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
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
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.
It’s impossible for a parent to be emotionally available all of the
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, rock-bottom 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 towards a 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
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
In term of addictions, first of all recognize that these people are
traumatized and what they need is not more trauma and punishment but
What most surprised you in working with some of the most severely
What’s most astonishing is just how people survive, no matter what.
Even amid drug dealing and mutual rip-offs, 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.