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Nikhita Singhal: [00:00:14] Welcome to Site the Psychiatry Podcast for Medical Learners Biomedical Learners. This episode covers trauma and addictions. My name is Nikhita and I'm a fourth year psychiatry resident here at the University of Toronto. I'll be one of the co-hosts for this episode. I'm joined by my colleagues who I'll let introduce themselves.
Angad Singh: [00:00:35] Hi, my name is Angad. I'm a second year medical student at McMaster.
Sena Gok: [00:00:39] Hi, I'm Sena. I'm an international medical graduate from Turkey.
Rhys Linthorst: [00:00:43] And I'm Reece Linthorst, a fourth year psychiatry resident at the University of Manitoba.
Nikhita Singhal: [00:00:47] We're thrilled to be welcoming our guest for this episode, Dr. Gabor Mate, a retired physician who, after 20 years of family practice and palliative care experience, worked for over a decade in Vancouver's downtown east Side, with patients challenged by drug addiction and mental illness. The bestselling author of five books published in 30 languages, including the award Winning in the Realm of Hungry Ghosts Close Encounters With Addiction. Dr. Mat is an internationally renowned speaker, highly sought after for his expertise on addiction, trauma, childhood development and the relationship of stress and illness. For his ground breaking medical work and writing, he has been awarded the Order of Canada, our country's highest civilian distinction, and the Civic Merit Award from his hometown, Vancouver. His fifth book, The Myth of Normal Trauma, Illness and Healing in a Toxic Culture, was released on September 13th, 2022.
Rhys Linthorst: [00:01:43] Maybe when. Next? We'll talk a little bit about our learning objectives. So the learning objectives today are as follows. By the end of this episode, the listener will be able to, number one, understand the connection between trauma and the development of addictions and other mental illnesses. Number two, critically reflect on current diagnostic and treatment paradigms. And number three, apply principles of trauma, informed care to psychiatric assessment and provision of mental health services. Next, we'll maybe turn things over to Sienna to get our discussion started.
Sena Gok: [00:02:11] Thank you so much, Chris. Doctor Matt, could we start off with how would you define trauma?
Dr Gabor Maté: [00:02:17] Sure. So trauma is one of these words that like the word God, everybody uses, it has a different meaning for it. So it is important to begin with the definition. So the way I'll be using it in this context, trauma means a wound. In fact, wound is the Greek origin of the word trauma. It literally means a wound or a wounding. It's a psychological wound that we sustain at some point in our lives, in my view, most frequently in childhood. And unless it's healed, it has all kinds of consequences for physical and mental health, including what we call mental health diagnoses and addictions. But in my view, it's also shows up in its manifestations in autoimmune disease and malignancy even. That's not a matter of just my opinion. It's scientific research. To give you an example of the latter, who would you say would be the most traumatised segment of the Canadian population? You'd probably agree it's Indigenous women. Indigenous women has six times the rate of rheumatoid arthritis than that of the average population. This is amongst a population that used to have no autoimmune disease prior to colonisation. So I'm saying there's a huge link between trauma and all manner of illness. Um, I'll also say that. Trauma is not what happened to you. Trauma is what happened inside you.
Dr Gabor Maté: [00:03:45] Trauma is not the blow on the head. It's the concussion that you sustain. Two people can sustain a blow on the head. One of them might not have a concussion at all. They're not wounded. But the other one is. So it's not what happens to you. It's what happens inside you as a result of what happens to you. Number one. And number two, traumatic events can take many forms. Most famously, the adverse childhood experiences ACE studies which, if anybody listening has not heard about that should be your first task tonight is to look them up because they've been published in major medical and psychological journals since the 1990s. They show that the more childhood adversity occurs to an individual, the greater the risk for addiction exponentially, the greater the risk of addiction for mental health problems, for autoimmune disease, malignancy, behavioural problems, sexually transmitted disease and so on. These ACE studies, again, are not in the least controversial. They don't show a causal relationship. They certainly show a statistical relationship. Causation has been shown in many other studies, but adverse childhood experiences include ten categories that originally listed physical, sexual or emotional abuse. That's three. The death of a parent, A parent being jailed. A parent being addicted. A parent being mentally ill. Violence in a family, a rancorous divorce and neglect, to which we have to add some social factors poverty and racism, which are also being shown to have traumatic impacts.
Dr Gabor Maté: [00:05:29] And those are what we call the big T traumas, the big T traumatic events. What physicians, physicians barely learn about these, at least not until very recently. What they don't learn about at all is that people can be wounded not by these big T traumatic events, not by just the bad things that happen to you, but also by the good things that don't happen to you. So human infants in utero onwards have certain needs. On birth and after birth in early childhood. They have certain emotional needs. If those needs are not met, the child can also be wounded without anything terrible having happened. Which also means that in this culture. Which is so out of alignment with the needs of children. Many kids are wounded in homes where there's nothing but love, nothing but good intention, no abuse, no big T traumas. But children are still wounded because they innate human needs are not being met. So trauma then, is a wound sustained through either through overt misfortune or through. Essential needs not being met. And then for purposes of this conversation, trauma then shows up. In addictions, all addictions and in mental health conditions, in my view, all mental health conditions.
Angad Singh: [00:06:56] Yeah. Thanks for that definition, Dr. Mate. So I was wondering, beyond the ACE studies, could you speak to the relationship between trauma and addiction and the many ways that they're connected?
