Episode 162 - Addiction with Hanna Pickard Transcript

Final Cut. Addiction with Hanna Pickard

[00:00:00] David: Hello and welcome to Overthink.

[00:00:19] Ellie: The podcast where two philosophy professors bring philosophy into dialogue with everyday life.

[00:00:24] David: I'm David Pena Guzman.

[00:00:26] Ellie: And I'm Ellie Anderson.

[00:00:28] David: Virtually all human cultures have used drugs in one way or another. Opium poppies have been used in Britain and Europe since at least 5,500 BCE. Alcohol production dates back all the way to 5,000 to 7,000 BCE, and on some accounts it's even older than that, all the way to 12,000 BCE.

You also have other drugs that have been used in ancient cultures. This includes peyote, mescaline, a bunch of psychedelics and hallucinogens in places like, Mexico, central and South America, as well as other places in the world. So drugs have been with us for a very long time and in many, many places, and that obviously continues into the present.

Many of us use very different kinds of drugs, sometimes regularly, sometimes infrequently. But I think it's fair to say that drug use is a fundamental feature of human experience.

[00:01:25] Ellie: I mean, I drink coffee every morning. That's a drug we often tend to equate drugs with illicit drugs, some of which I do partake in to occasionally, and I can say that now that I have tenure. Plus we have our intoxication and psychedelics episodes, which you can listen back to if you wanna hear a little bit about those.

But yeah, just simple coffee. What are your drugs of choice, David?

[00:01:46] David: From the licit ones, that would also include sugar. That's definitely a drug. From the illicit ones, I would also include psychedelics that we talked about. I do like mushrooms, certainly that's my favorite. But I was gonna say the one that never really worked for me was nicotine. I tried smoking. I didn't like it.

It didn't do anything for me. If anything, it just made me dizzy in a way that I did not really enjoy.

[00:02:10] Ellie: So I've actually never tried nicotine. Okay. I have smoked hookah, so I guess I have tried nicotine, but I've never smoked a cigarette, a cigar, or anything beyond like a hookah that I didn't realize was nicotine when I was younger.

[00:02:26] David: Oh, you didn't realize that's why you did it.

[00:02:28] Ellie: The reason for that is that my dad used to be addicted to cigarettes as well as to alcohol and cocaine.

He's been open about this before I was born, and he was so worried about me trying these substances and becoming dependent on them. Actually, he was most worried about nicotine 'cause he was like, that is the most addictive of all the drugs I've tried. If you make it to age 25 without ever trying a cigarette, I'll buy you a fancy watch.

His wager being that if I made it to 25 without trying a cigarette, I probably wouldn't try it after that is many years since then and I still never tried one. I just like kind of don't have an interest at this point.

[00:03:05] David: Well, and he was right because one of the things that I've discovered in my research about addiction is that one of the determining factors for addiction, both in humans and in animal models, is the age of first contact. So a juvenile animal is more likely to develop addiction if the first moment of use is during infancy or like, you know, the like adolescence basically than an older animal.

And so there is a genuine difference here in terms of age. So he was onto something, but who knows? Maybe now that you're definitely past 25, you can go ham, the cigarettes without much worry.

[00:03:42] Ellie: Now that I got tenure, I can celebrate by smoking a cigarette and becoming the true French existentialist specialist that I am. Right? Like you know, I've never smoked a cigarette and I write on Sartre and Beauvoir. That's wild.

[00:03:56] David: I know you're basically a fraud. Although, you know what I just thought about maybe the reason why cigarettes never worked for me is because when I was young, I did try cigarettes and my grandfather caught me smoking in the attic of our house. His punishment for me, he forced me to smoke a cigar in front of him and I vomited everything that was in my stomach because it was so intense and it created this deep aversion, I think, to cigarettes and I'm just now like remembering

[00:04:24] Ellie: So your grandfather had the opposite approach to my dad, but both worked. So David, you mentioned the maturity point and the fact that people often develop a dependency when they're young. That is something that the book we're gonna be discussing today, the beautifully titled, What Would You Do Alone in a Cage With Nothing But Cocaine? A Philosophy of Addiction discusses because the author and Hanna Pickard, whom we're gonna be interviewing in a bit, notes that most people actually age out not only of drug use, but also of addiction. So you started by saying that most people use drugs. Most civilizations have used drugs.

But I think an important thing to note here is that most people don't become addicted. And so what is it that drives some people into a pattern of drug use that is characterized as addiction, but not all? And this leads to what Pickard identifies as the puzzle of addiction.

