Gabor Mate on Why Addiction is Not a Disease

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Now, LET’S GET INTO IT!

I want to preface this particular post by reminding readers that I am not a doctor, psychologist, or scientist.

In every newsletter, I share my beliefs, theories, and insights.

Just because I think something doesn’t make it fact, even though I am prone to speaking in absolutes!

Please keep in mind that this piece is an organized record of my thoughts and feelings on a specific matter.

Now that we have comments, you can weigh in!

Okay, here we go:

I’ve never been convinced that addiction is a brain disease.

I have never been able to articulate why—in my gut, it just didn’t land right.

At the very least, it seemed like we hadn’t considered other categories outside the medical and mental-health models in which to place addiction.

If addiction is a brain disease then why have we treated people with substance use disorders like criminals instead of patients? If addiction is a brain disease, why would we arrest only addicts, and not those with other brain diseases, like dementia?

Viewing addiction as a disease implies that medicine and medical science are the best and only treatments.

But looking at addiction from a medical perspective alone overlooks fundamental areas that medicine rarely takes into consideration—like stress, loneliness, and lack of connection.

Medicine deals with biology. But what if addiction is not a biological problem, but a societal one?

The first time I ever used drugs was when a man I studied under in high school (who did not teach at my school) smoked a joint with me. I hated it. He gave me alcohol and while I pretended I was into it, I found the taste above my pay grade. And then he introduced me to cocaine.

I LOVED cocaine.

It was my favorite.

My undiagnosed panic and anxiety disorder fell away and I felt powerful, confident, and worldly. I wanted more, and when I couldn’t stop for two years, it felt not like a disease, but like an unhealthy answer to a lifetime of suffering an undiagnosed psychiatric illness. Cocaine made me feel like I was being lifted out of the burden of self and offered a new and better version of myself to inhabit.

If addiction is a disease, wouldn’t I also have become addicted to alcohol or cannabis?

What was it about cocaine?

I would hear people talk about addiction as a disease, and I understood how it might be helpful for some people, but it didn’t resonate with me. I believed I was suffering from the disease of a toxic society; of our inability to consider emotions and feelings significant enough to acknowledge and discuss. Mental anguish was too shameful, and so I had to hide.

Hiding something that fills your entire core self is exhausting. Hiding made me feel inadequate and defective. Taking drugs helped me feel at peace with this dysfunctional world that left people with psychiatric disorders with few alternatives but to escape the shame of their own existence.

Drugs helped me feel functional. For me, it felt like my drug use was a symptom of an underlying problem.

Cocaine is a dopamine reuptake inhibitor, and so is Bupropion (the active ingredient in Wellbutrin). So it makes sense that I would fall in love with cocaine. It acted on my brain much the way an antidepressant would. While I didn’t seek out cocaine initially, its action on my brain felt like it was a solution to a problem no one else had managed to solve for me. I was self-medicating with the closest thing to an antidepressant I had access to.

That I loved it and wanted to continue using the drug, was not a matter of having a diseased brain, but a matter of having discovered that there was a way for me to finally feel better.

Had someone offered me a healthier way to eliminate my constant mental anguish, I would have done that.

To me, addiction is LIKE a disease, but it’s not definitively a disease. I didn’t feel diseased, and I didn’t like feeling as though others thought of addicts as diseased.

When we call addiction a disease and criminalize addicts, we’re not being very congruent, are we? Something doesn’t add up.

I believe that there may be differences in people’s brains that might make some of us more vulnerable to addiction, but I, an uncredentialed, non-scientist, believe that those differences are formed through nurture, not nature, that they are a function of stress, trauma, or learned behaviors.

My hunch then is that addiction might be learned or formed early and that addiction itself might create or give rise to an actual disease. So why not call it a disorder?

When I stumbled across renowned addiction expert Dr. Gabor Maté’s work, I was surprised to discover that I wasn’t alone in this belief. Better yet, Dr. Maté had science to back it up and articulated my own muddled feelings with clarity and wisdom I hope to one day achieve.

