Scattered Minds-Gabor-Mate.pdf

GABOR MATÉ BOOKS SCATTERED MINDS “Scattered Minds: A New Look at the Origins and Healing of Attention Deficit Disorder” – published in the U.S. as “Scattered: How Attention Deficit Disorder Originates And What You Can Do About It” – is written from the inside by a doctor who himself has Attention Deficit Disorder. It offers a completely new perspective on ADD and a new approach to helping children and adults living with the problems Attention Deficit Disorder presents. − Demonstrates that ADD is not an inherited illness, but a reversible impairment, a developmental delay − Explains that in ADD, circuits in the brain whose job is emotional self-regulation and attention control fail to develop in infancy − and why − Shows how “tuning out” and distractibility are the psychological products of life experience, from in utero onwards − Allows parents to understand what makes their ADD children tick, and adults with ADD to gain insights into their emotions and behaviors − Expresses optimism about neurological development even in adulthood − Presents a program of how to promote this development in children and adults alike Praise for “Scattered Minds”: “This delightful, helpful book is a welcome addition to the literature on ADD. Based on solid research and a strong humanistic sensibility, it is written with humor and compassion, from an unsparingly honest personal perspective. I would enthusiastically recommend Scattered to anyone touched by ADD − adults, parents, and professionals.” John J. Ratey, M.D. co-author, Driven to Distraction “Those with ADD, their loved ones and their physicians will profit from reading this book. People who do not yet know they have it will have their lives transformed.” Canadian Medical Association Journal “Maté’s argument is organic, a refreshing change from the medicalized and mechanistic models dominating the debate. You won’t find a drug chart or Seven Easy Steps to the Road Less Scattered here. You will find family stories, an accessible description of brain development and sound information. You will also find hope.” The Globe and Mail “In one of the most comprehensive and accessible books about Attention Deficit Disorder (ADD), Maté , a Canadian physician and popular medical columnist, challenges many accepted notions about the condition, which afflicts more than three million children and a significant number of adults… In the closing pages of this well-documented but sure-to-be-controversial book, he effectively hammers home his suspicions about the possible over-prescription of Ritalin and other drugs to control rather than heal children, and proposes that, in some cases, emotional support, patience and love can be more powerful remedies than chemicals.” Publisher’s Weekly “[U]tterly sensible and deeply moving… Dr. Maté offers an original and helpful theory about a 1

condition whose diagnosis has spread like wildfire in North America. Until now, the medical profession has mostly proclaimed attention deficit disorder as a hereditary genetic disease and prescribed a drug called Ritalin by the bucketful.” Vancouver Sun “[Maté] challenges the standard view of ADD [and] asks questions that deserve to be considered about a debilitating disorder − and the kind of society in which is flourishes.” Maclean’s “Enlightening and sensitively told [with] a much needed focus on adults and adolescents with ADHD… For someone who is wondering if their own lack of attention, impulsiveness, distractibility, or hyperactivity may be ADHD, this would be a good read.” Winnipeg Free Press “Scattered Minds [is] necessary reading for anyone who lives with the effects of ADD, in himself or in others; it’s an encouraging and reassuring approach.” The Chronicle-Journal (Thunder Bay, ON) “Since reading this book, I have found myself being more aware of my parenting style. I will consider his advice of always thinking of the long term objectives for my son’s development when parenting him, rather than using short term approaches to controlling his behaviour. This will be a book to keep on the shelf for future reference.” Synergy Magazine (Vancouver Island, BC) “As a 27-year-old man in an increasingly pressured society I cannot express the value and life lessons that your books have elucidated for me. Just a year ago, I was dangerously close to outof-control binge partying and was using cocaine regularly. I always knew there was something amiss. My report cards always said: ‘Has potential but cannot apply himself’. The way you explained some of the ADD symptoms and daily accounts was like reading the daily itinerary of my life: the shame, attachment problems, aggression; misplacing keys, my wallet, the phone. I had not kept a job in years and was out of a degree just one year from completion. Since your book, I have changed my life. I am now just a month from completion of my undergraduate degree, I spend more time at the library than anywhere else and have had the best year of my recent life…” M.R. “Yesterday I finished your book Scattered. I went through almost two highlighters noting everything I found important… I couldn’t believe how insightful it was, over and over and over again. I learned invaluable information to apply as a parent, and as a psychotherapist. I’m sure I’ll get even more from it when I go through it a second and third time around. A very heartfelt thank you!” H. “I am reading Scattered and it is one of several books I have about ADD. My son was diagnosed a couple of years ago with ADHD, as was I. I have done a lot of research and reading on the topic since then. I have felt compelled to tell you that your book is far superior to all the other books and online articles I have read… I have never felt that someone understood and was able to describe so clearly the condition that is ADD. I feel great relief at being understood so completely, and I know that I will be able to convey some of this understanding to my 17-yearold son.”

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Gail “I just finished reading Scattered, and I do believe that this week is the first time I have exhaled in twenty years. I feel… explained, understood, accepted… by me. Finally! Thank you for helping me clear my own path and accept my own journey.” V.B. “Thank you very much for Scattered Minds. It has been a very validating book to read. I have learned so much about parenting, patience, self-love, the list goes on and on. Thank you so much for your book; I keep it by my bedside table and find that even after finishing it I can open to any chapter and become totally immersed in it.” J.T. “I just read and really enjoyed your book Scattered Minds. I found it extremely helpful and eyeopening. It described me to a tee. It was shocking to read what felt like my personal bio in your book, when we have never met! It’s nice to know I’m not alone!” Heather “I just want to tell you that your book Scattered Minds has deeply affected me and my husband and given us profound insight into some issues we are having with our 13-year-old son. Though we have struggled greatly with him and getting him to do his homework since kindergarten, it never once dawned on me he might have ADD until reading your book and seeing clearly some of his tendencies that are probable signs of ADD. After reading your book I now have many layers of insight into our family dynamics and how we have raised him, as well as how I was raised and some of my own ADD tendencies.” R.M. “I am 47 years old and I was assessed as ADD one year ago. I read your book this week and each page made me feel that I was reading my autobiography. I have hope now that I can turn my life around.” Mark “I wanted to let you know that I read Scattered, and it has answered so many questions about my childhood and adult ADHD. Knowing is half the battle. Most of all, I have found hope in your book. If we believe that we’re determined to live a debilitating life with medication being our only hope, then we will live out that belief. Now I am taking steps of healing from my past, and creating new desired patterns of behaviour for my future.” Eric “When I started reading Scattered Minds the first thought that came to me was ‘wow, this is so me’. The second thought that came to me was ‘if I were to ever write a book on ADHD, this is the book I’d write’. Thank you for making the world of ADHD so real and so easily understandable to those who do not have ADHD. I’m happy to report that in the 10 or so visits I’ve had with my son’s school teachers and principal this year, that they’ve all been enthralled by my words of wisdom (taken liberally from your book) about what ADHD is like for my son, and they’ve implemented all of my suggestions on how to help him learn.” Matthew “I love this book. I am a Classroom Assistant in Yellowknife, Northwest Territories. I work with students with various learning disabilities and I love my job. Last year I worked in a classroom that had a lot of behaviour problems – no big deal – but I clashed with one particular student. He

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has ADD (not medicated), as many of my students do, but he was so loud, demanding, inappropriate, angry, the list goes on. As I read your book and think about this child, and his childhood, I am filled with dread when I think about how I could have better handled almost every situation. By the end of the year I would do anything to avoid seeing this student outside the classroom – it seemed like he worked so hard to get my attention, like he was desperate for my affection. I gave him none. I always remained neutral and I think if I had just spent more quiet, one-on-one time with him we could have had a better year, a more productive year… Your book has also changed some ways we deal with our four year old in the mornings. As you described in your book, we now see the anxiety level rise as we run late and we have learned to prevent it. My husband teaches Grade 8 – you would think we could recognize this behaviour in ourselves but it was not until reading your book and the consequences of our actions that we made changes to our parenting style in tense situations. I also felt good about behaviours we felt we were doing properly with our daughter like giving choices, talking through disagreements and not forcing our child to do everything we think it right. When friends and family ask why we handle certain situations as we do, I tell them about your amazing book and what I have learned.” Rosie “I found Scattered Minds absolutely fascinating, and I feel like I finally have some understanding of my daughter, who is 17 years old, as well as my husband. The title of the book is what caught my attention, as I have often thought of my daughter as “scattered”. I am inspired by my newfound insight into the dynamics of our relationships [and] I am working on giving her the attention and unconditional love she needs. Thank you for your wonderful book.” B.G. “Thanks again for an amazing book. Your wisdom & humour are tremendous & SO therapeutic. I borrowed the book from the library, but have ordered it so that I can mark my own copy.” David “I am only a bit of the way through Scattered Minds and, of course, must stop before I read any further to extend a sincere ‘THANK YOU!!!’ and ‘God bless you’ for this incredible and insightful work. It is a relief and source of hope to be able to put a name to behaviors I have feebly tried to self-analyze for many years… Thank you for seeing ADD as one more manifestation of the beautiful diversity of creation instead of a disease, for your frankness about your own situation and growth, and the courage and conviction to share what you have both suffered and discovered. On those days when you may wonder whether or not your life has made a difference, know that one middle-aged mom in the Midwest is walking with a new hope in her heart because of the work you have done. Thank you so much.” Ann

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SCATTERED MINDS: A NEW LOOK AT THE ORIGINS AND HEALING OF ATTENTION DEFICIT DISORDER Chapter One − So Much Soup and Garbage Can Medicine tells us as much about the meaningful performance of healing, suffering, and dying as chemical analysis tells us about the aesthetic value of pottery. − Ivan Illich, Limits To Medicine Until four years ago I understood attention deficit disorder about as well as the average North American doctor, which is to say hardly at all. I came to learn more through one of those accidents of fate that are no accidents. As medical columnist for The Globe and Mail, I decided to write an article about this strange condition after a social worker acquaintance, recently diagnosed, invited me to hear her story. She had thought I would be interested – or more likely she sensed it, with a gut-level affinity. The planned one column became a series of four. To dip my toe in was to know that, unawares, I had been immersed in it all my life, up to my neck. This realization may be called the stage of ADD epiphany, the annunciation, characterized by elation, insight, enthusiasm, and hope. It seemed to me that I had found the passage to those dark recesses of my mind from which chaos issues without warning, hurling thoughts, plans, emotions and intentions in all directions. I felt I had discovered what it was that had always kept me from attaining psychological integrity: wholeness, the reconciliation and joining together of the disharmonious fragments of my mind. Never at rest, the mind of the ADD adult flits about like some deranged bird who can light here or there for a while but is perched nowhere long enough to make a home. The British psychiatrist R.D. Laing wrote somewhere that there are three things human beings are afraid of: death, other people, and their own minds. Terrified of my mind, I had always dreaded to spend a moment alone with it. There always had to be a book in my pocket as an emergency kit in case I was ever trapped waiting anywhere, even for one minute, be it a bank lineup or supermarket checkout counter. I was forever throwing my mind scraps to feed on, as to a ferocious and malevolent beast that would devour me the moment it was not chewing on something else. All my life I had known no other way to be. The shock of self-recognition many adults experience on learning about ADD is both exhilarating and painful. It gives coherence, for the first time, to humiliations and failures, to plans unfulfilled and promises unkept, to gusts of manic enthusiasm that consume themselves in their own mad dance, leaving emotional debris in their wake, to the seemingly limitless disorganization of one’s activities, of one’s brain, car, desk, room. ADD seemed to explain many of my behaviour patterns, thought processes, childish emotional reactions, my workaholism and other addictive tendencies, the sudden eruptions of bad temper and complete irrationality, the conflicts in my marriage and my Jekyll and Hyde ways of relating to my children. And, too, my humour, which can break from any odd angle and leave people laughing or leave them cold, my joke bouncing back at me, as the Hungarians say, like “peas thrown at a wall.” It also explained my propensity to bump into doorways, hit my head on shelves, drop objects, and brush close to people before I notice they are there. No longer mysterious was my ineptness following directions or even remembering them, or my paralytic rage when confronted by a sheet of instructions telling me how to use even the simplest of appliances. Beyond everything it revealed the reason for my life-long sense of somehow never

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approaching my potential in terms of self-expression and self-definition – the ADD adult’s awareness that one has talents or insights or some undefinable positive quality one could perhaps connect with if the wires weren’t crossed. “I can do this with half my brain tied behind my back,” I used to joke. No joke that. It’s precisely how I have done many things. My path to diagnosis was similar to that of many other adults with ADD. One finds out about the condition almost inadvertently, researches it, and seeks professional confirmation that one’s intuitions about oneself are reliable. So few doctors or psychologists are familiar with attention deficit disorder that people are forced to become self-cultivated experts by the time they find someone who can make a competent assessment. I was fortunate. As a physician I could negotiate the medical labyrinth and seek the best sources of help. Within weeks of having written my columns on ADD I was assessed by an excellent child psychiatrist who also sees adults with the disorder. She corroborated my self-diagnosis and began treatment, at first by prescribing Ritalin. She also spoke with me about how some of the choices I was making in life reinforced my ADD tendencies. My life, as the lives of many adults with ADD, resembled a juggling act from the old Ed Sullivan show: a man spins plates, each balanced on a stick. He keeps adding more and more sticks and plates, running back and forth frantically between them as each stick, increasingly unsteady, threatens to topple over. He could only keep this up for so long before the sticks totter and the plates begin to shatter, or he himself collapses. Something has to give, but the ADD personality has trouble letting go of anything. Unlike the juggler, he cannot stop the performance. With an impatience and lack of judgement characteristic of ADD I had already begun to selfmedicate, even before the formal diagnosis. A sense of urgency typifies attention deficit disorder, a desperation to have immediately whatever it is that one may desire at the moment, be it an object, an activity, or a relationship. And there was something else here too, well expressed by a woman who some months later came for help. “It would be nice to get a break from myself at least for a little while,” she said, a sentiment I fully understood. One longs to escape the fatiguing, ever-spinning, ever-churning mind. I took Ritalin in a higher than recommended initial dose on the very day I first heard about attention deficit disorder. Within minutes I felt euphoric and present, experienced myself as full of insight and love. My wife thought I was acting weird. “You look stoned,” was her immediate comment. I was not an undereducated teenager eager for kicks when I self-administered the Ritalin. Already in my fifties, I was a successful and respected family doctor whose columns of medical opinion were praised for their thoughtfulness. I practice medicine with a high value on avoiding pharmacology unless absolutely necessary and, needless to say, I have always advised patients against self-medicating. Such striking imbalance between intellectual awareness on the one hand and emotional and behavioural self-control on the other is characteristic of people with attention deficit disorder. This plunge into impulsiveness notwithstanding, I believed there was light at the end of the tunnel. The problem was clear, the remedy elegantly simple: certain parts of my brain were dormant half the time; all that needed to be done was to rouse them from slumber. The “good” parts of my brain would then take control, the calm, sane, mature, vigilant parts. It did not work out that way. Nothing much seemed to change in my life. There were new insights, but that which had been good stayed good and that which had been bad stayed bad. The Ritalin soon made me depressed. Dexedrine, the stimulant I was next prescribed, made me more alert and helped me become a more efficient workaholic. It is never that easy.

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Since being diagnosed myself, I have seen hundreds of adults and children with attention deficit disorder. I now think that physicians and prescriptions for drugs have come to play a lopsidedly exaggerated role in the treatment of ADD. What begins as a problem of society and human development has become almost exclusively defined as a medical ailment. Even if in many cases medications do help, the healing ADD calls for is not a process of recovery from some illness. It is a process of becoming whole– which, it so happens, is the original sense of the word “healing.” There is no disputing the malfunctioning neurophysiology in what we call attention deficit disorder. It does not follow, however, that we can explain all the problems of the ADD mind simply by referring to the biology of out-of-balance neurochemicals and short-circuited neurological pathways. A patient and compassionate inquiry is needed if we are to identify the deeper meanings manifested in the crossed neural signals, troubled behaviours, and psychological tumult which together have been named ADD. My three children also have attention deficit disorder – not by my own diagnosis, but according to evaluations at a hospital-based clinic. One has taken medication, with clear benefit, but none are requiring to do so at the present time. In light of such a strong family history it may seem surprising that I do not believe ADD is the almost purely genetic condition many people assume it to be. I do not see it as a fixed, inherited brain disorder but as a physiological consequence of life in a particular environment, in a particular culture. In many ways one can grow out it, at any age. The first step is to discard the illness model, along with any notion that medications can offer more than a partial, stop-gap response. A certain fad-like mystique has recently evolved around ADD, but – despite what many people think – it is not a recently discovered entity. In one form or another it has been recognized in North America since 1902; its present pharmacologic treatment with psychostimulants was pioneered over six decades ago. The names given to it and its exact descriptions have gone through several mutations. Its current definition is given in the fourth edition of the Diagnostic and Statistical Manual, scripture and encyclopaedia of the American Psychiatric Association. The DSM IV defines attention deficit disorder by its external features, not by its emotional meaning in the lives of individual human beings. It commits the faux pas of calling these external observations symptoms, whereas that word in medical language denotes a patient’s own felt experience. External observations, no matter how acute, are signs. A headache is a symptom. A chest sound registered by the doctor’s stethoscope is a sign. A cough is both a symptom and a sign. The DSM speaks the language of signs because the world view of conventional medicine is unfamiliar with the language of the heart. As UCLA child psychiatrist Daniel J. Siegel has said, “The DSM is concerned with categories, not with pain.” ADD has much to do with pain, present in every one of the adults and children who have come to me for assessment. The deep emotional hurt they carry, each and all, is telegraphed by the downcast, averted eyes, the rapid, meandering flow of speech that seems almost oblivious of the listener, the tense body postures, the tapping feet and fidgety hands, and by the nervous, selfdeprecating humour. “Every aspect of my life hurts,” a 37-year old man told me in the course of his second visit to my office. People express surprise when after a brief exchange I seem to be able to sense their pain and grasp their confused and conflicted history of emotions. “I am speaking about myself,” I tell them. At times I have wished that the “experts” and media pundits who deny the existence of attention deficit disorder could meet only a few of the severely affected adults who have sought my help. These men and women, in their thirties, forties and fifties, have never been able to maintain any sort of a long term job or profession. They cannot easily enter meaningful, committed 7

relationships, let alone stay in one. Some have never been able to read a book from cover to cover, some cannot even sit through a movie. Their moods fly back and forth from lethargy and dejection to agitation. The creative talents they have been blessed with have not been pursued, any thoughts of cultivating them abandoned. They are intensely frustrated at what they perceive as their failures. Their self-esteem is lost in some deep well. Most often they are firm in the conviction that their problems are the result of a basic, incorrigible flaw in their personalities. I would want any doubting Thomases to read and consider the autobiographical sketch submitted to me by John, a fifty-one year old unemployed single man. I quote it exactly as written: Had Jobs work Do my Best I could never good enough. when people Talk to me they ask me if I Listening or I seem Bored. Shown emotion or I drift off or when I get to do Something can’t finish it or start doing Something then eye start Something else. when I sometimes most of the time wait till Last minite To do things. Get a anxous feeling got to do it or else. feel pressured. Seem to mindwonder or daydream. for ever misplacing, loosing things. can’t remember where I put Something away. “forgetful” confused, jumbled thinking. get mad about nothing people ask me whats wrong I say nothing. I can’t seem to get what people want from me can’t understand. when I was a kid. couldnt sit still figety. Report cards in school would always have something like doesn’t pay Attention in class, doesn’t sit still took me longer to Learn or understand. Always was in trouble was stuck sitting in front of class or in back of class or principal’s office (strapped) been tied down in chair. always seeing counsellors. teachers always saying sit still be quiet. Sent to sit out in hall my dad was always telling me to sit still what lazy bum I am my room. was always yelling at me. John’s speech is far more articulate than his writing, but not less poignant. “My dad,” he said, “always rubbed my nose in it, that I should have been a doctor or a lawyer, or else I wouldn’t amount to anything. After my parents divorced the only time they would talk to each other was when my mother called my dad to say ‘give him heck.’” “I saw a video last week,” he added. “It’s title expressed how I feel: I Am Sick And Tired Of Being Sick And Tired.” Patients are graphic about their feeling states, often almost lyrical. “Ah,” a forty-seven-year old man said with a discouraged wave of the hand and a smile that was resigned and mischievous at the same time, “my life is just so much soup and garbage can.” What those words mean exactly, I could not say. Like poetry, they convey their meaning through the feelings and word associations they evoke. “Landed in the soup.” “Fog as thick as soup.” “Soup kitchen.” “Treated like a piece of garbage.” “I feel like garbage.” Images of distress, loneliness and confusion, presented with a tinge of humour. The strangely dissonant imagery tells also of a troubled soul who found reality harsh – so harsh that the mind had to be fragmented in order to fragment the pain. Chapter Two − Many Roads Not Travelled To get through each day, natures that are at all high strung, as was mine, are equipped, like motor cars, with different gears. There are mountainous, arduous days, up which one takes an infinite time to climb, and downward-sloping days which one can descend at full tilt, singing as one goes. − Marcel Proust, In Search of Lost Time Attention deficit disorder is defined by three major features, any two of which suffice for the diagnosis: poor attention skills, deficient impulse control, and hyperactivity. The hallmark of ADD is an automatic, unwilled “tuning out,” a frustrating non-presence of mind.