And the puzzle of addiction has to do with the fact that at a certain point, somebody's pattern of drug use no longer seems to be understandable because it seems like the costs have come to far outweigh the benefits. It might even look like the drug use is destroying a person's life to be counter to their own good. And Pickard says that, you know, often in behavioral economics people will describe that puzzle of addiction as a puzzle of irrationality.

Why is it that we behave so irrationally? But that's quite an oversimplification. And so she wants to offer an alternative model, and we'll get into her alternative model when we speak with her. But I'll just say from my perspective, David. I mentioned that my dad has a history of addiction, so too do a lot of my family members.

There's in particular in my family, a lot of people who struggle with alcohol addiction, and I think growing up this was always just like vaguely terrifying to me. I never understood it. It seemed like a puzzle from the outside, just like a, why would you do this? And the way that that puzzle was usually explained was in terms of a disease, you either had a gene for being an addict or you didn't.

And so I feel like growing up I was sort of waiting to see like, do I have this gene? Will I become an addict or not? And that was a very bizarre position to be in. I haven't struggled with drug addiction as an adult, but I think already as a kid, that disease model of like, you have this gene or not seemed very strange to me and it didn't seem quite satisfying.

[00:06:51] David: Yeah, I can imagine how it would be weird for a kid to wonder whether, you know, this massive variable that would automatically turn you into somebody who has to struggle with addiction would be there or not, right? Because it's completely outside of your control once it's explained exclusively in terms of genetic determinism.

But you also mentioned that it was incomprehensible, right? Why would you do this? And this is something that Pickard highlights in her writings on addiction. She says that what's so puzzling about the puzzle of addiction is that it seems to violate, one of the most basic principles of our self relation as humans, which is the principle of self concern.

We tend to assume, not inaccurately, that every human being has a basic concern for their own wellbeing and that therefore they will make choices that enhance that wellbeing. But when it comes to addiction, that principle seems to be violated because individuals are doing things that cost them dearly.

They lose friends, they lose their job, they lose relationships. Sometimes they even lose their sense of self-control, and so it makes it very difficult to understand why they would persist in that pattern of behavior given these very high costs that they're paying, which, as you mentioned, tip the balance from benefits to costs.

[00:08:22] Ellie: And we need to be thinking about that balance rather than just like the simple presence or absence of using drugs in order for a viable explanation of addiction to even get off the ground. I think oftentimes our society has such a stigma around certain drugs in particular that even using them suddenly brings you into addict territory.

And I think like one of Pickard's essential views is no, there's actually no drug that is intrinsically bad. It's all about on balance, how it's fitting into your life, and whether it's profoundly counting against your own good or not.

[00:08:56] David: And of course there are many kinds of addictions. One can be addicted to certain behaviors like gambling, having sex, watching porn. But the book. We're gonna be discussing today focuses specifically on addiction to drugs, and I think that's important to underscore because the scientific, philosophical, and therapeutic questions that arise in the context of drug addiction don't always apply to other forms of addiction. So let's just keep that in mind.

Hanna Pickard is Bloomberg distinguished professor of philosophy and bioethics and Krieger Eisenhower, professor at John Hopkins University. She specializes in the philosophy of mind, philosophy of psychiatry, moral psychology, and medical ethics. She's the author of the book that we are going to be discussing today, What would you do Alone in a Cage with nothing but Cocaine? A philosophy of addiction.

Hi Hannah. Welcome to the podcast.

[00:09:56] Hanna: Hey, David and Ellie, thanks so much for having me.

[00:09:59] Ellie: We're so excited to speak with you today about your book. We both just really enjoyed it and found it very thought provoking.

[00:10:06] David: Also kudos for the great title. I was originally drawn to the cover and I was like, what is this book? When I found it on the website of the press, and then I started reading about it and I was like, Ellie, we need to do an episode on this book. It sounds amazing. So it's one of those cases where I'm happy that I judged a book by its cover, 'cause then the content lived up to the title.

[00:10:29] Hanna: Oh, thank you so much.

[00:10:32] David: Hanna, I wanna begin by asking you about the problem with the typical way we think about addiction, which is the main target really of your book and of your work here. And the way we typically think about addiction, and I have to confess, I myself, have thought about addiction in this way in the past, is as if the people who struggle with addiction have a broken brain.

There's something that happens in the neurobiological dimension, such that the brain is hijacked by drugs, and so then we become addicted to them and we are out of sorts in relation to them. This is what you call the broken brain model of addiction. Tell us where this model of addiction comes from and how it shapes how we think about addiction, and maybe why we should not think about it in those terms.

