Last October I was privileged to attend the 3rd International Congress in Whole Person Care at McGill University in Montreal, Canada. One of the keynote speakers was Dr Gabor Mate. Dr Mate is 75 years old. He has retired from clinical practice as a family doctor and palliative care physician, with much of his career dedicated to caring for patients with drug addiction and mental illness in Vancouver. He himself has a personal history of trauma and mental illness. He now spends his time travelling the world sharing his expertise on addiction, trauma, childhood development, stress and illness. His presentation was captivating and now that I’ve had some space to reflect on the wisdom he shared, I thought it was time to share my reflections with you.
Dr Mate opened his talk with a quote from Sir William Osler, one of the founding members of the Medical Faculty at McGill University:
“The good physician treats the disease; the great physician treats the patient who has the disease.”
This statement really resonated with me. As a GP, I try my best to work together with my patients to address not only their disease, but all aspects of their personhood that is contributing to their health and wellbeing. I admit there are times when this can be a challenge, however supporting patients to restore their health is even more difficult if you ignore the social, emotional or spiritual factors that are impacting on their physical disease.
Dr Mate went on to explore the idea that social and environmental factors are far more influential than biological factors when it comes to the manifestation of disease, using addiction as an example. He provided his definition of addiction as follows:
“A complex medical condition, manifested in any behaviour that a person craves, finds temporary relief or pleasure in but suffers negative consequences as a result of, and yet has difficulty giving up.”
Dr Mate reflected that although the medical view of addiction is that it is a disease, there is a persistent sociocultural view that addiction is a “poor choice”. Consequently, this implicit bias impacts on the care that people with addiction receive from health professionals.
He posed the notion that all humans regularly behave in a way that allows us to find relief from pain, hence those of us with addiction are just being normal human beings with a deeply rooted pain that is driving their behaviour. He challenged the audience to consider that the first question we need to ask anyone suffering with addiction:
“What does your addiction do for you? What has happened to you that is causing you stress and pain? How did you lose your sense of belonging?”
Dr Mate then explained that many people, including those with a serious addiction, self-medicate with all sorts of “drugs”: alcohol, cigarettes, marijuana, cocaine, methamphetamine, opiates, gambling, food, sex and shopping. The common pathway to these addictions is not the behaviour, it is the dopamine circuit in the brain. All of these addictive behaviours are an attempt to boost dopamine levels in the brain and all of them end up with the same outcome: suffering.
Following on from this, Dr Mate highlighted the fact that many people with addictions also have attention deficit disorder (ADD), that is, poor impulse regulation. This is a risk factor for developing addiction. He asked us to consider what other population experience poor impulse control…that’s right, babies and children. This realisation suggests that brain development may be impaired in people with ADD and addiction.
Dr Mate then invited us to consider the cause for this impaired brain development. He suggested that three key circuits in the brain are disturbed, including
the hypothalamic-pituitary-adrenal (HPA) axis, which regulates stress
the opiate circuit, which regulates pain (both physical and emotional)
the dopamine circuit, which regulates motivation and interaction with the world
He then delved into how the brain develops in humans. He explained that the brain begins developing in the uterus in relation to the maternal environment. If the mother experiences stress during her pregnancy, this will have an impact on how the fetal brain develops. Once the baby is born, the brain continues to develop in response to the environment. He referenced the study by Weaver et al that demonstrates the epigenetic programming that occurs when rat mothers lick their pups in the first week of life. Essentially, this nurturing behaviour programs their HPA axis for adulthood, and consequently impacts how the offspring then nurture their own infants when they become parents. Furthermore, the pups who were separated from their mothers were deficient in dopamine, which increased their risk of addiction. The conclusion: the key determining factor of healthy brain development is the nature of the mother-infant interaction. Said another way, the necessary requirement for healthy brain development is available, loving parents. For more scientific evidence to support this hypothesis, he referred us to the Harvard University Department for the Developing Child website.
In addition, brain development can become disturbed during childhood by traumatic events, such as violence and neglect. The greater the number of traumatic events, the higher the risk of developing addiction, as well as other chronic diseases such as ADD, autoimmune disease, diabetes and cancer. There are no genes for addiction, but rather there are epigenetic exposures that predispose to abnormal brain development and consequently addiction. Similarly, stress during infancy can lead to the child “tuning out” to escape the pain, which then manifests as inattention and finally ADD.