In his book, In the Realm of Hungry Ghosts, Dr. Mate asks the question:

“What is addiction?”

He also sees addiction as an attempt to solve a problem—and not a disease.

When we feel disconnected from others, when we feel alone and misunderstood, we need something that sees us. Quite often, that something is drugs or alcohol.

As we define it now, addiction—a dysfunctional dependency on harmful behaviors, actions, or substances—is relatively new. Before the 20th century pathologized the word, “addiction” referred to being passionate about an activity.

On October 3, 1997, Alan Leshner, the director of the National Institute of Drug Abuse, published an article in Science Magazine titled “Addiction Is a Brain Disease, and It Matters,” positing that scientific advances have proven that drug addiction is “a chronic, relapsing disease that results from the prolonged effects of drugs on the brain.”

Leshner believed that the long-term changes in brain function and structure as a result of abuse and genetic predisposition created the disease. I take this to mean that he believes substance addiction gives rise to a brain disease, and not that a brain disease gives rise to substance addiction.

That’s a big difference.

Not coincidentally, the phrase “brain disease” surged in conversational usage giving credence and rise to the “disease model” paradigm of substance addiction.

Leshner thought that labeling addiction a “brain disease” might lessen the stigma of addiction. And using such terminology would also help build a case to convince Congress to increase funding for research, and persuade insurance companies to cover treatment for those in recovery (but that’s a separate conversation).

That all sounds great, except that it puts all focus on biology and genes, to the exclusion of all other factors.

According to Dr. Maté, the source of addictions is not genetic; he argues there is no evidence of an addictive gene. He believes that addiction is part of environmental conditioning in early childhood; people might be born with a genetic predisposition to addiction, but that doesn’t guarantee those babies will grow up to become users or addicts.

Environmental and other contributing factors, like exposure to adverse life experiences in childhood, learned behaviors, and psychiatric issues are what create the suffering that addiction helps them escape. These early experiences affect the developing brain, disrupting, harming, or altering the endorphins and serotonin systems that make up the self-soothing system.

When a child’s needs are not being met, a toxic stress response is activated in their brain. Prolonged activation of adverse experiences creates a cumulative toll, causes significant damage to key areas of the brain, and often leads to developmental delays and health issues later in life. Psychological disorders such as depression and anxiety can also develop.

According to Dr. Maté, “addiction is any repeated behavior, substance—related or not—in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others.”

Not all compulsions are the same, nor are they necessarily addictions. People with OCD, those who succumb to ritualized behavior that is psychologically debilitating, are not addicts. What distinguishes them from one another is they have no craving for their compulsion.

Dr. Gabor Maté is a unique medical professional who has taken his first-hand experience with childhood trauma and allowed it to inform his work.

Born in 1944 in Budapest, Maté was five months old when his maternal grandparents were murdered in Auschwitz. During the war, Nazis captured his father and put him into a labor camp; Maté’s aunt disappeared.

When Gabor was a year old, his mother was desperate to save her baby’s life and handed him over to a stranger. He didn’t see his mother for over five weeks. In infant time, that’s like 37 years. When they were finally reunited, little Gabor avoided looking at his mother for days (in attachment theory, we’d say that he was anxiously attached).

To this day, this early trauma continues to inform his life and interactions.

But Maté and his parents survived the war, and in 1956, they left Hungary for Vancouver, Canada. In 1977, Maté got his M.D. in general family practice, and would eventually specialize in addiction.

Because I am someone who has spent her life trying to create a functional existence with a crippling anxiety disorder, I tend to put a lot of stock into physicians and thinkers who have suffered firsthand from the disorders about which they write.

People who have suffered, and have fought to overcome their suffering, have an understanding that I value more than I do the theories and ideas of those without first-hand experience. Not to say I doubt science. I do not doubt science.

Maté believes that the first five years of life, and even the environment in the womb, dictate the likelihood of addiction. Addiction is not the problem itself, but the underlying pain. He writes, “Craving, pleasure and relief in the short term, negative consequences in the long-term, and the inability or refusal to desist, that’s what addiction is.”