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People suddenly find that they have heard nothing of what they have been listening to, saw nothing of what they were looking at, remember nothing of what they were trying to concentrate on. One misses information and directions, misplaces things, and struggles to stay abreast of conversations. Tuning out creates practical hardships, and it also interferes with one’s enjoyment of life. “A continuous and whole experience of music is unknown to me,” a high school teacher said. “My mind is off wondering after only a few chords. It is a major exercise for me even to hear one brief song through on my car radio.” There is a sense being cut off from reality, an almost disembodied separation from the physical present. “I feel like I am a human giraffe,” is how one man described it, “as if my head is floating in a different world, way above my body.” This absence of mind is one cause of the distractibility and short attention spans which bedevil the adult or child with ADD, except around activities of high interest and motivation. There is an almost active not noticing, as if a person purposefully went out of his way to be oblivious of what is around him. I compliment my wife for a new decoration in our living room, only to be told that the very same item has been in that very same place for months or even years. The distractibility fosters chaos. You decide to clean your room which, typically, looks like a tornado has just passed through. You pick a book off the floor and move to replace it on the shelf. As you do so, you notice that two volumes of poetry by William Carlos Williams are not stacked side by side. Forgetting the debris on the floor, you lift one of the volumes to place it beside its sibling. Turning a page, you begin to read a poem. The poem has a classical reference in it, which prompts you to consult your guide to Greek mythology; now you are lost because one reference leads to another. An hour later, your interest in classical mythology exhausted for the moment, you return to your intended task. You are hunting for the missing half of a pair of socks which has gone on furlough, perhaps permanently, when another item of clothing on the floor reminds you that you have laundry to wash before the evening. As you head downstairs, laundry hamper in arm, the telephone rings. Your plan to create order in your room is now doomed. Completely lacking in the ADD mind is a template for order, a mental model of how order comes about. One may be able to visualize what a tidy and organized room would look like, but the mind-set of how one would get there is missing. To begin with, there is a profound reluctance to discard anything – who knows when I may need that copy of The New Yorker which has gathered dust for three years without ever being looked at? There is little space for anything. You never feel you can master the confused mess of books, papers, magazines, pieces of clothing, compact discs, letters to be answered, and sundry other objects – you only shift portions of the chaos from one corner to the next. Should you nevertheless succeed now and then, you know full well that the order is temporary. Soon you will be throwing things about again, seeking some needed item you are sure you saw recently in some obscure nook or cranny. The law of entropy rules: order is fleeting, chaos is absolute. A relatively few people with ADD have extraordinary mechanical skills and are able to dismantle and assemble complex objects, pieces of machinery and the like, almost intuitively. Coordination difficulties affect most others, particularly in the area of fine motor control. Things are dropped, feet are stepped on, balls fly in the wrong direction. Objects piled on top of each other during clean-up are fated to come crashing down. By opening the closet door one precipitates an avalanche of books, clothes, and other items which had been gathered and arranged pell-mell, or simply thrown on top of each other in the hope that they would sort themselves out. Telephone numbers are scribbled with the digits misplaced: even if one can read what one has written, one will still get the number wrong. Like many others with ADD, I have little ability to form three dimensional mental representations 9

or to divine the spatial relationships of things, no matter how well explained. When in a novel I come to a physical description of, say, a room with a desk here, a bed there, a window, a night stand, my mind’s eye just glazes over. I can’t configure it in my imagination. Asking for directions in the street, the person with ADD loses track by the time his informant is half-way through her first sentence. Fortunately, he has perfected the art of nodding. Ashamed to admit his lack of comprehension and knowing the futility of asking for clarifications which he would grasp with no greater success, he gives a masterful impersonation of one who understands. Then he heads off, entrusting himself to good fortune. “When there is a fifty per cent possibility of choosing the wrong turn, I will do so about seventy-five per cent of the time,” one of my ADD patients said. The deficient visual-spatial sense works synergistically with the distractibility. Our hapless friend order just doesn’t stand a chance. The distractibility in ADD is not consistent. Many parents and teachers are misled: to some activities a child may be able devote, if anything, a compulsive, hyperconcentrated attention. But hyperfocusing which exludes awareness of one’s environment is also poor attention regulation. Too, often hyperfocusing involves what may be described as passive attention, as in watching television or playing video games. Passive attention permits the mind to cruise on automatic without requiring the brain to expend effortful energy. Active attention, in which the mind is fully engaged and the brain has to perform work, is mustered only in special circumstances of high motivation. Active attention is a capacity the ADD brain lacks whenever organized work must to be done, or when attention needs to be directed towards something of low interest. A facility for focusing when one is interested in something does not rule out ADD, but to be able to focus the person with ADD needs a much higher level of motivation than do other people. Ignorance of this fact has led many doctors to miss the diagnosis. “Indeed, the characteristic of our patient,” wrote a psychiatrist of a college lecturer I had diagnosed with attention deficit disorder but whose GP wanted a second opinion, “is that he is able to focus his attention on something that he is really interested in, which for patients afflicted with ADD is very difficult.” That is not what is very difficult. What can be immobilizingly difficult is to arouse the brain’s motivational apparatus in the absence of personal interest. ADD is situational: in the same individual its expression may vary greatly from one circumstance to another. There are certain classes, for example, in which the ADD child may perform remarkably well, while in others she is scattered, unproductive, and perhaps disruptive. Teachers may conclude that the child is wilfully deciding when, or when not, to buckle down and work diligently. Many children with ADD are subjected to overt disapproval and public shaming in the classroom for behaviours they do not consciously choose. These children are not purposively inattentive or disobedient. There are emotional and neurophysiological forces at play that do the actual deciding for them. We shall examine them in due course. The second nearly ubiquitous characteristic of ADD is impulsiveness of word or deed, with poorly-controlled emotional reactivity. The adult or child with ADD can barely restrain himself from interrupting others, finds it a torture awaiting his turn in all manner of activities, and will often act or speak impulsively as if aforethought had never been invented. The consequences are predictably negative. One is forever trying to shut the barn door after the horse has bolted. “I want to control myself,” a 33-year old man said at his first visit to my office, “but my mind won’t let me.” The impulsiveness may express itself as impulse buying, the purchase of unneeded items on a sudden whim without regard for cost or consequence. “Impulse buying?”, another man exclaimed during our first interview. “If I had the money I would impulse buy the whole world.” Hyperactivity is the third salient characteristic of ADD. Classically it is expressed by trouble 10

keeping physically still, but it may also be present in forms not readily obvious to the observer. Some fidgetiness will likely be apparent – toes or fingers tapping, thighs pumping, nails being chewed, teeth biting the inside of the mouth. The hyperactivity may also take the form of excessive talking. In a minority of cases, especially in girls, hyperactivity may be absent altogether. They may go through school inattentive and absent minded but, as they cause no trouble, they are “passed through” from grade to grade. While the finding of hyperactivity is not required for the diagnosis of ADD, it can be quite dramatic for some patients. “The only thing that ever slowed me down was the police siren when I was caught speeding,” said a twenty-seven year old woman. The loquacious hyperverbality of many children with ADD is notorious. One Grade Two little boy was called “talk bird” by his classmates, so incessant was his chatter. His parents, too, were often after him to be quiet. It’s as if such a child is saying “I am cut off from people. My anxiety is that if I don’t work overtime to establish contact with them, I will be left alone. I only know to do this through my words. I know no other way.” Some adults with ADD have told me that they speak so quickly in part because so many words and phrases tumble into their minds that they fear forgetting the most important ones unless they release them at a fast rate. The individual with ADD experiences the mind as a perpetual motion machine. “I have a mind like a butterfly,” a fifty-seven year old woman said. An intense aversion to boredom, an abhorrence of it, seizes hold as soon as there is no ready focus of activity, distraction, or attention. One experiences an unremitting lack of stillness internally – a constant background static in the brain, a ceaseless “white noise,” as Harvard psychiatrist Dr. John Ratey has put it. There is a merciless pressure in one’s mind impelling one on, without necessarily any specific aim or direction. As long ago as 1934 an article in The New England Journal of Medicine identified a distressing driven quality to some people’s lives, which the authors called “organic drivenness.” I, for one, have rarely had a moment’s relaxation without the immediate and troubling feeling that I ought to be doing something else instead. Like father like son. At the age of eight or nine my son said to me once that “I always think I should be doing something but I don’t know what it is.” The oldest person to whom I have prescribed a stimulant was an eightyfive year old woman who, on taking Ritalin, was able to sit still more than fifteen minutes for what was literally the very first time in her life. The restlessness coexists with long periods of procrastination. The threat of failure or the promise of reward has to be immediate for the motivation apparatus to be turned on. Without the rousing adrenalin rush of racing against time inertia prevails. Not once in high-school or university did I begin an assignment or essay before the eve of the day it was due. In that era of manual typewriters my rough copies had to serve simultaneously as final copies. They resembled academic tossed salad: sheet upon sheet pasted over by pieces of paper with hastily scribbled corrections. On the other hand, when there is something one wants neither patience nor procrastination exist. One has to do it, get it, have it, experience it, immediately. Frequent and frustrating memory lapses punctuate every day in the life of the person with ADD. A close friend of mine, Brian, has attention deficit disorder. He also has a dog. They take each other for walks every day. As Brian puts on his coat, hat, and boots the dog lies under the kitchen table, waiting. Brian leaves the house, the dog doesn’t move. The dog will not move until Brian has come back into the house for the third time for key, wallet, or whatever other items he has forgotten to take the first two times. “My master may take some perverse pleasure in this bizarre in-and-out-and-in ritual,” the hound probably says to himself, “but call me a bird dog if I’ll follow his example.” The dog has learned from experience, which is more than can be said for his 11

owner. My most recent memory failure, as I write this, occurred four days ago. I showed up at Ben Gurion Airport in Tel Aviv, all packed and ready for the flight home to Vancouver. I was pleased with myself for getting somewhere on time for a change. At the airline counter the ticket agent looked at my travel documents. Lines of puzzlement spread across her face. “But your flight is booked for tomorrow,” she finally said. Perhaps I was unconsciously trying to compensate for all the other occasions that saw me perilously late getting to airports. I am often asked how with such traits it was possible for me to get through the grind of medical school. The general answer is that there are many people who seem to be high achievers despite their ADD. ADD can blight various aspects of one’s life. The apparent professional success of the workaholic can mask serious problems in other areas. It is also true with ADD, as with everything else, that there are degrees of it, with wide variations from one end of the range to the other. Although I had planned to become a doctor all my life, I did not enter medical school until the age of twenty-eight, after several detours. In my early twenties I had gradually scaled down my academic ambitions because I could not get myself to work at my studies consistently. One memorable day in second year I walked into the examination room, bleary eyed, having read five Shakespeare plays between midnight and seven o’clock in the morning. Unfortunately, I had got the dates wrong – this particular examination was not in Shakespeare, but in European literature. So it went, term after term. In third year I dropped out altogether. In medical school I had a rough time of it for the first two years when the emphasis was on basic sciences, taught in excruciating detail. Even then I invariably began my exam preparations late the previous evening. I found it easier to become motivated and engaged as the courses become more practical and peopleoriented in the higher years. And, challenging as it can be, medical school does present one with consecutive deadlines, exams to pass, hoops to jump through. It is less a long-term project than an extended series of short-term ones. An adult with ADD looks back on his life to see plans never fully realized and intentions unfulfilled strewn about the landscape like abandoned casualties on a long march. “I am a person of permanent potential,” one patient said. Surges of initial enthusiasm quickly ebb. People report unfinished retainer walls begun over a decade ago, semi-constructed boats taking up garage space year after year, courses entered and quit in languages, in woodworking, in music, in art and in sundry other subjects, books half-read, business ventures forsaken, stories or poetry not written – many, many roads not travelled. Social skills are also an issue. Something about ADD hinders one’s capacity to recognize interpersonal boundaries. Although some ADD children shrink away from being touched, in early childhood most of them literally climb all over adults and generally exhibit an almost insatiable desire for physical and emotional contact. They approach other children with a naive and unrequited openness, to which rebuffs are often the response. Impaired in their abilities to read social cues, they may be ostracized by their peers. For parents it is heartbreaking to witness their child’s exclusion from school ground games, birthday parties, sleepovers, Valentine card exchanges. While generally the case, poor social skills are not universal. There is a type of ADD child who is socially adept and wildly popular. In my experience such success hides a lack of confidence in important areas of functioning and masks a very fragile self-esteem, although this may not emerge until these children grow into their late teens or early twenties.

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Adults may be perceived as aloof and arrogant or tiresomely talkative and boorish. Many are recognizable by their compulsive joking, their pressured, rapid-fire speech, by their seemingly random and aimless hopping from one topic to the next, and by their inability to express an idea without exhausting the English vocabulary. “I have never finished a thought in my life,” one young man lamented. Men and women with ADD have about them an almost palpable intensity to which other people respond with unease and instinctive withdrawal. “It’s as if I was from Mars and everyone else was from earth,” one forty-year old woman said. Or, as another put it, “everyone else seems to belong to some nice persons’ club, only I am excluded.” This sense of being always on the outside looking in, of somehow missing the point, is pervasive. At social events I tend to gravitate to the periphery, conscious of a feeling that somehow I cannot enter into the spirit of things. I observe people talking to each other, people I may know quite well, acutely aware that I have nothing to say to anyone. Social conversation has always been a mystery to me. I have at times looked at people engaged in animated talk and wished that I was invisible so that I could overhear them – not to eavesdrop, only to find out once and for all exactly what there is to talk about. My patients with ADD tell me much the same thing about their experience. “I don’t know how to make small talk, or I’m afraid of saying something stupid,” a twenty-six year old woman said. And the truth is, when the ADD adult does join conversations, she often finds herself bored by the minute attention others devote to subjects that to her seem to skim only the surface of life. To interview adults with attention deficit disorder is often to traverse a minefield booby-trapped with jokes. Unexpected turns of phrase and consciously absurd associations pepper life histories which, in themselves, are often not much to laugh about. “Thank God it’s only ADD,” said one man after I confirmed his diagnosis. “I always used to think I was one crouton short of a Caesar salad.” Children with ADD often act the part of the class clown. The moods of the ADD child are as capricious as the weather patterns El Nino has loosed upon the world. Happy smiles are transformed into frowns of displeasure or grimaces of despair in a matter of moments. Events awaited with joyful anticipation and begun with exuberant energy often end in bitter disappointment and a sulking, accusatory withdrawal. The emotional states of adults with attention deficit disorder are also up and down without apparent rhyme or reason. Good days and bad days follow each other according to some mysterious calendar written who knows where and by whom. The common theme on all days, good or bad, is a gnawing sense of having missed out on something important in life. Chapter Nineteen − Just Looking for Attention The child who seeks constant attention is, of necessity, an unhappy child. He feels that unless he gets attention he is worthless, has no place. He seeks constant reassurance that he is important. Since he doubts this, no amount of reassurance will ever impress him. −Rudolf Dreikurs M.D. ADD children, all too often even after they have been diagnosed, suffer the preconceived notions and judgements of the adult world. Common to all of these is the assumption that the child’s actions, and in particular how the parent responds to them, are the responsibility of the child and that he could change them at will. In this chapter we look at five of the most damaging misconceptions applied to the ADD child. Myth 1: The child is just looking for attention 13

There is no commoner knock on the ADD child than that he or she is “just looking for attention,” a phrase one hears from many an exasperated parent and teacher. “Yes,” I say. “That’s absolutely right. The child is looking for attention. Only there is no ‘just’ about it.” Attention of the right kind is the child’s central need, the lack of it his or her central anxiety. Recognizing that transforms the meaning of the very name, attention deficit disorder. As politicians intent on further cutbacks in public services such as health care and education are forever reminding us, a deficit is incurred when one pays out more than one receives. The child with ADD has had to pay out more attention than he or she has received, which is precisely how he or she has incurred an attention deficit. It may be perfectly true, as many parents point out, that their ADD child monopolizes their attention to such a degree that other children in the family come to feel neglected. The trouble is, by the time ADD behaviours are present the child is evoking much more negative than positive attention, a ratio which gets worse as he or she becomes older. It may seem paradoxical, but many children will go for negative attention rather than for no attention at all. They do not do this consciously, but they do it. A vicious cycle is initiated, one of many vicious cycles in the interactions of ADD children with the adult world. The child acts out, partly to gain attention. The adult responds with a punishing look, act, or statement which the child’s brain interprets as rejection. Her anxiety about being cut off from the adult is magnified, as is her desperation for attention. Only the adult can break this cycle. The key to doing so is learning to give the child not the attention he is asking for, but the attention he needs. “Do not mistake a child for his symptom,” wrote the psychotherapist Erik Erikson. The attitude adults are best to adopt when it comes to dealing with the distressing behaviours of the ADD child is one of compassionate curiosity. The compassion is for the child who, beneath of the surface of what so often is seen only as obnoxious behaviour, is anxious and is hurting emotionally. The curiosity, if genuine and open-minded, leads us to consider exactly what message the child may be trying to communicate to us by a particular behaviour, even more unbeknownst to herself than to us. Compassionate curiosity can help us break the coded language of attention-seeking. When the child is in one of her insatiable attention-hungry modes, the parent may become resentful and frustrated. She may feel trapped. She has already spent hours playing with the child, helping him clean his room, reading to him, being the audience for the child’s performances. She feels she has nothing left to give at that moment, yet still the child demands more. The parent points out to the child just how much attention has already been devoted to him. The child argues, the parent tries even harder to convince him. “You never want to play with me,” says the child, hurt and angry. How can we understand this? “I have an anxiety that you don’t want me around you,” the child is really saying, “and, when I am anxious I do not know how to be on my own.” One cannot successfully counter this unconscious stance by arguing with the child, by showing him how mistaken he is. The more we try to convince him the more he will be confirmed in yet another of his core beliefs, which is that nobody understands him and that, perhaps, no one wants to. The look-at-me-ism of the ADD youngster is tiresome, insatiable, and self-defeating. It represents a voracious appetite that cannot be appeased even if it achieves its immediate objective. Whatever the child receives in the emotional relationship with the parent only after demanding it has, by definition, no capacity to satisfy. Just as with unconditional acceptance, the child should not have to work for attention either by destructive acts or by look-at-me-istic behaviours, or by “good boy, good girl” compliance. The hunger is eased by the parent seizing every possible opportunity to devote positive attention to the child precisely when the child has not demanded it. 14

“We have to satiate the child with attention, stuff her full of it until it’s coming out her ears,” says developmental psychologist Gordon Neufeld. Once the attention hunger is alleviated the “justlooking-for attention” behaviours will lessen. As the child develops greater security in the relationship and greater confidence in herself, the motive driving these behaviours gradually weakens. The parent has to be able to say a kind but firm “no” whenever she or he is unable to meet the child’s insistent demands for attention. “I am just not up to doing that now,” one may tell the child. Or, “that does not work for me right now.” The statement is about the parent and does not express a judgement either about the child or about the particular activity in question. The operative word here is kindness. The problem is often not the parent’s legitimate refusal per se. It is the punishing irritability with which the message is delivered and with which the child’s frequently unpleasant expressions of disappointment are received. The demand for attention, like all of the child’s demands, is a compensation for an unconscious emotional hunger. The parent may rightly deny some demand of the child for attention, or any other demand, such as for the candy bar at the supermarket, but there is no reason why the child should be expected to understand that decision, or to like it. The emotionally wounded child is struck by every refusal as by a rejection, even though no such rejection is intended by the parent. If now the parent allows his reaction to the child’s reaction to become cold and punishing, the child’s anxiety will have turned into a self-fulfilling prophecy. In many situations it is fit and proper for the parent not to give in to the child’s demands. The main thing is give one’s refusal without blaming or humiliating the child for the attention-seeking or for the demanding behaviour. If we anticipate the child’s reactions, understand their source, and do not shame the child for them, the child will eventually learn to tolerate refusal. When we endure children’s anger or frustration with compassion, they will often move on to the sadness of not having what they wish for, of having to give up what they think they need just then. At such moments one can move in and witness that sadness with an empathy that will make the child feel understood and supported, despite the refusal. Finally, as we consider the child’s needs for attention, the parents’ lifestyle has to be carefully examined. Over and over again I am struck by just how insane can be the lives of many parents whose children have ADD. For the most part the craziness does not flow from the difficulties of raising these children, but the difficulties of parenting are multiplied many times over by the craziness. In an earlier chapter I mentioned my own workaholism and breakneck pace of living around the time my children were small. I observe the similar patterns almost universally in the families I see for ADD assessment. One and often both of the parents may work long hours. Morning is rush, rush, rush, and the evening is no different. The parent comes home depleted and must now put full energy into meeting the physical and emotional needs of a child who, for a whole day, may have been deprived of parental contact. And, if these were not enough, parents have often taken up other commitments – school committees, church bazaars, courses of various sorts, and so on. Such extracurricular activities magnify the parent’s level of preoccupation and stress, decreasing her/his patience with the child. Even during the time one devotes to the child the parent’s mind may be spinning with the events of the day and the chores yet to be done. Research shows that many parents spend virtually no more than five minutes, if that, of meaningful contact with their child. If that snippet of time is to grow, parents need to create some space around themselves, and in order to do so they may have to reconsider their lifestyle Socioeconomic trends greatly exacerbate the attention-starvation of children. According to the 15

Economic Policy Institute (U.S.), the average work year is now 158 hours longer than in it was three decades ago. “An extra month has been tacked on to what in 1969 was considered a fulltime job!” writes the psychologist Edward L. Deci. “It’s extraordinary really.” In such a society it is only to be expected that many children would be looking for attention – looking for it, but not finding it. Parents may need to change their lifestyles, sacrificing whatever activities that can be eliminated if these diminish their availability to their ADD child. This could mean saying no and disappointing friends or colleagues, and it may mean the giving up of projects and involvements close to one’s heart. There is a lot to be made up however, for their child has already incurred a deficit of attention. Too, a poorly self-regulated child can hardly learn to be calm in a hyperactive atmosphere. Narrowing one’s range of activities is wrenching for many of us, but in terms of our children’s development the rewards far outweigh the cost. It may be a non-negotiable condition for the healing of the child with attention deficit disorder. Myth 2: The child is deliberately trying to annoy the adult “He is out to get a rise out of me, I swear to God,” a father asserted of his ten-year old son. “I just know that’s what he is out to do.” Many parents find such motives to be a convincing explanation for their child’s distressing behaviours. On the face of it this is a seemingly reasonable conclusion to arrive at: given the intelligence of many ADD children and the number of times they have been told not to do this or that, it may seem like they are misbehaving knowingly and on purpose. Fortunately it’s wrong: these children are neither so cunning nor so malevolent. It is a mistake many of us commit in our relationships with others, whether children or spouses, acquaintances or strangers, to imagine that we know the intentions behind the actions of others. Some psychologists refer to this misbelief as “intentional thinking.” Family therapist David Freeman once concluded a public lecture on intimacy and relationships by saying that if there was any one thing he hoped his audience would remember from his talk, it was the awareness that one does not know his or her spouse, his or her children. We may believe we have a perfect idea of why they act as they do, when in reality our beliefs reflect no more than our own anxieties. Whenever we ascribe a motive to the other person, as in “you are doing this because…”, we discard curiosity and immobilize compassion. The person who knows has nothing to learn, has given up on learning. “In the beginner’s mind there are many possibilities, in the expert’s mind there are few,” said the Zen master Shunryu Suzuki. It is good to be aware that we are beginners as we approach the ADD child. In our interactions with children intentional thinking gets in the way of seeing the child for who he or she really is. Worse, the judgements we deliver upon our children become the selfjudgements they will carry in their psyche into adult life. “I was a bad kid,” or “I was always trying to cause some trouble,” are frequently how adults with ADD recall themselves as children. The child sooner or later comes to see himself, as much as he may protest against it, through the negative opinion of the parent. A dysfunctional search for attention underlies some of the behaviours of the ADD child, as we have just seen. Poor self-regulation, poor impulse control are also responsible for many behaviours. Unconscious shame or rage or anxiety are other motive forces. All of these are expressions of vulnerability and pain, not of bad intent. And even if, on a given occasion there is consciously harmful intent, we still need to maintain the spirit of compassionate curiosity. “Why would a child want to do harm?”, asked without prejudgement, is a question that can provide fertile ground for inquiry. “What happened to this child to make her so? What is happening now 16

