Chapter 15: Just Not to Be You: Debunking the Myths About Addiction

Maté spent twelve years working in Vancouver’s Downtown Eastside, the most concentrated area of drug use in North America. Some of the addicts he treated there had been middle class and a few had been wealthy, before losing everything; “their health, looks, teeth; their families, work, homes.” He asks what could lead anyone to behavior so obviously and thoroughly self-destructive, and goes on to discuss two misconceptions. The first is that addiction is the result of bad choices. This has been scientifically discredited but retains some hold on the popular imagination, particularly among social conservatives. The author has encountered a great many addicts but nobody who chose to become one. The second misconception is that drug abuse is a disease. This is a more compassionate view, but makes the mistake of seeing the brain in purely biochemical terms, without considering the subject’s life history.

Instead of a conscious choice or an illness, the author believes addiction should be viewed as a coping mechanism, a defense against pain one does not know how to endure. A physician should ask two essential questions of any addict. First, what benefit do they derive from the habit? This may be confidence, power, social interaction, creativity, peace, self-worth, or a feeling of warmth and comfort. The second question is what pain the addict is suffering, from which they are so desperate to escape. He cites examples, such as the hockey player Theoren Fleury, who was sexually abused by his coach, and the photographer Nan Goldin, whose sister committed suicide when she was eleven. When the author worked in Vancouver’s Downtown Eastside, he found that every one of his female patients had endured sexual abuse. He does not believe that addicts can be separated neatly from the rest of the population into a distinct group. “To twist a line from the great George Carlin, it’s a big club—and we’re all in it.”

Chapter 16: Show of Hands: A New View of Addiction

The author offers a new definition of addiction, remarking that many of his readers may find that they come under it:

Addiction is a complex psychological, emotional, physiological, neurobiological, social, and spiritual process. It manifests through any behavior in which a person finds temporary relief or pleasure and therefore craves, but that in the long term causes them or others negative consequences, and yet the person refuses or is unable to give it up. Accordingly, the three main hallmarks of addiction are:

1. Short-term relief or pleasure and therefore craving;
2. Long-term suffering for oneself or others; and
3. An inability to stop.

This definition is clearly not limited to drugs. It includes pornography, shopping, binge-eating, gambling, work, extreme sports, and many other activities. This means that everyone is an addict except, as the author likes to say when he speaks on this topic “the occasional liar.” Naturally, not all addictions are equally serious, just as not all childhoods are equally traumatic. However, the author believes that even the happiest childhoods contain some trauma, and these traumas are frequently the foundation for addiction.

No drug is addictive in itself, nor is there any single gene that predisposes people to addiction. Drugs, alcohol, food, or shopping become addictive when there is pain to be palliated. Dr. Vincent Felitti’s Adverse Childhood Experiences (ACE) Study showed that the more adversity children had been exposed to, the more likely they were to develop addictions and other medical problems as adults.

Addiction begins as an attempt to produce feelings through dopamine and endorphins, chemicals which would occur in the brain naturally, stimulated by social bonding and love, in an ideal case of healthy emotional development. The author ends with the observation that Robert Palmer’s song “Addicted to Love,” is universally applicable. “Except it’s not really love we get hooked on but our desperate attempts to cope with its lack, by any means necessary.”

Chapter 17: An Inaccurate Map of Our Pain: What We Get Wrong About Mental Illness

The comedian Darrell Hammond suffered from mental illness for over three decades, saw approximately forty psychiatrists, and received multiple diagnoses and prescriptions before he met Dr. Nabil Kotbi of the Weill Cornell Medical College in New York City. Kotbi was the first doctor who asked him about his traumatic childhood and told him that he had been injured. The author asserts that Hammond was the victim of biological determinism, his psychiatrists’ view that he was suffering from a genetic disease which could only be cured by drugs. Both doctors and patients often find this approach easier than revisiting childhood trauma to find the true root of the problem.

A diagnosis is merely a description, not an explanation. In a case of physical illness, however, the doctor can at least confirm that the diagnosis is correct with such objective physical measurements as blood tests. However, as the psychologist Lucy Johnstone observes, “in psychiatry, it’s simply a circular argument. . . . Why does this person have mood swings? Because they have bipolar disorder. How do you know they have bipolar disorder? Because they have mood swings.”

The author found that formal diagnosis was of little use in his own medical practice. However, he is not against medication. He himself took Prozac in his forties and found that it improved his mood and relationships markedly. However, the fact that the drug helped him, at least temporarily, does not explain the origin of his feelings or indicate that the success is replicable in other patients.

Finally, Maté points out that a genetically based idea of mental illness is a way of avoiding blame both for individuals and for the culture. People are content to think their problem is genetic because doing so—and taking medication—is a way to avoid revisiting past trauma. Such an explanation also means that the essential problem cannot be the toxic environment, and things can remain as they are.

Chapter 18: The Mind Can Do Some Amazing Things: From Madness to Meaning

The author suffers from depression, a state which he says occurs when one is compelled to suppress emotions too painful to confront. In his case, these include the effects of war, genocide, and abandonment, but he believes that most children in far less extreme circumstances are forced to banish emotions at some point in their childhood. Depression is a coping mechanism, not a genetic illness. It has been a transformative experience for the author to understand this.

Maté calls the mind a “meaning-making machine.” It creates stories to make sense of emotions. These stories may be the best option available in the circumstances, but adhering to them can cause damage later. Maté gives the example of a woman who blamed herself for her unhappy childhood because the only other option was to conclude that her caregivers were malicious and incompetent. If she was to blame, at least she could take steps to remedy the situation. He cites other examples, including the actor Robin Williams, of people driven to despair by the narratives they constructed for themselves.

A 2013 study of almost six hundred French and Norwegian subjects diagnosed with bipolar disorder showed a correlation between childhood trauma and more serious clinical characteristics. The author discusses similar results in the case of obesity, anorexia, and other disorders. He concludes with the image of Robin Williams in Good Will Hunting, playing a kindly psychologist who tells the protagonist that his trauma is not his fault. This is a message he would like to convey to everyone.