Dr Gabor Maté: [00:07:04] Sure. Now, one of the learning objectives that you outlined was critique of the current model. Let me begin with that. Okay. And then I'll revert back to answering your question directly. Because the because looking at the inadequacies of the current medical model of addiction is essential to then leading into the actual nature of addiction. So in this society, there are two dominant views of addiction. By far the most dominant view, the one that is infused into the legal system, is that addictions and some kind of a choice that somebody makes just through ethical lapse, moral weakness, failure of will. And so people then choose to do drugs. And addiction, by the way, is very much in a social mind associated with drugs. And it's a culpable, conscious, deliberate act. Now, I won't spend any time on it because it's complete nonsense. I've never met anybody who ever chose woke up one morning and decided to become an addict. But that's a dominant view. And that's why, by the way, largely why if you look at the jails of Canada, 50% of the women in jail in this country are indigenous. They make up 5% or 6% of the female population, 50% of the jail population. Because addictions are so widespread in the native communities. A lot of. Actions flow from that and then the people are punished. So that's the legal view. Now, the medical view, which is what concerns us here today, is a step forward.
Dr Gabor Maté: [00:08:46] The medical view sees addiction as a disease of the brain, primarily a disease of the brain, which affects behaviour and the sources of it, according to the medical view, is largely genetic. So the US Surgeon General, Dr. Vivek Murthy, published the overview of addiction is maybe six years ago now where 50 to 70% or 40 to 70% of addictions are ascribed to genetic tendencies. Now the medical view is a step forward. Markedly so from the popular choice model, because, number one, if somebody is a disease, at least you, you don't blame them for it. And furthermore, especially if the disease is genetically determined or influenced, who can you blame for inheriting certain genes? So it removes blame and shame, at least ideally, ideally, but not in practice, because a lot of physicians still practice shame based medicine when it comes to working with addicts. Just visit any emergency ward when an addict addicted person comes in and how they're treated by the nurses and the doctors. So theoretically, the medical model. Obviates shame and blame in practice. Not like that. But at least theoretically. Secondly, it provides treatment. So if somebody comes to you with rheumatoid arthritis, you'll treat them. That's good. Number three. When somebody relapses with cancer or multiple sclerosis or rheumatoid arthritis, you don't punish them for it. You don't judge them for it. You accept that that's the part of the so-called disease. So you just treat it.
Dr Gabor Maté: [00:10:33] So these are all steps forward that the medical model offers and they're valuable. But does that mean that they're accurate? No, doesn't mean they're accurate at all. So I'm going to assert for you that addiction is not genetic and it's not a disease. What is it? So we'll do a little test here with our four panellists. I'll ask for your but your honest participation. Maybe I'll draw a blank, but maybe I won't. I'll give you a definition of addiction that I don't think is controversial. And it's the one. Okay. Conflict of interest here, folks. I'm going to mention my books. Okay. So in this book, The Myth of Normal, which is the most recent book that I've written, I gave a definition of addiction. An addiction is a complex, biological, psychological process that is manifested in any behaviour in which a person finds temporary relief or pleasure and therefore craves. But then suffers negative consequences as a result of and cannot give up despite negative consequences or does not give up. So craving pleasure relief in the short term. Harm in the long term. Knack of giving it up. That's what an addiction is. Now, notice something I haven't said. I think about drugs. It could include drugs, certainly cocaine, crystal meth, heroin and caffeine, alcohol, nicotine, opiates, of course. But it could also include sex. Gambling. Pornography. Shopping. Eating. Bulimia. Gaming. The Internet. Cell phones. Extreme sports. Work. I could go on forever.
Dr Gabor Maté: [00:12:34] The point is not the behaviour as such. You can actually take heroin not addictively. Not that I recommend it, but you can or you can take it addictively. You can work not effectively or you can work addictively. You can eat. Not addictively. Or you can eat addictively. So the issue is not the behaviour per se. It's the internal relationship to the behaviour. Does it provide pleasure relief in the short term? Therefore, you crave it causes harm. You can't give it up. You got an addiction. So I'm going to ask my four brave panellists here if, according to that definition, you will acknowledge that any time in your life you had any kind of addictive pattern, just raise your hand and I'm not going to ask you what it was or when. I just I just ask you in general, did you ever have anything like that? Yes or no? Yes. Yes. Okay. Here's what I'm going to ask you. No, I'm not going to ask you what you're addicted to. What substance or behaviour. Nor am I going to ask you when or how long. I'm just going to ask you, each of you tell me what was right about it for you and what was wrong with it. You know what was wrong with it. What did it give you in the short term that you wanted? What did it give you that you craved, actually? So anybody would like to start.
Sena Gok: [00:13:56] I can start with idea of pleasure and distraction.
Dr Gabor Maté: [00:14:00] Pleasure and distraction. Thank you. What else.
Nikhita Singhal: [00:14:05] Made me feel safe? It was predictable.
Dr Gabor Maté: [00:14:08] So the sense of safety. Yeah. Okay. Sense of security. Go on. Thank you. Next. Anybody else? Yeah.
Angad Singh: [00:14:16] I can follow up with a sense of approval.
Dr Gabor Maté: [00:14:18] A sense of approval From whom?
Angad Singh: [00:14:21] From the outside world. Okay.
Dr Gabor Maté: [00:14:23] Thank you. And one more person.
Rhys Linthorst: [00:14:27] Really just sort of a relief from distress, like almost just finally being able to let go.