Maté argues that addiction—a complex issue that requires a multifaceted approach to treatment—is not a choice or a moral failing, but rather a response to trauma and emotional pain.

Lance Dodes, a psychiatrist at the Harvard Medical School Division on Addictions, has said that “addiction is a human problem that resides in people, not in the drug or in the drug’s capacity to produce physical effects.”

This is in line with Dr. Maté’s thinking. Maté feels it’s a grave misconception that drug taking by itself will lead to addiction. If drugs themselves were the problem, and if the cause of addiction was the power of the drug over the human brain, then every single person who took opioids for cancer pain would become addicted, and that simply isn’t the case.

Of course, some people do become addicted to opioids, but to understand why, we must know more about the people, their environments, and the circumstances that led to their addictions.

In my case, I was susceptible to drugs in part because I needed medication that wasn’t offered to children when I was growing up, and this put me at risk for drugs that worked as a dopamine reuptake inhibitor, like cocaine.

Is it a person’s fault for becoming addicted to a drug?

No.

It wasn’t mine, for example, for becoming addicted to cocaine. I didn’t know it at the time, but I had many of the risk factors that can lead to a substance-use disorder, including feeling emotionally isolated, powerless, and incredibly stressed and anxious.

But the drugs themselves did not make me addicted. It was that they felt like my only solution. Had I been an emotional eater, would food be the culprit for my addiction?

At the same time, it makes sense that people with backgrounds in developmental psychology, analysis, trauma, and personal development, as well as biology, scientific methods, and medicine, would view addiction through that lens.

So who is right? And more to the point: Does it even matter?

What if thinking addicts have a disease is what gives them the drive to get better? Taking that away from them could be harmful.

And if thinking they have a disorder, and not a disease, or were set up by their environment for a vulnerability, helps those addicts get better, then let’s not take that away either.

For me, thinking of addiction as a disease would make me feel hopeless. Having a disorder makes me feel like I have more agency, and can direct my efforts to get better, but I am someone who is soothed by learning methods and facing stark realities.

As a person whose childhood and adolescence were spent panicking without knowing that I had a “condition” that would later be identified as a panic disorder, I’ve spent my post-diagnosis life learning about myself and my condition and trying to unlearn all the very unhealthy ways I coped.

I learned early on that anxiety triggers an automatic reaction, like an ill-trained bodyguard who throws themselves in front of you at any sudden and innocuous movement. This primary reaction is where anxiety lives and thrives. But it’s the second reaction that matters more. Once you’ve assessed whether or not the danger is real, the second reaction is what will calm you down or push your anxiety into panic mode.

Addiction is like living inside a primary reaction, and the substance takes the place of the secondary response. Instead of attending to our primary reaction by some mollifying next steps, we keep ourselves hooked on the reactivity by rewarding it with drugs. When we avoid dealing with our emotions, we wind up holding ourselves hostage to them.

So, if we’re to follow the model that addiction isn’t a disease, but a nuanced condition that involves a complex array of things, how do we overcome our addictions?

Dr. Maté believes the answer comes down to mindfulness, reframing, conscious attention, and learning. When we begin to focus our attention on the way we think, the way we react, on the way we interpret situations, we begin to see that we’ve created our own reality.

As Anaïs Nin said:

We often blame our past for our present misery, when in fact, it’s not past events that keep us currently miserable; it’s our mistaken belief that we are what happened to us. It’s our misguided identification that other people’s poor treatment of us means we deserve poor treatment.

When we begin to separate ourselves from the distorted thinking that ill-treatment creates, we can begin to interpret the world through our own eyes, our own narratives, and not mediated through the filter of someone else’s dysfunction. What we believe about ourselves is only true because we make it true. And if that’s the case, instead of believing we’re worthless, why not choose to believe that we’re fucking amazing?

These three points come directly from “In the realm of Hungry Ghosts” and are so perfectly stated.

• Childhood trauma and neglect are most damaging when the child creates meaning from her unconscious interpretations of these events and builds her life from the meanings we’ve created. Unwittingly, we wrote the story of our future from narratives based on the past.