in her life to make her act it out?” There is much we can find out if we know that we don’t know. Myth 3: The child purposefully manipulates the parent In the category of intentional thinking is the belief that the child is manipulative or controlling. It’s worth a closer look because it is another commonly held misperception which visits a harsh judgement upon ADD children. In the first place, it is wrong. No child is by nature manipulative, no child is by nature controlling. Second, a child who does develop a propensity to manipulate or to control others is doing so out of weakness, not strength. Manipulation and the drive to control are fear responses based on unconscious anxieties. The truly strong person need not be so afraid that she has to direct and control every aspect of her environment. Given that children are always the weaker party in the relationship with the adult, it is natural for them to want to control at times. “I don’t know why we hold it against our child,” says psychologist Gordon Neufeld. “The most ridiculous thing we can say is that ‘My child is trying to manipulate me.’ It’s like saying the rain is wet. Of course children want to get their own way, and often they can do that only if they get the adult to go along with them.” Some children rely on manipulation and control more than others. If we can remain curious, we can explore why a child would need to manipulate. To manipulate is to subtly and covertly influence others, by dishonest means if necessary, to achieve goals that would be unachievable if we were being honest. Powerful people may do this, but only when they are in a morally weak position, as when a government hopes to induce a population to support an unjustifiable war. With children the manipulation occurs only because the child has learned that openly expressing his or her needs will not necessarily bring an understanding and nurturing response. It occurs also because the emotionally wounded child may no longer be able to articulate his or her real needs. Lacking a completely secure sense of attachment, he or she tries to compensate by getting things that the adult world, quite rightly perhaps, does not want to give – as, for example, another expensive toy or a candy bar at an inappropriate time. No healing would come if the adult yielded to inappropriate demands or manipulative tactics, but no healing is possible either if the adult insists on seeing the child behaviour as the primary problem. Excessive manipulation, controlling, bossiness are simply the dysfunctional and self-defeating acquired characteristics of a sensitive and anxious child. Just as these qualities developed in interaction with the environment, so they can atrophy when the environment becomes understanding, nurturing, and supportive. Myth 4: The ADD child’s behaviour causes the adult’s tension or anger Anger, anxiety, despair: all normal human emotional states. They belong to each one of us, in proportions that reflect our individual life histories and temperaments. They are distressing states to experience. The temptation is to blame someone else whenever we feel them. The parents of a child with ADD will often find themselves angry and upset. The parent tells the child to hurry: the child drags his feet, and may even say something insolent. The parent flies into a rage, and he imagines that his rage has been caused by the child’s behaviour. The child is chastised not for what he has done, but for the unpleasant feelings experienced by the parent. In reality, the child cannot cause the parent’s rage. He may have inadvertently triggered it, but he is responsible neither for the capacity for rage in the parent nor for the existence of the trigger he has set off. The parent acquired them before the child was born. The uncooperative behaviour may belong to the child, but the rage belongs to the parent. It is only one among many potential ways the parent could have responded to the child’s procrastination. In fact, when he later thinks about it he recognizes that his reaction was quite out of proportion to the stimulus. On another 17

day, had he slept better perhaps, he would have responded quite differently – with non-hostile impatience, with mild annoyance, possibly even with humour. Parents need to be aware of the wide range of their emotional responses, from the functional to what may be called the dysfunctional. They are then much less likely to insist that the child takes responsibility for how they feel, regardless of what the child may or may not have done. An enormous emotional burden is lifted off the child’s shoulders once the parent learns to acknowledge within himself the sources of his reactions to the child. That other people do not cause our reactions is a difficult concept, so automatically have we come to associate our feelings with what someone else is doing. The confusion is only natural. When we were children other people did, in fact, cause us to feel this way or that, depending on how they treated us. To the extent that this still remains true for one as an adult, it reflects the failure of self-regulation to develop. A simple example is how one may react if someone accidentally steps on one’s foot, say, on a crowded bus. One may address that individual politely or in a fit of rage or, if one feels intimidated, one may not even say anything. Although the stimulus in each case is the same, the reaction depends not on the stimulus but on one’s particular state of mind. Even the same person will react differently to the same stimulus from one moment to the next, so the stimulus cannot be said to cause any one particular reaction. We cannot blame the trigger for the shotgun blast. A person can squeeze the trigger all he wants, but if there is no bullet there the gun will not fire. The parent who learns to observe him/herself carefully will soon recognize that greatly complicating many situations is not what the child is doing as such, but the degree of anxiety which the child’s actions set off in the parent. When the child “misbehaves” the parent could react with curiosity and attempt to understand exactly what message is being acted out, which would make for a measured and much more effective parental response. When, instead, we as parents are flooded by anxiety we will move immediately to control the behaviour, which is to say, to control the child. The ADD child will feel emotionally secure when he can be certain that parental love and acceptance are constant, regardless of how he behaves. Parents reacting from anxiety they are unaware of cannot provide that certainty. I have noticed in myself, for example, that when I am seized by anger or the impulse to withdraw – my particular expressions of deep anxiety – I cannot convey any sense of warm loving to my children. I am not even in touch with loving feelings at such times. My voice is cold, the tone forbidding and accusatory. It is quite another story when I see my own anxiety, knowing that it is really about me and not about the child. Then I am able to tolerate the feelings that arise in response to the child’s “misbehaviour”. It is not that I allow the child to believe that the behaviour in question is acceptable, only my response to the behaviour does not become an attack on the child. Myth 5: Children with ADD are lazy Beneath the surface of the so-called laziness ADD children are often berated for is also emotional pain. When we consider the world lazy, we realize that it does not explain anything. It is only a negative judgement one makes about another person who is unwilling to do what one wants them to do. The so-called lazy individual will be a whirlwind of energy and activity when faced with a task that arouses their interest and excitement. So the laziness and the procrastination are not immutable traits of a person, but expressions of his or her relationship with the world, beginning with the family of origin.

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An exasperated couple related with what outrage and indignation their twelve-year old son would reject their demand that he contribute to the house work, for example by emptying the dishwasher. “I am always having to do everything,” he complained. The reality, of course, was that when it came to household duties the parents found it easier to wring water from a stone than any cooperation from their son. All they could do was to engage him in unwinnable verbal battles, or to give up. This child, too, was speaking in code language that could be deciphered by using the key of compassionate curiosity. “From early on I have had to work too hard enough on my relationship with you,” he was saying. “I am tired of doing that. I don’t want to do any more of the work that you should have been doing all along.” The solution came not from the parents trying to coerce their son into doing his share, or to bribe him, but from their work on reconnecting with him emotionally. As they did so, he spontaneously became more ready to help out. Eventually he hardly needed any reminders at all. What allowed the parents to achieve this is was their new-found ability to understand the code. Once they deciphered their son’s messages they became far more supportive of his needs and less threatened by his seeming indifference to responsibility. Another aspect of what is seen as laziness is the child’s automatic resistance. Probably the most frustrating and dispiriting aspect of dealing with ADD children is the virtually routine negative and defiant refusal with which they greet almost any demand, expectation, or suggestion the parent puts forward. This resistance serves an important purpose and tells an important story. It, too, has meaning. Chapter Twenty − The Defiant Ones: Oppositionality And one may choose what is contrary to one’s own interests and sometimes one positively ought… One’s own free unfettered choice, one’s own caprice, however wild it may be, one’s own fancy worked up at times to frenzy… What man wants is simply independent choice, whatever that independence may cost and wherever it may lead. − Fyodor Dostoevsky, Notes From The Underground Steven, a thirty-eight year old labour relations officer for a large company, was referred to me for ADD assessment. He was respected as a creative individual who brought original and innovative thinking to his work. A skilled negotiator, he was able to approach any situation from new angles and unique perspectives that could break a logjam when everyone else was stuck. “I do things nobody else would dream of doing, but I feel I could be doing a lot more,” he said. At times he would impulsively take on problems and responsibilities beyond his experience or control. This propensity for risk-taking had brought him and his company near the precipice of disaster more than once. As I wrote in my consult letter to his family doctor, “it is a tribute to Steven’s daring, acumen, and creativity, and thanks to some good luck, that so far he has avoided catastrophic consequences to his original and idiosyncratic approach to his work.” In this and in every other way the diagnosis of ADD was self-evident. As he related his life story Steven expressed one major regret. He had been an extraordinarily gifted classical musician in his childhood and adolescence. An international solo career had been widely predicted. In his midteens, however, he had given up his instrument, the clarinet, and completely severed his involvement with music. My consultation report noted: The parents were both artistically inclined. The mother was an actress, the father a talented musician. Steven himself was introduced to music at an early age and was apparently something of a child prodigy on the clarinet, being invited as an adolescent to 19

play with the… National Youth Orchestra. He was at one time considered to be a great prospect. He quit the clarinet at age sixteen for what he says were reasons of spite and defiance towards his father, who forced him into practising and would beat him when he refused to do so. He was made to practice four hours a day. He continues to love classical music and deeply regrets not having continued with his musical studies. Steven has for a long time considered his abandonment of a musical career as a perverse, thickskulled misjudgement. “It was the stupidest thing I have ever done,” he said. He was surprised to find that I did not agree with him. “It was one of the most necessary things you have ever done,” I told him. “To have continued under those circumstances would have been to surrender your soul to your father. Psychologically you may not have survived that.” The mistake, if we could speak of it as a conscious act, was not committed by the son but by the father. The force he had exerted on his son evoked its own counter-force, resulting in the impulse which finally sent Steven in the direction exactly opposite to what his father had wished. Sadly, it also went against Steven’s interests and contrary to the choice he probably would have made, had he been truly free to make a choice. He did not have that freedom. Steven had not acted, which would have meant autonomy, but reacted, which reflected psychological subjection – not to his father, but to the unconscious defences he had built up against his father. Quitting music was not an act of will, it was an expression of what Vancouver developmental psychologist Gordon Neufeld calls counterwill. Distinguishing will from counterwill is important for any successful parenting. Understanding counterwill is particularly crucial for the parenting of the ADD child, and for the self-understanding of the ADD adult. Children with attention deficit disorder are often characterized as stubborn, oppositional, cheeky, insolent, spoiled. “Wilful” is a description almost universally applied to them. Parents worry that the difficulty is rooted in some deeply embedded negative trait in their child’s personality that will impede her future success in life. The truth is more complicated than that, and it leaves more ground for optimism. Oppositionality cannot arise on its own. By definition, it has to develop in response to something. It is not an isolated trait of the child but an aspect of the child’s relationship with the adult world. Adults can change the relationship by changing their own role in it. ADD children can hardly be said to have a will at all, if by that is meant a capacity which enables a person to know what he wants and to hold to that goal regardless of setbacks, difficulties, or distracting impulses. “But my child is strong-willed,” many parents insist. “When he decides that he wants something he just keeps at it until I cannot say no, or until I get very angry”. What is really being described here is not will, but a rigid, obsessive clinging to this or that desire. An obsession may resemble will in its persistence, but has nothing in common with it. Its power comes from the unconscious and it rules the individual, whereas a person with true will is in command of his intentions. The child’s oppositionality is not an expression of will. What it denotes is the absence of will which – as with Steven’s abandonment of music – only allows a person to react, but not to act from a free and conscious process of decision making. Counterwill is an automatic resistance put up by a human being with an incompletely developed sense of self, a reflexive and unthinking going against the will of the other. It is a natural but immature resistance arising from the fear of being controlled. Counterwill arises in anyone who has not yet developed a mature and conscious will of their own. Although it can remain active throughout life, normally it makes its most dramatic appearance during the toddler phase, and

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again in adolescence. In many people, and in the vast majority of children with ADD, it becomes entrenched as an ever-present force and may remain powerfully active well into adulthood. It immensely complicates personal relationships, school performance, and job or career success. Counterwill has many manifestations. The parent of a child with attention deficit disorder will be familiar with them. Most obviously, it is expressed in verbal resistance, the “no’s”, the “I don’t have to’s”, the ” can’t make me’s”, in the constant arguing and countering whatever the parent proposes, in the ubiquitous “you are not the boss of me’s”. Like a psychological immune system, counterwill functions to keep out anything that does not originate within the child herself. It is present when the four-year old puts both hands over the ears to keep out the parent’s voice, or when the older child pins up an angry “keep out” sign on her door. It is visible in the body language of the adolescent and teenager: the sullen look and the shrugged shoulder. Its signs drive some adults around the bend, as in the futile “I’ll soon wipe that smirk off your face” of many a parent or teacher. Counterwill is also expressed through passivity. Every parent of an ADD child has had the experience of feeling intense frustration when, being pressured for time, they have tried to hurry their son or daughter along. The greater the parent’s anxiety and the greater the pressure he puts on the child, the more slothfully slow the child seems to become. Passivity begins to look like almost second nature to some of these children, although one may notice that when highly motivated the child will perform many tasks with alacrity. This passivity, what people may call laziness, can signal a strong internal resistance. Counterwill is a natural inclination and does not mean there is anything intrinsically wrong with the child. It is not as if the individual does it; it happens to the child rather than being instigated by him. It may take the child as much by surprise as the parent. “It really is simply a counterforce,” says Dr. Neufeld. “The counterwill dynamic is simply a manifestation of a universal principle. The same principle is seen in physics, where it is considered fundamental to keeping the universe together: for every centripetal force there has to be a centrifugal one; for every force, a counterforce.” As all natural phenomena and all stages in the child’s life, counterwill has a positive purpose. It first appears in the toddler to help in the task of individuating, of beginning to separate from the parent. In essence, the child erects a wall of “no’s”. Behind this wall the child can gradually learn her likes and dislikes, aversions or preferences, without being overwhelmed by the far more powerful force generated by the parent’s will. Counterwill may be likened to the small fence one places around a young tender shoot to protect it from being eaten. The vulnerable little plant here is the child’s will. Without that protective fence it cannot survive. In adolescence counterwill serves the same goal, helping the young person loosen his psychological dependence on the family. It comes at a time when the sense of self is having to emerge out of the cocoon of the family. It is a defence mechanism to protect this fragile, threatened sense of self. By keeping out the the parent’s expectations and demands, counterwill helps to make room for the growth of the child’s own, self-generated motivations and preferences. Figuring out what we want has to begin with having the freedom to not want. “Far from being depraved, counterwill is bequeathed by nature, to serve the ultimate purpose of becoming a separate being,” says Dr. Neufeld. “Counterwill, the dynamic, should not be identified with the child’s self. This is really important. It is not the person that we are getting to know when we get to know the resistance. Nature designed the child that way. It is really Nature that has a purpose, not the child.” The great importance of understanding counterwill in attention deficit disorder stems from the extreme sensitivity of the ADD child who in this, as in many other things, is affected by 21

environmental stimuli more than the average. Any force or pressure of whichever sort, no matter how good the intention, will be experienced by the ADD toddler, child, adolescent, or teenager to a highly magnified degree, and will generate counterwill of greatly heightened intensity. A vicious cycle ensues. The tendency of the ADD child is to behave in ways that evoke disapproval and attempts at parental control. Disapproval makes the child feel more insecure and promotes acting out, and the parent’s controlling responses deepen the child’s automatic resistance. Emotional hypersensitivity in ADD is coupled with psychological underdevelopment. The weaker the child – or, for that matter, the adult – is psychologically, the more automatic and rigid the counterwill response becomes. A strong unconscious defence indicates a weak, undeveloped will, which is what is reflected in the oppositionality that seems intrinsic – but only seems that way – to the ADD personality. A strong defence is only there because there is threat, and the child is threatened only because a strong sense of his own self has not developed sufficiently. So the root of the problem is that, rather than being too powerful, the inner core of self, the true will, is stunted. This why the various epithets such as stubborn, wilful, and so on, denote not a strong will but the lack of one. An emotionally self-confident person does not have to adopt an oppositional stance automatically. She may resist others’ attempts to control her, but she will not do so rigidly and defensively. If she opposes something, it is from a strong sense of what her true preferences are, not out of a knee-jerk reflex. A child not driven by counterwill does not automatically experience any advice, any expression of the parent’s opinion as an attempt at control. Registering deep in her psyche is a sense of solidity about this inner core, this nucleus of the self, so there is no necessity to defend the will against being overwhelmed. “I will be able to hang onto myself,” an inner voice reassures her, “even if I listen to what somebody else thinks, or do what someone else wants me to do. I won’t lose my identity, so I don’t have to protect myself through resistance. I can afford to cooperate. I can afford to heed.” In contrast, the counterwill of the child with an underdeveloped self asserts itself ferociously. A parent meekly suggests that the child may wish to do her homework, only to get the automatic and combative “You are always telling me what to do!”. In the ADD child the underdeveloped circuitry of self-regulation reinforces the counterwill reaction. Because the child with attention deficit disorder is unable to disengage impulse from action, his automatic negative responses are expressed immediately and dramatically, in ways the adult world usually interprets simply as deliberate rudeness. Further magnifying the brazen outbursts of oppositionality is another feature of underdevelopment, the one-dimensionality of the ADD child’s emotional processing. In a manner characteristic of infants and toddlers, children with attention deficit disorder are unable to hold in their minds simultaneously two different images of themselves or of others. For the preverbal child the “me” is either happy or miserably upset. Mommy is either good or bad. “When a twelve- to fourteen-month-old gets angry at someone he may have no sense that just moments ago he was playing happily with that person,” writes Dr. Stanley Greenspan. “If he had a gun, one suspects, he’d shoot without remorse. By fifteen months or so, however, a dawning awareness that a relationship of trust and security can coexist with anger has often begun to moderate his temper.” For ADD children (and for ADD adults) it’s all or nothing. When anger arises, all feelings of attachment and love are banished. Since counterwill grows as attachment weakens, the child who is upset and angry may, in that moment, resist the parent with the emotional fury one would feel towards a despised enemy. In the literature of child rearing counterwill is sadly neglected because so much of the emphasis has been placed on behaviours. If specific behaviours are the goal, then threats, punishments, 22

promises, and rewards may work very well – for a while. That, unfortunately, characterizes much of the advice parents of ADD children receive. With counterwill, as with every other aspect of parenting, it is far wiser to put the emphasis on long-term development. The long-term objective here is the growth of a healthy and robust sense of self. Counterwill becomes maladjusted, as it does in ADD, only when adults do not understand it and try to overcome it by some sort of pressure, be it physical or emotional, be it inducement or threat. Counterwill is triggered whenever the child senses that the parent wants him to do something more than she, the child, wants to do it. It arises not just when the child absolutely does not wish to do that something but also when she does wish it, only not as much as the parent. Many parents find out to their chagrin that there is no better way to kill a child’s interest in music than to force him to practice, even if by methods much milder than the brutality Steven’s father employed. All one ends up with is the child’s resistance. The use of rewards – what might be called positive coercion – does not work in the long run any better than threat and punishment, or negative coercion. In the reward the child senses the parent’s desire to control no less than in the punishment. The issue is the child’s sense of being forced, not the manner in which the force is applied. This was well illustrated in a classic study using magic markers. A group of children were screened, and those were selected who seemed to show a natural interest and inclination for playing with magic markers. They were then divided into three different groups. One group was given no reward, in fact no instructions whatsoever as to whether they should or should not play with the magic markers. Another group was given a mild reward if they did so, and the third group was promised and given more substantial rewards. When retested sometime later, the group that had been most rewarded showed the least interest in playing with the magic markers, while the children who had been left uninstructed showed by far the greatest motivation to do so. According to simple behaviouristic principles it ought to have been the other way around, another illustration that behavioural approaches have no more than a short term efficacy. At work here, of course, was the residual counterwill that had been evoked in response to the positive coercion. In a parallel experiment the psychologist Edward Deci observed the behaviours of two groups of college students vis-à-vis a puzzle game they had originally all been equally intrigued by. One group was to receive a monetary reward each time a puzzle was solved, the other was given no external incentive. Once the payments stopped the paid group proved far more likely to abandon the game than their unpaid counterparts. “Rewards may increase the likelihood of behaviours,” Dr. Deci remarks, “but only so long as the rewards keep coming… Stop the pay, stop the play.” We have seen that the very first step in helping the ADD child is to strengthen the security of her relationship with the parents. The process of making the child feel safer, more secure in the relationship becomes much smoother and less frustrating if the parents understand counterwill and do what they can to relax its chronic hold on the child. Chapter Twenty-Five − Justifying One’s Existence: Self-Esteem and the ADD Adult If you persist in throttling your impulses you end by becoming a clot of phlegm. You finally spit out a gob which completely drains you and which you only realize years later was not a gob of spit but your inmost self. If you lose that you will always race through dark streets like a madman pursued by phantoms. You will be able to say with perfect sincerity: “I don’t know what I want in life.” − Henry Miller, Sexus

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“I have wasted most of my life,” said Andrea, a fifty-year old unemployed woman. “I have achieved nothing, I have no excuse for existence. I haven’t justified my existence yet.” Guilt, shame, and self-judgement are commonly heard when one interviews adults with attention deficit disorder. Low self-esteem and a merciless self-criticality are so much part and parcel of the ADD personality that it would be difficult to know where ADD ends and low self-esteem begins. Many of the traits thought to be caused by attention deficit disorder are, I am convinced, not the expressions of the specific neurophysiological impairments associated with ADD but of low self-esteem. Workaholism, drivenness, and inability to say ‘no’ – all endemic in the adult ADD population – are some of the examples discussed in this chapter. In the ADD child low self-esteem is manifested not just by the self-putdowns she may utter, such as “I’m stupid,” or “I’m dumb.” Above all, it is visible in the perfectionism and in the dejection and discouragement she experiences when she fails at a task or loses in a game. Nor can she accept not being in the right. The fragile and self-rejecting ego is unable to endure any reminders of its fallibility. Many people with attention deficit disorder retain that fragility into adulthood. Where do self-judgement and lack of self-respect originate? The conventional view is that the low self-esteem of ADD adults is a natural consequence of the many failures, lost opportunities, and setbacks they have experienced since childhood, owing to their neurophysiological deficits. Plausible as it sounds, this explanation accounts only in small measure for why people with ADD think so very little of themselves. Andrea, like so many others I have seen, would never hold anyone else under the severe judgement she imposes on herself. When asked, she rejects the idea that people should have to justify their existence. Life is its own justification. To demand that people earn the right to live and breathe is to reject the innate dignity of human life; nor can one logically insist on some arbitrary achievement level as a condition for self-respect. That people do judge themselves so harshly reflects low self-esteem, not low achievement. Self-esteem, we must realize, is not what the individual consciously thinks about himself. It is the quality of self-respect that is evident in one’s emotional life and in one’s behaviours. By no means are a superficially positive self-image and true self-esteem necessarily identical. In some cases they are not even compatible. People who have a grandiose and inflated view of themselves on the conscious level are lacking true self-esteem at the core of their psyche. Their flattering and exaggerated self-evaluation is a defence against their deepest feelings of worthlessness. The professionally successful workaholic suffers from low self-esteem, no matter what his conscious self-image may be. Some years ago a hapless Toronto study purported to discover that men had higher self-esteem than women by asking people whether they ever felt despondent, or vulnerable, or lonely. Male respondents tended to deny such feelings, hence the study’s conclusions. It appears not to have occurred to the researchers that what they may have been measuring was not, in fact, self-esteem but the denial and suppression of negative emotions – hallmarks of low self-esteem! There are some adults with attention deficit disorder who exhibit great self-confidence in specific areas of functioning and are high achievers according to social standards. Many others are low achievers who bring little confidence to any field of endeavour. What they share in common is that they all have low self-esteem. The low achievers may believe they would gain self-esteem if their ADD impairments could be eliminated and they could perform better in society’s eyes; the high achievers could tell them otherwise. The wide chasm that may yawn between success and self-acceptance is illustrated by a diary fragment shown to me by a forty-three year old