Dr Mate then proposed the question: what is the optimal parenting environment? Surprise, surprise, it’s the Hunter-Gatherer style. Further to this, when grandmothers are involved in providing care to their grandchildren, the child’s brain development is healthier. In addition to this, the closer that grandparents live to their grandchildren, the healthier the child’s brain development.
According to Dr Mate, modern parenting practices, such as sleep training and time out, are training our children to ignore their need for human connection. His advice: don’t focus on the child’s behaviours, instead, concentrate on the attachment needs of the child. His interpretation of the evidence is that adults struggle with unpleasant sensations as a result of their experience of lack of control as an infant AND not receiving regulation/soothing from their parents, creating the belief that they the unpleasant sensations will go on forever.
At this point Dr Mate turned towards the issue of addiction that arises in medical students: workaholism. He suggested that medical students often choose to study medicine because they have a need that must be fulfilled: to feel important. This need is likely to have resulted from experiences in infancy: not getting enough attention, not feeling important enough or not feeling loved. When this need of feeling important is fulfilled, there is a dopamine hit and this can become addictive. Add to this the stressful environmental of medical school, with a culture that teaches students and doctors to ignore our own needs and meet others’ needs no matter the cost. The result is a group of physicians who are addicted to their jobs and lacking the insight to understand themselves.
But there is an antidote to this. Dr Mate proposed that we need to transform the medical curriculum to spend less time learning facts that are not that important (does any doctor who is not a neurosurgeon recall the detailed anatomy of the brain and its cranial nerves???) and spend more time learning the really important stuff, such as tuning in to ourselves, debriefing on a regular basis and learning to soothe ourselves in a healthy way rather than succumbing to our cravings.
Dr Mate then led us through an exercise in pairs. We were instructed to sit facing one another, and Person A had to ask Person B “What is your relationship to addiction in your life?”. Person B was given 3 minutes to respond, with Person A instructed not to provide any verbal or non-verbal feedback, but simply listen. After 3 minutes, we swapped and repeated the process. Participants were then given the opportunity to share how the experience was for them. They reflected that it was difficult not to talk or use body language to acknowledge the other person when they were listening, however when they were talking it did not bother them that they were not receiving feedback as they didn’t need acknowledgement to feel heard. They needed space.
This led into a discussion about Polyvagal Theory, which is based on the idea that the vagus nerve has both myelinated fibres and unmyelinated fibres. Myelinated fibres are more the evolved fibres and are part of the parasympathetic nervous system. They are involved in creating social engagement. The more primitive unmyelinated fibres, which are part of the sympathetic nervous system, are involved in survival behaviours such as flight, fight or freeze. Dr Mate went on to explain that our nervous system has an expectation of social connection, and if this expectation is not met, we feel assaulted, which it turn stimulates a stress response. Further to this, we only learn and heal when we are in a relaxed state, so human connection is necessary for stimulating the relaxation response and consequently learning and healing. Dr Mate then suggested that as medical educators, we should use the sharing and listening exercise with our medical students and ask them how it feels such that they learn how to connect to their own emotions and reactions.
A member of the audience then shared how she often feels hopeless when she is sitting with a patient with an addiction, that she has nothing to offer them that will help in their healing. Dr Mate described how powerlessness and hopelessness is a perception that leads to feelings of despair in the healer. He explained that, again, the first time we experience despair is in childhood when we were powerless to help someone who was suffering and so when we feel despair as an adult, it brings up these same beliefs that we are powerless. This is called implicit memory. He highlighted that if we see a person with an addiction as broken and hopeless, then we are not seeing them as a whole person. The challenge for us as healers is to see the person as whole and to be a mirror to them, allowing them to see their wholeness and to have faith in their capacity for healing.
Finally, Dr Mate provided some well-known tips on how to clear the negative energy we absorb as healers working with patients who are suffering:
Reflection time at the end of each day – talking, journaling
Sleep and rest
Exercise
Eating well
Nurturing our relationships
Meditation/yoga practice
In closing, Dr Mate left us with three powerful take-home messages:
1. Safety is not the absence of threat, it is a process of connection.
2. Listening without an agenda is key to healing.
3. Trauma is disconnection from the self. Recovery is reconnection to the self.