Author’s Note: I completed the final draft of this post before I wrote my 03.17.16 post wherein I recognized the “elephant in the room”: the demise of mourning practices both individual and collective. As a result, I repeat information here that also appears in my earlier post. I left the repeated information here so that this post could stand on its own. Hopefully the repeated information will serve as a review. This post tends to look at the repeated information in more detail.
As promised in my February 3rd, 2016, blog post, I just finished reading In the Realm of Hungry Ghosts: Encounters with Addiction (2008) by Canadian MD Gabor Maté. I read Maté’s book because on the surface it appeared that Hungry Ghosts tracks the information presented in the 2014 edited volume entitled Addictions from an Attachment Perspective—Do Broken Bonds and Early Trauma Lead to Addictive Behaviours?  As you will recall I wrote a series of blog posts wherein I summarized Addictions & Attachment (for short). The main message delivered in Addictions & Attachment is as follows: There is a correlation between early insecure attachment and later addictive behavior. Maté’s main message (as encapsulated by Huffington Post writer Carolyn Gregoire, who I am quoting here) is as follows: “[T]he root of addictive behaviors can be traced all the way back to childhood.” So, do these two books track each other? Well, yes and no. In the rest of this post I’ll try to briefly point out where the two books jive (which is substantial) and where they tend to part ways (which is significant). And where they part ways, I’ll try to point out how theses partings may cause problems from conceptual and intervention standpoints. Let’s dig in.
Using very wide brush strokes, Maté’s book Hungry Ghosts is made up of four major sections:
- CASE STUDIES: Stories and vignettes concerning person’s battling addiction
- SCIENTIFIC DATA: Information mainly from the areas of human development and brain research concerning addiction
- POLICY & POLITICS: Dominant policies and politics used to frame the addictive process and addiction treatment
- ALTERNATIVE WORLDVIEW: Using Buddhist mindfulness and meditation to frame the addictive process and addiction treatment
I would say that it is fair to use these same four categories to broadly group the topics covered in Addictions & Attachment (although Addictions & Attachment, in the last section, does not focus in on Buddhist practices as we will see). Using these four broad categories let’s look at the dovetails and partings between these two books on addiction.
CASE STUDIES: Both books present compelling stories, vignettes and case studies concerning persons battling addiction. Because Maté has a bit more space, he spends more time telling personal stories from his work with addicts at a residency center in Vancouver’s Downtown Eastside. Maté definitely puts a face (or faces) on the problem of addiction. Sadly (and tragically) many of Maté’s accounts end with a passage similar to, After so-and-so visited my office, he (or she) died of some acute medical problem like liver damage caused by hepatitis C. Maté’s medical background really shines through here. If you are looking for heart wrenching, in-the-trenches stories concerning addiction (and you have an interest in medicine), the first part of Maté’s book is the place to go. However you would not be at a loss if you only read the stories contained in Addictions & Attachment. You will have to decide where your comfort level is with respect to hearing stories about struggles with addiction.
SCIENTIFIC DATA: Both books present good scientific information concerning addiction. The researchers profiled in Addictions & Attachment tend to rely on clinical observation combined with data pulled from the areas of human development and attachment research. Maté combines clinical observation with data pulled primarily from the areas of human development and brain studies. I particularly liked Maté’s Scientific Data section. Why? Maté pulls from some of my favorite authors and researchers. Allow me to list some (along with their research focus):
- Antonio Damasio (neurobiology – the development of consciousness)
- Dan Siegel (neurobiology – attachment and brain development)
- Allan Schore (neurobiology – attachment and affect regulation) 
- Joseph LeDoux (neurobiology – emotions and brain development)
- Russell Barkley (psychiatry – ADHD and Executive Functions)
- Bruce Perry (neurobiology – trauma and society)
One glaring omission: Maté makes absolutely no mention (or use) of John Bowlby and his theory of attachment. Frankly, I found this to be stunning considering that Maté uses so many attachment concepts and frames. I think I know why Maté does not bring in Bowlby’s work. The big difference between the two books in the area of Scientific Data centers on the systems continuum used (a topic I also covered in my 03.17.16 post). I ran across the idea of a systems continuum when I wrote an executive summary of Gerald Midgley’s 2000 book entitled Systemic Intervention: Philosophy, Methodology, and Practice. (Contact the Foundation for a copy of this executive summary.) Here’s Midgley’s systems continuum:
worldview <==> ideology <==> methodology <==> intervention
For the purpose of this post, I constructed a “back of napkin” systems continuum for each book. You may not agree with my constructions, but I would invite you to come up with your own and use them as guides to your understanding of the worldviews, ideologies, methodologies, and interventions advocated for by each book.