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professional with attention deficit disorder who enjoys a high income, the good opinion of his clients, and no lack of public recognition. The diary is typical of attention deficit disorder in the depth of self-laceration it reveals. It is typical, too, in its format, written on dog-eared scraps of paper filed in no particular order, months and years separating individual entries: I have not achieved enough in life. I feel that my abilities exceed my attainments. I feel I could do more… I vegetate, my ambitions like rotting weeds around me. I want to paint. I want to study languages: French, German, Spanish… What else? I want to exercise. I want to meditate. I want to read. I want to see people. I want to take in more culture. I want to sleep enough. I don’t want to watch junk television any more. I want an end to the binge cramming of food into myself every evening… I want to live! Characteristically, what this man did not think to write was: I want to learn to accept myself. Self-esteem based on achievement has been called contingent self-esteem or acquired selfesteem. Unlike contingent self-esteem, true self-esteem has nothing to do with a self-evaluation regarding achievement or the lack of it. It doesn’t say “I am a worthy human being because I can do such and such.” It says “I am a worthy human being whether or not I can do such and such.” Contingent self-esteem evaluates, true self-esteem accepts. Contingent self-esteem is fickle, it goes up and down with one’s ability to produce this or that result. True self-esteem is steadfast, not subject to that kind of oscillation. Contingent self-esteem places great store by what others think. True self-esteem is independent of others’ opinions. Acquired self-esteem is a false imitation of true self-esteem: however good it makes one feel in the moment, it does not esteem the self. It esteems only the achievement, without which the self in its own right would be rejected. True self-esteem regards who one is, contingent self-esteem sees only what one does. ADD adults don’t have low self-esteem because they are poor achievers, but it is due to their low self-esteem that they judge themselves and their achievements harshly. Much of the initial counselling I do is to help people recognize that in many ways the problem is not in what they have done in life, but in how they view themselves. There live human beings afflicted with far more debilitating impairments who do not necessarily hold the low opinion of the self prevalent among ADD adults. The deep shame adults with attention deficit have carried all their lives predates any recollections of poor achievement. The association between low self-esteem and attention deficit disorder is not that the first arises from the second, but that they both arise from the same sources: stress on the parenting environment and disrupted attunement/attachment. In its earliest origins the core self is forged in the attunement contact with the parent. Its healthy development needs the atmosphere of what Carl Rogers had called “unconditional positive regard.” It requires that the adult world understands and accepts as valid the child’s feelings, from which kernel the core self will grow. A child taught to still the voice of her innermost feelings and thoughts assumes automatically that there is something shameful about them, and therefore about her very self. Absolutely universal in the stories of all adults with ADD is the memory of never being comfortable about expressing their emotions. When asked who they confided in when, as children, they were lonely or in psychic pain, almost none recall feeling invited and safe enough to bare their souls to their parents. They kept their deepest griefs to themselves. On the other hand, many recall being hyper-aware of the parents’ difficulties and struggles in the world, of not wanting to trouble them with their own petty and childish problems. The sensitive child, writes the Swiss psychotherapist Alice Miller, has “an amazing capacity to perceive and respond intuitively, that is unconsciously, to this need of the mother, or of both parents…” When I

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explore with my clients their childhood histories, emerging most often are patterns of relationships in which the child took care of the parent emotionally, if only by keeping her inmost feelings to herself so as not to burden the parent. ADD adults are convinced that their low selfesteem is a fair reflection of how poorly they have done in life only because they do not understand that their very first failure – their inability to win the full and unconditional acceptance of the adult world – was not their failure at all. Although low self-esteem springs originally from the disrupted attunement/attachment relationship with the parent, the belief that it is fed by poor achievement is not wrong. Only, the link is not a direct one. In the majority of adults I have interviewed it was evident that the inability to accept themselves was heavily reinforced throughout childhood by their parents’ expectations of better performance, and by their disappointment and disapproval at the absence of it. Superimposed on the parents’ anxieties were the contemptuous judgements and shaming that, throughout their childhoods, many of these ADD adults had experienced in school. Not performance as such but the attitudes of the adult world towards performance defined how many children learned to value themselves. At our second session I asked Andrea, the fifty year old self-confessed failure at the game of existence justification, if she had truly never done anything worthwhile in her life. She was silent for a while. “I have tried to be kind to people,” she finally replied. “I have tried not to hurt people. I am creative in crafts, I teach people. I do a bit of gardening. But to me those things come easy. That’s just who I am. I didn’t have to work at them much. I mean, I’m not an accountant, I’m not a lawyer.” “Would you want to be an accountant or a lawyer?” “It’s not that I feel like doing those things,” Andrea said, again after a moment’s pause, “it’s that I think I should feel like doing them. I am still trying to get my father’s approval.” Andrea’s dismissal of her own talents resonated with me. In my undergraduate years and even beyond I had little respect for my ability to write. I could use it to advantage, for example by dressing some pretty thin essays in relatively elegant verbal garb to inflate their value, but I had little regard for it precisely because I felt it came naturally to me. “I don’t trust my words,” I would say, “they come too easily.” It never occurred to me that possessing a vein of talent did not mean that one could not work diligently at mining it. If I had a facility for something, or if I enjoyed it, it could not be worth much. Unless it was pure blood, sweat, and tears, it could not have value. A case of “I would never belong to any club that would have someone like me as a member.” Much the same has been said to me by many adults with ADD. A few have even butted their heads against the wall trying to become accountants, which, in my estimation, must be the profession least suited for anyone with attention deficit disorder. So far as I could see, they were working to convince themselves of their own self-worth by striving to achieve something completely contrary to their nature. Debra, a woman in her early thirties with a Bachelor of Science degree in Zoology, wanted help with her difficulties remembering and concentrating. “I feel so dumb,” she said. “I can never keep up with discussions. People talk about politics and current affairs and I have no head for those things. I try hard to remember facts and names and dates from the newspaper, but it doesn’t stick. I tune out.” What Debra does have a mind for is seeking the emotional truth in people’s lives, what their existence is like underneath the surface of social niceties. Her desire to be more adept at social conversation was not an unreasonable goal. It struck me though that she seemed to place a greater value on a facile awareness of peripheral facts, which she did not have, above insight, empathy, and understanding, with which she was gifted. One of the barriers faced by adults with attention deficit disorder in their quest for self-esteem is 26

that they do not really know who exactly that self to be esteemed is. “It drives me nuts when someone asks me what my feelings are,” a student in his mid-twenties said. “I have no idea what my feelings are. I am lucky if figure out what my feelings were hours or days after something happens, but I never know what they are.” Since having a strong core self relies on one’s acceptance of one’s feelings, being out of touch with one’s emotional side puts one out of touch with one’s self. What then remains to be esteemed? Only a false self, a concoction of what we would like to imagine ourselves to be and what we have divined others want us to be. Sooner or later people come to realize that this false self – wanting what they think they should want, feeling what they think they should feel – does not work for them. When they look inside themselves they discover a frightening emptiness, a vacuum, void of a true self or of intrinsic motivation. Many a time I have heard ADD adults say, “I don’t know who I am,” or, “I don’t know what I want to do in my life.” Women with ADD are especially prone to give a higher priority to protecting the needs of others than on respecting their own. “I don’t know how to say ‘no.’ I’m always so worried about what the other person is feeling,” said Catherine, a forty-three year old high school teacher. “I don’t know why. I guess it’s my second nature.” As always, people’s language is revelatory. Catherine was uttering a deep truth when she spoke those words: suppressing her own feelings in preference to those of others was second nature to her. It had never been her first nature. It was acquired. Human infants are born with no capability whatsoever to hide or suppress feelings, be it hunger, fear, discomfort, or pain. Healthy newborns are skilled at communicating anger and have a superbly articulate talent for saying “no,” as anyone can attest who has witnessed the rage of an frustrated infant or who has ever tried to feed some unwanted substance to a baby. She shouts out her responses to the world, loud and clear. Given the powerful survival value of emotional expression, Nature would not have us give up that capacity unless the suppression of emotion was demanded by the environment. When we forget how to say “no”, we surrender self-esteem. The adult with ADD is buried under the mound of yes’s, many of which are not true yes’s at all, only no’s he dared not say. Life is one long exercise in trying to tunnel out from under them, a frustrating task since one keeps adding to the stack faster than one can take away from it. As busy as I ever was, I always found it almost impossible to refuse whenever anyone asked to become my patient. My addiction to serving the world got so out of hand that in one memorable month thirteen years ago, the very time we were to move to our new house, I ended up delivering fifteen babies. Most of these were first pregnancies, which meant that labour tended to be long and almost inevitably took up at least part of the night. I became more wan and bedraggled by the day, precisely when my wife, Rae, needed the most help with packing, organizing, and parenting. With the addict’s typical shiftiness, I had not told her what I had taken on. She just noticed me disappearing day in, day out. I was dutiful when at home, as dutiful as a person could be whose mind was buzzing with the self-imposed duties and responsibilities that kept me running day and night. I could feel myself becoming more and more hollow, a non-presence for my family. Behind the image of the busy, empathetic, and selfless physician was a person who, in his desperation to be needed, was willing to sacrifice his personal life. And, too, a person who felt so alienated from his own self that he had to keep running away from any awareness of it. The need to be needed at all costs comes from one’s earliest experiences. If the child does not feel accepted unconditionally, she learns to work for acceptance and attention. When she is not doing this work he feels anxious, due to an unconscious fear of being cut off from the parent. Later – as an adult – when not doing something specific, she has a vague unease, the feeling that he should somehow be working. The adult has no psychological rest because the infant and child 27

had never known psychological rest. She has a dread of rejection and an insatiable need to have her desirability and value affirmed by others. Being wanted becomes one’s drug. Self-esteem is pre-empted by its false shadow, contingent self-esteem. What one does and what others think of it take precedence over who one is. The driven and hyperfunctioning workaholic tries to delude himself that he must be very important, since so many people want him. His frenetic activity numbs him to emotional pain and keeps his sense of inadequacy out of sight, out of mind. During a group psychotherapy session a few years ago I heard one of the leaders say that a truly important person is one who considers himself worthy enough to grant himself at least one hour each day that he can call his own. I had to laugh. I realized I had worked so hard and made myself so “important” that I couldn’t beg, borrow, or steal a minute for myself. There is one major respect in which the specific neurophysiological impairments of ADD do hinder the development of a core sense of self and the attainment of self-esteem. It is appropriate here to speak hereof a sense of self, because from the neurophysiological point of view the self simply does not exist. There is no neurobiological “self circuit” in the brain, no little gnome pulling all the levers. What we see as the self is really a construct, akin to the optical illusion that makes us believe that a series of photographic images projected onto a screen in rapid progression are people and objects in the real world. The “self” we experience is an unimaginably rapid series of firings of countless neurological circuits. “At each moment the state of self is constructed, from the ground up,” writes Antonio Damasio. “It is an evanescent reference state, so continuously and consistently reconstructed that the owner never knows it is being remade unless something goes wrong with the remaking.” It is the relative consistency of the repetitious neurological activities of the brain that convinces us there is a solid self. We might say that in ADD this consistency lacks consistency. The fluctuations are greater than most people experience. Thought patterns and emotional states pursue each other with an exaggerated rapidity and across a broader range. It seems there is less to hold on to. Too, self-esteem does require a degree of self-regulation, which the neurophysiology of ADD sabotages. The child or adult easily flung into extremes of emotion and behaviour does not acquire the mastery over impulses that self-esteem demands. It is ironic, but despite her poor impulse control the ADD adult has persistently throttled her impulses, to use Henry Miller’s phrase. Submerged beneath a surface rippling with superficial and childish impulses are truer impulses for meaningful activity, the assertion of one’s autonomy, the pursuit of one’s own truth, and human connectedness. The deeper these have sunk, the less one knows who one is or in which direction one’s path lies. Attaining self-esteem begins with finding our true impulses and raising them to the light of day.

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WHEN THE BODY SAYS NO Can a person literally die of loneliness? Is there a connection between the ability to express emotions and Alzheimer’s disease? Is there such a thing as a “cancer personality”? Drawing on scientific research and the author’s decades of experience as a practicing physician, “When the Body Says No: The Cost of Hidden Stress” − published in the U.S. under the subtitle “Exploring the Stress-Disease Connection, and also available in audiobookformat − provides answers to these and other important questions about the effect of the mind-body link on illness and health and the role that stress and one’s individual emotional makeup play in an array of common diseases. − Explores the role of the mind-body link in conditions and diseases such as arthritis, cancer, diabetes, heart disease, IBS, and multiple sclerosis − Draws on medical research and the author’s clinical experience as a family physician − Shares dozens of enlightening case studies and stories, including those of people such as Lou Gehrig (ALS), Betty Ford (breast cancer), Ronald Reagan (Alzheimer’s), Gilda Radner (ovarian cancer), and Lance Armstrong (testicular cancer) − Includes The Seven A’s of Healing: principles of healing and the prevention of illness from hidden stress An international bestseller translated into fifteen languages, When the Body Says No promotes learning and healing, providing transformative insights into how disease can be the body’s way of saying no to what the mind cannot or will not acknowledge. Praise for “When the Body Says No”: “This is a most important book, both for patient and physician. It could save your life.” Peter Levine, author, Waking the Tiger “Gabor Maté, M.D., skillfully blends recent advances in biomedicine with the personal stories of his patients to provide empowering insights into how deeply developmental experiences shape our health, behavior, attitudes, and relationships. A must read.” Bruce Lipton, Ph.D., The Biology of Belief “In this important book, Dr. Gabor Maté combines a passionate examination of his patients’ life histories with lucid explanations of the science behind mind-body unity.” Richard Earle, Ph.D. “When The Body Says No is full of startling insights and hard won poetry.” Toronto Star “I was deeply drawn into this compelling and meticulously researched book, particularly by the transcribed interviews in which patients are allowed to speak in their own voices. If you have ever doubted the link between childhood pain and organic disease, these deeply poignant stories might just convince you. There is something about Maté, perhaps his ability to listen respectfully and react compassionately, that makes his patients open up their souls to him. What he hears is a cri du coeur, a lifetime of unexpressed psychic pain erupting through the body in fatal disease… His book is a plea for understanding of the deeper dynamics that contribute to disease. His ‘seven A’s of healing’ (acceptance, awareness, anger, autonomy, attachment, assertion, affirmation) provide a blueprint for greater emotional and bodily health. Full of complex and powerful truths, When the Body Says No has the potential to change medical thinking – and perhaps even save 29

lives.” Edmonton Journal “The interviewees’ stories are often touching and haunting... Maté carefully explains the biological mechanisms that are activated when stress and trauma exert a powerful influence on the body... Readers will be grateful for the final chapter... in which Maté presents an open formula for healing and the prevention of illness from hidden stress.” Quill & Quire “Your book unequivocally changed my life by giving me a new lease on it… You allowed me articulate a complex problem that had exhausted my mind, and then my body. So, from the bottom of my heart and the depths of my soul, thank you for that.” Carolynn “After reading [When the Body Says No] I bought six more, one for each of my siblings. I told them that it was the best gift I could ever give them. And it would be the best gift they could ever give themselves to read it. Even if they don’t maybe someone in some future generation will read it and carry on the healing.” Gertrude “…I have just finished reading When the Body Says No and have been absolutely blown away by the personal significance it has for me. Parts of this book have been like reading a personal history of my childhood and my subsequent life… the stories are different, but the feelings I had and their impact are identical. I now have a crystal-clear picture of why, at age 33 and in very good physical health, I have developed breast cancer. Your book has helped me to better recognize behaviours and patterns of which I have been aware my whole life, but only vaguely. Until now I have been masking so many things and while knowing this on some level, have at the same time chose to believe that I was doing just fine… My body is most certainly speaking to me, and I am now prepared to fully listen. I feel so empowered and grateful for this experience, as crazy as that may sound.” Chelsea “I’ve never written a fan letter to an author before, but I just finished When the Body Says No and want to thank you for it… I appreciate the way you use scientific studies and anectodal stories to back up your arguments, and the way you explore the questions that arise, for example, positive vs. negative thinking and anger vs. rage. I found both those discussions extremely useful… I’ve still got lots of work to do. But how liberating it is to let go of the pressure to think ‘positively’ all the time − even if my friends and family don’t always like the new me!” Cathy “…I believe this book has to go farther than just being recommended (which I have to a number of my patients and colleagues). It seems to me this book should be a study guide, a basis of small group discussion… I’d love to see your book as required reading for every health care provider, with short videos made to educate patients as to the importance of nurturance in their lives and that of their children. I know I’m sounding highly enthusiastic and evangelical, yet I feel your book for me has shed a light on what is possible.” Don “In trying to think why I found this book so moving, I come back again and again to the word ‘compassion’. The book is full of it. Every page seems to speak of a deep understanding of the vulnerability and fragility of the human psyche. I am currently working through the darkest time 30

in my life and I recognize more and more the need for deep compassion (for myself, for others) as the essential lever for healing. Your writing speaks so richly of that, and I thank you. It has given me much to think about, especially in terms of my own life-long patterns of dealing with stress…” D.R. “I began reading When the Body Says No this morning and have had to put it down after three chapters as my heart is pounding so and I keep crying and feeling scared and mostly ever so grateful to have found you and your book. To find a doctor who hears me is a blessing. Thank you, even after only three chapters I am comforted. I will read on and reread and reread and soon be well. I so appreciate the support.” L. B. “Only this, that I have waited fifteen years to read these words that articulate so concisely and compassionately all I have learned as therapist and now program director in a cancer support centre.” L.S. “I have just begun to read your latest book. On page twenty you sum up much of my thesis on this relationship between trauma and Alzheimer’s disease with the words ‘The fundamental problem is not the external stress but an environmentally conditioned helplessness that permits neither of the normal responses of fight or flight.’ I believe that Alzheimer’s disease could frequently be avoided were we to pay attention to our, and others’, emotional pain, seeing it as the precursor of physical pain. Thank you for writing your book. I believe that it is a groundbreaking offering to the public, the medical profession… and to those working in psychoneuroimmunology!” S.R. “I’ve just finished reading When the Body Says No and think that I must have set some sort of land speed reading record, which is helpful since it’s a library copy and I want to read it a second time before returning it… I have rheumatoid arthritis. It both amused and bemused me to see the struggles I wrote about − feeling reticent about seeking help, resistance to taking meds, not voicing complaints − as being ‘rheumatoid characteristics’. I had a funny jostling of my ego on reading that description − a combination of ‘Oh, thank God! It’s not just me!’ and ‘Hey, you mean I’m typical?!’ It was a definite relief to read that something I have believed all along about the biochemical components of emotions, illness and healing has a basis in scientific fact. I’d like to give your book to my rheumatologist, who has yet to ask me anything about my personal life or family history. Again, thank you for writing the book. It’s already had a powerful effect in my life.” G. A. “I am a pharmacist who is very interested in how biography creates biology. I have always believed that disease is the body’s way of telling us something. Even as a pharmacist I believe medication is rarely the first choice to heal yourself (of course I keep that thought to myself at work). Your book confirms my belief. I will be recommending your book to people I see at work and also my family. You will help a lot of people.” D.F. “You entered my life as I was seeking help. Your book has been a catalyst of change, of growth, of self-awareness and self transformation for me. Thank you. I weep as I write for all those you 31

mentioned in your book, who now provide insight for those of us who follow. You’ve honoured their lives.” Don “After losing my sister to breast cancer when she was only 37, eleven years ago, I was left stunned with only vague ideas and theories of how this disease could have drowned my boisterous, energetic, young sister. Your book helped me to partially unravel the mystery as to why I was left standing (weakly), while she lay in the ground. Her life reads much like a case history of one of your patients… I witnessed and experienced the early troubles at home, her choice of an unsavory husband, and the terrible decline and pain she suffered… I miss her more than ever, and just wanted to tell you how much your wisdom, intelligence, and kind warm heart have meant to me. You see the emotional truths and are able to express them. I’m just starting to grasp the ideas about anger, and how it can be expressed in a healthy way.” Judee “I cannot tell you how this book hit home. I was just recently diagnosed with MS and every personal account I read in your book sounds like me. Although I spend my life lecturing, writing and teaching others how to get well using nutritional medicine, lifestyle changes, spiritual growth etc., your book has touched my heart.” Lorna “I have just finished reading your book and I feel like I have once again found my centre… I am so appreciative that you listened to your call to write. Reading your book affirmed many of my values, brought them into awareness for me. A sort of personal inventory. And so I say ‘thank you, thank you, thank you.’ To myself I say ‘go for it, go for it, go for it.’” Marion “Thank you for sharing your words and wisdom. I’m on the very last chapter and don’t want to read any further for fear that it will end.” Sarah “Wow. This book of yours has been one of the best if not best pieces art/literature/insight into health and humanity I’ve ever read… It was the first time that I considered seriously the mind body connection… I had never heard of psychoneuroimmunology (PNI) and found this to be very interesting. I found it very difficult to read parts of your book at times, not because the content was hard to understand, but because I could see myself reflected in the stories. Which is exactly why I needed to read it… My body was screaming ‘no’ at me my whole life but I never listened until recently. I felt like these changes are helping to transform me and continue to every day. Your book was very beneficial for me and I am very grateful that it is available for others. I hope that it helps many other people.” Andrea “Thanks for writing this book, for you have helped to save my life, the lives of generations in my family, and the lives of many communities I serve or influence. I would be remiss if I did not express my gratitude for the great wisdom you shared.” Hank