[00:11:26] Hanna: Lemme start with an anecdote, if I may, because I don't think you are unusual in sort of unreflectively taking for granted that that's what addiction is, and certainly I did as well until I started to work clinically. So in some sense, I actually wanna start us with an anecdote which comes at the end of the book.

Just to give a little personal context for this. I used to work clinically in a specialist service with people with personality disorder and complex needs. Many of whom struggled with drug and behavioral addictions. And one of the therapeutic mechanisms that we use to help people stop using drugs and alcohol was a contract where they would basically write on a piece of paper that they were going to quit using and that if they struggled, they would make support calls to other people in the group.

And these were people with a diagnosis of substance use disorder. The whole group would sign the contract and write messages of support on it, and then they would take that contract away with them for the week and if they were struggling, make those support calls, but also take it out and read it and look at it and have it with them all the time.

And the contracts didn't help everyone, but they helped many, many, many people. And I suppose it was at that sort of moment, that sort of personal experience when I first started thinking actually addiction can't just be a brain disease that compels use because a contract is nothing more than a piece of paper that you carry in your pocket.

It has important, meaningful messages on it, but those are not the kinds of things that could possibly cure a brain disease. So it was partially through seeing a kind of therapeutic treatment that was effective, at least with some people, but that really undermined the premises of the brain disease model that I first myself, started really questioning that model.

And I think it's kind of nice to begin there just because the model really does have a hold on our thinking. And so, you know, sort of sometimes the anecdotes and personal experiences are ways to start to loosen that hold before we then delve into the more theoretical, scientific and philosophical points.

[00:13:41] Ellie: Absolutely. The idea of the broken brain has come to have such force in our society such that it makes sense to me that it would've taken you a while to even realize that that's worth questioning. I myself have often questioned this as a non-specialist and been like, is this really the way to think about this?

And I think also because some of my commitments to rejecting mind body dualism, but then also rejecting the weird oversimplified materialism that we see in our society. It just didn't really make sense to me metaphysically, which is maybe a story for another time. 'cause you're focusing I think, a bit more on the ethical commitments that people experiencing addiction are making.

But one thing that I was really interested to find in your book is a kind of account of how this came to the fore as well. I didn't know, for instance, that there was a 1984 book written by a psychiatrist called The Broken Brain, and then how this model really ended up kind of becoming as important as it is in part, as a result of so many centuries of moralizing addiction and wanting to say like, no, you know, this isn't something that people should just necessarily feel guilty about it, and we'll come back to that later. And I think even throughout probably our interview, but as something, even with kind of a good intention, well, it's not really rooted in science and therefore it's gonna have very limited utility.

[00:15:01] Hanna: Right, exactly. So it's really helpful, I think, to situate the brain disease model in contrast to the moral model of addiction, which it sort of was created precisely to counter and try to displace. So moralism about drugs and addiction is really deep in our thinking in the US and around the world. It's in our culture, it has religious roots, and it sort of has been codified in a sense in what's been called the moral model of addiction, which is just the idea that basically there's nothing different between drug use and addiction and ordinary drug use, and that in both cases it's morally wrong.

So the moral model is really a basis for stigmatizing and punitive attitudes towards treat people with addiction and for withholding care. So the brain disease model was sort of emerging over the course of the late 19th century and 20th century, but then was really codified in 1997 by Alan Leshner, who was then the director of the National Institute on Drug Abuse in this really seminal article called Addiction is a Brain Disease and it matters.

And it's a very, very short article, but in it, Leshner is really explicit, A, that we're starting to understand the neuroscientific mechanisms underpinning addiction, and B, that seeing it as a brain disease will help counter stigma and increase funding for research and treatment and help people become less punitive towards people with addiction. So the motivation for the model was very much its social, practical, interpersonal consequences.

And that's really important for two reasons. So one is there's this kind of tacit claim about what kinds of consequences the model is going to have in society. And that's something I think it's really worth talking about because the consequences haven't been as Leshner and the advocates of the brain disease model hoped. But it's also really important to note that we don't use, usually evaluate scientific models based on their practical, social and interpersonal consequences.

We evaluate them based on whether the theoretical and empirical claims they make are well evidenced. Right? And so in the book, I really try to separate those two things. Part of the book does address the lack of evidence for the model when it's considered from a scientific perspective.

But you know, in some sense when we're just talking about the social importance of it, I think that part of what it's really done is kind of position itself as the only antidote to the moral model, right? As if you know we're in this sort of forced choice between either the moral model or the brain disease model. So if you reject the brain disease model, you can count as someone who is stigmatizing people with addiction and really doesn't care about them or believe that there ought to be research and support for treatment.