|Hungry Ghosts||A Brain Science View of the World||Organisms possess a brain comprised of a number of brain centers (i.e., hippo-campus and prefrontal cortex)||Methods designed to encourage the healthy development of brain centers||Buddhist meditation as one possible way to appropriately (re)wire brain center(s)|
|Addictions & Attachment||An Evolution View of the World||Organisms possess innate behavioral systems (i.e., attachment and sex)||Methods designed to encourage the healthy operation and integration of behavioral systems||12 step program as one possible surrogate attachment figure|
Simply, Hungry Ghosts focuses in on brain centers such as the hippocampus and prefrontal cortex; Addictions & Attachment focuses in on innate behavioral systems such as attachment and caregiving(receiving). Again, the reader is free to toss out my constructions, however, I recommend that the reader take some time to flesh out the worldview <==> ideology <==> methodology <==> intervention continuum for themselves as they read books like Hungry Ghosts or Addictions & Attachment. As cognitive researcher George Lakoff suggests in his work, there is no right or wrong worldview, they just are. The point to keep in mind is that if you read about interventions—for instance Buddhist meditation or surrogate attachment figures—these interventions are held by a worldview. Conversely, if an author expresses a clear worldview—for instance brain science or evolution—then these wordviews place certain constraints on the types of interventions that could be used.  Both John Bowlby and Gabor Maté pull from areas such as animal studies (ethology), attachment, brain research, and human development. However I would argue that some (including myself) will be drawn toward Bowlby because of his focus on innate behavioral systems like attachment, sex, and caregiving(receiving), while others will be drawn toward Maté because of his focus on brain studies. If you’re a brain studies person, then you will feel right at home in the Scientific Data section of Maté’s book. If you’re an innate behavioral systems person, then Addictions & Attachment is for you. But here’s a big caveat: if you’re good at porting information from one worldview to another, then a person of either persuasion will find value invading their “enemy’s camp.” I’ll have more to say about the Scientific Data category when I talk about the Alternative Worldview category. For now I’d like to turn to the Policy & Politics category where Addictions & Attachment and Hungry Ghosts are in lockstep.
POLICY & POLITICS: Here’s where Addictions & Attachment and Hungry Ghosts really sing in unison. It is here where both find common enemies: reductionism and conservatism. One of the Addictions & Attachment authors comes right out and says that addiction is a software problem and not a hardware problem. I get the sense that the other Addictions & Attachment authors agree. Translation: addiction is a psychological problem and not a genetic problem. Again, we are looking at a conflict of wordviews. Some believe in a software framing of addiction; others believe in a hardware framing of addiction, that is to say, there is an addiction gene. Although both books speak (or sing) with one voice concerning hardware versus software framings of addiction, Maté spends considerable time pointing out why genetic explanations of addiction are not tenable. Maté even presents a section debunking the significance of twin studies (studies conducted on two people who are twins, both maternal and fraternal), often held out as proof of genetic explanations. I was floored by how strongly Maté came out in opposition to genetic determinism. This material in Hungry Ghosts is definitely worth a read.
With all due respect to Dr. Maté, his compelling stance against genetic determinism will probably change not one mind. Why? Maté is engaging in what George Lakoff (mentioned above) calls the Rationalist Myth: the myth that if you present enough compelling information, people’s minds will be changed. Lakoff makes it clear that people do not think using facts, they think using frames like the worldviews I’ve been talking about. Worldviews and frames are cognitive models not unlike Bowlby’s Inner Working Models. Once cognitive models are set up, they are exceedingly difficult to change. The only way to fight frames is with other effective frames, not facts. But, yes, you can use facts as a way of delivering frames. This is the hallmark of good propaganda (which scientists tend to abhor). I’ll move on.