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Chapter One − The Bermuda Triangle Mary was a Native woman in her early forties, slight of stature, gentle and deferential in manner. She had been my patient for eight years, along with her husband and three children. There was a shyness in her smile, a touch of self-deprecation. She laughed easily. When her ever-youthful face brightened it was impossible not to respond in kind. My heart still warms − and constricts with sorrow − when I think of Mary. Mary and I had never talked much until the illness that was to take her life gave its first signals. The beginning seemed innocent enough: a sewing-needle puncture wound on a fingertip failed over several months to heal. The problem was traced to Raynaud’s phenomenon, in which the small arteries supplying the fingers are narrowed, depriving the tissues of oxygen. Gangrene can set in, and unfortunately this was the case for Mary. Despite several hospitalizations and surgical procedures, she was begging within a year for an amputation to rid her of the throbbing ache in her finger. By the time she got her wish the disease was rampant and powerful narcotics were inadequate in the face of her constant pain. Raynaud’s can occur independently or in the wake of other disorders. Smokers are at greater risk, and Mary had been a heavy smoker since her teenage years. I hoped that if she quit, normal blood flow might return to her fingers. After many relapses she finally succeeded. Unfortunately, the Raynaud’s proved to be the harbinger of something far worse: Mary was diagnosed with scleroderma, one of the autoimmune diseases, which include rheumatoid arthritis, ulcerative colitis, systemic lupus erythematosus (SLE), and many other conditions that are not always recognized to be autoimmune in origin, such as diabetes, multiple sclerosis and possibly even Alzheimer’s disease. Common to them all is an attack by one’s own immune system against the body, causing damage to joints, connective tissue or to almost any organ whether it be the eyes, the nerves, the skin, the intestines, the liver, or the brain. In scleroderma (from the Greek word meaning “hardened skin”) the immune system’s suicidal assault results in a stiffening of the skin, esophagus, heart, and tissues in the lungs and elsewhere. What creates this civil war inside the body? Medical textbooks take an exclusively biological view. In a few isolated cases toxins are mentioned as causative factors, but for the most part a genetic predisposition is assumed to be largely responsible. Medical practice reflects this narrowly physical mindset. Neither the specialists nor I as her family doctor had ever thought to consider what in Mary’s particular experiences might also have contributed to her illness. None of us expressed curiosity about her psychological state before the onset of the disease, or how this influenced its course and final outcome. We simply treated each of her physical symptoms as they presented themselves: medications for inflammation and pain, operations to remove gangrenous tissue and to improve blood supply, physiotherapy to restore mobility. One day, almost on a whim, in response to a whisper of intuition that she needed to be heard, I invited Mary to make an hour-long appointment so that she would have the opportunity to tell me something about herself and her life. When she began to talk, it was a revelation. Beneath her meek and diffident manner was a vast store of repressed emotion. Mary had been abused as a child, abandoned and shuttled from one foster home to another. She recalled huddling in the attic at the age of seven, cradling her younger sisters in her arms, while her drunken foster parents fought and yelled below. “I was so scared all the time,” she said, “but as a seven-ear-old I had to protect my sisters. And no one protected me.” She had never revealed these traumas before, not even to her husband of twenty years. She had learned not to express her feelings about anything 33

to anyone, including herself. To be self-expressive, vulnerable and questioning in her childhood would have put her at risk. Her security lay in considering other people’s feelings, never her own. She was trapped in the role forced on her as a child, unaware that she herself had the right to be taken care of, to be listened to, to be thought worthy of attention. Mary described herself as being incapable of saying no, compulsively taking responsibility for the needs of others. Her major concern continued to be her husband and her nearly adult children, even as her illness became more grave. Was the scleroderma her body’s way of finally rejecting this all-encompassing dutifulness? Perhaps her body was doing what her mind could not: throwing off the relentless expectation that had been first imposed on the child and now was self-imposed in the adult − placing others above herself. I suggested as much in my very first article as medical columnist for The Globe and Mail in 1993. “When we have been prevented from learning how to say no,” I wrote, “our bodies may end up saying it for us.” I cited some of the medical literature discussing the negative effects of stress on the immune system. The idea that people’s emotional coping style can be a factor in scleroderma or other chronic conditions is anathema to some physicians. A rheumatic diseases specialist at a major Canadian hospital submitted a scathing letter to the editor denouncing both my article and the newspaper for printing it. I was inexperienced, she charged, and had done no research. That a specialist would dismiss the link between body and mind was not astonishing. Dualism − cleaving into two that which is one − colours all our beliefs on health and illness. We attempt to understand the body in isolation from the mind. We want to describe human beings − healthy or otherwise − as though they function in isolation from the environment in which they develop, live, work, play, love and die. These are the built-in, hidden biases of the medical orthodoxy most physicians absorb during their training and carry into their practice. Unlike many other disciplines, medicine has yet to assimilate an important lesson of Einstein’s theory of relativity: that the position of an observer will influence the phenomenon being observed and affect the results of the observation. The unexamined assumptions of the scientist both determine and limit what he or she will discover, as the pioneering Czech-Canadian stress researcher Hans Selye pointed out. “Most people do not fully realize to what extent the spirit of scientific research and the lessons learned from it depend upon the personal viewpoints of the discoverers,” he wrote in The Stress of Life. “In an age so largely dependent upon science and scientists, this fundamental point deserves special attention.” In that honest and self-revealing assessment Selye, himself a physician, expressed a truth that even now, a quarter century later, few people grasp. The more specialized doctors become, the more they know about a body part or organ and the less they tend to understand the human being in whom that part or organ resides. The people I interviewed for this book reported nearly unanimously that neither their specialists nor their family doctors had ever invited them to explore the personal, subjective content of their lives. If anything, they felt that such a dialogue was discouraged in most of their contacts with the medical profession. In talking with my specialist colleagues about these very same patients, I found that after even after many years of treating a person, a doctor could remain quite in the dark about the patient’s life and experience outside the narrow boundaries of illness. In this volume I set out to write about the effects of stress on health, particularly of the hidden stresses we all generate from our early programming, a pattern so deep and so subtle that it feels like a part of our real selves. Although I have presented as much of the available scientific 34

evidence as seemed reasonable in a work for the lay public, the heart of the book − for me, at least − is formed by the individual histories I have been able to share with the readers. It so happens that those histories will also be seen as the least persuasive to those who regard such evidence as “anecdotal.” Only an intellectual Luddite would deny the enormous benefits that have accrued to humankind from the scrupulous application of scientific methods. But not all essential information can be confirmed in the laboratory or by modern statistical analysis. Not all aspects of illness can be reduced to facts verified by double-blind studies and by the strictest scientific techniques. “Medicine tells us as much about the meaningful performance of healing, suffering, and dying as chemical analysis tells us about the aesthetic value of pottery,” Ivan Ilyich wrote in Limits to Medicine. We confine ourselves to a narrow realm indeed if we exclude from accepted knowledge the contributions of human experience and insight. We have lost something. In 1892 the Canadian William Osler, one of the greatest physicians of all time, suspected rheumatoid arthritis − a condition related to scleroderma − to be a stressrelated disorder. Today rheumatology all but ignores that wisdom, despite the supporting scientific evidence accumulated in the 110 years since Osler first published his text. That is where the narrow scientific approach has brought the practice of medicine. Elevating modern science to be the final arbiter of our sufferings, we have been too eager to discard the insights of previous ages. As the American psychologist Ross Buck has pointed out, until the advent of modern medical technology and of scientific pharmacology, physicians had traditionally to rely on “placebo” effects. They had to inspire in each patient a confidence in his, the patient’s, inner ability to heal. To be effective, a doctor had to listen to the patient, to develop a relationship with him, and he had also to trust his own intuitions. Those are the qualities doctors seem to have lost as we have come to rely almost exclusively on “objective” measures, technology-based diagnostic methods and “scientific” cures. Thus the rebuke from the rheumatologist was not a surprise. More of a jolt was another letter to the editor, a few days later − this time a supportive one – from Noel B. Hershfield, clinical professor of medicine at the University of Calgary: “The new discipline of psychoneuroimmunology has now matured to the point where there is compelling evidence, advanced by scientists from many fields, that an intimate relationship exists between the brain and the immune system… An individual’s emotional makeup, and the response to continued stress may indeed be causative in the many diseases that medicine treats but whose [origin] is not yet known – diseases such as scleroderma, and the vast majority of rheumatic disorders, the inflammatory bowel disorders, diabetes, multiple sclerosis, and legions of other conditions which are represented in each medical subspecialty.” The surprising revelation in this letter was the existence of a new field of medicine. What is psychoneuroimmunology? As I learned, it is no less than the science of the interactions of mind and body, the indissoluble unity of emotions and physiology in human development and throughout life in health and illness. That dauntingly complicated word means simply that this discipline studies the ways that the psyche – the mind and its content of emotions − profoundly interacts with the body’s nervous system and how both of them, in turn, form an essential link with our immune defences. Some have called this new field psychoneuroimmunoendocrinology to indicate that the endocrine, or hormonal, apparatus is also a part of our system of whole body response. Innovative research is uncovering just how these links function all the way down to the cellular level. We are discovering the scientific basis of what we have known before and have 35

forgotten, to our great loss. Many doctors over the centuries came to understand that emotions are deeply implicated in the causation of illness or in the restoration of health. They did research, wrote books and challenged the reigning medical ideology, but repeatedly their ideas, explorations and insights vanished in a sort of medical Bermuda Triangle. The understanding of the mind-body connection achieved by previous generations of doctors and scientists disappeared without a trace, as if it had never seen daylight. A 1985 editorial in the august New England Journal of Medicine could declare with magisterial self-assurance that “it is time to acknowledge that our belief in disease as a direct reflection of mental state is largely folklore.” Such dismissals are no longer tenable. Psychoneuroimmunology, the new science Dr. Hershfield mentioned in his letter to the The Globe and Mail, has come into its own, even if its insights have yet to penetrate the world of medical practice. A cursory visit to medical libraries or to online sites is enough to show the advancing tide of research papers, journal articles and textbooks discussing the new knowledge. Information has filtered down to many people in popular books and magazines. The lay public, ahead of the professionals in many ways and less shackled to old orthodoxies, finds it less threatening to accept that we cannot be divided up so easily and that the whole wondrous human organism is more than simply the sum of its parts. Our immune system does not exist in isolation from daily experience. For example, the immune defences that normally function in healthy young people have been shown to be suppressed in medical students under the pressure of final examinations. Of even greater implication for their future health and well being, the loneliest students suffered the greatest negative impact on their immune systems. Loneliness has been similarly associated with diminished immune activity in a group of psychiatric inpatients. Even if no further research evidence existed – though there is plenty – one would have to consider the long-term effects of chronic stress. The pressure of examinations is obvious and short term, but many people unwittingly spend their entire lives as if under the gaze of a powerful and judgmental examiner whom they must please at all costs. Many of us live, if not alone, then in emotionally inadequate relationships that do not recognize or honour our deepest needs. Isolation and stress affect many who may believe their lives are quite satisfactory. How may stress be transmuted into illness? Stress is a complicated cascade of physical and biochemical responses to powerful emotional stimuli. Physiologically, emotions are themselves electrical, chemical and hormonal discharges of the human nervous system. Emotions influence − and are influenced by – the functioning of our major organs, the integrity of our immune defences and the workings of the many circulating biological substances that help govern the body’s physical states. When emotions are repressed, as Mary had to do in her childhood search for security, this inhibition disarms the body’s defences against illness. Repression − dissociating emotions from awareness and relegating them to the unconscious realm – disorganizes and confuses our physiological defences so that in some people these defences go awry, becoming the destroyers of health rather than its protectors. During the seven years I was medical coordinator of the Palliative Care Unit at Vancouver Hospital, I saw many patients with chronic illness whose emotional histories resembled Mary’s. Similar dynamics and ways of coping were present in the people who came to us for palliation with cancers or degenerative neurological processes like amyotrophic lateral sclerosis [or ALS, 36

also known in North America as Lou Gehrig’s disease, after the great American baseball player who succumbed to it (and in Britain as motor neuron disease). In my private family practice I observed these same patterns in people I treated for multiple sclerosis, inflammatory ailments of the bowel such as ulcerative colitis and Crohn’s disease, chronic fatigue syndrome, autoimmune disorders, fibromyalgia, migraine, skin disorders, endometriosis and many other conditions. In important areas of their lives, almost none of my patients with serious disease had ever learned to say no. If some people’s personalities and circumstances appeared very different from Mary’s on the surface, the underlying emotional repression was an ever-present factor. One of the terminally ill patients under my care was a middle-aged man, chief executive of a company that marketed shark cartilage as a treatment for cancer. By the time he was admitted to our unit his own recently diagnosed cancer had spread throughout his body. He continued to eat shark cartilage almost to the day of his death, but not because he any longer believed in its value. It smelled foul – the offensive stench was noticeable even at some distance away − and I could only imagine what it tasted like. “I hate it,” he told me, “but my business partner would be so disappointed if I stopped.” I convinced him that he had every right to live his last days without feeling responsible for someone else’s disappointment. It is a sensitive matter to raise the possibility that the way people have been conditioned to live their lives may contribute to their illness. The connections between behaviour and subsequent disease are obvious in the case of, say, smoking and lung cancer – except perhaps to tobacco industry executives. But such links are harder to prove when it comes to emotions and the emergence of multiple sclerosis or cancer of the breast or arthritis. In addition to being stricken with disease, the patient feels blamed for being the very person she is. “Why are you writing this book?” said a fifty-two-year-old university professor who has been treated for breast cancer. In a voice edged with anger she told me, “I got cancer because of my genes, not because of anything I did.” “The view of sickness and death as a personal failure is a particularly unfortunate form of blaming the victim,” charged the 1985 editorial in The New England Journal of Medicine. “At a time when patients are already burdened by disease, they should not be further burdened by having to accept responsibility for the outcome.” We will return to this vexing question of assumed blame. Here I will only remark that blame and failure are not the issue. Such terms only cloud the picture. As we shall see, blaming the sufferer − apart from being morally obtuse − is completely unfounded from a scientific point of view. The NEJM editorial confused blame and responsibility. While all of us dread being blamed, we would all would wish to be more responsible – that is, to have the ability to respond with awareness to the circumstances of our lives rather than just reacting. We want to be the authoritative person in our own lives: in charge, able to make the authentic decisions that affect us. There is no true responsibility without awareness. One of the weaknesses of the Western medical approach is that we have made the physician the only authority, with the patient too often a mere recipient of the treatment or cure. People are deprived of the opportunity to become truly responsible. None of us are to be blamed if we succumb to illness and death. Any one of us might succumb at any time, but the more we can learn about ourselves, the less prone we are to become passive victims. Mind and body links have to be seen not only for our understanding of illness, but also for our understanding of health. Dr. Robert Maunder, on the psychiatric faculty of the University of Toronto, has written about the mind-body interface in disease. “Trying to identify and to answer

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the question of stress,” he says, “is more likely to lead to health than ignoring the question.” In healing, every bit of information, every piece of the truth may be crucial. If a link exists between emotions and physiology, not to inform people of it will deprive them of a powerful tool. And here we confront the inadequacy of language. Even to speak about links between mind and body is to imply that two discrete entities are somehow connected to each other. Yet in life there is no such separation; there is no body that is not mind, and no mind that is not body. The word mindbody has been suggested to convey the real state of things. Not even in the West is mindbody thinking completely new. In one of Plato’s dialogues Socrates quotes a Thracian doctor’s criticism of his Greek colleagues: “This is the reason why the cure of so many diseases is unknown to the physicians of Hellas; they are ignorant of the whole. For this is the great error of our day in the treatment of the human body, that physicians separate the mind from the body.” You cannot split mind from body, said Socrates − nearly two and a half millenia before the advent of psychoneuroimmunoendocrinology! Writing When the Body Says No has done more than simply confirm some of the insights I first articulated in my article about Mary’s scleroderma. I have learned much and have come to appreciate deeply the work of hundreds of physicians, scientists, psychologists and researchers who charted the previously unmapped terrain of mindbody. Work on this book has also been an inner exploration of the ways I have repressed my own emotions. I was prompted to make this personal journey in response to a question from a counsellor at the British Columbia Cancer Agency, where I had gone to investigate the role of emotional repression in cancer. In many people with malignancy there seemed to be an automatic denial of psychic or physical pain and of uncomfortable emotions like anger, sadness, or rejection. “Just what is your personal connection to the issue?” the counsellor asked me. “What draws you to this particular topic?” The question brought to mind an incident from seven years ago. One evening I arrived to see my seventy-six-year-old mother at the nursing home where she was a resident. She had progressive muscular dystrophy, an inherited muscle-wasting disease that runs in our family. Unable to even sit up without assistance, she could no longer live at home. Her three sons and their families visited her regularly until her death, which occurred just as I began to write this book. I had a slight limp as I walked down the nursing home corridor. That morning I had undergone surgery for a torn cartilage in my knee, a consequence of ignoring what my body had been telling me in the language of pain that occurred each time I jogged on cement. As I opened the door to my mother’s room, I automatically walked with a nonchalant, normal gait to her bed to greet her. The impulse to hide the limp was not conscious, and the act was done before I was aware of it. Only later did I wonder what exactly had prompted such an unnecessary measure − unnecessary because my mother would have calmly accepted that her fifty-one-year old son would have a gimpy knee twelve hours post-surgery. So what had happened? My automatic impulse to protect my mother from my pain even in such an innocuous situation was a deeply programmed reflex that had little to do with the present needs of either of us. That self-suppression was a memory − a re-enactment of a dynamic that had been etched into my developing brain before I could possibly be aware of it. I am both a survivor and a child of the Nazi genocide, having lived most of my first year in Budapest under Nazi occupation. My maternal grandparents were killed in Auschwitz when I was five months old; my aunt had also been deported and was unheard from; and my father was in a forced labour batallion in the service of the German and Hungarian armies. My mother and I barely survived our months in the Budapest ghetto. For a few weeks she had to part from me as 38

the only way of saving me from sure death by starvation or disease. No great powers of imagination are required to understand that in her state of mind, and under the inhuman stresses she was facing daily, my mother was rarely up to the tender smiles and undivided attention a developing infant requires to imprint a sense of security and unconditional love in his mind. My mother, in fact, told me that on many days her despair was such that only the need to care of me motivated her to get up from bed. I learned early that I had to work for attention, to burden my mother as little as possible and that my anxiety and pain were best suppressed. In healthy mother-infant interactions, the mother is able to nourish without the infant’s having in any way to work for what he receives. My mother was unable to provide that unconditional nourishing for me − and, since she was neither saintly nor perfect, quite likely she would not have completely succeeded in doing so even without the horrors that beset our family. It was under the circumstances that I became my mother’s protector − protecting her in the first instance against awareness of my own pain. What began as the automatic defensive coping of the infant soon hardened into a fixed personality pattern that, fifty-two years later, still caused me to hide even my slightest physical discomfort in front of my mother. I had not thought about the When the Body Says No project in those terms. This was to be an intellectual quest, to explore an interesting theory that would help explain human health and illness. It was a path others had trod before me, but there was always more to be discovered. The counsellor’s challenge made me confront the issue of emotional repression in my own life. My hidden limp, I realized, was only one small example. Thus, in writing this book I describe not only what I have learned from other individuals or from professional journals, but also what I have observed in myself. The dynamics of repression operate in all of us. We are all self-deniers and self-betrayers to one extent or another, most often in ways we are no more aware of than I was conscious of while “deciding” to disguise my limp. When it comes to health or illness, it as only a matter of degree and also a matter of the presence or absence of other factors − such as heredity or environmental hazards, for example − that also predispose to disease. So in demonstrating that self-repression is a major cause of stress and a significant contributor to illness, I do not point fingers at others for “making themselves sick.” My purpose in this book is to promote learning and healing, not to add to the quotient of blame and shame, both of which already exist in overabundance in our culture. Perhaps I am overly sensitized to the issue of blame, but then, most people are. Shame is the deepest of the “negative emotions,” a feeling we will do almost anything to avoid. Unfortunately, our abiding fear of shame impairs our ability to see reality. Each of us must reclaim the autonomy we lost when we parted company with our ability to feel what was happening within. That lost capacity for physical and emotional self-awareness is at the root of much of the stress that chronically debilitates health and prepares the ground for disease. Despite the best efforts of many physicians, Mary died in Vancouver Hospital eight years after her diagnosis, succumbing to the complications of scleroderma. To the end she retained her gentle smile, though her heart was weak and her breathing laboured. Every once in a while she would ask me to schedule long private visits, even in hospital during her final days. She just wanted to chat, about matters serious or trivial. “You are the only one who ever listened to me,” she once said. I have wondered many times how Mary’s life might have turned out if someone had been there to hear, see and understand her when she was a small child − abused, frightened, feeling responsible for her little sisters. Perhaps had someone been there consistently and dependably, she could have 39

learned to value herself, to express her feelings, to assert her anger when people invaded her boundaries physically or emotionally. Had that been her fate, would she still be alive?

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HOLD ON TO YOUR KIDS International authority on child development Gordon Neufeld, Ph.D., joins forces with bestselling author Gabor Maté, M.D., to tackle one of the most disturbing trends of our time: children today increasingly look to their peers for direction − their values, identity, and codes of behavior. This “peer orientation” undermines family cohesion, interferes with healthy development, and fosters a hostile and sexualized youth culture. Children end up becoming overly conformist, desensitized, and alienated; being “cool” matters more to them than anything else. Hold On to Your Kids explains the causes of this crucial breakdown of parental influence − and demonstrates ways to “reattach” to sons and daughters, establish the proper hierarchy in the home, make kids feel safe and understood, and earn back your children’s loyalty and love. By helping to reawaken parenting instincts innate to us all, this book will empower parents to be for their children what nature intended: a true source of contact, security, and warmth. Praise for “Hold On to Your Kids”: “A brilliant book on the level of Paul Goodman’s Growing Up Absurd. Give a copy to every parent you know.” Robert Bly, author, The Sibling Society “Hold on to Your Kids blows in from Canada like a Blue Northern, bringing us genuinely new ideas and fresh perspectives on parenting. The authors integrate psychology, anthropology, neurology and their own personal and professional experiences as they examine the “context” of parenting today. This is a worthy book with practical implications for mom and dad.” Dr. Mary Pipher, author, The Shelter of Each Other “With original insights on parent-child attachments and how parents can restore them, this is a book for revitalizing families and rekindling the song in their children’s hearts.” Raffi Children’s troubadour Founder, Child Honoring Society Institute “This important book boldly states the problem of ‘peer orientation’ and maps out plans for its solution. Let us take its suggestions seriously now so that together we can improve our children’s futures.” Daniel J. Siegel, M.D., professor of Psychiatry, UCLA, Parenting from the Inside Out “A wonderful book and a powerful wakeup call to parents. The authors’ description of how peer orientation gets in the way of healthy emotional maturation is both striking and sobering. But the book is also upbeat, as it emphasizes the extreme importance of attachment in child raising and how it can get implemented day to day. I found the book both thoughtful and thought provoking. It is a wise and important book.” Anthony Wolf, clinical psychologist, Get Out of My Life “Hold on to Your Kids is visionary book that goes beyond the usual explanations to illuminate a crisis of unrecognized proportions. The authors show us how we are losing contact with our children and how this loss undermines their development and threatens the very fabric of sociey. Most importantly they offer, through concrete examples and clear suggestions, practical help for parents to fulfill their instinctual roles. A brilliant and well written book, one to be taken seriously, very seriously.” Peter A. Levine Ph.D., It Won’t Hurt Forever: Guiding Your Child through Trauma “The thoughts and perspectives presented by the authors are informative − even inspirational −

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for those who choose to dedicate their lives and energy to students.” Bulletin of the National Association of Secondary School Principals “Beautifully written… terrific, poignant.” Publishers’ Weekly (starred review) “Highly recommended… [Neufeld and Maté] offer readers much more than simple platitudes in this excellent book.” Library Journal (starred review)

HOLD ON TO YOUR KIDS: WHY PARENTS NEED TO MATTER MORE THAN PEERS Chapter One − Why Parents Matter More Than Ever Twelve-year-old Jeremy is hunched over the keyboard, his eyes intent on the computer monitor. It’s eight o’clock in the evening and tomorrow’s homework is far from complete but his father’s repeated admonishments to “get on with it” fall on deaf ears. Jeremy is on MSN Messenger, exchanging notes with his friends: gossip about who likes who, sorting out who is a buddy and who an enemy, disputes over who said what to who at school that day, the latest on who is hot and who is not. “Stop bugging me,” he snaps at his father who, one more time, comes to remind him about schoolwork. “If you were doing what you’re supposed to,” the father shoots back, his tone shaking with frustration, “I wouldn’t be bugging you.” The verbal battle escalates, the voices grow strident and in a few moments Jeremy yells “You don’t understand anything,” as he slams the door. The father is upset, angry with Jeremy but above all, with himself. “I blew it again,” he thinks. “I don’t know how to communicate with my son.” He and his wife are both concerned about Jeremy: once a cooperative child, he is now impossible to control or even to advise. His attention seems focused exclusively on contact with his friends. This same scenario of conflict is acted out in the home several times a week and neither the child nor the parents are able to respond with any new thoughts or actions to break the deadlock. The parents feel helpless and powerless. They have never relied much on punishment, but now they are more and more inclined to “lower the boom.” When they do, their son becomes ever more embittered and defiant. Should parenting be this difficult? Was it always so? Older generations have often in the past complained about the young being less respectful and less disciplined than they used to be, but today many parents intuitively know that something is amiss. Children are not quite the same as we remember being. They are less likely to take their cues from adults, less afraid of getting into trouble. They also seem less innocent and naïve – lacking, it seems, the wide-eyed wonder that leads a child to have excitement for the world, for exploring the wonders of nature or of human creativity. Many children seem inappropriately sophisticated, even jaded in some ways, pseudomature before their time. They appear to be easily bored when away from each other or when not engaged with technology. Creative, solitary play seems a vestige of the past. “As a child I was endlessly fascinated by the clay I would dig out of a ditch near our home,” one forty-four yearold mother recalls. “I loved the feel of it; I loved moulding it into shapes or just kneading it in my hands. And yet, I can’t get my six-year-old son to play on his own, unless it’s with the computer 42

or Nintendo or video games.” Parenting, too, seems to have changed. Our parents were more confident, more certain of themselves and had more impact on us, for better or for worse. For many today, parenting does not feel natural. Today’s parents love their children as much as parents ever have, but the love doesn’t always get through. We have just as much to teach, but our capacity to get our knowledge across has, somehow, diminished. We do not feel empowered to guide our children toward fulfilling their potential. Sometimes they live and act as if they have been seduced away from us by some siren song we do not hear. We fear, if only vaguely, that the world has become less safe for them and that we are powerless to protect them. The gap opening up between children and adults can seem unbridgeable at times. We struggle to live up to our image of what parenting ought to be like. Not achieving the results we want, we plead with our children, we cajole, bribe, reward or punish. We hear ourselves address them in tones that seem harsh even to us and foreign to our true nature. We sense ourselves grow cold in moments of crisis, precisely when we would wish to summon our unconditional love. We feel hurt as parents, and rejected. We blame − ourselves for failing at the parenting task, or our children for being recalcitrant, or television for distracting them, or the school system for not being strict enough. When our impotence becomes unbearable we reach for simplistic, authoritarian formulas consistent with the do-it-yourself / quick-fix ethos of our era. The very importance of parenting to the development and maturation of young human beings has come under question. “Do Parents Matter?” was the title of a cover article in Newsweek magazine in 1998. “Parenting has been oversold,” argued a book that received international attention that year. “You have been led to believe that you have more of an influence on your child’s personality than you really do.” The question of parental influence might not be quite so crucial if things were going well with our young. That our children do not seem to listen to us or to embrace our values as their own would, perhaps, be acceptable in itself – if they were truly self-sufficient, self-directed and grounded in themselves, if they had a positive sense of who they are and if they possessed a clear sense of direction and purpose in life. We see that for so many children and young adults those qualities are lacking. In homes, in schools, in community after community developing young people have lost their moorings. Many lack self-control and are increasingly prone to alienation, drug use, violence, or just a general aimlessness. They are less teachable and more difficult to manage than their counterparts of even a few decades ago. Many have lost their ability to adapt, to learn from negative experience and to mature. Unprecedented numbers of children and adolescents are now being prescribed medications for depression, anxiety or a host of other diagnoses. The crisis of the young has manifested itself ominously in the growing problem of bullying in the schools and, at its very extreme, in the murder of children by children. Such tragedies, though rare, are only the most visible eruptions of a widespread malaise, an aggressive streak rife in today’s youth culture. Committed and responsible parents are frustrated. Despite our loving care, kids seem highly stressed. Parents and other elders no longer appear to be the natural mentors for the young, as always used to be the case with human beings and is still the case with all other species living in their natural habitats. Senior generations, parents and grandparents of the baby boomer group, look at us with incomprehension. “We didn’t need how-to manuals on parenting in our days, we just did it,” they say, with some mixture of truth and misunderstanding.