Dr Gabor Maté: [00:14:32] Distress. Okay. Very good. So pleasure was the first thing that a good thing or a bad thing in itself? Distraction from unpleasant. When do we need to be distracted? When we're in uncomfortable? So it's a sense of comfort. Is that a good thing or a bad thing in itself? Safety, security. Is that a good thing or a bad thing in itself being accepted or approved of by others? Sense of I'm okay. Is that a good thing or a bad thing? We all want it. It's a good thing. Distraction again from distress. Stress relief. Is that a good thing or a bad thing? Clearly in itself, it's a good thing. The lack of pleasure, the stress, the lack of safety, the fear of not being approved of, and the feeling of distress. These are all forms of emotional pain. Hence, addiction is not a disease. It's not genetic, but it actually is is an attempt to resolve the problem of human pain. So the addiction wasn't your primary problem. It was your attempt to solve a problem. The problem of some form of emotional psychological distress. Therefore, if you want to understand the addiction and here's my mentor and if you remember nothing from this conversation, try to keep this phrase in mind. The question is not why the addiction, but why the pain? Now, if we understand why the pain and the question was the relationship between trauma and addiction, the pain is an imprint of trauma.
Dr Gabor Maté: [00:16:21] The pain that you're still carrying. An adult life is an imprint of trauma that you sustained at one point in your life. It's the wound that hasn't healed yet. No. You want this proven? Statistically, if you look at the adverse childhood experiences studies, if a male child had six of those, his risk of becoming an injection using substance dependent person as an adult is not six times greater than the average is 46 times greater. They multiply each other. And I like also to talk about it from the point of view of the human brain. And I wonder if this would be a good time to do that, because certainly it's a manifestation of brain dynamics. But the big mistake made by neuroscientists and psychiatrists is they think the brain is the origin of things. So I would like to discuss the question of it's a brain disease. Let's look at why do addictive substances even work in the human brain? We're talking about substances now for the moment. So let's take the opiates. So I think it was mentioned in the introduction, or if it wasn't for seven years, I was the medical coordinator of the palliative care unit at Vancouver Hospital looking after terminally ill people. So I dealt with a lot of death and a lot of pain. Thank God for the opiates. The opiates are the strongest pain relievers that we have.
Dr Gabor Maté: [00:17:47] We know that. But why do they work in a human brain? The opiates come from opium papaver somniferum the poppy that puts you to sleep. That's the Latin word for it. And it goes in Afghanistan. Why do we find relief from a plant that grows in Afghanistan? Because we have receptors in our brain for opiates. But why do we have receptors from a plant that grows in Afghanistan? We don't. As you will probably all know, we have receptors for opiates because we have our own internal opiate system. And our internal opiates are called endorphins, which simply means endogenous morphine like substance. S. So our bodies are full of endorphin receptors in our guts, in our immune system, in our mucous membranes, in our brains. And in each of these areas, they play different roles. So I'm here now concerned with the role they play in addiction and specifically in the brain. The endorphins. Played three major roles in the brain now. If you want to understand why people crave opiates, you gotta understand endorphins. What do endorphins do? Well, the first thing they do, I've already mentioned this. They provide pain relief. Pain is an essential part of human life. As you know, if it wasn't for pain, we would not be able to protect ourselves. But there has to be pain relief as well. The endorphins help provide that. So in a placebo effect where you give 100 people an inert pill for pain and 25 have complete pain relief, it's their own internal endorphins that are being released that.
Dr Gabor Maté: [00:19:25] So, you know, this is not a it's a real effect. It's actually an opiate that's helping them when they think they're getting an opioid. They're getting their substance, but they won't. Endorphins kick in. So that's the first job. But not only physical pain relief, the emotional pain relief as well, because the part of the brain that experiences the suffering of physical pain is also the part that experiences the suffering of emotional pain, and that's the anterior cingulate cortex. Now pain is felt different areas of the brain, but the suffering is felt largely in the ACC, which is heavily endowed with endorphin receptors so that the first job of the endorphins then is emotional and physical pain relief. Number one. Number two. They help. Experience. They help us experience. Moments of pleasure and reward and elation. So when people go bungee jumping, the higher their resultant endorphin level, the more exalted they are, the more exaltation there is. That's important in human life because human life is full of suffering. We have to have pleasure and reward. Endorphins help to do that. That's the second important role. The third one is the most important, which is a word we never even talk about in medical school. The third rule of the endorphins is to help potentiate a little thing called love.
Dr Gabor Maté: [00:20:53] My love. I mean, the attachment between two human beings for the purpose of caretaking, which is an essential dynamic between mother or parent and infant. So both the infant and the mother have endorphin surges when they're looking into each other's eyes. That's why parents get so addicted to their kids. It's that endorphin high, which is a good thing because otherwise parenting would be a very difficult business. If you take infant mice and genetically you knock out their endorphin receptors, they will not cry on separation from their mother. What would that mean in the wild? Their death. That's how important detachment is. That's how important the endorphins are. And if you ask heroin addicts, what does the heroin do for you? You know what they'll tell you? They'll say, it makes me feel like a warm, soft hug. It makes me feel like. One person told me this in. In a detox facility. I said, What does it do for you? He said, You know, Doc, it's like when you're three years old and you're shivering with a fever. And your mother puts you on her lap, wrapped in a warm blanket and gives you a warm chicken soup. That's what the heroine feels like. Love. That's the endorphin circuitry. That's where the opiates are so powerful. No. Then is dopamine. Dopamine is another little mouse experiment where you put a little mouse in front of a plate of food.