Both books take a dim view of the conservative frames that are typically used to frame the addictive process and addiction treatment. Maté condemns the simple “just say no” framework that often guides addiction treatments. “Contrary to Nancy Reagan’s simplistic billboard messages,” admonishes Maté, “people cannot ‘just say no’ in the face of addictive drives.” Pulling once again from Lakoff’s work (see his 1996 book Moral Politics), just say no expresses a Strict Father (to use Lakoff’s frame) conservative worldview that places problems within the individual. Shaming the individual who violates Law & Order is also a part of that Strict conservative worldview. Consider this excerpt from my summary of Addictions & Attachment (quotes are by the authors of Addictions & Attachment):
The authors caution against shaming addicts by calling them weak willed and only interested in having a good time. Using Bowlbian attachment theory as a background, the authors tell us that addiction is a “signpost [or connection] to earlier suffering” and also provides evidence of a “human being’s struggle to survive.” There’s nothing fun about an addictive process. As Bowlby wrote about, humans will find any number of ways to satisfy their need for attachment. Unfortunately, an early history of insecure attachment will often put us on a path toward satisfying our need for attachment using self-defeating strategies such as addiction. The authors alert us to the fact that treatment has one overarching goal: move the need for attachment from self-defeating strategies to self-fulfilling and enriching strategies, strategies often associated with secure attachment.
The above excerpt points out that the authors of Addictions & Attachment take a strong stand against the Strict Father conservative worldview that tends to shame and condemn persons struggling with addiction. The above quote is a good segue to our final category: finding a liberal, Nurturant Parent (another Lakoff frame) approach to treating addiction that can go up against dominant conservative approaches. Here’s where the two books diverge.
ALTERNATIVE WORLDVIEW: The authors of Addictions & Attachment frame their interventions using Bowlbian attachment theory. Maté frames his interventions using Buddhist mindfulness, reflection, and meditation practices. I’m not sure it’s correct to say that Maté is expressing a theoretical position concerning intervention. Frankly, I’m not sure what to call Maté’s intervention position. I view Buddhism as a religion and not as a theory. But Maté is not alone. Neurobiologist Dan Siegel presents the same therapeutic position in his 2007 book entitled The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being (a book that Maté references). As a matter of fact, the West Coast is home to a mindfulness movement of sorts. This movement seeks to make teaching mindfulness in schools mandatory. If I had to summarize Maté’s therapeutic position, it would be something like the following:
- adverse childhood experiences prevent the brain from wiring properly
- this ill-wiring creates addictive urges and motivations that exist primarily in mid brain centers (home to the emotions)
- we need to take up a position in the upper brain (home to the Executive Functions like reflection) where we can honor and observe but yet set certain limits on addictive processes
If I had to, I’d say that this is the same therapeutic position that Dan Siegel presents in The Mindful Brain. Siegel takes a slightly different approach by saying in essence that we need to drop down below the level of personal cognitive models as well as cultural cognitive models (e.g., worldviews). In Bowlbian terms, Siegel is suggesting that we do not try to change our Inner Working Models (which, as mentioned above, is exceedingly difficult to do) but to simply detach from them. This fits with a Buddhist focus on detachment. But all of this leaves me feeling a bit cold because I get the impression we’re looking at a liberal form of “just say no,” namely, “just say yes to reflection.” If people are not able to access their upper reflective brains because of whatever damage or dysfunction, then how can they simply say yes or no? I’m not sure I see the difference. Let’s look a bit deeper.
Maté writes openly about his struggle with his addiction to buying classical music CDs. (He calls this a behavioral addiction as opposed to a substance addiction.) Maté writes about how Buddhist meditation practices have helped him control his addiction. But Dr. Maté earned a medical degree, ran a family practice for many years, and has written books. According to Executive Function expert Russell Barkley (who Maté references), Maté has considerable Executive Function skills, the same skills needed to engage in detached observation and reflection. By his own clinical observations, Maté points out that most addicts, especially those addicted to substances, lack well developed EF skills. I just see a huge theoretical disconnection here. Allow me to explain.
You cannot simply tell someone to detach from Inner Working Models. That’s simply poppycock. As Bowlby (and cognitive scientists like Lakoff after him) points out, we use Inner Working Models to navigate our world, especially the social world of relationships and relating. To have us simply detach from these Inner Working Models is tantamount to psychological annihilation.  To suggest that we are able to take up a position in our upper brains (which appears to have escaped damage or dysfunction) as a way of healing the mid brain suggests that all ill-wiring takes place in the mid brain. I’m not sure this is true. Brain studies show that certain areas of the prefrontal cortex (which are in the upper brain) are operating in young children. Let’s take an organic systems theory view (one that Bowlby also adopted).
