Alone in a cage with cocaine

Summary

Podcast Summary: "Alone in a Cage with Cocaine"
The Gray Area with Sean Illing (Vox) | Guest: Hannah Pickert | March 9, 2026

Overview of the Episode

This episode explores the complex nature of addiction, challenging conventional models like the "brain disease" and "moral failure" paradigms. Sean Illing is joined by philosopher and clinician Hannah Pickert, author of What Would You Do Alone in a Cage with Nothing but Cocaine?, to discuss addiction through the lenses of agency, responsibility, identity, and societal context. The conversation seeks nuance beyond simple explanations and critiques the black-and-white thinking pervasive in public discourse and addiction science.

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Key Discussion Points & Insights

1. The Metaphor of the Cage and Cocaine

• Purpose of the Book Title:
  • Pickert’s title is meant to spark reflection on how environment shapes behavior, referencing both the human dimension of addiction and historical animal experiments that interpreted behavior as compulsion.
  • Quote (Hannah Pickert, 03:41):
    "Being alone in a cage with nothing but cocaine is a kind of good metaphor for the social, economic, and material circumstances that...many people with addiction live in."
  • The infamous "rat in a cage with cocaine" experiments led to the idea of drugs hijacking the brain, but Pickert encourages us to use our imagination: Would we also overuse cocaine out of desperation, not because of pharmacology alone but due to isolation and suffering?
• Reframing Addiction Science:
  Pickert insists that we must move beyond reductive models and understand addiction’s true context.

2. Debunking Common Models of Addiction

• The Moral and Disease Models:
  • The moral model, though outdated, still lingers in culture.
  • The brain disease model, popularized since the 1990s to combat stigma, brings its own issues and oversimplifications.
  • Quote (Hannah Pickert, 06:26):
    "Those misconceptions, in my view, span the political divide...My ultimate concern is the way in which the rest of us misconceive. It actually impacts the treatment and attitudes we take towards people with addiction."
  • Pickert argues for a “middle ground”: seeing addiction as a behavioral disorder linked to, but not reduced to, brain pathology.

3. Defining Addiction and Disease

• Addiction as 'Drug Use Gone Wrong':
  • Ordinary drug use (caffeine, alcohol, nicotine) is widespread and often beneficial, but addiction is characterized by persistent use "deeply against your own good" despite clear costs.
  • Quote (Pickert, 11:32):
    "I would say something becomes an addiction when you persist in doing it, even though it’s really deeply against your own good. But notice that persist in doing it doesn’t entail you can’t stop."
• Disease? Brain Disease?
  • Pickert distinguishes between being predisposed to addiction (by gene or environment) and actually having a disease.
  • There is no single "addiction gene" (14:32). Risk factors (genetics, adversity, socioeconomic status) affect likelihood, but do not amount to disease.

4. The Gray Area Between Use and Addiction

• Spectrum of Behavior
  • Not all habitual uses (e.g., a glass of wine at dinner) signify addiction; rather, addiction is about destructive consequences and loss of personal good (17:33–18:43).
  • Quote (Pickert, 18:43):
    "It really is the case that...the costs to a person of drinking or using a drug are really profoundly undermining their good for them."
  • Acknowledges “gray areas” where the distinction is unclear, challenging black-and-white thinking.

5. Agency, Responsibility, and Free Will

• Challenging 'Either-Or' Thinking
  • Agency isn't absolute or absent—it's complex and individualized (24:39). Most damaging is the idea that addicts are purely compelled, lacking any agency.
  • Quote (Pickert, 24:39):
    "It's not like they have agency or they don't...it's complicated and impaired in different ways for different people."
  • Recovery is an agential project requiring personal effort and social support, not a medical “cure.”
• Subjective Experience of Craving
  • Cravings and compulsions vary in intensity and meaning; understanding their roots can suggest different types of support (27:19–29:30).
  • Quote (Pickert, 27:19):
    "Some people crave drugs...but not that intensely...Other people do feel really overwhelmed. And I guess...the question...is...why?"

6. Root Causes: Beyond Pathology

• Multiple Explanations for Addictive Behavior
  • Isolation, psychological distress, self-harm/suicidal impulses, and identity all play roles.
  • Quote (Pickert, 32:31):
    "I think that people use drugs to deliberately self harm and sometimes to commit suicide...without having to be violent towards themselves in direct physical ways."

7. Responsibility vs. Blame

• Distinguishing Concepts
  • Recognizing some level of choice doesn’t mandate blame. As caregivers, clinicians, or loved ones, we can hold people responsible with care and respect, avoiding hostility and condemnation (36:42–39:12).
  • Quote (Pickert, 36:42):
    "You really can think of practices of answerability and accountability…conducted with care, concern, respect."
  • Practical challenges remain, but the parental analogy highlights possible approaches.