Dr Gabor Maté: [00:22:30] He is hungry, he hasn't eaten, and he will not budge two inches to eat. Why? Because genetically they knocked out his dopamine receptors. Dopamine is essential for motivation, for seeking, for curiosity, for vitality. Dopamine flows were seeking a novel object, were exploring a novel object or a novel environment. Dopamine flows when we are seeking food or seeking a sexual partner. I got news for you. Sex addicts are not addicted to sex. If they were. And it's a serious condition, even though the DSM doesn't recognise it. But that's a whole other picture. But sex addiction is a serious problem for a lot of people. What they're looking for is not sex because it was sex. They just had to marry another sex addict. It'd be okay for the rest of their lives. It's the dopamine hit of seeking that they're looking for and all the behaviour addicts. And I've had my own. Believe me, we're not seeking the object. What you're shopping for or the gambler is not after winning money. Because if they want a big. Role, they'd quit, but they don't get back the next morning and they lose it thereafter. The seeking the dopamine hit the excitement. So all behaviour addicts are actually substance addicts, but the substance is their internal dopamine apparatus. So that's the second circuitry. Of the brain that's implicated in addiction. The third one is stress regulation.
Dr Gabor Maté: [00:24:12] If you talk to addicted people who were clean for a while, then they relapsed. You ask them what happened. Usually something stressful happened. They couldn't handle it. They used the addiction behaviour, whether it's gambling or sex or pornography or shopping or drugs to soothe the stress. Now, our brains, as you know, is medical students, medical people. We do have a stress apparatus and, you know, the hypothalamic pituitary adrenal axis, but we also have the stress regulation. Addicts don't have good stress regulation. They use the addiction to soothe their stresses. As a couple of you have already told me. And finally, there's the impulse regulation circuitry. I'm pointing at it. The right orbitofrontal cortex. And his job is to tell you you may want to do this thing, but it's not good for you. Don't do it. No, babies don't have good impulse regulation or any impulse regulation. But a baby wants they'll reach for it right away. Addicted people are the same thing. What should that tell us? It should tell us that addiction is not an inherited disease but a developmental problem. Certain circuits in the brain did not develop properly. So what we're looking at in addicted people is that these various brain circuits, the endorphin apparatus, the dopamine apparatus, the special litigation circuitry, the impulse regulation circuitry did not develop properly. And I'm going to just spend two more minutes to talk to you about brain development and then I'll stop.
Dr Gabor Maté: [00:25:47] So how does the human brain actually develop? And here's another one of these little secrets that I would wager to say most of you in medical school have never heard about. And I am not critical here of individual physicians, but I'm telling you, your education is bereft of some of the most important dynamics in human life, including normal psychological development, which you probably never heard a lecture about. We just learn about pathology or including healthy brain development. So I'm going to read you an article that's not in the least controversial. It's from the Journal of Paediatrics, February 2012. That's the Journal of the American Paediatric Academy. The article is from the most prestigious centre on Child development in the world, the Harvard Centre on Child Development. Again, it was published 11 years ago now in February. And. I'm going to read you two sentences on brain development. This article, when it was published in 2012, was no longer in use. I'd known about this stuff since the 90s. You know, there was by the 90s there was not news anymore. It was just, you know, being established in the literature. Here's an article from 2012 summarising all that knowledge. The architecture of the brain is constructed through an ongoing process that begins before birth, continues into adulthood, and establishes either a sturdy or a fragile foundation for all the health, learning and behaviour that follow.
Dr Gabor Maté: [00:27:27] I'm going to parse that sentence for you. The architecture of the brain is constructed through an ongoing process that begins before birth. You know what that means. It means that the emotional states of the mother are already promoting and influencing the physiological development of the child's brain. Now I could cite for you X number of studies if you want the references on which I rely. You're welcome to find them in my books, most recently The Myth of Normal. Previous to that, my book on addiction in the Realm of Hungry Ghosts. Previous to that, published 24 years ago, my book on ADHD called Scattered Minds. So the architecture being is constructed through an ongoing process begins before, which also means that the prevention of addiction needs to begin at the first prenatal visit. We have to pay attention to the emotional states of the mother when she's carrying the child. Because stress is depression. Anxiety on the part of the mother will have a physiological impact on the child's brain, including on a number of dopamine receptors, for example. So because before birth continues into adulthood, so goes on throughout childhood. So childhood is a period of being development. And establishes either a sturdy or a fragile foundation for all the health, learning and behaviour that follow. Not some of the health learning and behaviour that follow all the health learning and behaviour that follow. The base of it is established early on.
Dr Gabor Maté: [00:29:04] Okay. Second sentence The interactions of genes and experiences literally shapes the circuitry of the developing brain. So it's experience is acting on the genes. This is called epigenetics. How the genes are turned on or on off by the environment based on methylation and a whole lot of other biological mechanisms, which I'm not smart enough to understand or not patient enough to memorise. But it's genes being affected by the environment. That's why you can have people with the same genes, two animals with the same genes, totally different behaviours if you put them in different environments. So the addiction is not genetic. It may run in families, but so what? Those All four of you here are medical doctors or medical doctors to be. If any, future children you might have go into medicine. Does that prove that the passage of medicine is a genetic disorder? I mean, maybe it is, right? So it's critical. So so these experiences shaped the circuit of developing brain and is critically influenced by the mutual responsiveness of adult child relationships, particularly in the early childhood years. In other words, the biggest influence on the physiological development of the brain, the circuitry, the systems, the neurotransmitters is the quality of emotional relationship with the early environment. Now what happens to a traumatised brain? Guess what? These circuits don't develop. Now you got the template for addiction. That's it in a nutshell.
Angad Singh: [00:30:47] Thanks, Dr. Matt for outlining those normal physiological mechanisms ranging from the brain circuits you outlined that underlie sort of the normal motivation and and attachment mechanisms to the HPA axis and the Neuroendocrinology as well as the genetics and epigenetics. And you sort of hinted at this at the end of what you were saying. But I'm wondering what are the ways that trauma gets encoded into those systems? And then how does that lay the groundwork for addiction and other problems?