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This state of affairs is ironic, given that more is known about child development than ever before and that we have more access to courses and books on child rearing than any previous generation of parents. The Missing Context For Parenting So what has changed? The problem, in a word, is context. No matter how well intentioned, skilled or compassionate we may be, parenting is not something we can engage in with just any child. Parenting requires a context to be effective. A child must be receptive if we are to succeed in nurturing, comforting, guiding and directing her. Children do not automatically grant us the authority to parent them just because we are adults, or just because we love them or know what is good for them or have their best interests at heart. Stepparents often are often confronted by this fact, as are others who have to look after children not their own, be they foster parents, baby sitters, nannies, daycare providers or teachers. Even with one’s own children the natural parenting authority can become lost if the context for it becomes eroded. If parenting skills or even loving the child are not enough, what then is needed? There is an indispensable special kind of relationship without which parenting lacks a firm foundation. Developmentalists − psychologists or other scientists who study human development − call it an attachment relationship. For a child to be open to being parented by an adult, he must be actively attaching to that adult, be wanting contact and closeness with him. At the beginning of life this drive to attach is quite physical in nature − the infant literally clings to the parent and needs to be held. If everything unfolds according to design, the attachment will evolve into an emotional closeness and finally a sense of psychological intimacy. Children who lack this kind of connection with those responsible for them are very difficult to parent or, often, even to teach. Only the attachment relationship can provide the proper context for child rearing. The secret of parenting is not in what a parent does but rather who the parent is to a child. When a child seeks contact and closeness with us, we become empowered as a nurturer, a comforter, a guide, a model, a teacher or a coach. For a child well attached to us, we are her home base from which to venture into the world, her retreat to fall back to, her fountainhead of inspiration. All the parenting skills in the world cannot compensate for a lack of attachment relationship. All the love in the world cannot get through without the psychological umbilical cord created by the child’s attachment. The attachment relationship of child to parent needs to last at least as long as a child needs to be parented. That is what is becoming more difficult in today’s world. Parents haven’t changed − they have not become less competent or less devoted. The fundamental nature of children has also not changed − they have not become less dependent or more resistant. What has changed is the culture in which we are rearing our children. Children’s attachments to parents are no longer getting the support required from culture and society. Even parent-child relationships that at the beginning are powerful and fully nurturing can become undermined as our children move out into a world that no longer appreciates or reinforces the attachment bond. Children are increasingly forming attachments that compete with their parents, with the result that the proper context for parenting is less and less available to us. Not a lack of love or of parenting know how but the erosion of the attachment context is what makes our parenting ineffective. The Impact of the Peer Culture The chief and most damaging of the competing attachments that undermine parenting authority and parental love is the increasing bonding of our children with their peers. It is the thesis of this 44

book that the disorder affecting the generations of young children and adolescents now heading toward adulthood is rooted in the lost orientation of children toward the nurturing adults in their lives. Far from seeking to establish yet one more medical-psychological disorder here − the last thing today’s bewildered parents need – we are using the world “disorder” in its most basic sense: a disruption of the natural order of things. For the first time in history young people are turning for instruction, modeling and guidance not to mothers, fathers, teachers and other responsible adults but to people whom nature never intended to place in a parenting role − their own peers. They are not manageable, teachable or maturing because they no longer take their cues from us. Instead, children are being brought up by immature persons who cannot possibly guide them to maturity. They are being brought up by each other. The term that seems to fit more than any other for this phenomenon is peer orientation. It is peer orientation that has muted our parenting instincts, eroded our natural authority and caused us to parent not from the heart but from the head − from manuals, the advice of “experts” and the confused expectations of society. What is peer orientation? Orientation, the drive to get one’s bearings and become acquainted with one’s surroundings, is a fundamental human instinct and need. Disorientation is one of the least bearable of all psychological experiences. Attachment and orientation are inextricably intertwined. Humans and other creatures automatically orient themselves by seeking cues from those to whom they are attached. Children, like the young of any warm-blooded species, have an innate orienting instinct: they need to get their sense of direction from somebody. Just as a magnet turns automatically toward the North Pole, so children have an inborn need to find their bearings by turning toward a source of authority, contact and warmth. Children cannot endure the lack of such a figure in their lives: they become disoriented. They cannot endure what I call an orientation void. The parent − or another adult acting as parent substitute − is the nature-intended pole of orientation for the child, just as adults are the orienting influences in the lives of all animals that rear their young. It so happens that this orienting instinct of humans is much like the imprinting instinct of a duckling. Hatched from the egg, the duckling immediately imprints on the mother duck − he will follow her around, heeding her example and her directions until he grows into mature independence. That is how nature would prefer it, of course. In the absence of mother duck, however, the duckling will begin to follow the nearest moving object − a human being, a dog, or even a mechanical toy. Needless to say, neither the human, the dog, nor the toy are as well suited as the mother duck to raise that duckling to successful adult duckhood. Likewise, if no parenting adult is available, the human child will orient to whoever is near. Social, economic and cultural trends in the past five or six decades have displaced the parent from his intended position as the orienting influence on the child. The peer group has moved into this orienting void, with deplorable results. As we will show, children cannot be oriented to both adults and other children simultaneously. One cannot follow two sets of conflicting directions at the same time. The child’s brain must automatically choose between parental values and peer values, parental guidance and peer guidance, parental culture and peer culture whenever the two would appear to be in conflict. Are we saying that children should have no friends their own age or form connections with other children? On the contrary − such ties are natural and can serve a healthy purpose. In adultoriented cultures, where the guiding principles and values are those of the more mature 45

generations, kids attach each other without losing their bearings or rejecting the guidance of their parents. In our society that is no longer the case. Peer bonds have come to replace relationships with adults as children’s primary sources of orientation. What is unnatural is not peer contact, but that children should have become the dominant influence on each other’s development. Normal But Not Natural Or Healthy So ubiquitous is peer orientation these days that it has become the norm. Many psychologists and educators, as well as the lay public, have come to see it as natural − or, more commonly, do not even recognize it as a specific phenomenon to be distinguished. It is simply taken for granted as the way things are. But what is normal, in the sense of conforming to a norm, is not necessarily the same as natural or healthy. There is nothing either healthy or natural about peer orientation. Only recently has this counter-revolution against the natural order triumphed in the most industrially advanced countries, for reasons we will explore. Peer orientation is still foreign to indigenous societies and even in many places in the Western world outside the “globalized” urban centers. Throughout human evolution and until about the Second World War adult orientation was the norm in human development. We, the adults who should be in charge − parents and teachers − have only recently lost our influence without even being aware that we have done so. Peer orientation masquerades as natural or goes undetected because we have become divorced from our intuitions and because we have unwittingly become peer oriented ourselves. For members of the post war generations born in England or North America and many other parts of the industrialized world, our own preoccupation with peers is blinding us to the seriousness of the problem. Culture, until recently, was always handed down vertically, from generation to generation. For millennia, wrote Joseph Campbell, “the youth have been educated and the aged rendered wise” through the study, experience and understanding of traditional cultural forms. Adults played a critical role in the transmission of culture, taking what they received from their own parents and passing it down to their children. However, the culture our children are being introduced to is much less likely to be the culture of their parents than that of their peers. Children are generating their own culture, very distinct from that of their parents and, in some ways, also very alien. Instead of culture being passed down vertically, it is being transmitted horizontally within the younger generation. Essential to any culture are its customs, its music, its dress, its celebrations, its stories. The music children listen to bears very little resemblance to the music of their grandparents. The way they look is dictated by the way other children look rather than by the parents’ cultural heritage. Their birthday parties and rites of passage are influenced by the practices of other children around them, not by the customs of their parents before them. If all that seems normal to us, it’s only due to our own peer orientation. The existence of a youth culture, separate and distinct from that of adults, dates back only fifty years or so. Although half a century is a relatively short time in the history of humankind, in the life of an individual person it constitutes a whole era. Most readers of this book will already have been raised in a society where the transmission of culture is horizontal rather than vertical. In each new generation this process, potentially corrosive to civilized society, gains new power and velocity. Even in the twenty-two years between my first and my fifth child, it seems that parents have lost ground. According to a large international study headed by the British child psychiatrist Sir Michael Rutter and a criminologist, David Smith, a children’s culture first emerged after the Second 46

World War and is one of the most dramatic and ominous social phenomena of the twentieth century. This study, which included leading scholars from sixteen countries, linked the escalation of antisocial behavior to the breakdown of the vertical transmission of mainstream culture. Accompanying the rise in a children’s culture distinct and separate from the mainstream culture, were increases in youth crime, violence, bullying and delinquency. Such broad cultural trends are paralleled by similar patterns in the development of our children as individuals. Who we want to be and what we want to be like is defined by our orientation, by who we appoint as our model of how to be and how to act − by who we identify with. Current psychological literature emphasizes the role of peers in creating a child’s sense of identity. When asked to define themselves, children often do not even refer to their parents but rather to the values and expectations of other children and of the peer groups they belong to. Something significantly systemic has shifted. For far too many children today, peers have replaced parents in creating the core of their personalities. All indications a few generations ago were that parents mattered the most. Carl Jung suggested that it is not even so much what happens in the parent-child relationship that has the greatest impact on the child. What is missing in that relationship leaves the greatest scar on the child’s personality − or “nothing happening when something might profitably have happened,” in the words of the great British child psychiatrist D.W. Winnicott. Scary thought. An even scarier thought is that if peers have replaced us as the ones who matter most, what is missing in those peer relationships is going to have the most profound impact. Absolutely missing in peer relationship is unconditional love and acceptance, the desire to nurture, the ability to extend oneself for the sake of the other, the willingness to sacrifice for the growth and development of the other. When we compare peer relationships with parent relationships for what is missing, parents come out looking like saints. The results spell disaster for many children. Paralleling the increase of peer orientation in our society is a startling and dramatic increase in the suicide rates among children, fourfold in the last fifty years for the ten-to-fourteen age range in North America. Suicide rates among that group are the fastest growing with a 120 percent increase from 1980 to 1992 alone. In inner cities, where peers are the most likely to replace parents, these suicide rates have increased even more. What is behind these suicides is highly revealing. Like many students of human development, I had always assumed that parental rejection would be the most significant precipitating factor. That is no longer the case. I worked for a time with young offenders. Part of my job was to investigate the psychological dynamics in children and adolescents who attempted suicide, successfully or not. To my absolute shock and surprise, the key trigger for the great majority was how they were being treated by their peers, not their parents. My experience was not isolated, as is confirmed by the increasing numbers of reports of childhood suicides triggered by peer rejection and bullying. The more peers matter, the more children are devastated by the insensitive relating of their peers, by failing to fit in, by perceived rejection or ostracization. No society, no culture is immune. In Japan, for instance, traditional values passed on by elders have succumbed to Westernization and the rise of a youth culture. That country was almost free of delinquency and school problems among its children until very recently but now experiences the most undesirable products of peer orientation, including lawlessness, childhood suicide and an increasing school drop out rate. Harper’s magazine recently published a selection of suicide notes left by Japanese children: most of them gave intolerable bullying by peers as the reason for their decision to take their own lives. The effects of peer orientation are most obvious in the teenager, but its early signs are visible by 47

Grade 2 or 3. Its origins go back to even before kindergarten and need to be understood by all parents, especially the parents of young children who want to avoid the problem or to reverse it as soon as it appears. A Wake-up Call The first warning came as long as four decades ago. The textbooks I used for teaching my courses in developmental psychology and parent-child relations contained references to an American researcher in the early 1960s who had sounded an alarm that parents were being replaced by peers as the primary source of cues for behavior and of values. In a study of seven thousand young people, Dr. James Coleman also discovered that relationships with friends took priority over those with parents. He was concerned that a fundamental shift had occurred in American society. Scholars remained skeptical however, pointing out that this was Chicago and not mainstream North America. They were optimistic that this finding was probably due to the disruption in society caused by the Second World War and would go away as soon as things got back to normal. The idea of peers becoming the dominant influence on a child came from untypical cases on the fringe of society, maintained his critics. James Coleman’s concerns were dismissed as alarmist. I, too, buried my head in the sand until my own children abruptly disrupted my denial. I had never expected to lose my kids to their peers. To my dismay, I noticed that on reaching adolescence both my older daughters began to orbit around their friends, following their lead, imitating their language, internalizing their values. It became more and more difficult to bring them into line. Everything I did to impose my wishes and expectations only made things worse. It’s as if the parental influence my wife and I had taken for granted had all of a sudden evaporated. Sharing our children is one thing, being replaced is quite another. I thought my children were immune: they showed no interest in gangs or delinquency, were brought up in the context of relative stability with an extended family that dearly loved them, lived in a solid family-oriented community and had not had their childhood disrupted by a major world war. Coleman’s findings just did not seem relevant to my family’s life. When I started putting the pieces together, I found that what was happening with my children was more typical than exceptional. “But aren’t we meant to let go?” many parents ask. “Aren’t our children meant to become independent of us?” Absolutely, but only when our job is done and only in order for them to be themselves. Fitting in with the immature expectations of the peer group is not how the young grow to be independent, self-respecting adults. By weakening the natural lines of attachment and responsibility, peer orientation undermines healthy development. Children may know what they want, but it is dangerous to assume that they know what they need. To the peer-oriented child it seems only natural to prefer contact with his friends to closeness with his family, to be with them as much as possible, to be as much like them as possible. A child does not know best. Parenting that takes its cues from the child’s preferences can get you retired long before the job is done. To nurture our children, we must reclaim them and take charge of providing for their attachment needs. Extreme manifestations of peer orientation catch the attention of the media: violent bullying, peer murders, childhood suicides. Although we are all shocked by such dreadful events, most of us do not feel that they concern us directly. And they are not the focus of this book. But such childhood tragedies are only the most dramatic signs of peer orientation, a phenomenon no longer limited to the concrete jungles and cultural chaos of large urbanized centers like Chicago, New York, 48

Toronto, Los Angeles. It has hit the family neighborhoods – the communities characterized by middle class homes and good schools. The focus of this book is not what is happening out there, one step removed from us, but what’s happening in our very own backyard. For the two authors, our personal wake up call came with the increasing peer orientation of our own children. We hope Hold On To Your Kids can serve as a wake-up call to parents everywhere and to society at large. The Good News We may not be able to reverse the social, cultural and economic forces driving peer orientation, but there is much we can do in our homes and in our classrooms to keep ourselves from being prematurely replaced. Because culture no longer leads our children in the right direction towards genuine independence and maturity, parents and other child rearing adults matter more than ever before. Nothing less will do than to place the parent-child (and adult-child) relationship back onto its natural foundation. Just as relationship is at the heart of our current parenting and teaching difficulties, it is also at the heart of the solution. Adults who ground their parenting in a solid relationship with the child parent intuitively. They do not have to resort to techniques or manuals but act from understanding and empathy. If we know how to be with our children and who to be for them, we need much less advice on what to do. Practical approaches emerge spontaneously from our own experience once the relationship has been restored. The good news is that nature is on our side. Our children want to belong to us, even if they don’t know that or feel that and even if their words or actions seem to signal the opposite. We can reclaim our proper role as their nurturers and mentors. In Part Four of this book we present a detailed program for keeping our kids close to us until they mature, and for re-establishing the relationship if it has been weakened or lost. There are always things we can do. Although no approach can be guaranteed to work in all circumstances, in my experience there are many, many more successes than failures – once parents understand where to focus their efforts. But the cure, as always, depends on the diagnosis. We look first at what is missing and how things have gone awry.

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IN THE REALM OF HUNGRY GHOSTS Winner of the 2009 Hubert Evans Non-Fiction Prize. From street-dwelling drug addicts to high-functioning workaholics, the continuum of addiction cuts a wide and painful swath through our culture. Blending first-person accounts, riveting case studies, cutting-edge research and passionate argument, In the Realm of Hungry Ghosts: Close Encounters with Addiction takes a panoramic yet highly intimate look at this widespread and perplexing human ailment. Countering prevailing notions of addiction as either a genetic disease or an individual moral failure, Dr. Gabor Maté presents an eloquent case that addiction – all addiction – is in fact a case of human development gone askew. Dr. Maté, who for twelve years practiced medicine in Vancouver’s notorious Downtown Eastside – North America’s most concentrated area of drug use, begins by telling the stories of his patients, who, in their destitution and uniformly tragic histories, represent one extreme of the addictive spectrum. With his trademark compassion and unflinching narrative eye, he brings to life their ill-fated and mostly misunderstood struggle for relief or escape, through substance use, from the pain that has tormented them since childhood. He also shows how the behavioural addictions of society’s more fortunate members – including himself – differ only in degree of severity from the drug habits of his Downtown Eastside patients, and how in reality there is only one addiction process, its core objective being the self-soothing of deep-seated fears and discomforts. Turning to the neurobiological roots of addiction, Dr. Maté presents an astonishing array of scientific evidence showing conclusively that: 1) addictive tendencies arise in the parts of our brains governing some of our most basic and lifesustaining needs and functions: incentive and motivation, physical and emotional pain relief, the regulation of stress, and the capacity to feel and receive love; 2) these brain circuits develop, or don’t develop, largely under the influence of the nurturing environment in early life, and that therefore addiction represents a failure of these crucial systems to mature in the way nature intended; and 3) the human brain continues to develop new circuitry throughout the lifespan, including well into adulthood, giving new hope for people mired in addictive patterns. Dr. Maté then examines the current mainstream social and legal frameworks for dealing with the addiction epidemic, and shows why they are doomed to failure. He proposes an evidence-based, compassionate approach to treating and healing addiction in ourselves, in our families, and in our society. Praise for “In the Realm of Hungry Ghosts”: “Gabor Maté is a voice of reason and compassion in a sea of white noise. In the realm of the hungry ghost, where so many others see only the comeuppance of lives of sloth and foolishness, he sees the human spirit battered by the crush of indifference.” Ed Burns, Former Baltimore City Homicide detective and co-creator, HBO’s The Corner “Gabor Maté is a common-sense doctor and a truth-teller. By looking at causes and their effects, he helps you find your way home.” Jamie Lee Curtis, Actress “Maté’s resonant, unflinching analysis of addiction today shatters the assumptions underlying our

