, how they would share food with each other and some would volunteer and go at night and look after the young sex trade workers to make sure they were not getting hurt. There is that acceptance and community, and people need community. Especially for people who have not had emotional support, that community is very powerful.

Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.

28 comments
Juju Costa
Juju Costa

only love can cure my eating disorder 

Lisa_D
Lisa_D

Dr. Mate – By your standards, being a pedophile is an addiction. With your logic of “just give them what they need to soothe themselves in a healthy way,” Jerry Sandusky is no monster; he just needed young boys provided to him in a safe environment.

Lisa_D
Lisa_D

sorry for the duplicate

Ivan
Ivan

Love conquers all...stay strong...

Diane Murray Wernet
Diane Murray Wernet

I do not believe that the trauma of being born is enough to make you an addict.  You are now blaming even the good mothers for their children's problems. GET REAL! You must really hate your mom to think that.

Bershawn300
Bershawn300

Fact is, hitting bottom DOES help some people.  Not that kind love can't too.  Usually a combination of the both is in order.

Disquskurr
Disquskurr

Makes sense. Only if Governments legalized certain drugs, but under the condition, that , these drugs will be administered by nurses(increases employment), at certain government regulated sites only(again increases employment), and the drugs will be supplied by the government for a fee to cover the costs, and the drugs will be taxed too. Drug users will have to undergo medical check-up(again for a fee), and will have to undertake healthy diet/exercise. Drug users will of-course be given special ID's which will identify them as 'Regulated Drug Users', which will prohibit them from driving amp; other privileges.

So street gangs and drug pedlars are out. Government makes huge revenues. Employment increases.Drug users maintain better health and are monitored.

Now, now, this is just an idea. I am neither Einstein, nor do I claim to be.

Malcolm Kyle
Malcolm Kyle

Do you hate the idea of corrupt public officials and the whole criminal fraternity laughing their way to the money launderer? Then fortunately for you there is one last peaceful avenue for change: Jury Nullification.

We must create what we can no longer afford to wait for: PLEASE VOTE TO ACQUIT!

Malcolm Kyle
Malcolm Kyle

Do you hate the idea of corrupt public officials and the whole criminal fraternity laughing their way to the money launderer? Then fortunately for you there is one last peaceful avenue for change: Jury Nullification.

* It only takes one juror to prevent a guilty verdict. 

* You are not lawfully required to disclose your voting intention before taking your seat on a jury.

* You are also not required to give a reason to the other jurors on your position when voting. Simply state that you find the accused not guilty!

* Jurors must understand that it is their opinion, their vote. If the Judge and the other jurors disapprove, too bad. There is no punishment for having a dissenting opinion.

We must create what we can no longer afford to wait for: PLEASE VOTE TO ACQUIT!

Malcolm Kyle
Malcolm Kyle

Do you hate the idea of corrupt public officials and the whole criminal fraternity laughing their way to the money launderer? Then fortunately for you there is one last peaceful avenue for change: Jury Nullification.

If you sincerely believe that prohibition is a dangerous and counter-productive policy, then you must stop helping to enforce it. You are entitled to act according to your conscience:  Acquit the defendant/s if you feel that true justice requires such a result. You, the juror, have the very last word! 

* It only takes one juror to prevent a guilty verdict. 

* You are not lawfully required to disclose your voting intention before taking your seat on a jury.

* You are also not required to give a reason to the other jurors on your position when voting. Simply state that you find the accused not guilty!

* Jurors must understand that it is their opinion, their vote. If the Judge and the other jurors disapprove, too bad. There is no punishment for having a dissenting opinion.

We must create what we can no longer afford to wait for: PLEASE VOTE TO ACQUIT!

Malcolm Kyle
Malcolm Kyle

Do you hate the idea of corrupt public officials and the whole criminal fraternity laughing their way to the money launderer? Then fortunately for you there is one last peaceful avenue for change: Jury Nullification.

Jury Nullification is a constitutional doctrine that allows juries to acquit defendants who are technically guilty but do not deserve punishment. All non-violent 'drug offenders' who are not selling to children, be they users, dealers or importers, clearly belong in this category. 

If you sincerely believe that prohibition is a dangerous and counter-productive policy, then you must stop helping to enforce it. You are entitled to act according to your conscience:  Acquit the defendant/s if you feel that true justice requires such a result. You, the juror, have the very last word! 

* It only takes one juror to prevent a guilty verdict. 

* You are not lawfully required to disclose your voting intention before taking your seat on a jury.

* You are also not required to give a reason to the other jurors on your position when voting. Simply state that you find the accused not guilty!

* Jurors must understand that it is their opinion, their vote. If the Judge and the other jurors disapprove, too bad. There is no punishment for having a dissenting opinion.

“It is not only [the juror's] right, but his duty … to find the verdict according to his own best understanding, judgment, and conscience, though in direct opposition to the direction of the court.” —John Adams

We must create what we can no longer afford to wait for: PLEASE VOTE TO ACQUIT!