Dr Gabor Maté: [00:31:14] Well, first of all, if we look at any development, so look at the development of a plant. If you're growing a plant in your garden, what questions would you have to ask yourself? I'm asking you.
Angad Singh: [00:31:25] Whether the soil is fertile.
Dr Gabor Maté: [00:31:27] Good. That's an important one. What's another one?
Angad Singh: [00:31:30] Whether there's enough sunlight.
Dr Gabor Maté: [00:31:32] Very good. That's 2 or 3. There's one more.
Angad Singh: [00:31:35] Whether you're watering enough.
Dr Gabor Maté: [00:31:36] Very good. In other words, you would take care of the conditions that the plant needed for the development. Same with human beings. Human beings have certain needs, a certain expectations into which they are brought into this world. They include safe, secure attachment relationships. Where the child is absolutely can rest in the awareness that they're accepted and seen and loved for exactly who they are. That's a human need. They have a need not to have to work inside that relationship. In other words, the child shouldn't have to be pretty compliant. Presentable. Good. Corroborative shouldn't have to try to make the parents feel better in their own miseries. Judges rest. Because growth happens during rest. Not doing struggle. That's the second need of the child. The child is a third need. And again, this is a chapter on this and the myth of normal, the irreducible needs of children. The third need is now the great neuroscientist. His name is Jacques Jaak Panksepp PR and SCP. Unfortunately, he died a few years ago before his time of cancer. But he distinguished seven number of brain circuits that we share with other mammals. They include caring love. That's the endorphin circuitry seeking curiosity. That's the dopamine circuitry. Fear. Grief. Anger. These are all essential for human functioning. Now. We asked you about what does a plant need? Irrigation, sunlight and minerals in the soil. Yeah.
Dr Gabor Maté: [00:33:35] Well, the human child needs these conditions. Do you mean the child? Also, by the way, needs free play out in nature. Spontaneous play. Play plays a huge role in brain development, much more important than academic learning. We have a huge circuit in our brain dedicated to play. Cats play. Lions play. Bear Cubs play. Everybody plays because the brain promotes healthy brain development. You know, society free spontaneous play is barely available for kids anymore. They don't play anymore. They play with cell phones. That's not play. So these are the four irreducible needs of children. When they're not met. These circles don't develop properly. The receptors don't develop stress mothers. The kids dopamine circuitry won't develop properly. You know, so. Because don't forget what this article from Harvard said, that the brain develops under the influence of the mutual responsiveness, responsiveness of adult child relationships, particularly in the early childhood years. Now, come to the downtown east side with me in Vancouver, North America's most concentrated area of drug use, where I worked for 12 years. In 12 years of work in the downtown east Side, I didn't have a single female patient out of hundreds who had not been sexually abused as a child. Not one. And what was amazing is that until I asked them, nobody had asked him that before. In most cases. What does sexual abuse do to your child's brain? The stress of it, the activation of the HPA axis, the release of cortisol which interferes with brain development.
Dr Gabor Maté: [00:35:12] Which undermines the availability of dopamine receptors. Which interferes with healthy stress responses. Because the child who is being. Abused. Take an extreme case. Can't generate the healthy stress response because the healthy stress responses to fight or to escape. Can a four year old being abused fight or escape? They actually they have to gut their own stress responses. No wonder. Then later on, they don't know how to handle stress. It's a wonderful volume by my colleague and friend Bessel Van der Kolk called the body keeps the score. On, on on stress. If you want to really know the traumatic impact of severe trauma, read that book. But as I said to you earlier, you don't need those big T traumas. And this is where genetics do come in. Here's what I'm going to tell you. This is true for mental health conditions in general. There's no gene for depression. There's no gene for schizophrenia. There's no gene for bipolar. There's no gene for addiction. There's no gene for ADHD. There's no gene for nothing. Nobody's ever found a single gene. That if you have it, you will have this disease. And if you don't, you won't. Don't believe me, by the way. Look it up for yourselves. Nobody's ever found a group of genes that if you have them, you'll have this or that condition.
Dr Gabor Maté: [00:36:41] And if you don't, you won't. What they have found. As best I could tell, when I did the research last time, a year and a half ago, in preparation for my most recent book, A Large Group of Genes, that the more of them you have, the more likely you are to have any number of mental health conditions. But no specific one. So those jeans are not for diseases. You know what they're for. Susceptibility sensitivity. So the more of these sensitivity genes you inherit, the less it takes to make you suffer, the less it takes to have an impact on you. Now that is inherited, but that in itself does not lead to disease. It's the action of the environment. On sensitivity genes that makes some people much more prone for addiction. Now, you don't have to have those genes to become addicted, but the more you have, the more likely to have any number of mental health conditions. And that's one more thing I want to say. When I was working in the Downtown Eastside, it wouldn't be unusual for somebody to say to me, Hey, doc, I don't get it. But most people, they do cocaine. They go all hairy. But me, I calm down and I cleaned my room. What do you think they were telling me?
Nikhita Singhal: [00:37:57] Self-medicating in a way, I guess.