8. Identity and Recovery

• Addiction as an Identity/Story
  • Changing the narrative of self—breaking from the “addict” identity—is pivotal but very hard to do alone (39:19–42:13).
  • Quote (Pickert, 40:56):
    "Identity can be so fundamental...It really does then require the construction of a story where I was an addict and now I'm not, and I'm somebody else."
• Role of Groups and Social Support
  • Group therapy (AA, support groups) is transformative by fostering belonging, accountability, and helping individuals internalize a new, non-addict identity (42:13–46:12).
  • Behavioral contracts and visible, tangible support often make the difference, undercutting the pure brain-disease narrative.

9. Moral & Societal Obligations

• Personal and Collective Responsibility
  • On a personal level, we owe those struggling with addiction empathy, care, and sustained relationship according to our roles (patients, friends, family, colleagues).
  • On a societal level, we must address structural conditions that foster addiction: social injustice, poverty, isolation.
  • Quote (Pickert, 46:59):
    "As a society we are responsible for allowing conditions which we know addiction flourishes in to continue...We have built the cage, so we have to do what we can to open the door to that cage." (49:15).

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Memorable Quotes & Moments

• On the insufficiency of contemporary models:
  "The truth is that none of those ways of talking about addiction feel quite right. They're too simple, too certain about what's going on inside people's heads." (Host, 02:52)
• On the lived reality of addiction:
  "You can't cure a brain disease with a piece of paper...What’s going on is that people went away with this piece of paper, which on the one hand was a symbol of them taking responsibility, but on the other hand was like a concrete manifestation of the care and support of the group that they could just have in their pocket." (Pickert, 45:41)
• On collective responsibility:
  "We have built the cage, so we have to do what we can to open the door to that cage." (Pickert, 49:15)

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Notable Timestamps for Key Segments

• 03:41 – Pickert’s explanation of the book title and metaphor
• 06:26 – Critique of moral and brain disease models
• 14:32 – No “addiction gene,” but risk factors exist
• 17:33 – Distinction between enjoyment, habit, and addiction
• 24:39, 27:19 – Agency and phenomenology of cravings
• 32:31 – Self-harm and suicide as drivers of destructive drug use
• 36:42 – Separating responsibility from blame
• 40:56 – The challenge of changing identity in recovery
• 42:13 – The transformative role of groups and behavioral contracts
• 46:59 – What society owes to people with addiction

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Tone & Language
The conversation is analytical yet deeply humane, with Pickert blending philosophical clarity with clinical wisdom. Illing brings candor and vulnerability to the discussion, grounding abstract ideas in everyday life and personal experience.

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For Further Reference

• Hannah Pickert's book: What Would You Do Alone in a Cage with Nothing but Cocaine? (Princeton University Press)
• www.hannahpicker.com – Further writings and articles

This summary is intended for listeners seeking an in-depth but approachable guide to the episode’s major ideas, notable moments, and actionable insights about addiction, agency, and societal responsibility.

Transcript

[Host]

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[Host]

Okay, imagine this. You're stuck in a room all by yourself. Nothing on the walls, no windows. You've got no phone. Your pockets are empty. No entertainment, no distractions, no input of any kind. You are stuck in a room alone with absolutely nothing. Except for a giant pile of cocaine. Maybe you've never done drugs in your life. Maybe you think people who use cocaine are morally suspect. Maybe you think people who use cocaine have some kind of disease. But one thing is for sure, you are stuck in a room for a

[Sean Elling]

long time with nothing else to do. I'm Sean Elling, and this is the gray area.

[Host]

Today's guest is Hannah Pickert. She's a philosopher, a clinician, and the author of the most perfectly titled book I have ever seen. What would you do alone in a cage with nothing but cocaine? At first glance, the book looks like it's about addiction science. Lots of stuff about rat experiments and brain scans and neurotransmitters. And it is about those things, but really it's a book about agency, about

[Sean Elling]

how much control people have, what kind

[Host]

of responsibility makes sense, and how badly we misunderstand both when it comes to addiction. I mean, what really is addiction?

[Sean Elling]

A disease?

[Host]

A moral failure? Has our brain been hijacked? Or do we just have to make better choices? The truth is that none of those ways of talking about addiction feel quite right. They're too simple, too certain about what's going on inside people's heads. But getting it right, that feels really important. Which is why I'M glad to have Hannah on the show to talk about it.

[Sean Elling]

That title, is it intended to be a rhetorical question? Because I gotta say, if I was

[Host]

alone in a cage.

[Hannah Pickert]

Yeah. What would you do?

[Sean Elling]

Nothing but cocaine.

[Host]

I would do a lot of cocaine, probably.

[Hannah Pickert]

Right.

[Sean Elling]

Is that bad? Is that good or bad?

[Sponsor Voice]

No.

[Hannah Pickert]

No. So, I mean, what you have just done is exemplify.

[Sean Elling]

What else are you gonna.