• The moment a person becomes truly present is the moment they stop identifying with the conditioned patterns of the mind.

• Becoming conscious of your unconscious programming and your defensive impulses is the only way to choose whether to act on your dysfunctional past learnings or to make a new, and healthier decision.

Dr. Maté is an advocate for harm reduction which aims to reduce the negative consequences of substance abuse. Instead of confiscating drugs, harm reduction might include a safe injection site, a needle-exchange program, and more accessible social services and medical care.

He argues that addicts need to feel a sense of connection and belonging in order to recover—which is why 12-step programs help so many people. His approach is rooted in compassion, understanding, and treating addicts with respect and dignity.

Like many people in his field and position, Dr. Maté recommends meditation. While I think that’s a noble pursuit, I can hear the audible eye rolls. I’d like to reframe the idea of meditation as a time for silence. We all need to take time for silence. It’s the only way we can disconnect from the external world and connect to our inner lives to hear our own needs.

It’s easier, I think, to start there. I am often overwhelmed by the choices thrown at me when it comes to meditation. I have found one meditation that I love (it’s the first 8 minutes of the one below) but I need others—finding them has been hard.

In his book The Mindful Brain, Reflection and Attainment in the Cultivation of Wellbeing, psychiatrist and brain researcher Dr. Daniel Siegel explains how mindfulness is useful.

Mindfulness is simply paying close attention to one’s experience of each moment, without seeking distraction.

Maté’s specific method for behavioral addictions or anyone wishing to disengage from maladaptive habits of thinking or acting is FOUR STEPS, PLUS ONE.

This method is an adaption to Dr. Jeffrey Schwartz’s OCD “brain lock.” The stuck neurological gears cause thought to be acted out before the action can be stopped. The program devised at the UCLA School of Medicine for the treatment of OCD is formally called the Four-Step Self-Treatment Method.

Healing depends on a high level of motivation for success. We must first do as they do in “the program,” and admit—and commit to confronting—the full impact addiction has had on our lives.

The four steps should be practiced daily.

I will briefly lay out the modified four steps (plus one), but to read them in full, go here!

STEP ONE: RELABEL

In step one you label the addictive thought or urge exactly for what it is, not mistaking it for reality.

STEP TWO: REATTRIBUTE

In Reattribute you learn to place the blame squarely on your brain. This is my brain sending me a false message.

STEP THREE: REFOCUS

In the refocus step, you buy yourself time. “It’s not how you feel that counts; it’s what you do.”

STEP FOUR: REVALUE

Do not take the addictive thoughts at face value. It is not significant in itself. This step’s purpose is to help drive into your head the real impact the addictive urge has on your life: disaster.

STEP FIVE: RE-CREATE (This is Gabor Maté’s Plus-One step.)

Life, until now, has created you. You’ve been acting according to ingrained mechanisms wired into your brain before you had a choice in the matter, and it’s out of those automatic mechanisms that you’ve created the life you now have.

Dr. Maté also believes in the 12-step model. Although he doesn’t go himself, he recognizes the extraordinary impact it’s had on people who are suffering from substance-use disorders.

Recovery starts with acceptance. Not just of the addict, but of those around them. Allowing the addict to feel supported in their environment will be what makes going toward conscious awareness feel safe.

What matters most is not what you think addiction is or isn’t, but that you don’t see it for what it isn’t: a moral failing, a corrupt soul, criminal behavior.

Addiction rises in the context of the environment. If we all made the effort to be more self-reflective, honest, and open in our dealings with our loved ones, then perhaps we might make the world a better, easier place for all.

Were we to allow others to grieve and mourn, to express their needs and desires, and to meet them with acceptance and connection, no matter how awkward or uncomfortable we may feel, then perhaps we can recognize that what an addict needs is not something punitive and carceral, but support and a sense of community, family, and home.

For more on Dr. Mate, go here.

So, tell me your thoughts. Do you believe addiction is a disease, and if so, why?

Tell me in the comments!

I promise next week’s newsletter will be shorter (like me)!!

Amanda

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