Dr Gabor Maté: [00:37:59] They were self-medicating ADHD because Hobby Medicate, ADHD is with dopaminergic drugs. You know, Dexedrine, Adderall, Ritalin, methylphenidate. These people were using the stimulus to medicate themselves. People also use these people also tend to use. And so but in the study, statistically, about 30% of of amphetamine addicts or stimulant addicts, nicotine, caffeine, crystal meth, they're actually self-medicating ADHD. And most doctors don't even realise that. And in general, very often the drugs are self. Heroin is a wonderful self-medication for PTSD. Do. Cocaine elevates serotonin levels. Not as long as Prozac does, but it does. People self-medicate depression with cocaine. So very often people medicate. I mentioned maybe marijuana. People sued the ADHD brain with marijuana. I was talking to Prince Harry a few weeks ago. Some of you may have heard that. And I kind of controversially, but diagnosed him with Add because it's in his book. He couldn't pay attention. It was distractable, you know, And and marijuana really helped him because it helps the hyperactive brain calm down. So very often addictions to substance are self medications.
Nikhita Singhal: [00:39:19] So mean so much of what you've talked about. You know, things start in childhood. There's there's something that happens. And it's not necessarily what happened is, you know, how how we respond. There's certain maybe genes that make us more susceptible to respond certain ways. And then thinking about how the addictions are serving some purpose, some function. And we don't maybe take on more adaptive ways of coping with things as we grow up. Bring that. Then maybe to our third learning objective thinking about how can we use this pen to provide better care for people?
Dr Gabor Maté: [00:39:52] Sure, if you believe that what you have in front of you is a person afflicted by some genetic disease which manifests in a certain behaviour. Well, what can you do about anybody's genes? All you can do is manage the behaviour. So to an opiate addict, you might provide some medically assisted help. You know, give them Suboxone or methadone. That's useful. You might put them into a group where they learn better behaviours that can be useful. But you're forgetting or not knowing. Not that you forget it because you never knew it. You're ignoring the fact you're not aware of the fact that underlying those behaviours is trauma. So we need to have a trauma informed view. Of treatment. Now, trauma informed view of treatment doesn't mean that all you talk about is trauma. It means trauma informed. It means that you're informed by the fact that this person of any gender, of any age, when they come to you with an addiction, and I would argue with any mental health condition, if there's time, we can talk about that. If not, we just talk about addiction. Actually, there's a traumatic wound inside them so that any healing program needs to address not just their behaviour, like with cognitive behaviour therapy and dialectical behaviour therapy. You need to address the underlying pain. Now why the addiction, but why the pain? And that pain shows up in self-loathing. in self-blame. In aggression. In. Mistrust in a skewed view of the world, in constant behaviours designed to soothe the pain or to numb the pain.
Dr Gabor Maté: [00:41:43] So let's deal with. And. The ultimate pain is. When you're suffering as a child. Whether it's emotional suffering or physical or both. And you're alone with that suffering. You almost are forced to disconnect from yourself because the pain is too much. And that disconnection from yourself no longer knowing your gut feelings, not trusting yourself, not even liking yourself. That's the ultimate wound. So that trauma informed care would help lead people back to themselves. And let's face it, pain is a part of life. You can't escape pain if you're a human being. You don't have to inflict on inflicted on people. Which incidentally, the medical system often does unwittingly, but it does just by how it treats them. But you have to help them cope with pain. So part of the trauma informed care is how can we help you develop ways of being with the genuine pain of being alive without having to resort to escape from it all the time? So it's healing that traumatic wound. That's the ultimate goal here, which doesn't obviate or invalidate other approaches. And I'm all in favour of, you know, Suboxone and methadone when it's required. I'm not against psychiatric medications. I've taken them with benefit but taken antidepressants and I've taken stimulants for my ADHD. But they're not the answer. They only deal with symptoms.
Rhys Linthorst: [00:43:27] Think that's a really helpful kind of approach to the treatment of addictions and trauma. Dr. Mate And actually noticed in your latest book, The Myth of Normal, there was like a chapter on kind of Steps towards healing, which kind of elaborates on strategies that individuals can use to move toward more adaptive ways of thinking was actually sort of curious, kind of on a broader scale how you see the role of the medical doctor, whether it's the family doctor, the psychiatrist or addiction specialist in regards to the provision of the psychological work versus the prescribing, and if there's any upside or pitfalls to having the same person do both.
Dr Gabor Maté: [00:43:59] Well, I certainly did both. In fact, I couldn't have imagined not doing both. And it's not as complicated as you might think. You know, I'll tell you, for myself and I teach a therapeutic program internationally. We've had over 3000 students now in over 80 countries. It's called Compassion Inquiry. I've never had a day's training in psychotherapy. I'm not saying you shouldn't. I'm just saying. The formal training is not the essence of it. Something else is the essence of it. I'm not saying it's just like that. And I've learned a lot from others and from my clients and so on. But the most important thing is, is what you have to keep in mind. This makes all the difference in the world. Even if you have no factual knowledge. People were hurt in relationship. They were hurt unwittingly. We're not blaming parents here, by the way. Parents do their best. Your parents did their best. My parents did their best. I did my best as a parent. And I'm telling you, I hurt my kids. Not because I meant to, because I didn't know any better. There were stuff I hadn't worked out yet that I invented. And trauma is multigenerational that way. You can see that especially in the Aboriginal community in Canada, just a multigenerational it is, but it's multigenerational. But it means that we were hurt originally in relationship. It also means that we need to heal in relationship. So the therapeutic relationship is the most important thing you bring to your client. I don't care what training you had and I don't care what training you didn't have. Can you see them as human beings? Can you accept them? Can you look at them without judgement? When they come in your office having relapsed yet again.