[Hannah Pickert]

Okay, so what you've just done is exemplify the point of the title. Right. So I want the title to do two things. One is to kind of stop people and make them actually think for themselves about what the effect of a certain environment on their drug taking would be. Because being alone in a cage with nothing but cocaine is a kind of good metaphor for the social, economic, and material circumstances that. That not all, but many people with addiction live in. Right. So the book is, in ways, quite iconoclastic. Although it's deeply connected to addiction science, it also really makes the case that to understand addiction, we have to think way more humanistically and psychologically and use our imaginations. Right. So the book is really supposed to make the reader stop and think for themselves about what they might do in relation to drugs. Right. In a certain context. But it's also a shout out to the history of animal models, which is a really important part of addiction science, because one of the seminal early experiments about addiction literally put rats alone in the cage with nothing but cocaine to see what they would do.

[Sean Elling]

Yep.

[Hannah Pickert]

Yep. Do you want to guess what the rats did? We know what you would do. What do you think the rats would do?

[Sean Elling]

Cocaine. Right. Lots of it.

[Hannah Pickert]

Right, exactly. But I guess what's so interesting about that history is that that was really interpreted as providing evidence for a brain disease model where we see the rat's drug taking behavior as stemming from the way in which cocaine can hijack the brain and compel them to use. Well, when we do the imagination in our own case, it's not like you're imagining doing a lot of cocaine alone in a cage with nothing el there, because you're thinking of cocaine as hijacking your brain. You imagine doing cocaine because you're living in isolation and you're bored and you know there's nothing but suffering for you in that cage. And cocaine is the only thing that offers relief. So it's a very. In some sense, it allows you to, by yourself, generate an alternative hypothesis about what might be going on for the rats than the one that, at least traditionally, that experiment led people to conclude

[Sean Elling]

what compelled you to write the Book. Was there something that bothered you about the way people talk about addiction or think about addiction that felt wrong or incomplete or maybe even worse?

[Hannah Pickert]

Basically, I think there are deep misconceptions about addiction, both in public discourse and in addiction science. Those misconceptions, in my view, span the political divide. They're really to be found everywhere. And having spent time working with people with addiction, I guess, in some sense, my ultimate concern is the way in which the rest of us misconceive. It actually impacts the kind of treatment and attitudes that we take towards people with addiction themselves. And, of course, in some sense, the misconceptions that I want to correct really are the idea that there are two and only two different kinds of models or approaches we could take to addiction. One is this antiquated moral model, which basically just sees drug use and addiction as no different from ordinary drug use and contends both is morally wrong. No scientist or policymaker really holds that model, but it really has contaminated, I think, the cultural air. I think all of us, at some level, have just little sort of unconscious bits of that model in us that can come out, and then the supposed antidote to it is the brain disease model of addiction, which really gained ascendancy in the 90s and really has positioned itself as a way of combating the stigma that has been associated with the moral model. But the brain disease model is rife with its own problems and also, in my view, not doing what we need for people with addictions. So the book really tries to hold something new and distinctive and sort of much less black and white and simplistic, which, you know, is kind of a middle ground.

[Sean Elling]

So do you think of addiction as a disease in any conventional sense of that term? Or do you think that that. Or do you think that term is actually obscuring more than it's revealing about the phenomenon?

[Hannah Pickert]

Yeah, so. So what you just did was move from brain disease to disease. And so, you know, just to be a pedantic philosopher for one moment, I definitely think it's.

[Sean Elling]

Did I make a mistake?

[Hannah Pickert]

No, no, no, no. I just.

[Sean Elling]

I was rolling on the cocaine question.

[Hannah Pickert]

I know, I know. That was like, a plus. You got an a plus there. Okay. So I think addiction is not a brain disease as that model has traditionally been constructed. And that means that we should not understand addiction as pathology in the brain, which is the cause of compulsive drug use. Okay. So this is a very, very specific way of interpreting what it is for addiction to be a brain disease. That said, there are many diseases that Aren't brain diseases. So if you want to think about whether addiction is a brain disease, we need two things. We need to have an understanding of what addiction is, and we need to have an understanding of what we mean by disease. And without those two components, Right. We're just sort of talking loose. Right.

[Sean Elling]

Well, as simply as possible, then how would you define an addiction? And how would you define a disease?

[Hannah Pickert]

So I think that to just give you a very easy gloss to begin with, we need to think of addiction as drug use gone wrong. So I actually think we need to start with the idea that a lot of drug use is perfectly ordinary. Caffeine is a drug. Alcohol is a drug. Nicotine is drug. The majority of people in our society use drugs regularly in ways that bring them benefits, don't carry tremendous costs. And we accept that. It's very easy for us to understand psychologically why people use drugs in that way. Right. This is a. This is a behavior, an ordinary human behavior that's been with us as a species probably since before 12,000 BCE right. It's a deep part of our heritage as humans. Okay. So there's drug use, ordinary drug use. And then there's something that happens when we start to worry that somebody is struggling with addiction, which is that all of a sudden, alongside the benefits of drugs, these costs ratchet up and we're

[Sean Elling]

all start to tilt.