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War on Drugs.” Norm Stamper, Retired Former Police Chief of Seattle, Member, Law Enforcement Against Prohibition “Gabor Maté’s connections – between the intensely personal and the global, the spiritual and the medical, the psychological and the political – are bold, wise and deeply moral. He is a healer to be cherished and this exciting book arrives at just the right time.” Naomi Klein, author, The Shock Doctrine “With superb descriptive talents, Gabor Maté takes us into the lives of the emotionally destitute and drug addicted human beings who are his patients. In this highly readable and penetrating book, he gives us the disturbing truths about the nature of addiction and its roots in people’s early years − truths that are usually concealed by time and protected by shame, secrecy and social taboo.” Vincent Felitti M.D., Clinical Professor of Medicine, University of California, Co-Principal Investigator, Adverse Childhood Experiences Study “I recommend this wonderful book for anyone struggling with the heartache of addiction personally or professionally. Dr. Maté makes the thought-provoking and powerful arguments that human connections heal; and that the poverty of relationships in the modern world contributes to our vulnerability to unhealthy addictions of all manner. His uniquely humane perspective − all too absent from much of the “modern” approach to addictions − should be a part of the training of all therapists, social workers and physicians.” Bruce Perry M.D., Ph.D., Senior Fellow, Child Trauma Academy, Houston, TX, Former Director, Mental Health Services for Children, Alberta, The Boy Who Was Raised As a Dog “Dr. Gabor Maté distills the suffering of injection drug users into moving case histories and reveals how clearly he himself, as music collector and workaholic physician, fits his own definition of addiction. Informed by the new research on brain chemistry, he proposes sensible drug laws to replace the War on Drugs. Inspired by the evolving spirituality that underlies his life and work, he outlines practical ways of overcoming addiction. This is not a fix-it book to hurry through, but a deep analysis to reflect upon.” Dr. Bruce Alexander, Professor Emeritus (Psychology), Simon Fraser University, The Globalization of Addiction “With unparalleled sympathy for the human condition, Gabor Maté depicts the suffocation of the spirit by addictive urges, and holds up a dark mirror to our society. This is a powerful narrative of the realm of human nature where confused and conflicted emotions underlie our pretensions to rational thought.” Dr. Jaak Panksepp, Professor of Psychobiology, Bowling Green University, Professor of Psychiatry, Medical College of Ohio “Whether you are an addiction medicine professional, a family member of a loved one struggling with addiction, a student or a curious member of the public, In the Realm of Hungry Ghosts is a clarifying and positive work that can bring optimism and hope for transformation and change. Dr. Maté’s experience, eloquence, insights and conclusions contribute to improving ourselves, our work and society.” Ken Saffier, MD, CSAM News (California Society of Addiction Medicine) “If you are a victim of crime, a police officer, politician, lawyer or judge; if you are the parent of an addict, child of an addict, a recovering addict yourself; if you believe that drug users are 51

simply immoral or weak; if you are like millions of other angry citizens, read In the Realm of Hungry Ghosts. I cannot begin to tally how many revelatory, shocking and reassuring words, lines, paragraphs and whole pages I have highlighted in this astonishing book.” Susan Musgrave, writer and poet “He would dispute it, pointing instead to a deep clinical understanding of the nefarious workings of addiction, but Dr. Gabor Maté is something of a compassion machine, hugely wary of casting the first stone… In the Realm of Hungry Ghosts (the title refers to a point on the Buddhist Wheel of Life) is enormously compelling and Maté, as noted, is admirably, sometimes inexplicably, empathetic to all who cross his path.” Toronto Star “…Yet for all the suffering in these addicts’ lives, Maté does not regard them as victims. By listening to them and capturing with a novelist’s precision their language and other ways of expressing themselves, he posits an unusual, bold twist on the classic doctor-patient relationship and its built-in imbalance of power… A powerful and compassionate work.” NOW Magazine (Toronto, ON) “A moving, debate-provoking and multi-layered look at how addiction arises, and the people afflicted with it.” The Globe and Mail “One of the book’s strengths is Maté’s detailed and compassionate characterization of the afflicted addicts he treats, but this is not just a memoir. Rather, using his own experience as well as the most advanced recent research, he attempts to delineate the closely interrelated psychological, social, and neurological dimensions of addiction…” The Walrus (Toronto, ON) “Maté does a great service by forcing us to confront the us-and-them mentality that drives the get-tough responses to addiction… I highly recommend Hungry Ghosts to everyone seeking insight into addiction.” Dr. Gerald Thomas, Centre for Addictions Research of British Columbia, Vancouver Sun “[An] excellent scientific and personal read, and a solid starting point to developing an informed perspective on addiction.” Canadian Family Physician “If stigma still shapes the ways we understand and respond to addictions in contemporary society – and it does – then this book deserves our attention. Gabor Maté employs both passion and reason in shaping an ambitious, sprawling book that is engaging and provocative.” Canadian Medical Association Journal “If the book succeeds, it is not by offering tidy proposals to solve a sprawling problem, but by reaching a wide audience, provoking more open, active (and not always polite) dialogue about what we think addiction is, and what needs to be done about it.” Cross Currents (the Journal of Addiction and Mental Health) “I have been reading, nay, devouring your addiction book. Thank you for your insights and for your bold compassion. I have been able for the first time to identify as an addict without any shame, and to accept the mission of recovery.” Hannah

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“I have worked in the field of addictions treatment for 20+ years, and also suffered the recurrent torment of the illness in my own life. You offered some very fresh and humane ideas that have caused me to reflect a lot on my own basic assumptions, as well as my experiences. That’s the kind of gift we experience all too infrequently.” Finn “I am a Registered Nurse and work for Alberta Health Services. The portfolio that I work in is currently training all Corrections staff (officers and health care) in addictions and mental health…. [We] have incorporated some of your work into our training and I have to tell you that it has made the addiction section of the day so much more vibrant and conducive to learning… [We] have seen a change in attitude and learning during the sessions… I believe your work is a great catalyst for an overall change in attitude.” Andrea (RN, BScN) “I truly believe your book is an absolute blessing. I am now 1/3 of the way through and I cannot put it down. I was always in denial about how my personal traumas as a child reflecting the need for me to numb my post-traumatic stress with opiates. I always believed my addiction was simply a substance issue, and your book has been proving to me that the issues are much deeper than that. It has been a difficult process, however; I am truly grateful to have recognized the deeper truths to my addiction. This has helped me heal slowly but surely every day.” Eric “I am an Alaskan native woodcarver in Washington State… I thank you deeply for your work with the drug addicted… My attitude was radically changed from reading your book. I still have it, and have loaned it out once, but am always looking to have it go to another person, who can also have a life-changing enlightenment…” Jerry “I just finished your book In the Realm of Hungry Ghosts. I want to thank you for taking the time and effort for creating such a brilliant masterpiece. I have read a lot of self-help books in the last couple of years, trying to heal from an eating addiction, and your book was everything I am looking for all in one read. I rarely have the patience to finish a book of that sort, or I end up skimming a lot of it – but your book, I read word for word… I love the rawness of your material and the intensity it brings about in me…” Denali “Thanks for this book! As a drug and alcohol counselor, this is a book that makes sense, is compassionate and equally realistic. You have made it easier for me to do my work and to spread the word about the people we serve in the realm of compassion and understanding. Thank you again!” Deb “I worked in the field of addiction for a number of years, (I am now in private practice as a psychotherapist in Dublin, Ireland), and I teach. A lot of my students work in the addiction field. I absolutely love your approach to addiction and have sent the links to your interviews, lectures, etc., to anyone and everyone that I know who’s working in this field.” Norah “I just wanted to tell you, reading about you and reading this book – it has touched me, on the inside, finally I wasn’t alone – you reached me down to my bones – I saw myself, my lifelong struggles, my difficult inner fights with myself, finally put into writing – clear – not alone.” 53

Karen “Thank you for confirming in your book what my heart knew all along yet did not know the ways in which to convey truth… We need you in our native communities, keep working and keep writing… our lives and families depend upon such great contributions.” Bonnie “I have recently finished reading In the Realm… and I have to say it has changed me forever… Hungry Ghosts made me look at my addiction in a totally new light and now I understand on a deeper level WHY the cravings were so bad and I feel less guilt for the powerlessness over the whole thing. I am still accountable but at least now I know that my brain wasn’t working at 100% and it wasn’t just my personal weakness.” Lisa “I have just finished reading your book In the Realm of Hungry Ghosts, and I just wanted to say thank you. I have been an alcoholic for over twenty years, the last seven years being the worst… I am saying thank you because you have explained the reasons (abandonment, sexual abuse) behind my addiction in layman’s terms and that has allowed me to accept the “why” and to start to re-wire my brain in a healthy way.” Diane “Your book has really helped me see that I actually have an addicted brain. Because my substance abuse flies under the radar (i.e. it’s sugar and food and not hard drugs) it’s been harder for me to get that I am dealing with addictive patterns… I am especially hearted by your distinction between the mind and the brain, and how the mind can actually be pressed into service to help mediate with a brain that has been wired to be primitive, reactive and at times, desperate… [Your] self-disclosure is brave and encouraging and adds a level of compassion and understanding that is rare.” Sheila “I have just finished reading this magnificent book. I have lived and/or worked in the crossroads of addiction, mental health and corrections for most of my life. I learned a great deal from your excellent and comprehensive book. I wish that I had read it years ago. Also I found better understanding of my family, myself and my sister in it.” Bert “I am writing to express my appreciation for In the Realm of Hungry Ghosts. It was illuminating to read a truly holistic exploration of addition, one which posits addiction as a fluid, experiential phenomena rather than an inherent, static defect.” Stephanie “First let me thank you for ‘getting it’. I’ve been reading your book In the Realm of Hungry Ghosts for the past 3 graveyard shifts and can’t put it down. I’ve shared excerpts with my clients and we’ve laughed and cried. I’m a recovering crystal meth addict of just over 5 years… Thanks again for your incredible intuitiveness and from all addicts everywhere for the great work you do, both as a physician and as a writer.” Kerri “The tears are rolling down my cheeks as I write to you. I just finished the book and I can’t tell you how much it aided me in fuller understanding of addictions. My husband is currently in [treatment] for crack addiction. The problem had gone on for a year without my knowledge. After

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reading the book, I am better able to help and support him on the road back to our life… Thank you for your amazing compassion. I look at humans in a whole different light.” Janey “An anecdote: I was lying with my niece reading your book while she was watching television and she wanted to know what the book was about, and initially I didn’t know what to say to her – she is 5 – and then it came to me. I told her it was a book about learning to love.” Loren “I just finished your book In the Realm of Hungry Ghosts and found it truly amazing. I love someone very much who is an alcoholic and reading your book has really helped me understand the bigger picture about addiction and has also pointed out some areas in my own life I need to work on before I can try to assist him in correcting his own.” Fran “I was a Buddhist monk for eight years back in the 1980s, and now teach meditation in the guise of stress management. I’ve struggled for years to convey a true sense (not just description) of compassion… Reading your book creates a sustained sense of empathy that cuts to the bone, and your ability to write about abject misery in such a riveting way is amazing.” Stephen “I have just finished reading In the Realm… and I feel compelled to tell you what a powerful and helpful experience it has been, not to mention amusing and touching… Thank you for the section on healing, it gives hope and encouragement with a strong dose of reality. As an avid reader of the human condition, and as one trying to learn to live life more happily, I am so appreciative.” Helen “I am a doctor from Australia undergoing training in Physical and Rehabilitation medicine, with an interest in chronic pain. Your book has inspired me to look very closely at myself and how I want to practice medicine… I will insist your book is read by as many of my colleagues as possible.” Kim “I am recently retired and have had by most measures a good life to this point. However, for as long as I can remember I have had trouble with addictive behaviors, particularly sexual addictions. I have seen therapists about this in the past but nothing has really made sense for me until I read your book. I am also going to start reading the book all over again because there is so much in it on so many levels that I think a 2nd or 3rd reading will be even more helpful to me…” Allan “I was so moved by this book, your openness, your compassion… the willingness you have to share your insights about yourself. I am a R.N. It isn’t often that one sees a doctor like you… I appreciated your comments about nurses and doctors and the things they need to look at to benefit the patient.” Lisa “…Thank you for shedding light on this important topic and for being honest about your own struggles. I thinking having our so-called ‘experts’ admit their own vulnerabilities is key to humanizing addiction and the only way we can take steps towards healing.” Anne-Rachelle “If I were reviewing your book, I would say make room on your bookshelf for this one by 55

clearing your shelf of so many shortsighted tomes on addiction gathering dust. This is the best one yet.” Maggie “I have finished reading your latest book and it has helped me to understand my 37-year-old adopted son. He has suffered with ADHD all his life and is now addicted to smoking crack cocaine. He is a talented artist. He has been in rehab twice and incarcerated as well. You have helped me understand his craving for cocaine as well as his mental illness.” Sharon “Dear [Canadian] Prime Minister Harper, I am writing for three reasons: to insist that you change your drug policies, that you keep InSite open and that you read Dr. Gabor Maté’s book In the Realm of Hungry Ghosts: Close Encounters with Addiction… This intelligent, well researched and ultimately compassionate book is necessary reading for you and anyone else involved in developing policies to address addictions.” Lenore

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IN THE REALM OF HUNGRY GHOSTS: CLOSE ENCOUNTERS WITH ADDICTION Introduction − Hungry Ghosts: The Realm of Addiction Yon Cassius has a lean and hungry look. − William Shakespeare, Julius Caesar The mandala, the Buddhist Wheel of Life, revolves through six realms. Each realm is populated by characters representing aspects of human existence − our various ways of being. In the Beast Realm we are driven by basic survival instincts and appetites such as physical hunger and sexuality, what Freud called the Id. The denizens of the Hell Realm are trapped in states of unbearable rage and anxiety. In the God Realm we transcend our troubles and our egos through sensual, aesthetic or religious experience, but only temporarily and in ignorance of spiritual truth. Even this enviable state is tinged with loss and suffering. The inhabitants of the Hungry Ghost Realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects or pursuits we hope will soothe it are not what we really need. We don’t know what we need, and so long as we stay in the hungry ghost mode, we’ll never know. We haunt our lives without being fully present. Some people dwell much of their lives in one realm or another. Many of us move back and forth between them, perhaps through all of them in the course of a single day. My medical work with drug addicts in Vancouver’s Downtown Eastside has given me a unique opportunity to know human beings who spend almost all their time as hungry ghosts. It’s their attempt, I believe, to escape the Hell Realm of overwhelming fear, rage and despair. The painful longing in their hearts reflects something of the emptiness that may also be experienced by people with apparently happier lives. Those whom we dismiss as “junkies” are not creatures from a different world, only men and women mired at the extreme end of a continuum on which, here or there, all of us might well locate ourselves. I can personally attest to that. “You slink around your life with a hungry look,” someone close once said to me. Facing the harmful compulsions of my patients, I have had to encounter my own. No society can understand itself without looking at its shadow side. I believe there is one addiction process, whether it is manifested in the lethal substance dependencies of my Downtown Eastside patients; the frantic self-soothing of overeaters or shopaholics; the obsessions of gamblers, sexaholics and compulsive Internet users; or the socially acceptable and even admired behaviours of the workaholic. Drug addicts are often dismissed and discounted as unworthy of empathy and respect. In telling their stories my intent is twofold: to help their voices to be heard and to shed light on the origins and nature of their ill-fated struggle to overcome suffering through substance abuse. They have much in common with the society that ostracizes them. If they seem to have chosen a path to nowhere, they still have much to teach the rest of us. In the dark mirror of their lives, we can trace outlines of our own. There is a host of questions to be considered. Among them: − What are the causes of addictions? − What is the nature of the addiction-prone personality? − What happens physiologically in the brains of addicted people? − How much choice does the addict really have?

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Why is the “War on Drugs” a failure and what might be a humane, evidence-based approach to the treatment of severe drug addiction? − What are some of the paths for redeeming addicted minds not dependent on powerful substances − that is, how do we approach the healing of the many behaviour addictions fostered by our culture? The narrative passages in this book are based on my experience as a medical doctor in Vancouver’s drug ghetto and on extensive interviews with my patients − more than I could cite. Many of them volunteered in the generous hope that their life histories might be of assistance to others who struggle with addiction problems or that they could help enlighten society regarding the experience of addiction. I also present information, reflections and insights distilled from many other sources, including my own addictive patterns. And finally, I provide a synthesis of what we can learn from the research literature on addiction and the development of the human brain and personality. Although the closing chapters offer thoughts and suggestions concerning the healing of the addicted mind, this book is not a prescription. I can say only what I have learned as a person and describe what I have seen and understood as a physician. Not every story has a happy ending, as the reader will find out, but the discoveries of science, the teachings of the heart and the revelations of the soul all assure us that no human being is ever beyond redemption. The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate question. I dedicate this work to all my fellow hungry ghosts, be they inner-city street dwellers with HIV, inmates of prisons or their more fortunate counterparts with homes, families, jobs and successful careers. May we all find peace. Chapter One − The Only Home He’s Ever Had As I pass through the grated metal door into the sunshine, a setting from a Fellini film reveals itself. It is a scene both familiar and outlandish, dreamlike and authentic. On the Hastings Street sidewalk Eva, in her thirties but still waif-like, with dark hair and olive complexion, taps out a bizarre cocaine flamenco. Jutting her hips, torso and pelvis this way and that, bending now at the waist and thrusting one or both arms in the air, she shifts her feet about in a clumsy but concerted pirouette. All the while she tracks me with her large, black eyes. In the Downtown Eastside this piece of crack-driven improvisational ballet is known as “the Hastings shuffle,” and it’s a familiar sight. During my medical rounds in the neighbourhood one day, I saw a young woman perform it high above the Hastings traffic. She was balanced on the narrow edge of a neon sign two storeys up. A crowd had gathered to watch, the users among them more amused than horrified. The ballerina would turn about, her arms horizontal like a tightrope walker’s, or do deep knee bends − an aerial Cossack dancer, one leg kicked in front. Before the top of the firemen’s ladder could reach her cruising altitude, the stoned acrobat had ducked back inside her window. Eva weaves her way among her companions, who crowd around me. Sometimes she disappears behind Randall − a wheelchair-bound, heavy-set, serious-looking fellow, whose unorthodox thought patterns do not mask a profound intelligence. He recites an ode of autistic praise to his indispensable motorized chariot. “Isn’t it amazing, Doc, isn’t it, that Napoleon’s cannon was pulled by horses and oxen in the Russian mud and snow. And now I have this!” With an innocent 58

smile and earnest expression, Randall pours out a recursive stream of facts, historical data, memories, interpretations, loose associations, imaginings, and paranoia that almost sound sane − almost. “That’s the Napoleonic Code, Doc, which altered the transportational mediums of the lower rank and file, you know, in those days when such pleasant smorgasboredom was still well fathomed.” Poking her head above Randall’s left shoulder, Eva plays peek-a-boo. Beside Randall stands Arlene, her hands on her hips and a reproachful look on her face, clad in skimpy jean shorts and blouse − a sign, down here, of a mode of earning drug money and, more often than not, of having been sexually exploited early in life by male predators. Over the steady murmur of Randall’s oration comes her complaint: “You shouldn’t have reduced my pills.” Arlene’s arms bear dozens of horizontal scars, parallel, like railway ties. The older ones white, the more recent red, each mark a souvenir of a razor slash she has inflicted on herself. The pain of self-laceration obliterates, if only momentarily, the pain of a larger hurt deep in the psyche. One of Arlene’s medications controls this compulsive self-wounding, and she’s always afraid I’m reducing her dose. I never do. Close to us, in the shadow of the Portland Hotel, two cops have Jenkins in handcuffs. Jenkins, a lanky Native man with black, scraggly hair falling to below his shoulders, is quiet and compliant as one of the officers empties his pockets. He arches his back against the wall, not a hint of protest on his face. “They should leave him alone,” Arlene opines loudly. “That guy doesn’t deal. They keep grabbing him and never find a thing.” At least in the broad daylight of Hastings Street, the cops go about their search with exemplary politeness − not, according to my patients’ stories, a consistent police attitude. After a minute or two Jenkins is set free and lopes silently into the hotel with his long stride. Meanwhile, within the span of a few minutes, the resident poet laureate of absurdity has reviewed European history from the Hundred Years’ War to Bosnia and has pronounced on religion from Moses to Mohammed. “Doc,” Randall goes on, “the First World War was supposed to end all wars. If that was true, how come we have the war on cancer or the war on drugs? The Germans had this gun Big Bertha that spoke to the Allies but not in a language the French or the Brits liked. Guns get a bad rap, a bad reputation—a bad raputation, Doc − but they move history forward, if we can speak of history moving forward or moving at all. Do you think history moves, Doc?” Leaning on his crutches, paunchy, one-legged, smiling Matthew − bald, and irrepressibly jovial − interrupts Randall’s discourse. “Poor Dr. Maté is trying to get home,” he says in his characteristic tone: at once sarcastic and sweetly genuine. Matthew grins at us as if the joke is on everyone but himself. The chain of rings piercing his left ear glimmers in the bronzed gold of the late afternoon sun. Eva prances out from behind Randall’s back. I turn away. I’ve had enough street theatre and now I want to escape. The good doctor no longer wants to be good. We congregate, these Fellini figures and I − or I should say we, this cast of Fellini characters − outside the Portland Hotel, where they live and I work. My clinic is on the first floor of this cement and glass building designed by Canadian architect Arthur Erickson, a spacious, modern, utilitarian structure. It’s an impressive facility that serves its residents well, replacing the formerly luxurious turn-of-the-century establishment around the corner that was the first Portland Hotel. The old place, with its wooden balustrades, wide and winding staircases, musty landings and bay windows had a character and history the new fortress lacks. Although I miss its Old World aura, the atmosphere of faded wealth and decay, the dark and blistered windowsills

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varnished with memories of elegance, I doubt the residents have any nostalgia for the cramped rooms, the corroded plumbing or the armies of cockroaches. In 1994 there was a fire on the roof of the old hotel. A local newspaper ran a story and a photograph featuring a female resident and her cat. The headline proclaimed, “Hero Cop Saves Fluffy.” Someone phoned the Portland to complain that animals should not be allowed to live in such conditions. The nonprofit Portland Hotel Society for whom I am the staff physician turned the building into housing for the nonhousable. My patients are mostly addicts, although some, like Randall, have enough derangement of their brain chemicals to put them out of touch with reality even without the use of drugs. Many, like Arlene, suffer from both mental illness and addiction. The PHS administers several similar facilities within a radius of a few blocks: the Stanley, Washington, Regal and Sunrise hotels. I am the house doctor for them all. The new Portland faces the Army and Navy department store across the street, where my parents, as new immigrants in the late 1950s, bought most of our clothing. Back then, the Army and Navy was a popular shopping destination for working people − and for middle-class kids looking for funky military coats or sailor jackets. On the sidewalks outside, university students seeking some slumming fun mixed with alcoholics, pickpockets, shoppers and Friday night Bible preachers. No longer. The crowds stopped coming many years ago. Now these streets and their back alleys serve as the centre of Canada’s drug capital. One block away stood the abandoned Woodward’s department store, its giant, lighted “W” sign on the roof a long-time Vancouver landmark. For a while squatters and antipoverty activists occupied the building, but it has recently been demolished; the site is to be converted into a mix of chic apartments and social housing. The Winter Olympics are coming to Vancouver in 2010 and with it the likelihood of gentrification in this neighbourhood. The process has already begun. There’s a fear that the politicians, eager to impress the world, will try to displace the addict population. Eva intertwines her arms, stretches them behind her back and leans forward to examine her shadow on the sidewalk. Matthew chuckles at her crackhead yoga routine. Randall rambles on. I glance out eagerly at the rush-hour traffic flowing by. Finally, rescue arrives. My son Daniel drives up and opens the car door. “Sometimes I don’t believe my life,” I tell him, easing into the passenger’s seat. “Sometimes I don’t believe your life either,” he nods. “It can get pretty intense down here.” We pull away. In the rearview mirror the receding figure of Eva gesticulates, legs akimbo, head tilted to the side. **** The Portland and the other buildings of the Portland Hotel Society represent a pioneering social model. The purpose of the PHS is to provide a system of safety and caring to marginalized and stigmatized people − the ones who are “the insulted and the injured,” to borrow from Dostoevsky. The PHS attempts to rescue such people from what a local poet has called the “streets of displacement and the buildings of exclusion.” “People just need a space to be,” says Liz Evans, a former psychiatric nurse, whose upper-tier social background might seem incongruous with her present role as a founder and director of the PHS. “They need a space where they can exist without being judged and hounded and harassed. These are people who are frequently viewed as liabilities, blamed for crime and social ills, and... seen as a waste of time and energy. They are regarded harshly even by people who make compassion their careers.” From very modest beginnings in 1991, the Portland Hotel Society has grown to participate in activities such as a neighbourhood bank; an art gallery for Downtown Eastside artists; North 60