As Antonio Damasio (who Maté references) points out in his work (see his 2010 book Self Comes to Mind) consciousness should be looked at as an emergent property that involves the body as well as all brain centers from the lower reptilian brain (with it focus on maintaining systems), to the mid mammalian brain (with its focus on emotional responses) to the so-called upper rational brain (home to the Executive Function skills like reflection and attention). In and of itself, the upper reflective brain does not do anything. To focus attention or to be reflective, the upper brain must work collectively with not only the body but with other brain centers such as the amygdala (the brain’s primary fear center) and the hippocampus (which plays a central role in creating, maintaining, and updating cognitive maps). The Mindfulness approach to treating addiction seems to violate organic systems theory precepts in that it encourages a person to detach the upper brain from the other brain centers (and possibly the body) and simply use the upper brain to observe and reflect. All of this brings up what I consider to be an important question: Where exactly is the attachment behavioral system (given that we believe in such a thing)?
Maté suggests that there are three dominant brain systems involved in the addictive process: “the opiod attachment-reward system, the dopamine-based incentive-motivation apparatus, and the self-regulation areas of the prefrontal cortex” (quoting Maté). In essence, within the brain studies worldview, the attachment behavioral system is reduced to one of the brain’s reward systems. And Maté’s model holds that the self-regulation areas of the prefrontal cortex are compromised when addiction is in evidence. So, how then do we use the EF skills of the upper brain (like observation, reflection, and attention) if these brain centers are compromised? And what happens to the attachment behavioral system if we view it as a damaged reward system? As Bowlby pointed out, the attachment behavioral system does not become damaged (unless there are certain organic issues); it will satisfy its need for attachment relationships using whatever strategy it can, including addiction. If anything, addiction points out that the attachment behavioral system is working quite well. It may be engaging in self-defeating strategies, but it’s working.
From a Bowlbian attachment theory perspective, our need for attachment should be honored, and therapy should consist of moving self-defeating strategies over to life-enhancing strategies (which are talked about in more detail in my summary of Addictions & Attachment). I hate to say it but hopefully the reader can see that Maté’s therapeutic position depends heavily on the concept of brain plasticity: the brain’s ability to rewire itself in response to new experiences. As I have blogged about before, critics point out that liberals tend to use brain plasticity as a catchall panacea. I received this impression as I read Hungry Ghosts. Hungry Ghosts provides great information concerning addiction (much of which dovetails with the information presented by Addictions & Attachment) but in my opinion, it falls flat theoretically speaking because of the brain studies worldview that it uses. I’ve presented a lot of information, but few persuasive frames. If you believe in the brain studies worldview, chances are you still do. That’s just how the brain works.
 I ran a search for Maté’s name using my Kindle copy of Addictions from an Attachment Perspective. I did not come up with any hits. So it would appear that the authors who contributed to Addictions & Attachment (which came out six years after Hungry Ghosts) were not aware of Maté’s work in the area of addiction.
 In the interest of full disclosure, our Foundation made a grant in support of Dr. Schore’s work.
 I’d be remiss if I did not mention that postmodernism is the worldview of no worldviews. A “no worldview” view of the world is still a worldview, a fact that tends to irritate postmodernists. If you plug postmodernism into Midgley’s systems continuum, what you discover is an eclectic approach to interventions (aka “whatever works”). When I was in my masters program in counseling back in the mid 1990s, an eclectic approach to interventions was all the rage (probably still is). If you run across eclectic interventions, just know that postmodernism is the worldview at large. There are hints of postmodern eclecticism in Maté’s Hungry Ghosts but I’m not going to spend any time teasing out these currents. Counseling great Carl Rogers has been accused of being a postmodern thinker and Maté does pull from Rogers briefly. My guess is that Maté is not aware of Roger’s postmodern leanings. Accusations of postmodern leanings leveled against Rogers can be found in Kay Hymowitz’ 1999 book entitled Ready or Not: Why Treating Children as Small Adults Endangers Their Future—And Ours (executive summary available).
 In his thought-provoking 2003 article entitled An Evolutionary Function of the Depressive Reaction: The Cognitive Map Hypothesis (New Ideas in Psychology vol. 21, Issue 2, p. 147–156), psychology researcher Hans Welling suggests that depression actually serves an evolutionary function, that of taking Inner Working Models offline just enough so they can be properly updated. Writing in his 2000 book Chemicals for the Mind, psychology professor Ernest Keen suggests that when we feed people drugs to treat their depression, we disrupt nature’s attempts to update Inner Working Models.