[Hannah Pickert]

Right? Right. We're all familiar with the kinds of costs that can happen. Right. People's lives go in disarray. They. They lose relationships, they lose family, they lose jobs, they lose housing.

[Sean Elling]

So if I may jump in, Hannah, if you don't mind. So would you say then that maybe something becomes an addiction?

[Hannah Pickert]

Yeah.

[Sean Elling]

When you can no longer stop doing it, even though it's like, materially, spiritually, emotionally damaging your life?

[Hannah Pickert]

I would not quite say that. I would say something close to that. I would say something becomes an addiction when you persist in doing it, even though it's really deeply against your own good. But notice that persist in doing it doesn't entail you can't stop. The idea that you can't stop could be one reason why you persist. But I think there are other reasons why people persist. So if we come back to how to understand addiction, Right. It's drug use that has this feature, which is that it persists despite these really obvious, really severe costs in ways that are deeply undermining of a person's own good. Okay, so what is that? Well, it's a pattern of behavior, drug use. So the natural way, I'm Inclined to label addiction, if you force me to, is as a behavioral disorder. Because I think it's really important that we keep our eyes squarely on the idea that addiction is a kind of behavior, right? It's drug use gone wrong. And then the question is, what explains that behavior? Right? So for me, that's the really interesting question, right? How should we understand this behavior? Why do people use drugs so self destructively? Right. The hypothesis that they can't help it is one hypothesis, as I say, that I think there are others. But does a behavioral disorder count as a disease? Well, I guess my sense is at this point I just want to say, well, it depends what we mean by disease and what we want that concept to do, right? So in America you might want the concept of disease to apply to something like addiction because it's important, it's categorized as such, so. So that people get treatment through insurance. In which case it's very easy to fashion an idea of disease whereby all behavioral disorders are covered by it. But we're not sort of answering a deep question about addiction by doing that.

[Sean Elling]

And there's the behavior part, which I'll set aside for just a second because I think it gets at sort of like the core of what you're doing in the book, which is why I want to ask you this question about predispositions, right? Are some people more predisposed to behave in ways that we would call addiction? Right. Like something, alcoholism runs in my family, like across several generations. And in some cases, like very, very severe. Like, you know, life ending severe. And you'll, sorry, you will hear people say, thank you, but you'll. What you hear all the time is like, yeah, I've got the gene. I got the, you know, it's, it's

[Host]

in my family, you know, I got the gene too. Is that a thing? Is there, is there an addiction gene?

[Hannah Pickert]

So I'm not a geneticist, but my basic take on the last systematic review that I read is that the answer to that is no. There are a number of genes that predispose to a range of mental disorders. Okay? So there are genes that predispose towards mental disorder, I believe are not yet discovered to be genes that predispose only towards alcoholism or even to addiction more broadly, to substance use disorder more broadly. But I mean, I take it at the heart of your question is the idea that, look, if we think there are predispositions or factors which increase the probability of somebody becoming addicted, which there are, it's genetic, but also sociocultural, right? So we Know that childhood adversity and socioeconomic disadvantage and comorbid mental disorders are all associated with increased risk of addiction. Right. So all of these things predispose. What does that mean? Does it mean addiction is a disease? It doesn't. It means that the explanation of how somebody, how somebody might end up using drugs in ways which are so self destructive is going to include these other factors which increase their background risk factors level. Right? So just in general, we don't think that a risk of a disease is the same as a disease. Right? So if you smoke, you put yourself at much higher risk of cancer. We don't think smoking is cancer. It just makes it more likely you will get cancer. And the same is true of all of these different factors, genetic and environmental, which predispose. Okay, so that doesn't show it's a disease. It just shows we can track what increases the likelihood of developing the condition.

[Host]

Can I poke at something if you don't mind?

[Sean Elling]

Yeah, and I guess I'm doing the annoying philosophy thing a bit here, but you'll appreciate it. You're, you're a fellow.

[Hannah Pickert]

Join me.

[Sean Elling]

And you say something. When you say something like, like trying to determine when something becomes bad for you or against your own interest or, or your, your, your good as you define it. It's a little slippery, right? Like, so I'm not an alcoholic, but I like red wine and I like to have a glass or two with my dinner. And when I'm cooking, I don't drink excessively. You know, I, I'm pretty health conscious, right? So if anything, like undercuts that, I'll, I'll back off. Right? But I, I'll put it this way. I find it very difficult to have dinner without having a glass of wine. I don't like it. I do it sometimes, often, but I don't like it. Would you say someone like me in that case is like, am I on the spectrum of addiction?