And so, although part of the book is negative, it does sort of aim to address what I see as the deficiencies in the brain disease model. Really, the thrust of it is positive and it's to offer a new paradigm that puts something else on the table, which I think is better, more scientifically evidenced, more psychologically real, and more ethically powerful than either of those models.

Which are incredibly black and white, incredibly simplistic, right? So if you just stop for a moment, I mean, how could anything as complicated as human minds, human behaviors, our relationship to each other, our relationship with drugs be distilled into something so childishly simple. It can't be the whole truth.

So I really want us to start talking about the complexity. That's the point of the

[00:18:48] Ellie: it's all your fault versus none of it is your fault.

[00:18:51] Hanna: Not at all.

[00:18:52] Ellie: you're like, what about the middle ground?

[00:18:54] Hanna: Right. I mean, things are complicated. Humans are complicated, morality is complicated. Right. And that is just not reflected in either model. And you know, we need to get much more real about that complexity, I think.

[00:19:07] David: Yeah. And Hannah, as you were speaking just now about the limitations of this broken brain or the disease model of addiction, you mentioned that it's not well evidenced, and I'm wondering whether you can just say a word or two about that, because I think your average listener would say, what do you mean? That's how the National Institutes of Health are thinking about it. There must be some evidence. Don't we solve addictions in some cases? So what's the state of the evidence in connection to this?

And secondarily, you also mentioned in the book that although this broken brain model originally had good intentions as a way of avoiding stigmatizing people, it also has had a negative result, which is that it has led to pessimism about the possibility of recovery.

Because if I'm an addict and my brain is broken, that's the end of the road for me, and so I wanna hear more about the evidence and then about this particular danger of pessimism about the future.

[00:20:09] Hanna: Of course, but if it's okay, I'm gonna take those questions in reverse order because I think sometimes seeing that it hasn't had what we might call the ethical consequences that we hoped for, helps to create sort of a little bit more open-mindedness towards looking at the science, right? The phrase I like to use following the sociologist Nick Haslam, is that the broken brain model has been a mixed blessing in terms of its real world practical effects.

So it has done some good things. It has increased public support for research into addiction and treatment for addiction. It's also done some negative things. You named a few of them. It has really actually increased stigma because it creates a sense of dangerousness and difference between people with addiction and people without a kind of us and them.

And it also looks like it has contributed to what you might think of as a kind of internalized stigma, right? Where, you know, people with addiction feel like something is wrong with them because their brain is broken, right? That's actually a really a quite devastating thing for any of us to think about ourselves.

And in consequence of that, it does two more things. One is that it can impede problem recognition, right? Because if you think that acknowledging you have addiction is to acknowledge your brain is broken, you might be motivated not to acknowledge you have addiction and therefore not to recognize you have a problem and go seek help.

But it also impedes recovery because once you do acknowledge it, in some sense, the cure for a broken brain can't possibly lie in your hands, right? And again, in this very flatfooted, simplistic way of thinking. It's to be cured by a doctor, by a neurologist, right? Needless to say, we don't have those cures, so that's also not a great thing about the model.

But the truth is that recovery is very complicated. It's a hard process, which requires a person to sort of refashion their life and their relationship with drugs, and often their sense of self. And none of that is aided by thinking they have a broken brain and that's what the problem is. So they need a sort of medical cure.

If you just stop and think. You shouldn't be surprised that that's the case because we don't tend to think that diseases are the kinds of things that reduce stigma or help people figure out how to manage their lives on their own. Right there was something like, how did we ever get into a place where we thought that calling a condition of brain disease was really going to help with the social and societal problems that we have with that condition.

Okay. So that's the kind of reason why, you know, I don't think that it's done the good that it was intended to do. Now let's just look at the kind of state of the scientific evidence. So what does it mean to say that addiction's a brain disease?

Well, fundamentally it means that the explanation of drug use in addiction is the presence of brain pathology and that that brain pathology is what we're going to identify addiction with. And so there are a number of things going on in that claim, right? So one is that brain pathology is present.

So we need to know, first of all, what a non-pathological brain is like in order to be able to know what a pathological brain is like. And we don't currently have a great account what a non-pathological brain is like. So there's a sort of missing piece there.

The second thing we need to know is that it's present with people in addiction. And that is the cause of their drug use. And again, we have a lot of evidence with many people that it's not a primary cause and we also might have a lot of evidence really, that it's not even present. What I try to do in the book is really clarify the notion of brain pathology. Clarify the notion of brain pathology being the cause of drug use in addiction, and point out that the picture that we get when we sort of look seriously at the science is that it might be present in some people, but probably not all.