America’s first supervised injection site; a community hospital ward, where deep-tissue infections are treated with intravenous antibiotics; a free dental clinic; and the Portland Clinic, where I have worked for the past eight years. The core mandate of the PHS is to provide domiciles for people who would otherwise be homeless. The statistics are stark. A review done shortly after the Portland was established revealed that among the residents three-quarters had over five addresses in the year before they were housed, and 90 per cent had been charged or convicted of crimes, often many times over, usually for petty theft. Currently 36 per cent are HIV positive or have frank AIDS, and most are addicted to alcohol or other substances − anything from rice wine to mouthwash, to cocaine or heroin. Over half have been diagnosed with mental illness. The proportion of Native Canadians among Portland residents is five times their ratio in the general population. For Liz and the others who developed the PHS, it was endlessly frustrating to watch people go from crisis to crisis, with no consistent support. “The system had abandoned them,” she says, “so we’ve tried to set up the hotels as a base for other services and programs. It took eight years of fundraising and four provincial government ministries and four private foundations to make the new Portland a reality. Now people finally have their own bathrooms, laundry facilities and a decent place to eat food.” What makes the Portland model unique and controversial among addiction services is the core intention to accept people as they are − no matter how dysfunctional, troubled and troubling that may be. Our clients are not the “deserving poor”; they are just poor − undeserving in their own eyes and in those of society. At the Portland Hotel there is no chimera of redemption nor any expectation of socially respectable outcomes, only an unsentimental recognition of the real needs of real human beings in the dingy present, based on a uniformly tragic past. We may (and do) hope that people can be liberated from the demons that haunt them and work to encourage them in that direction, but we don’t fantasize that such psychological exorcism can be forced on anyone. The uncomfortable truth is that most of our clients will remain addicts, on the wrong side of the law as it now stands. Kerstin Stuerzbecher, a former nurse with two liberal arts degrees, is another Portland Society director. “We don’t have all the answers,” she says, “and we cannot necessarily provide the care people may need in order to make dramatic changes in their lives. At the end of the day it’s never up to us − it’s within them or not.” Residents are offered as much assistance as the Portland’s financially stretched resources permit. Home support staff clean rooms and assist with personal hygiene for the most helpless. Food is prepared and distributed. When possible, patients are accompanied to specialists’ appointments or for X-rays or other medical investigations. Methadone, psychiatric medications and HIV drugs are dispensed by the staff. A laboratory comes to the Portland every few months for mass screening for HIV and hepatitis and for follow-up blood tests. There is a writing and poetry group, an art group − a quilt based on residents’ drawings hangs on the wall of my office. There are visits from an acupuncturist, hairdressing, movie nights and, while we still had the funds, people were taken away from the grimy confines of the Downtown Eastside for an annual camping outing. My son Daniel, a sometime employee at the Portland, has led a monthly music group. “We had this talent evening at the Portland a few years ago,” says Kerstin, “with the art group and the writing group, and there was also a cabaret show. There was art on the wall and people read their poetry − we changed the venue into a café. A long-time resident came up to the microphone. He said he didn’t have a poem to recite or anything else creative... What he shared was that the Portland was his first home. That this is the only home he’s ever had and how 61

grateful he was for the community he was part of. And how proud he was to be part of it, and he wished his mom and dad could see him now.” “The only home he’s ever had” − a phrase that sums up the histories of many people in the Downtown Eastside of “the world’s most liveable city.” **** The work can be intensely satisfying or deeply frustrating, depending on my own state of mind. Often I face the refractory nature of people who value their health and well-being less than the immediate, drug-driven needs of the moment. I also have to confront my own resistance to them as people. As much as I want to accept them, or as much as I do so in principle, some days I find myself full of disapproval and judgment, rejecting them and wanting them to be other than who they are. That contradiction originates with me, not with my patients. It’s my problem − except that, given the obvious power imbalance between us − it’s all too easy for me to make it their problem. My patients’ addictions make every medical treatment encounter a challenge. Where else do you find people in such poor health and yet so averse to taking care of themselves or even to allowing others to take care of them? At times, one literally has to coax them into hospital. Take Kai, who has an immobilizing infection of his hip that could leave him crippled, or Hobo, whose breastbone osteomyelitis could penetrate into his lungs. Both men are so focused on their next hit of cocaine or heroin or “jib” − crystal meth − that self-preservation pales into insignificance. Many also have an ingrained fear of authority figures and distrust institutions, for reasons no one could begrudge them. “The reason I do drugs is so I don’t feel the fucking feelings I feel when I don’t do drugs,” Nick, a forty-year-old heroin and crystal meth addict once told me, weeping as he spoke. “When I don’t feel the drugs in me, I get depressed.” His father drilled into his twin sons the notion that they were nothing but “pieces of shit.” Nick’s brother committed suicide as a teenager; Nick became a lifelong addict. The Hell Realm of painful emotions frightens most of us; drug addicts fear they would be trapped there forever but for their substances. This urge to escape exacts a fearful price. The cement hallways and the elevator at the Portland Hotel are washed clean frequently, sometimes several times a day. Punctured by needle marks, some residents have chronic draining wounds. Blood also seeps from blows and cuts inflicted by their fellow addicts or from pits patients have scratched in their skin during fits of cocaine-induced paranoia. One man picks at himself incessantly to get rid of imaginary insects. Not that we lack real infestation in the Downtown Eastside. Rodents thrive between hotel walls and in the garbage-strewn back alleys. Vermin populate many of my patients’ beds, clothes and bodies: bedbugs, lice, scabies. Cockroaches occasionally drop out from shaken skirts and pant legs in my office and scurry for cover under my desk. “I like having one or two mice around,” one young man told me. “They eat the cockroaches and bedbugs. But I can’t stand a whole nest of them in my mattress.” Vermin, boils, blood and death: the plagues of Egypt. In the Downtown Eastside the angel of death slays with shocking alacrity. Marcia, a thirty-fiveyear-old heroin addict, had moved out from her PHS residence and was now living in a tenement half a block away. One morning, I received a frantic phone call about a suspected overdose. I found Marcia in bed, her eyes wide open, lying on her back and already in rigor mortis. Her arms

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were extended, palms outward in a gesture of alarmed protest as if to say: “No, you’ve come to take me too soon, much too soon!” Plastic syringes cracked under my shoes as I approached her body. Marcia’s dilated pupils and some other physical cues told the story − she died not of overdose but of heroin withdrawal. I stood for a few moments by her bedside, trying to see in her body the charming, if always absent-minded, human being I had known. As I turned to leave, wailing sirens signalled the arrival of emergency vehicles outside. Marcia had been in my office just the week before, in good cheer, asking for help with some medical forms she needed to fill out, to get back on welfare. It was the first time I’d seen her in six months. During that period, as she explained with nonchalant resignation, she had helped her boyfriend, Kyle, blow through a hundred-and-thirty-thousand-dollar inheritance − a process selflessly aided by many other user friends and hangers-on. For all that popularity, she was alone when death caught her. Another casualty was Frank, a reclusive heroin addict who would grudgingly let you into his cramped quarters at the Regal Hotel only when he was very ill. “No fucking way I’m dying in hospital,” he declared, once it became clear that the grim reaper AIDS was knocking at his door. There was no arguing with Frank about that or anything else. He died in his own ragged bed, but his bed, in 2002. Frank had a sweet soul that his curmudgeonly abrasiveness could not hide. Although he never talked to me about his life experience, he expressed the gist of it in “Downtown Hellbound Train,” a poem he wrote a few months before his death. It is a requiem for himself and for the dozens of women − drug users, sex trade workers − said to have been murdered at the infamous Pickton pig farm outside Vancouver: Went downtown − Hastings and Main Looking for relief from the pain All I did was find A one-way ticket on a Hellbound Train On a farm not far away Several friends were taken away Rest their souls from the pain End their ride on the Hellbound Train Give me peace before I die The track is laid out so well We all live our private hell Just more tickets on the Hellbound Train Hellbound Train Hellbound Train One-way ticket on a Hellbound Train Having worked in palliative medicine, care of the terminally ill, I have encountered death often. In a real sense, addiction medicine with this population is also palliative work. We do not expect to cure anyone, only to ameliorate the effects of drug addiction and its attendant ailments and to soften the impact of the legal and social torments our culture uses to punish the drug addict. Except for the rare fortunate ones who escape the Downtown Eastside drug colony, very few of my patients will live to old age. Most will die of some complication of their HIV or Hepatitis C or of meningitis or a massive septicemia contracted through multiple self-injections during a

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prolonged cocaine run. Some will succumb to cancer at a relatively young age, their stressed and debilitated immune systems unable to keep malignancy in check. That’s how Stevie died, of liver cancer, the sweet-sardonic expression that always played on her face obscured by deep jaundice. Or they’ll do a bad fix one night and die of an overdose, like Angel at the Sunrise Hotel or like Trevor, one floor above, who always smiled as if nothing ever bothered him. One darkening February evening, Leona, a patient who lives in a nearby hotel, awoke on the cot in her room to find her eighteen-year-old son, Joey, lifeless and rigid in her bed. She had taken him in from the street and was keeping watch to save him from self-harm. Mid-morning, after an all-night vigil, she fell asleep; he overdosed in the afternoon. “When I woke up,” she recalled, “Joey was lying motionless. Nobody had to tell me. The ambulance and fire guys came, but there was nothing anybody could do. My baby was dead.” Her grief is oceanic, her sense of guilt fathomless. One constant at the Portland Clinic is pain. Medical school teaches the three signs of inflammation, in Latin: calor, rubror, dolor − heat, redness and pain. The skin, limbs or organs of my patients are often inflamed, and for that my ministrations can be at least temporarily adequate. But how to soothe souls inflamed by the intense torment imposed first by childhood experiences almost too sordid to believe and then, with mechanical repetition, by the sufferers themselves? And how to offer them comfort when their sufferings are made worse every day by social ostracism − by what the scholar and writer Elliot Leyton has described as “the bland, racist, sexist and ‘classist’ prejudices buried in Canadian society: an institutionalized contempt for the poor, for sex trade workers, for drug addicts and alcoholics, for aboriginal people.” The pain here in the Downtown Eastside reaches out with hands begging for drug money. It stares from eyes cold and hard or downcast with submission and shame. It speaks in cajoling tones or screams aggressively. Behind every look, every word, each violent act or disenchanted gesture is a history of anguish and degradation, a self-writ tale with new chapters added each day and scarcely a happy end. **** As Daniel drives me home, we’re listening to CBC on the car radio, broadcasting its whimsical afternoon cocktail of light-hearted patter, classics and jazz. Jolted by the disharmony between the urbane radio space and the troubled world I’ve just left, I recall my first patient of the day. Madeleine sits hunched, elbows resting on her thighs, her gaunt, wiry body convulsed by sobbing. She clutches her head in her hands, periodically clenching her fists and beating rhythmically at her temples. Straight brown hair, fallen forward, veils her eyes and cheeks. Her lower lip is swollen and bruised, and blood trickles from a small cut. Her thick, boyish voice is hoarse with rage and pain. “I’ve been fucked over again,” she cries. “It’s always me, the sucker for everyone else’s bullshit. How do they know they can do it to me every time?” She coughs as the tears trickle down her windpipe. She’s like a child telling her story, asking for sympathy, pleading for help. The tale she tells is a variation on a theme familiar in the Downtown Eastside: drug addicts exploiting each other. Three women Madeleine knows well give her a hundred-dollar bill. The deal is, she buys twelve “rocks” of crack from the person she calls “the Spic.” She gets one; they’ll keep some for themselves and resell the rest. “We can’t let the cops see us buy that much,” they tell her. The transaction is completed, money and rocks are exchanged. Ten minutes later the “great big Spic” catches up with Madeleine, “grabs me by the hair, throws me on the ground, gives me a punch in the face.” The hundred-dollar bill is counterfeit. “They set me up. ‘Oh, Maddie, you’re my buddy, you’re my friend.’ I had no idea it was a bogus hundred.”

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My clients often speak about the “Spic,” but he’s an unseen presence, a mythical figure I only hear about. On the street corners near the Portland Hotel, young, olive-hued Central Americans congregate, black baseball caps over their eyes. As I walk by, they call out to me in a low whisper, even with my signal stethoscope around my neck: “up, down” or “good rock.” (Up and down are junkie slang for cocaine − an upper, a stimulant − and for heroin − a downer, a sedative. Rock is crack cocaine.) “Hey, can’t you see that’s the doctor?” someone occasionally hisses. The “Spic” may well be amongst that group or perhaps the epithet is a generic term that refers to any of them. I don’t know who he is or the path that led him to Vancouver’s Skid Row, where he pushes cocaine and slaps around the emaciated women who steal, deal, cheat or sell cheap oral sex to pay him. Where was he born? What war, what deprivation forced his parents out of their slum or their mountain village to seek a life so far north of the Equator? Poverty in Honduras, paramilitaries in Guatemala, death squads in El Salvador? How did he become the “Spic,” a villain in a story told by the rake-thin, distraught woman in my office who, choking on her tears, explains her bruises and asks that I don’t hold it against her that she failed to show for last week’s methadone visit. “I haven’t had juice for seven days,” Madeleine says. (“Juice” is slang for methadone: the methadone powder is dissolved in orange-flavoured Tang.) “And I won’t ask anybody for help on the street because if they help you, you owe them your goddamn life. Even if you pay them back, they still think you owe them. ‘There’s Maddie, we can hustle her for it. She’ll give it to us.’ They know I won’t fight. ’Cause if I ever fight I’m going to fucking kill one of these bitches down here. I don’t want spend the rest of my life in jail because of some goddamn cunt I never should’ve got involved with in the first place. That’s what’s going to happen. I can only take so much.” I hand her the methadone prescription and invite her back to talk after she’s had her dose at the pharmacy. Although Madeleine agrees, I won’t see her again today. As always, the need for the next fix beckons. Another visitor that morning was Stan, a forty-five-year-old Native man just out of jail, also here for his methadone script. In his eighteen months of incarceration he has become pudgy, and this has softened the menacing air bestowed by his height, muscular build, dark, glowering eyes, Apache hair, and Fu Manchu moustache. Or perhaps he’s mellowed, since he’s been off cocaine all this time. He peers out the window at the sidewalk across the street, where a few of his fellow addicts are involved in a scene outside the Army and Navy store. There is much gesticulation and apparently aimless striding back and forth. “Look at them,” he says. “They’re stuck here. You know, Doc, their life stretches from here to maybe Victory Square to the left and Fraser Street to the right. They never get out. I want to move away, don’t want to waste myself down here anymore. “Ah, what’s the use. Look at me, I don’t even have socks.” Stan points at his worn-out running shoes and baggy, red-cotton jogging pants with the elastic bunched a few inches above his ankles. “When I get on the bus in this outfit, people just know. They move away from me. Some stare; most don’t even look in my direction. You know what that feels like? Like I’m an alien. I don’t feel right ’til I’m back here; no wonder nobody ever leaves.” When he returns for a methadone script ten days later, Stan is still living on the street. It’s a March day in Vancouver: grey, wet and unseasonably cold. “You don’t want to know where I slept last night, Doc,” he says.

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For many of Vancouver’s chronic, hard-core addicts, it’s as if an invisible barbed-wire barrier surrounds the area extending a few blocks from Main and Hastings in all directions. There is a world beyond, but to them it’s largely inaccessible. It fears and rejects them and they, in turn, do not understand its rules and cannot survive in it. I am reminded of an escapee from a Soviet Gulag who, after starving on the outside, voluntarily turned himself back in. “Freedom isn’t for us,” he told his fellow prisoners. “We’re chained to this place for the rest of our lives, even though we aren’t wearing chains. We can escape, we can wander about, but in the end we’ll come back.” **** People like Stan are among the sickest, the neediest and the most neglected of any population anywhere. All their lives they’ve been ignored, abandoned and, in turn, self-abandoned time and again. Where does a commitment to serve such a community originate? In my case, I know it is rooted in my beginnings as a Jewish infant in Nazi-occupied Budapest in 1944. I’ve grown up with the awareness of how terrible and difficult life can be for some people − through no fault of their own. But if the empathy I feel for my patients can be traced to my childhood, so can the reactively intense scorn, disdain and judgment that sometimes erupt from me, often towards these same pain-driven individuals. Later on, I’ll discuss how my own addictive tendencies stem from my early childhood experiences. At heart, I am not that different from my patients − and sometimes I cannot stand seeing what little psychological space, what little heaven-granted grace separates me from them. My first full-time medical position was at a clinic in the Downtown Eastside. It was a brief, sixmonth stint but it left its mark, and I knew that someday I’d come back. When, twenty years later, I was presented with the opportunity to become the clinic physician at the old Portland, I seized it because it felt right: just the combination of challenge and meaning I was seeking at that time in my life. With hardly a moment’s thought I left my family practice for a cockroach-infested downtown hotel. What draws me here? All of us who are called to this work are responding to an inner pull that resonates with the same frequencies that vibrate in the lives of the haunted, drained, dysfunctional human beings in our care. But of course, we return daily to our homes, outside interests and relationships while our addict clients are trapped in their Downtown Gulag. Some people are attracted to painful places because they hope to resolve their own pain there. Others offer themselves because their compassionate hearts know that here is where love is most needed. Yet others come out of professional interest: this work is ever challenging. Those with low self-esteem may be attracted because it feeds their egos to work with such powerless individuals. Some are lured by the magnetic force of addictions because they haven’t resolved, or even recognized, their own addictive tendencies. My guess is that most of us physicians, nurses and other professional helpers who work in the Downtown Eastside are impelled by some mixture of these motives. Liz Evans began working in the area at the age of twenty-six. “I was overwhelmed,” she recalls. “As a nurse, I thought I had some expertise to share. While that was true, I soon discovered that, in fact, I had very little to give − I could not rescue people from their pain and sadness. All I could offer was to walk beside them as a fellow human being, a kindred spirit. “A woman I’ll call Julie was locked in her room and force-fed a liquid diet and beaten by her foster family from age seven on − she has a scar across her neck from where she slashed herself 66

when she was only sixteen. She’s used a cocktail of painkillers, alcohol, cocaine and heroin ever since and works the streets. One night she came home after she’d been raped and crawled into my lap, sobbing. She told me repeatedly that it was her fault, that she was a bad person and deserved nothing. She could barely breathe. I longed to give her anything that would ease her pain as I sat and rocked her. It was too intense to bear.” As Liz discovered, something in Julie’s pain triggered her own. “This experience showed me that to keep our own issues from turning into barriers, we have to look at ourselves.” “What keeps me here?” muses Kerstin Stuerzbecher. “In the beginning I wanted to help. And now... I still want to help, but it’s changed. Now I know my limits. I know what I can and cannot do. What I can do is to be here and advocate for people at various stages in their lives, and to allow them to be who they are. We have an obligation as a society to... support people for who they are, and to give them respect. That’s what keeps me here.” There’s another factor in the equation. Many people who’ve worked in the Downtown Eastside have noticed it: a sense of authenticity, a loss of the usual social games, the surrender of pretense − the reality of people who cannot declare themselves to be anything other than what they are. Yes, they lie, cheat and manipulate − but don’t we all, in our own ways? Unlike the rest of us, they can’t pretend not to be cheaters and manipulators. They’re straight-up about their refusal to take responsibility, their rejection of social expectation, their acceptance of having lost everything for the sake of their addiction. That isn’t much by the straight world’s standards, but there’s a paradoxical core of honesty wrapped in the compulsive deceit any addiction imposes. “What do you expect, Doc? After all, I’m an addict,” a small, skinny forty-seven-year-old man once said to me with a wry and disarming smile, having failed to wheedle a morphine prescription. Perhaps there’s a fascination in that element of outrageous, unapologetic pseudoauthenticity. In our secret fantasies who among us wouldn’t like to be as carelessly brazen about our flaws? “Down here you have honest interactions with people,” says Kim Markel, the nurse at the Portland Clinic. “I can come here and actually be who I am. I find that rewarding. Working in the hospitals or in different community settings, there’s always pressure to toe the line. Because our work here is so diverse and because we’re among people whose needs are so raw and who have nothing left to hide, it helps me maintain honesty in what I do. There’s not that big shift between who I am at work and who I am outside of work.” Amidst the unrest of irritable drug seekers hustling and scamming for their next high, there are also frequent moments of humanity and mutual support. “There are amazing displays of warmth all the time,” Kim says. “Although there’s a lot of violence, I see many people caring for each other,” adds Bethany Jeal, a nurse at InSite, North America’s first supervised injection site, located on Hastings, two blocks from the Portland. “They share food, clothing and makeup − anything they have.” People tend to each other through illness, report with concern and compassion on a friend’s condition and often display more kindness to someone else than they usually give themselves. “Where I live,” Kerstin says, “I don’t know the person two houses down from me. I vaguely know what they look like, but I certainly don’t know their name. Not down here. Here people know each other, and that has its pros and its cons. It means that people rail at each other and rage at each other, and it also means that people will share their last five pennies with each other. “People here are very raw, so what comes out is the violence and ugliness that often gets highlighted in the media. But that rawness also brings out raw feelings of joy and tears of joy − 67

looking at a flower I hadn’t noticed but someone living in a one-room at the Washington Hotel has noticed because he’s down here every day. This is his world and he pays attention to different details than I do...” Nor is humour absent. As I walk my Hastings rounds from one hotel to another, I witness much back-slapping banter and raucous laughter. “Doctor, doctor, gimme the news,” comes a jazzy sing-song from under the archway of the Washington. “Hey, you need a shot of rhythm an’ blues,” I chant back over my shoulder. No need to look around. My partner in this well-rehearsed musical routine is Wayne, a sunburned man with long, dirty blond curls and Schwarzenegger arms tattooed from wrist to biceps. I wait to cross an intersection with Laura, a Native woman in her forties, whose daunting life history, drug dependence, alcoholism and HIV have not extinguished her impish wit. As the red hand on the pedestrian cross light yields to the little walking figure, Laura chimes up, her tone a shade sardonic: “White man says go.” Our paths coincide for the next half-block, and all the while Laura chuckles loudly at her joke. So do I. The witticisms are often fearlessly self-mocking. “Used to bench press two hundred pounds, Doc,” Tony, emaciated, shrivelled and dying of AIDS, said to me. “Now I can’t even bench press my own dick.” When my addict patients look at me, they are seeking the real me. Like children, they are unimpressed with titles, achievements, worldly credentials. Their concerns are too immediate, too urgent. If they come to like me or to appreciate my work with them, they will spontaneously express pride in having a doctor who is occasionally interviewed on television and is an author. But only then. What they care about is my presence or absence as a human being. They gauge with unerring eye whether or not I am grounded enough on any given day to co-exist with them, to listen to them as persons with feelings, hopes and aspirations as valid as mine. They can tell instantly whether I’m genuinely committed to their well-being or just trying to get them out of my way. Chronically unable to offer such caring to themselves, they are all the more sensitive to its presence or absence in those charged with caring for them. It is invigorating to operate in an atmosphere so far removed from the regular workaday world, an atmosphere that insists on authenticity. Whether we know it or not, most of us crave authenticity, the reality beyond roles, labels and carefully honed personae. With all its festering problems, dysfunctions, diseases and crime, the Downtown Eastside offers the fresh air of truth, even if it’s the stripped, frayed truth of desperation. It holds up a mirror in which we all, as individual human beings and collectively as a society, may recognize ourselves. The fear, pain and longing we see are our own fear, pain and longing. Ours, too, are the beauty and compassion we witness here, the courage and the sheer determination to surmount suffering.

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