[Hannah Pickert]

So if I put on my clinical hat, Sean, I haven't yet done a sufficient interview of you to really, really make a judgment about your own inner life in relationship to alcohol. But I'm nonetheless going to venture, I guess, based on what you just told me. And the answer is, of course, of course not. Right. So the pattern you just told me involves finding value in drinking, which is the kind of value many people find. Right. I take it, it's social. You enjoy it as a way of winding down or unstressing at the end of the day. It has a kind of ritual to it. It's it doesn't sound like the amount you're drinking is something which is interfering with other things in your life that you really value. Right. You haven't talked to me about it affecting your family life or making it difficult for you to get up and do your work the next day, or, you know, you're finding over the course of the day you can't focus on your work. All you're doing is thinking about getting home and having that drink.

[Host]

So.

[Hannah Pickert]

So the way in which I think about addiction is that it really is the case that it looks that the costs to a person of drinking or using a drug are really profoundly undermining their good for them. Now, I do need to tell you what it is for something to be good for someone, but it seems pretty clear like the kind of drinking that you're engaged in, if you've been honest with me, isn't profoundly undermining your own good. Right? And I also think that part of the challenge for us in thinking about drugs and addiction is to recognize that things are gray and there's a lot of uncertainty and a lot of ambiguity. And in ways like, you know, if we go back to the misconceptions that I said I wanted to correct, part of it has to do with the rigidity and black and white nature of our thinking about addiction. And I think it just is true that although there are some people where there's just no question they're addicted, some people there's just no question. There's not. There's a gray area, Sean, a metaphor you might appreciate in between where it's tricky to make those decisions. But yet that's what we must be called upon to do.

[Host]

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[Sean Elling]

I want to ask you about agency and responsibility. And I want to ask you, how much agency do you think an addict has? Right? Like, what is. I'm not sure how much free will any of us have, even under the best of circumstances. But that's. That's sort of a separate conversation. But what does free will look like in the mind of. Of. Of an addict? Like, how much. How much freedom of choice do they really have?

[Hannah Pickert]

Okay, so I'm not going to use the term free will because that's a philosophical can of worms, but we can talk about the kind of normal agency that we all enjoy. And the first thing to say to your question is that again, it can't be black and white, right? It's not like they have agency or they don't. Yeah, right. It's clearly complicated and impaired in different ways. But really importantly, it's complicated and impaired in different ways for different people. So typically we're interested, I think, in questions of agency partially because we want to know whether we can hold somebody responsible or to blame. And of course, we'd all like there to be a simple yes, no answer because then our work is done for us, right? We can just pretend that we know how to be and how to respond. But I think the actual truth is that it's very, very different in different cases with different people, possibly at different times in their lives and their history with drugs, possibly in relation to different drugs, in relation to the social context and the level of support and treatment that they're able to access. So what I will say is that the kind of really toy model of addiction where we should see drug use as compelled in the sense that a person just can't do otherwise. Right. That they're driven by irresistible cravings such that no alternative is possible is something that I do think we need to reject. Agency can be compromised while still being evident to some extent while still being present. And that's really important because people with addiction need to exercise their agency to get better. Right? We don't have a medical cure. You can't just, you know, take a pill that cures you. There's actually a very arduous process of finding ways to stop and finding ways to rebuild your life such that other meaningful things fill the space that drugs used to occupy. And that's an agential project. Right? That's a big Thing to be asked to do.

[Sean Elling]

Well, that's what I'm trying to pull at. To go philosophy nerd again, I guess. The phenomenology of choice, the. The cravings, the. The habits, the. The compulsion, right? Like, when you're. When you're feeling the pull of those things are those forces. Choosing doesn't really feel like choosing, right. It's, like, so overpowering, right? Like, so how do you explain to someone that even. Even in those moments, there is still agency? Even if, like, subjectively, it feels like you don't have it? Like you're being almost like a, like, puppeteered, you know?

[Hannah Pickert]

Again, I want to push back against what is certainly like the picture of cravings and desire that dominates our cultural understanding, but I think is a toy model and which loses a lot of the complexity. Some people crave drugs at different stages of their addiction very, very regularly, but not that intensely. They don't say the cravings are absent, absolutely dominant, right? They just say there's a lot of them and they have to manage things over a period of time, and that's difficult. Other people do feel really overwhelmed. And I guess for me, the question in those moments is always, why, right? Like, what is it about the drugs that you're craving? And there really are a number of different reasons why people with addiction, cravings, crave drugs. So, okay, why does all this matter? Right? Why do this sort of panoply of answers to the question, why would someone feel so overwhelmed by craving matter? And the answer is that it takes us away from just being focused on this simple idea. Well, like, if you're overwhelmed, you can't do it because, you know you can't not use. Because once you understand where that craving is coming from, you see what might help you not use, right? So it's going to be very, very different in all those cases. If somebody is craving drugs because they're really scared of withdrawal, what do we need to do? We need to provide them with treatment so that they don't go into withdrawal even though they're stopping using drugs. We can do that. If somebody is craving drugs because of the role drugs has for them and helping them manage psychological pain and distress, we need to give them another way to manage psychological pain and distress. Right? Someone is craving drugs because of the way addiction is so deeply embedded in their identity, part of what they need is a new identity. Right? And so those different routes to help are ways in which we can make it much more easy for someone from that subjective perspective to feel like a craving is Something they can manage.