In those people, it might, in some cases, be a really important cause. But not all. And so we have a kind of heterogeneity of explanations of drug use in a, in addiction that comes into view. So for me, this is really important. I don't deny that it might be true in some cases that brain pathology is the cause of drug use in addiction.

I deny that it's always the case, and I think this is incredibly important because I think the way in which we've sort of been trapped in this simplistic model has stopped us from seeing the other explanations that are just as important for some people, more important for other people. And in consequence we fail to understand what addiction is across the spectrum or to sort of think in creative ways about how we might intervene to help.

So ultimately, you know, the sort of the way in which the brain disease model has dominated our thinking, has a cost for people with addiction when it's not the fundamental thing that's going on with them. Because it keeps us fixed on only one part of the problem, as opposed to looking more broadly and thinking about all of the other components that might be at play.

[00:25:39] Ellie: Yeah, and I think this idea of. Well, it's complicated. It's not simply just gonna be this one explanation. It was really compelling to me as I was reading your work on this, because what you articulate is that in spite of our desire to find one simple way of understanding addiction, that is not actually something we can achieve.

And in fact, like our, we do have to have a more heterogeneous model, and that has to very seriously take into account the social, political, economic conditions of individuals who are struggling with addiction. And so I think this leads me to a question about how we do identify when somebody's pattern of drug use counts as addiction.

And you say that in order to make an addiction diagnosis, we have to consider what is good for a person. What is good for a person? There's no one size fits all for that. Like there might be different goods for different people and according to your, I think you don't use the word definition of addiction, right?

You say like it's a kind of working, you use something different

[00:26:45] Hanna: I say it's an explication, which is a term of art from the philosopher of science, Rudolf Carnap.

[00:26:50] Ellie: Yes, yes. Thank you. And so, according to your explication, addiction is a pattern of drug use that counts profoundly against the user's own good. But then that raises some questions around, for instance, what happens when a person with addiction insists that their drug use isn't a problem for them?

And you know, suggests maybe it's actually good for them, right? Like, drinking makes me social. It makes me friendly. It makes me fun. So in those cases. How can we explain what this person is experiencing as an addiction, even if they're not describing their pattern of drug use as counting profoundly against their own good.

How do we get to what their own good is?

[00:27:35] Hanna: Okay, good. So there's a huge amount in that question, and you sort of ended up with one of the really hard cases,

[00:27:41] Ellie: It's kinda the whole book.

[00:27:42] Hanna: So let' s rewind and just start with the explication and what it means and how I generate it. I think in some sense the really missing piece of our understanding of drug use and addiction is the fact that drug use is perfectly ordinary.

Much of it is rational and makes good sense, and it's absolutely pervasive, not only in our society, but in all human societies across our history. So we are a species that uses many drugs and we use drugs for many good reasons, right, which is they're what we call in psychology, they're positive and negatively reinforcing effects, but very broadly, drugs do things for us that both involve alleviating negative states like pain and suffering and boredom and misery, but also involve doing things to us cognitively and emotionally that are good for us.

They give us pleasure. They create social connections. Some people describe certain drugs as giving them some of the most meaningful experiences of their lives. They make us cognitively sharper, so they do all of these things. If you sort of just stop and recognize that what counts as a drug isn't just what we criminalize in contemporary society, right?

Alcohol is a drug, nicotine is a drug, caffeine is a drug, right? They're just everywhere. So most drug use is perfectly ordinary, and it's perfectly explicable from a psychological perspective. We use drugs because of the value and whatever costs they have don't begin to undermine the benefits that they bring.

And so I really use this sort of anchoring point about the rationality and prevalence and normalcy of ordinary drug use. I use that point to sort of anchor the idea of addiction as occurring when suddenly drug use that was, well, it's not suddenly, it's typically a sort of long process, but there comes a time when drug use that was perfectly ordinary, all of a sudden looks unintelligible, all of a sudden looks like we can't make sense of it.

It's no longer ordinary. Precisely because that kind of balance between costs and benefits has tipped right, and now all of a sudden we see costs that are significant and severe that, sort of to use the language of the explication really count profoundly against a person's own good, and yet the person persists.

So to put this in a kind of pithy slogan, you might think that addiction is drug use that's gone wrong precisely because it's become self-destructive. And then the question is, why? Right. Why is a person using drugs self destructively? Okay, so we can come on to the why question, but you really want me to talk about the notion of a person's own good.

[00:30:36] Ellie: You can take them. Actually, yes, I do.