Dr Gabor Maté: [00:45:55] We feel resentment and frustration and judging. Because if you are. And you're saying to yourself, I got this difficult client. There are no difficult clients. Who's got the difficulty? You've got the difficulty. Look at where that judgement, where that resentment comes from. You don't look at your rheumatoid arthritis patient that way, do you? Where is your judgement coming from? So if we can strive to provide an accepting, unconditionally accepting. I'm not saying to put up with bad behaviour. I'm not saying somebody wields a knife at you. I'm not saying sit there, accept it. You know, I'm not talking that nonsense. I'm talking about their behaviour in their own lives. If you cannot judge them, if you can see the pain behind it, if you can accept them and not only accept them, but see the possibility of wholeness in them. The to that relationship. That's a huge healing influence. And many of you who are listening to this, at some point, I hope you experience this, that somebody will say to you. Dark many years ago or some years ago. I came to your office and you listened and you didn't judge me and you accepted me. And that made all the difference in the world. And it does. So trauma informed doesn't mean like a huge load of training necessarily. It doesn't mean that you show up seeing that person as carrying a wound that can heal and you look at them with compassion and acceptance and you take responsibility for your own reactions. That's the biggest part of it.
Sena Gok: [00:47:41] Thank you, Dr. Mate. You mentioned the impact of multigenerational trauma and that we see within the indigenous population, and especially in women in Canada, highly this impact. And also there are societal barriers that are impact addiction population. Could we maybe speak to these? And I've also read that you mentioned trauma informed care can be applied from our society. Could we could you speak to that as well?
Dr Gabor Maté: [00:48:11] So what are the societal barriers?
Sena Gok: [00:48:13] Yeah.
Dr Gabor Maté: [00:48:16] Well, so let's just own the fact that we live in a society of high inequality. So these barriers are not general. They're specific. Some barriers affect everybody, but some barriers affect some people much more than others. So poverty is a huge barrier. Lack of drinking water. A lot of our native communities until very recently and some even now don't have potable water. We make societal choices as to where we're going to spend our money. We spend our money on sports stadiums, millions of dollars on certain celebrations. We don't spend it on drinking water for our indigenous communities. That's a barrier. But it's an arbitrary one. Which speaks to the values of this particular society. Race is a barrier. Not in itself. In itself, race doesn't even exist. There's no race. Skin colour and shape of lips or nose does not create a new race. Race is a function of a society that in its evolution, dependent on making some people inferior for the sake of enslaving them or of depriving them of their goods and lands. Race is a concept arose only with the rise of capitalism. But that's a huge barrier. Article yesterday or two days ago. The Toronto police are much more likely to be violent with black people than with Caucasians.
Dr Gabor Maté: [00:49:56] What a surprise. That's a barrier. Gender is a barrier. Um, in that there are certain acculturated tasks that devolve onto women more than onto men, particularly being the stress absorbers of everybody. Women have much more risk of of being on psychiatric medications, antidepressants, anxiolytics, and so on. Women have more PTSD. Obviously not exclusively, but there are more prone for sexual abuse in childhood. These are barriers. Class is a barrier to receiving treatment. The Canadian health care system does not cover psychotherapy. One of the reasons I developed my own psychotherapy therapeutic skills such as they are, because as a general practitioner, once I began to recognise the connections between people's emotional states and their mental health or their physical health. I thought, well, okay, I can I can give them the antidepressant or I can give them the anti-inflammatory or the immunosuppressant or whatever they need, but who's going to talk to them about their emotional needs? In the medical system, only psychiatrists are paid to spend money and only in Toronto with their GP psychotherapists. But in B.C. there aren't. Most provinces do not. Emojis are not trained in that way. So then I'd have to send people to psychiatrists. But I hate to tell you. Most doctors are not trained in decent therapy.
Dr Gabor Maté: [00:51:36] That is not even part of their training. They at least wasn't. They mostly deal with hospitalised patients with severe mental health conditions. Therapy barely comes into it. So therefore I had to start talking to my patients myself. So money is a barrier because here in Vancouver, to see a private therapist. You know what? $100 an hour, $150 an hour, maybe more. Well, in a in the East Vancouver family practice I used to have before I worked in the Downtown Eastside, my people were working class immigrants. They couldn't afford $150 an hour for psychotherapy. So these are all barriers. But the biggest barrier is an ideological one. Which is that the medical profession itself doesn't recognise the connections that have been trying to draw for you. You can go to medical school and I hope you'll tell me otherwise today. I hope you'll tell me right now that I'm wrong. But my assertion is that the average medical student doesn't hear a single lecture on trauma. In a way that I talked about it today, the significance of it now. In, at least in the undergraduate years. Tell me if I'm wrong. Okay. I'd like to know that I'm wrong on that one. Yes or no?
Angad Singh: [00:52:57] No, you're not wrong.
Dr Gabor Maté: [00:52:58] Okay. Which means that the biggest dynamic in causing addictions and mental health problems is not even mentioned in medical school. Now, talk about barriers. That's a barrier. All the more. I'm appreciative that you guys are giving me this opportunity to address some doctors in training. I mean, I, you know, am I an evangelist? Yes, I am. I'd really like people to know about this stuff. And you know what frustrates me here? When I allow myself to be frustrated. It's not that the medical practice is scientific, it's that it's not scientific enough. Because what I'm talking about, you know, when I wrote this book, The Myth of Normal, I collected 25,000 articles. Multiple hundreds on trauma and its impact on the brain and the body and unity of mind and body and the connection between addictions and ADHD and everything else. You guys don't even learn the science. And you would call yourself a scientific discipline. So that's the biggest barrier is our ideological blinders Imho.