[Sean Elling]

So let me ask you this, Hannah. So we have this unhelpful binary, right? Like either someone is like a hapless victim of a, of a brain disease or they're a moral failure of some sort. You want to, you want to toss that out or complicate that picture, right? What do you want to replace it with? Like what, what is it? What is a more like rich and accurate and humane way of, of framing the phenomenon of addiction and that, that will actually lead us to both like treat people who are struggling with it more compassionately, but also just help us understand what we're actually looking at as opposed to just the caricatures.

[Hannah Pickert]

I'm going to say something which is kind of like a background piece and then answer the question directly. Right? And the background piece is that I think we do just need to be real that moralism about drugs is deep in our society and that it's wrong that there's nothing intrinsically, morally wrong with using drugs. Of course there are contexts in which you do something wrong when you use drugs. But we do need to remember caffeine is a drug. A glass of wine is a drug. Nicotine is a drug. There are many, many contexts. The drugs we use in medical settings are the same chemical drugs as the drugs we find on streets. So intrinsically there's nothing morally wrong with using drugs. And we, we just need to get real about facing that kind of knee jerk tendency that's so rampant in our society to be moralistic and condemnatory about drugs in this kind of background, shadowy way. But then once we've done that, this takes us back to the idea of addiction as a behavioral disorder. So I do think that again, very crudely, we see addiction as drug use gone wrong. Drug use that is persistent, existing despite evident and significant costs in ways that are really destroying a person's life really profoundly against their own good. And then the question to ask is why? Why is someone behaving that way? And when we ask that question, we get different answers for different people. And that's so important. I appreciate that we all like neat, clean, black and white reductive answers, but if we're not honest about that panoply, we don't see the different ways we need to think and be to help the different people.

[Sean Elling]

What are those different answers that you get?

[Hannah Pickert]

So some of that we've kind of touched on already in relation to craving.

[Sean Elling]

Yeah, yeah, the isolation, disconnection.

[Hannah Pickert]

So I think some people use. Right, they use drugs because they were really in contexts of Deep misery. Misery and suffering where they're isolated and there aren't other things to help them. And it's the only thing that provides some relief. Connected to that is the idea that drugs can then actually be something that they're almost in a relationship with in that context. Right. So an attachment.

[Sean Elling]

Yeah.

[Hannah Pickert]

Self identity. Some people use drugs because they identify as an addict and that's what you do if you're an addict. You use drugs in ways that are self destructive. Right. So the interesting question there is how people get stuck in that identity and why it might have value to them. There's another explanation I think is incredibly important to talk about more than we do. So given that you've given me this opportunity, I'm going to put it on the table and that is that I think that people use drugs to deliberately self harm and sometimes to commit suicide in ways which allow them to do that without having to be violent towards them themselves in direct physical ways, which people can find very difficult to do while yet harboring intense desires to kill themselves or to self harm. And I think this is an aspect of human psychology we're incredibly bad at talking about. And we just need to start getting more serious about making space to think about self harm and suicide generally in mental health and psychology, but also in the way that can be an explanation a person using drugs in such a self destructive way.

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[Host]

Well, I. I think we have to

[Sean Elling]

at least address the question of all right, given everything you've said, how do you. How do we treat this right? Well, what. What is the. What is the responsible approach? Right? I mean, you. How do we understand someone as being both responsible in some sense, but also not worthy of blame or condemnation, Right? How do we. Because blame and responsibility just are just tangled up with each other. It's hard to separate them in your head, but it seems like we kind of need to somehow.

[Hannah Pickert]

So the question you're asking is that if we're acknowledging some kind of agency which comes with a kind of responsibility, how do we avoid all of that punishing, hostile, punitive stuff? Okay. And I guess for me there's like a conceptual and a practical part of the answer to the question, right? The conceptual bit is how to articulate an idea of responsibility and an idea of blame such that they're distinct. And the practical bit is like, how do you actually do that in practice, right? Like when you're trying to hold someone responsible, how do you, for something that is upsetting you or harmful, how do you do that without blaming them? And I guess I actually think that, surprisingly to me, as a philosopher, the conceptual trick feels to me easier to pull off than the practical trick. The way to understand the conceptual trick is just this. In a kind of slogan. We attribute responsibility when we think there is some kind of choice, some kind of agency. But just like there's choice or agency in how that person is behaving. There's choice and agency in how we're behaving. And I see blame as really the idea that we take ourselves to be entitled to make moral judgments and behave in punishing and hostile ways. Right. And we don't have to do that. Right. We have a choice, just like they have a choice. So you really can think of practices of answerability and accountability, which are ways of holding responsible as conducted with care, concern, respect. This is something I had to learn to do as a clinician, but as a really easy way to, like, land it for, you know, many people in ordinary life. Think of how you are with your teenage children when they are behaving in ways which are really not okay. And you need to help them learn not to do that and hold them responsible. But you don't become hostile and punitive and condemnatory in their character and blame them. Like, as a parent, you're trying to do this because you care about them and you want them to learn not to do this. And, you know, like, the. The. The emotional affect and attitudes are good. So I feel like there is a place in many of our lives where we can land this clinical idea and sort of see how those concepts of responsibility and blame are distinct.