[00:30:39] Hanna: Okay. So the book spends a lot of time thinking about how to understand the idea of a person's own good, and one of the ideas that for me is really, really crucial is that for creatures like us that is self-conscious and self-reflective beings, our self-conception of our own good has to be partly determinative of our own good.

So we each of us have a sense of what we value and what we don't. What makes life meaningful and what bleeds it dry, what we want and what scares us or we despise right. And that conception has to be reckoned with in understanding what is and isn't good for a person, right? Because I think for self-conscious and self-reflective beings, it just is good to be able to live in a accord with your self-conception. That is a basic good for us,

[00:31:38] Ellie: I am totally with you on that.

[00:31:39] Hanna: okay, but it's not all of it. And the book really tries to make this point substantively, right? So we could be wrong about what's actually good for us. That doesn't mean that we can totally avoid talking to a person about their self-conception of the good, about the ways they might be wrong, but we can be wrong, right?

So there's this balance between, on the one hand, the self-conception being absolutely integral to understanding what's good for a person. And it's different between people and consequence, but also it not being exhaustive of what's good for a person, right? Because a person can be wrong about what is and isn't good for them.

So that objectivity is really core to the idea of a person's good that I develop in the book. Okay, so now with that in mind. Let's go back to your question about the person who says, actually Ellie, you are wrong when you tell me, when you've intervened in my life and told me that my drug use is a problem, it's not, it makes me happy, it makes me sociable. It's doing me good.

What are we to say? So the first thing is that there is not one thing to say. It's going to depend on the individual person, their own self-conception and what is and isn't good for them. And in particular, once you've seen that, you are also gonna have to have a substantive conversation with them, right?

So there's no, from the armchair delivering of verdict on another person's life. Right. We have to be actively involved in talking with them and trying to understand them, and really importantly, that doesn't mean that we can't question them, challenge them, that we have to believe everything they say.

That's part of a good, respectful, serious conversation with another person when you're worried about them and you're worried that they're not right about the role that drugs are playing in their lives, but you can't get past the need to have that conversation, and you have to take their own perspective into account, not just your own.

So that is sort of the theoretical answer to your question. But now there are two particular ways in which conversations with people with addiction can be especially fraught and complicated. So one is that we know that denial can be a feature of many cases of addiction, and this is another reason why the brain disease model is insufficient as an understanding of addiction because there's no room for denial in it.

Denial is a cognitive process. It's a kind of motivated irrationality to protect us against something that would otherwise cause us pain. So people with addiction can be in denial about any number of things. One is just sometimes there's a way of denying that the problems in their lives are due to drugs, they find other ways of explaining the problems.

But sometimes they can be in denial that the problems in their lives which they recognize are actually such given their values as to make it the case that drug use isn't worth it. So in a certain sense, they're in denial about their values. So you really then have to talk to them and really have a serious conversation about what their values really and truly are.

So that's one place where these conversations can be particularly complicated in relation to addiction. Another is what you might think of as addiction inflected adaptive preferences. And to elucidate this idea, I actually thought I might pull one of the quotes from the book to read to everyone.

[00:35:17] Ellie: Please do.

[00:35:17] David: Love that.

[00:35:18] Hanna: Okay, great.

[00:35:19] Ellie: You have so many good quotes and like excerpts from memoirs and novels in the book, so I'm so glad you're bringing this here.

[00:35:26] Hanna: Okay, good. So, I mean, it really is part of the book that to understand addiction, we have to start listening to people who use drugs in ways that are self-destructive. And that's part of what brings the panoply of explanations and factors into view. So this is a quotation from a patient of Gabor Maté.

It's from his book, In the Realm of Hungry Ghosts, and he calls the patient, Jake. Yeah, the coke's my life. I care more about the dope than my loved ones or anything else for the past 15 years. It's part of me now. It's part of my every day. I don't know who to be without it. I don't know how to live every day without it.

You take it away. I don't know what I'm going to do. If you were to change me and put me in a regular style life, I wouldn't know how to retain it. I was there once in my life, but it feels like I don't know how to go back. I don't have the, it's not the will. I don't have, I just don't know how.

Okay, so this is a really heartbreaking piece of testimony from a person who's been living with addiction so long that in some sense it is what his life is structured around. It is what he values. He doesn't know how to live or who to be note the identity connection here without using drugs and being an addict.

And so here. I think it would be absolutely wrong to say that this man is in denial about what his true values are. He knows what his values now are at this point in his life, but what we wanna say is that for his own sake, the values he has are not the values he ought to have.