Katnip_UK
Katnip_UK

I am a recovering drug addict. I did not get the emotional nurturing I desperately needed as a child I never felt love or warmth. I then had a succession of abusive relationships, which totally crushed any little confidence or self esteem I may of had. So I wound up feeling worthless, hopeless and in despair, that's when I found heroin. It gave the loving warm feeling I had searched for all my life. Now 10 years later I have lost everything to support my drug habit. I am currently doing a lot of work on myself to try and repair all the years of hurt. I have to learn to love myself. It is bloody hard work and at times I feel like just going back to drugs, but if I do I will die. A spiritual way of life is the only hope for me now. The 12 steps, meditation the 5 precepts is my only hope now. The healing has to come from within. Dr Mate is one of the best Dr's regarding addiction. What he says makes perfect sense

Elwyn Williams
Elwyn Williams

Kind love, tough love, sometimes nothing works with an addict.  My former best friend is a hard-core drunk and has been for more than 12 years.  He lost everything, including his job and family, and was arrested and jailed.  Didn't matter -- he continued to drink, threaten to kill me, beat me up.  He tried AA, private counselors, group therapy.  I stood by him and tried to encourage him to go to meetings, get and stay sober, and he would for a week or two at a time.  I got him a great job:  free room and board and $90K a year and what did he do?  Started sneaking alcohol into work, drinking to black-out stage.  That was the end of it for me.  I know there's nothing I can do and I think he is just going to drink himself to death.  So sad -- we were best friends for 25 years and he is a wonderful, brilliant man when he is not drinking.

Betsy Warren Jennings LifeCoac
Betsy Warren Jennings LifeCoac

I so agree with this article. Addiction is about profound grief in ones heart and soothing the grief comes from the behavior of turning to things, substances, people and thought patterns that create instant relief. As a person in recovery and as a Life/Recovery/HOPE coach . I know first hand what love care do for a broken heart. What love can do for somone who is full of grief. What love can do for a soul that needs to be soothed, accepted, and given hope.

Addictional Mytha
Addictional Mytha

Of course addicts should be treated with compassion and we need to end this crazy War on Drugs.  However, Dr. Mate's 'humane' position ultimately will not help addiction and will only make it worse.  He proposes funding more social services to help addicts, but in fact giving away free stuff (like housing) to 'help' people generally backfires because it increases dependency and lowers self-esteem.  

Drug addicts like the ones he describes, in addition to early childhood trauma (which many people experience), have serious long standing emotional and lifeskills issues that prevent them from holding down jobs, leaving them with few career options other than "junkie". 

Of course we should reduce harm through needle exchanges, etc, but at the same time we must understand that all addictions are by choice, not compulsion.  Ultimately, all recovered addicts admit that they used drugs to suppress underlying issues, and nothing helped until they addressed them honestly.  Then the cravings stopped and they could become self-sufficient.

The best treatment for drug addiction is to stop trying to 'help' the addict with material things because this unintentionally creates the incentive to use more.  Drug addicts may act crazy but they are still quite rational.

Addiction Myth dot com

TheCur13
TheCur13

This is already common knowledge to people who aren't cave dwelling barbarians.  Unfortunately, the legal system is entirely composed of cave dwelling barbarians.

DaisyClementine
DaisyClementine

@Lisa_D  Being a pedophile is not an addiction. That is a sickness of the mind. It is some sort of craziness (for lack of a better word).  You are choosing to be so blatantly ignorant about what he was saying than eating, breathing and sleeping are also "addictions" 


Obviously he was talking about drugs and the like. 


My comment could be considered tough love, I'm trying to point out the error of your words, does it work? 

pravchaw
pravchaw

I think he was talking about drug addiction not sexual deviance.

DaisyClementine
DaisyClementine

@Diane Murray Wernet  Some kids have problems even with so called "good mothers." There are some kids who need extra love in life and they don't receive that from their parents. Just because they feed/clothe/shelter their children doesn't make them good parents. Just because society says so doesn't make it true. 

Neil Harrison
Neil Harrison

he didn't say "the trauma of being born." are you illiterate???  he's talking about neglect. he didn't blame mothers in general

pravchaw
pravchaw

Something similar is going on with alcohol and cigarettes (legal drugs), but I agree.

pravchaw
pravchaw

@Katnip_UK I think you are well on your way to recover.  Clearly you are not in denial, have hit bottom and are on to the truth. Now its a matter of time and practice.  Good luck and best wishes for your life.

pravchaw
pravchaw

@Elwyn Williams It has to come from within.  We cannot do anything about it.  See Katnip above.

Elwyn Williams
Elwyn Williams

But for some, love will do nothing at all.  See my post.  

PJiam
PJiam

@Addictional Mytha 

Wow...fancy seeing you here, Addictionmyth,:-)...with the same 'ol, passive-aggressive, addicts-are-to-be tarred-and-feathered kind of stuff. Yep. Real shocker to read the above from you...NOT.

Lisa_D
Lisa_D

I can see where you'd think that but he specifically said "any behavior."

pravchaw
pravchaw

" An addiction is any behavior that is associated with craving and temporary relief, and with long-term negative consequences, that a person is not able to give up - is addiction."  This is not the same as criminal beheviour.  For workholics or gym rats are looked favorably upon by society while guys like Sandulsky are clearly criminal deviants, who needs to be locked up.   Context is key.  The article is in the context of serious drug addiction.   The idea is to help the stabilize the addict - before any treatment can be affected.   Dr. Mate is advocating compassion rather than punishment as a means to move forward.