[Sean Elling]

You've used the word identity a few times here. And, you know, when I think of identity, I think of a story.

[Hannah Pickert]

Say more.

[Sean Elling]

Our identities, in many ways, are.

[Hannah Pickert]

Oh, okay. Yeah.

[Sean Elling]

Our identities are stories we. We tell ourselves about ourselves. And they are stories that are affirmed in various ways by the people in the institutions around us. And I bring that up because I wonder when it comes to identity, like, how important it is for someone who's struggling with addiction or trying to overcome it, to tell themselves a different story about themselves.

[Hannah Pickert]

Yeah.

[Sean Elling]

A new story in which they are not their addiction. A, how important is that? And B, how difficult is that? And how much of that can you do alone? And. And how much of that requires support around you? Because one of the shitty things that happens to anyone, and I think we've all experienced this in different ways. If you're trying to change, you're trying to be a different person, a better person.

[Host]

Not a different.

[Sean Elling]

A better person. And everyone around you continues to remind you of the you used to do that you're trying to not do. And it's very dispiriting, you know, like, I. I was. I've, like, always sort of inclined towards pessimism, you know, and I'm trying to, like, be less pessimistic. And every time someone I know is like, there you go. You're so, you know, you're so. You're so pessimistic. Drives me nuts because they won't let

[Host]

me get out of that story.

[Hannah Pickert]

Right.

[Sean Elling]

The story of me as a pessimist when I'm, you know, I'm trying to rewrite it.

[Hannah Pickert]

You seem a very optimistic. You know what I'm saying, though? You seem a really optimistic person to me, Sean.

[Sean Elling]

Thank you. Finally, somebody sees me.

[Hannah Pickert]

I really. I see that in your future. It's okay. I really do.

[Sean Elling]

Thank you.

[Hannah Pickert]

The. Actually, I mean, I was making a joke, but I want to say the fact that you do this podcast in today's time, I actually do see that in your future. Like, I see that that's a optimistic thing to do. So thank you for doing that. So the answer is. The answer to everything is yes, yes, yes. I mean, I do think. I mean, I think all of the different things that I mentioned can be very important to understanding someone's addictive relationship with drugs. But I think identity can be so fundamental, and it really does then require the construction of a story where I was an addict and now I'm not, and I'm somebody else. Right. So there's both. That transition, how did I get from there or then to here or now, and then there's that, and who am I in the here and now? You know, the answer is that nobody can do the work of telling that story, making those changes, constructing the new identity for anyone else. But we can support and help way, way more than we do.

[Sean Elling]

Is that why things like AA and group therapy seem to really do a lot of good for people? Is it about having that support structure and the social connections and I guess the. The accountability, the mutual accountability? I mean, is that something you've observed in your clinical.

[Hannah Pickert]

Absolutely. Absolutely. So, I mean, I just. I love groups. I'm a groupie. I think, like, you know, many people don't like to do group therapy. They're scared of it. But actually, groups are where it's at. Like, groups are so powerful. They make so much change for people. They're just wonderful. Yeah. So what does a group do? Well, the first thing it does is that it gives you a place to belong, where you get support, where, yes, there's accountability, but there's a community and a shared endeavor, and that's hugely valuable. But also to be part of that group, you need to be committed to not using. Those are the norms of therapy groups for addiction. I mean, there's divergence between how strict people are and how different groups handle lapses and so on. But the basic thought is that to be a member of this group, we are committed to making a change in each of our lives and collectively away from drugs and towards a different sense of self, a different possibility for our futures. And so if you care about the group and you want, as it were, those connections and that sense of belonging, you kind of have to identify as a person who's no longer using, right. Who's no longer an active addiction. When I was working clinically in group, we used behavioral contracts to help people stop using drugs self destructively, right? So to do really serious emotional psychological therapy, you have to not be using drugs because you simply can't get in touch with your inner self and your feelings if you're always high, right? So it's kind of like a very first step, right, Just to get people to come off to handle their addictions so that they can then do in ways the harder work. I know that might sound funny, but it's harder to do the emotional and psychological work for many people than it is to, to stop using. And prior to being in this group, like most of us, I was just like, oh yes, it's a brain disease. People are compelled, they can't do otherwise. And the way we used to work with people in group is get them to write a behavioral contract where they take a blank sheet of paper and they write on it something like, I, Hannah, will not use drugs, and if I do, I commit to making a support call to somebody else in the group or to using support in my family life to help me not do it. And they would sign it publicly and then we would sign it and we would write messages of support. Things like, you can do this, you deserve this, I'm thinking of you. I know it's going to be hard, but you know, I can't wait to see you next week in group and hear how, how it went. And people would go away with this piece of paper, which sometimes they like carried everywhere with them and read repeatedly. I'm not saying it worked for everyone, but quite often they came back and for the first time potentially in decades they hadn't used. You can't cure a brain disease with a piece of paper. That's not the mechanism by which we fix someone's brain. So what's going on is that people went away with this piece of paper, which on the one hand was a symbol of them taking responsibility, but on the other hand was like a concrete manifestation of the Care and support of the group that they could just have in their pocket. It was just so meaningful to see that. Right. So I really do think the power of groups and sort of thinking about how they can be a mechanism for individual change is just so important and something that we don't tap into enough when we're thinking about how to address addiction.