Right, that his self-conception of his good isn't really good for him. And so that's very different from denial, but it's another place where especially in conversation with people with addiction who've been living with it deeply and profoundly for a very long time, there can be a stickiness, right. And what you want to do when someone says something like this is help them imagine and bit by bit start to live out a life which is different, right, which isn't structured around drugs, to help them find and shape an identity which moves beyond that drug anchored identity.

So here's a place where you might say, well, this really is his self-conception, but it's not good for him and I'm gonna talk with care and compassion and concern with him about that.

[00:37:58] David: Well, and what you just said, and thanks for sharing that really powerful quote. It highlights. The two Hs that ground your book, the Age of Heterogeneity, which is that different cases of addiction require different causal explanations. And just to give our listeners a sense of what you mean by that, you talk about things as diverse as cases of addiction that are caused by self-medication, by a desire for self-harm, by questions of self-identity.By denial and also by cases of brain pathology, right? Like these are all explanations that fall into that umbrella of heterogeneity.

But what you said also highlights the second age of your book, which is humanism, and that is that addiction is not. A problem that brains face. It's a problem that whole human beings with complex, rich inner lives have to deal with.

And that's why that reduction to neural circuits or brain chemistry misses so much of what is intuitive to anybody who has a relationship to addiction in the flesh, or who has dealt with family members or loved ones who struggle with addiction. And so I want to now ask you a question about how we should think about drug use in light of these two Hs, the heterogeneity and the humanism, because you make an argument that might strike a lot of people as surprising, if not counterintuitive, which is that drug use is voluntary.

Somebody who deals with addiction is voluntarily choosing to use the drugs that they're using. And normally for some of the reasons that you already talked about, we want to avoid this way of talking because it gets very close to the moralizing discourse It's a problem of the will. They have no self-control. There is no impulse control.

And you want to insist on the voluntary nature of this human behavior, and you use an articulation that I think is really useful and that is we should think about this as responsibility without blame. I want you to tell us what this is and how it might change the way in which we deal with addiction on the ground.

[00:40:22] Hanna: First, let me say something about the claim that drug use and addiction is voluntary because I use a very specific notion of voluntary here that I think is important, and I think it's also important to at least present some of the reasons why I say this. So the notion of voluntary here is a notion that comes out of psychology that contrasts flexible goal-directed behavior with habitual behavior understood as a sort of stimulus response style behavior.

And there is a lot of evidence that drug use in addiction is voluntary in the sense that it's flexible and goal directed and driven by how people or indeed animals, because some of this research has to do with animal models of addiction. So people or animals who use drugs are, no matter the state of addiction weighing decisions and considering sort of a range of factors and what options are available.

So voluntary is a specific notion of voluntary here, which involves flexible goal-driven behavior, goal-directed behavior, and the evidence for it is really the way in which if you change the options available, people will take them.

Right? So we know that for humans, and again, this is mirrored in animal studies, one of the most protective factors against addiction, and one of the most important aspects of recovery is the availability of meaningful alternatives to drugs. Because there's this very robust finding that if there are meaningful alternatives to drugs, people tend to take them or animals tend to take them.

So I look at that evidence quite carefully in the book, and I think it's important because one of the things I think we have to do is make sure that, first of all, we understand what we mean by voluntary, but second of all, that we're not resistant to it, simply because we're worried that if we start down on that track, we end up in this blaming place.

Right. Because in some sense, that's what's went wrong with the brain disease model of addiction. Right. We didn't take it seriously empirically and scientifically. We just were very concerned about avoiding a certain ethical outcome and we thought this was the solution. And not getting things right is never the solution.

We have to get things right and in a very profound way. Part of the point of the book is to say, look. Science is one thing, and ethics is another. And we have to think hard and seriously about ethics and our own role in our relationships with drug users and our own role in our stigmatizing attitudes.

And not just try to wash that away by making incredibly hyperbolic scientific claims, like everything's compelled, or it's all a brain disease or something like that.

[00:43:12] Ellie: Totally, and I, I think also what gets eliminated in that type of model. Is responsibility. Right? And so I really, really appreciated that. And I think I was craving it to some extent because I come from a family where there's a lot of individuals who've struggled with addiction. And in my own case, like my father has been part of Alcoholics Anonymous for many years, stopped drinking before I was born, but has identified as an addict ever since.

So, I mean, there's a lot to unpack there about ways, and you talk about this a bit as well in your book about how like those types of frameworks emphasize an addict identity beyond a pattern of drug use. But what I found in my own family scheme was that the addict identity was often used to completely eshoo accountability.