Dr. Alex Raben: [00:54:02] Thanks so much, Dr. Mate. I haven't introduced myself, but I'm Alex Raben. I'm a psychiatrist from here in Toronto. Great. Um, and I have to say, yes, in my own medical training, I would agree with what Angad was saying there and many of our panellists here today, thankfully, I think in psychiatry training is a bit different and we certainly have had some episodes on trauma, thankfully before, not not the same lens as today. I just wanted to jump in with a question as well that came to me to do with harm reduction because we've talked a lot and in your book you talk a lot about the biological, psychological, developmental, multifactorial aspects of addiction and, and the way trauma layers on top of that. Yeah. But there's also, I guess, this element of the substance or whatever the target of the addiction is. And it strikes me that some of those behaviours may lead to bigger harms than others. And I'm thinking about, for instance, the opioid crisis which is rampant in the country, has been getting worse and particularly in BC. How do, how do we view, how do we make sense of that from this model, right where we see this substance being taken up in greater quantities and causing greater and greater harm? Is there a role here to do something in that realm as well? Or how how does that fit into all this?
Dr Gabor Maté: [00:55:32] Sure. So in this in my previous book, which is in the realm of Hungry Ghosts, Close Encounters addiction, there's a chapter on harm reduction. Um, so I was the physician at North America's at that time only and first supervised injection site which is called Insite or here in Vancouver on Hastings Street, where people could bring their substances of abuse or use and get clean needles and sterile water and a tourniquet and inject under supervision. And if they're overdosed. They'll be resuscitated. The Canadian government In its wisdom at the time, the Harper Conservative government tried to shut it down. Under the principle that we're aiding and abetting addiction. From their point of view, it would have been better to what I'm saying now. The Supreme Court of Canada ruled. Unanimously against them. So now there are other injection sites throughout the country. Not nearly enough. So that's a harm reduction measure. Harm reduction says basically harm reduction says it's not just a practice. Harm reduction is an attitude. And it says, we know that right now you find yourself incapable of not using. So let's. Can we help you use in a way that reduces the harm so that you don't infect yourself or somebody else with HIV or hepatitis C so that you don't develop a brain abscess from a dirty needle? or abscess in joints. Um, so that we can talk to you and you can start to trust us and maybe accept treatment from us because we're not judging you. Harm reduction also includes provision of safer forms of opiates like Suboxone or methadone. But basically it says that while sobriety or abstinence is a legitimate and ultimately the hoped for goal, it's not the only goal.
Dr Gabor Maté: [00:57:44] By the way, there's nothing so unusual about that in medicine. I mean, if you come if you come if you come here as a type one diabetic. Nobody's hoping to cure you. But they are hoping to reduce the harm. By maintaining your sugar levels, insulin levels at an optimal range. By dealing with foot injuries so they don't get infected. But make sure that your kidney functioning stays within normal parameters. These are all harm reduction measures. So it's the same principle. And sometimes people say this is controversial. Well, we shouldn't have harm reduction. I mean, these people brought it on themselves. Let them suffer. There's that attitude which I say I go along with as long as we're consistent. Which means that the next time a workaholic, cigarette smoking businessman shows up in the emergency room with a heart attack, we don't give them a bypass. We kick them out. You're saying you brought this on yourself, not deal with it. You know, but no, we go in there and and we reduce the harm. You know, we give them the medications and if needed, the stent or whatever they need. Well, harm reduction is in the same range. And by the way, nobody stays in addict because of harm reduction and nobody becomes an addict because of harm reduction. So it's just a part of the to me, it's totally irrational. Hopefully it'll lead to abstinence if people trust enough and they enter the treatment system. But unfortunately, there's not a good enough treatment system to enter. So I think. Once you understand trauma, harm reduction becomes a self explanatory dynamic.
Dr. Alex Raben: [00:59:36] Right. Sounds very complimentary. Going back to what you were saying earlier about being able to be a doctor while also providing trauma informed care in that combination being essential. Right. It's not just one or the other.
Dr Gabor Maté: [00:59:49] But listen, Alex, why why also like it's like it was somewhat extraneous, you know, not while also that ought to be part of your work as a physician.
Dr. Alex Raben: [01:00:01] Right? They're there. They're inextricably linked and linked in a sense. And the even the language you use around it can kind of make these false dichotomies. Yeah. Yeah.
Dr Gabor Maté: [01:00:12] Yeah.
Dr. Alex Raben: [01:00:14] Nikita. Maybe I'll hand it back to you to wrap us up.
Nikhita Singhal: [01:00:17] Yeah, I think we could go on for ages talking about it. And thank you so much for, you know, providing us with this perspective, because as as you alluded to, it's not one that we are often, you know, exposed to, although increasingly, I think it's becoming. Know, thanks to your work and others more more in the general awareness. But really, I think, you know, just a quick recap. You covered, you know, trauma and how we can really think about trauma in a broad sense and how that is really linked to not only addictions, all kinds of health conditions, and that the current approaches, the way we think about things doesn't really do the people we serve justice in allowing us to understand and and then to best be able to help help empower them to move past what they're struggling with. And you gave us some really great considerations for ways that we can be trauma informed. And that is our job is to be trauma informed and provide that care. So really, we we thank you so much for for your time and speaking to us. And we think this will be a really helpful for all those future providers out there.
Dr Gabor Maté: [01:01:31] Well, my pleasure. Thanks for the opportunity and the great questions and I'll talk to you again sometime. You take care.
Nikhita Singhal: [01:01:39] This concludes our episode on understanding. Trauma and Addictions featuring Dr. Gabor Mate. Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Sena Gok. The episode was hosted by Sena Gok, Rhys Linthorst, Angad Singh, Nikhita Singhal, and Alex Raben. The audio editing was done by Sena Gok. Our theme song is Working Solutions by Olive Musique. A special thanks to our incredible guest, Dr. Gabor Mate, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org, Thank you so much for listening.