[Sean Elling]

That's beautiful.

[Host]

I'm just gonna ask you one more

[Sean Elling]

question, if you don't mind. It's kind of a big question, maybe an unfairly big question. You can answer it if you like.

[Hannah Pickert]

Yeah, okay.

[Sean Elling]

Or not. No, you shouldn't be. Or you can not answer it. Or you can just do what politicians do and just answer the question you would have preferred to have been asked.

[Hannah Pickert]

Do you know, as a philosopher, I'm so bad at that. Ask the question.

[Sean Elling]

Because it's. It's. It's. It's not a scientific question. It's not a clinical question. It's really a moral.

[Hannah Pickert]

Okay.

[Sean Elling]

Question or political question, really. And it is. What do you think we as a society owe people struggling with addiction? What are. What are our obligations?

[Hannah Pickert]

Let me start just by answering that personally. Okay. So there are people in all of our lives who struggle with addiction. I mean, rates of addiction are high. And I do think we owe at least the chance for relationship and care and compassion and empathy. Right. When people really are in our lives, the exact contours of that. How much. What the limits are are really going to depend on the nature of the relationship. Right. And this is because this is true with everything. Right. So what I owe a colleague is different from what I owe a patient, which is different again from what I owe my children. Right. Or what a child owes a parent. Right. So there are obligations. Relationships come with obligations. And that includes being there for people and doing what you can in moments when there's the potential for real rupture. And there's a lot of hurt and a lot of pain for many relationships anyway. So I don't say this is easy, but I do think we're on the hook for certain things just in virtue of being in those relationships. As for society, I think that what's clear is that a lot of the injustices in our society which we permit, at least insofar as we turn a blind eye and don't actively try to correct. If we go back to your notion of being disposed to addiction, they predispose to addiction. And that is therefore something that I feel as a society we have to take some responsibility for. Now, of course, that's not going to be true of everyone with addiction. But when we're talking about social and political context, we have to paint with a broad brushstroke. And the basic fact is that I think as a society we are responsible for allowing conditions which we know addiction flourishes in to continue. And so that means we build the cage. That's a beautiful metaphor and I wish I had said it, not you, but I'm going to lift it from you. We have built the cage, so we have to do what we can to open the door to that cage.

[Sean Elling]

I'm going to leave it right there and I have. I'm not going to miss an opportunity to say the title of the book again. First off, thank you Hannah for coming on the show. It's an important book and I really love the conversation same and once again it is called what would you do alone in a cage with nothing but cocaine.

[Hannah Pickert]

Thanks so much for having me. It's been great to talk. I really appreciate the chance to be here with you.

[Sean Elling]

If people want to read the book or follow your research, where can they go to find it?

[Hannah Pickert]

You can get the book at bookstores on Amazon. It's published by Princeton University Press, so by their website. And yeah, I have a website where you can get other of my articles. Www.hannahpicker.com Foreign.

[Host]

I hope you enjoyed this episode. I really, really do think this is an important book that is very much

[Sean Elling]

worth your time, which is why we

[Host]

will link to it in the show notes so you can check it out for yourself. As always, we want to know what you think, so drop us a line at the gray [e-mail] or you can leave us a message on our new voicemail line at 1-800-214-5749. Please also rate Review subscribe to the podcast that helps us grow our show. This episode was produced by Beth Morrissey and Thor New writer edited by Jorge Just engineered by Joe Plord Fact Checked by Melissa Hirsch and Alex Overington wrote our theme music. New episodes of the Gray Area drop on Mondays and Fridays.

[Sean Elling]

Listen and subscribe and if you have

[Host]

eyes to go with those sweet, sweet ears, you can treat them too and watch this [e-mail] Vox the show is part of Vox. Support Vox's journalism by joining our membership program today.

[Sean Elling]

Go to Vox.com members to sign up

[Host]

and if you decide to sign up because of this show, let us know.

[Sean Elling]

Sam.