And so it was kind of, it's like if somebody appealed to that, then it was like, okay, well I can't hold you accountable for ways that you've harmed me or others. And so I think like this, just reading this was like drinking a fresh glass of water in the sense that I was just like craving, although craving, not in the irresistible desire sense because you get into that as well in the text.

Read the book if listeners wanna learn more about that. But I just really think I was like wanting something that made sense of accountability and responsibility without moving into that moral model.

[00:44:31] Hanna: Okay, good. Well, I'm so glad to know that it sort of spoke to you in that way. That's always lovely to hear. And yeah, so let's talk a bit about responsibility without blame, right? So, so we have this like falsely simplistic model, where we think if something's voluntary and you know. We don't like the behavior or we think it's wrong, or something like that.

So it's voluntary negative behavior, then someone's responsible for it, then we can blame them for it as if all of those steps are necessary and then the notion that it's not voluntary, that it's compelled, then serves to block all of those steps.

In ways, the idea of responsibility without blame that I develop in the book really also, if we hark back to the anecdote that I started our conversation with, it really is anchored in my clinical experience just as that anecdote was because in the context of working with people with personality disorders and addiction, part of what you need to do is get them to change the behavior that is so harmful to themselves and sometimes to others.

And the way to do that is to recognize that it is voluntary to a degree and engage their agency. So the sort of tools of answerability and accountability, right? Think of that as asking someone to take responsibility or holding someone responsible are really essential to recovery.

And you can see that in the use of contracts, right? That I talked about in that anecdote. Like what is a contract? Well, it's a formal mechanism for taking responsibility and making yourself accountable to the group to do what you say you're going to do. So it really is this lovely symbol of responsibility. But yet everyone in a clinical context, therapists and fellow group members alike, recognizes that if you wanna help each other take responsibility, the last thing you should be doing is blaming and punishing and judging and stigmatizing, right?

Because that's just going to destroy the relationship and make somebody feel terrible about themselves and like either they don't deserve to have a better life, they don't deserve to change. Or they don't have it within them to do that. So it's completely counterproductive to using responsibility in this forward looking, constructive way that you end up blaming and punishing and sort of expressing angry, entitled hostile attitudes.

So clinically, this notion of responsibility without blame is this idea of using responsibility out of care, and concern and respect and empathy. As opposed to using it as a license for you to be resentful and angry and blaming, and punishing, to put it in a very pithy way, I like to just say, look, there are kind of choices on both sides.

Like we hold somebody responsible when we think they have some kind of choice, some kind of voluntary capacity to control their behavior, but we have a choice in how we respond, right? We also have a voluntary capacity to control our response to a person who we're holding responsible. So that's really the model is to kind of stop this incredibly simplistic slide from voluntary behavior to responsibility, to blame as if this is just like an inevitability that we have nothing that we could possibly do to stop and to offer alternatives that can help people constructively, fashion relationships with people with addiction, and maybe help them to use less.

[00:48:06] David: And that's such an important wake up call for those of us. You know, Ellie mentioned her family. I have my own family relationships involving addiction for how we respond. I can say I do think a lot of us think that responsibility entails blame, and so decoupling those is an invitation to reflection on our part about what it is that our goals are in dealing with somebody who struggles with addiction.

And it, it just reminds me of something that I read now too long ago, that many people with addiction often hide the history of drug use when they go to the ER because they know doctors and nurses will treat them differently because even in medical context, there is they feel that blame, they feel those eyes sort of falling on them, and in many cases it translates into different care delivery and therefore different care outcomes.

So thank you for saying that. I think it's a really important moral message on which to end, but , Hanna, we want to thank you immensely for A, having written this work and b, coming to overthink to talk to us about it. It has been a pleasure to read and to chat with you, and we encourage our listeners and readers to check this book by Hanna Pickard.

What would you do alone in a cage with nothing but cocaine?

[00:49:27] Ellie: A philosophy of addiction.

Thank you so much, Hanna.

[00:49:29] Hanna: Oh, thanks so much for having me. It was a lovely conversation. I enjoyed meeting you both.

[00:49:35] Ellie: We hope you enjoyed today's episode. Please consider subscribing to our substack for extended ad free episodes, community chats, and additional overthink content.

[00:49:44] David: To connect with us, find episode transcripts and make one-time tax deductible donations. Go to overthink podcast.com. You can also check us out on YouTube as well as TikTok and Instagram at Overthink _Pod.

[00:49:56] Ellie: We'd like to thank our audio editor, Aaron Morgan, our production assistant, Bayarmaa Bat-Erdene and Kristen Taylor, and Samuel PK Smith for the original music. And to our listeners, thanks so much for overthinking with us.