Hanna Pickard

One of the key themes of the book is that understanding addiction is not just a scientific project but a humanistic and imaginative one. At various points throughout the book, I address the reader directly to invite them to imagine what it would be like to live in some of the conditions we know to be associated with addiction or to have addiction themselves. I chose the title to both symbolize and launch this humanistic and imaginative project.

But as you say, the title also refers to a famous rat experiment that was conducted by the scientists Michael Bozarth and Roy Wise in 1985. In this early experiment, rats were trained to press a lever to get a dose of cocaine, which was delivered immediately and intravenously. They were then permanently housed in an experimental chamber containing only food, water, and the lever, which they could press for as much cocaine as they wanted. Cocaine is an anorectic, so it suppresses hunger and thirst. The rats in this experiment pressed the lever repeatedly for cocaine, and they stopped eating and drinking. Within a month, 90 percent died, presumably from a combination of starvation, dehydration, and exhaustion.

This experiment is a beautiful illustration of the idea that addiction is a brain disease of compulsion, the currently dominant model of addiction in both scientific and popular discourse. Suppose we ask, what would compel an animal to press the lever for cocaine, forgoing food and water, to the point of death? The idea that drugs hijack the brain and compel use is a powerful explanation of this behavior.

But the conditions these rats were made to endure for the experiment — in effect, being alone in a cage with nothing but cocaine — is also a striking metaphor for the life circumstances known to be associated with human addiction — namely, severe adversity, comorbid mental health problems, and limited socioeconomic opportunities. Although it is of course metaphorical, there is nonetheless something apt about thinking of the life circumstances faced by some people with addiction as like being alone in a cage with nothing but cocaine. So this is another reason why I chose the title, to evoke these life circumstances.

The irony is that animal models have moved on while our own image of addiction hasn’t. The idea that the power of drugs to compel use is the explanation of why the rats pressed the lever for cocaine to the point of death has, in effect, been falsified by subsequent rat experiments.

Hanna Pickard

Here’s one thing you might notice about the initial experiment: the rats are alone in a cage with nothing but cocaine! That is not how rats, highly social and intelligent animals, live. They live in large groups and in natural environments where, for example, they forage, eat, mate, play — they have choices. The addiction scientist Serge Ahmed had the simple but ingenious idea that, to make the experiment more realistic, we needed to give rats a choice. He therefore ran a series of experiments where he introduced a second lever into the chamber, offering rats a choice between cocaine and saccharin water. He found that even when rats showed every indication of addiction-like behavior, 90 percent of them chose the saccharin water over cocaine.

Ahmed’s experiment was then extended by Marco Venniro and Yavin Shaham by switching the saccharin water reward to a social reward, namely a minute of playtime with another rat. Extraordinarily, virtually 100 percent of the rats in these experiments, even when they showed every indication of addiction-like behavior, chose the minute of playtime over drugs.

Just in case you were wondering, none of the rats in these experiments were socially deprived. Apart from their time in the experimental chamber, they were socially housed.

What do these experiments show? At least for rats, even when they look to be addicted, if you give them choices — that is, you give them alternative rewards that compete with drugs — they take them. So if we go back and ask why the rats in the early experiment took cocaine to the point of death, it looks like the answer can’t be the power of drugs to hijack the brain and compel use. That power, if it existed, would surely have been effective in the new experimental chamber where the rats had a choice. The answer is that the rats in the early experiment were alone in a cage with nothing but cocaine. Just stop and ask yourself the question that is the title of the book: What would you do in that environment? I think most of us, if we’re honest, would take a lot of cocaine. Cocaine is the only way to get any relief from the boredom, the loneliness, the misery, and the suffering that we would all experience if we were alone in a cage for weeks on end.

The moral of the story of rat experiments for human addiction is obvious. To put it bluntly and somewhat anthropomorphically, the rats in the early experiment pressed the lever for cocaine because of the emptiness of their environment and its psychological effect on them. We can see the subsequent experiments almost as a kind of treatment for addiction. By giving the rats alternatives to drugs that they genuinely valued — sweet water, playtime with another rat—the experimentalists intervened to get them to stop taking drugs.

These findings are mirrored in human addiction studies. As I mentioned, we know that addiction is associated with severe adversity, comorbid mental health problems, and extremely limited socioeconomic opportunities. We also know that what has been called “a stake in conventional life” — the phrase comes originally from the sociologists Dan Waldorf, Craig Waldorf, and Sheila Murphy, and is basically the idea that life is experienced as valuable and as having meaning, purpose, and a sense of possibility — is both protective against addiction and often crucial to recovery. Rather than explain addiction simply by appeal to a hijacked brain, we have to think seriously both about the environments in which people live and their inner lives — in other words, the life circumstances and psychologies that can shape and sustain addiction.

Hanna Pickard

Your question assumes that the brain disease model has taken us away from the moral model. In one sense, of course, it has. The moral model treats drug use as morally wrong and judges people, including people with addiction, for using drugs. The brain disease model claims that people with addiction cannot help using drugs because they have a brain disease that compels them to use. To this extent, they shouldn’t be judged, because they have an excuse. But notice the moralism implicit in this line of thought. We only need an excuse when we do something morally wrong. Like the moral model, the brain disease model invites — even if it does not explicitly state — the idea that drug use is morally wrong.

Before we talk about a “psychology first” orientation and what it can offer us, I want to say directly and plainly that I think we must recognize and reject the tendency in all of us to moralize drug use.

There is nothing intrinsically morally wrong with using drugs. Yes, of course there are particular contexts in which it is morally wrong to use drugs. For example, it is wrong to drink and drive. It is wrong to use drugs in ways and at times that compromises your ability to look after your children, whether you are addicted to drugs or not. But there are many, many cases of drug use, both in addiction and apart from it, where absolutely nothing is done that is morally wrong. Remember, caffeine and nicotine are drugs. Alcohol is a drug. Many of the drugs we find on the streets are pharmacologically identical to the drugs used in hospitals and for medical purposes. It is simply a mistake to think that drug use is intrinsically morally wrong, however deep in our history the mistake goes.

I make this point repeatedly in the book. I believe it is imperative to keep it clearly in mind if we are to be in any position to understand what addiction is and how best to address it and treat those people who struggle with it.

With that said, let’s talk about “psychology first.” Psychology is our most basic, powerful tool for understanding ourselves and each other. Humans are self-conscious and self-reflective beings. We understand ourselves to act for reasons, both good and bad. We take our actions to be explained by our thoughts and feelings, beliefs and desires, pleasures and pains, hopes and fears, plans and intentions. In other words, we take our actions to be explained by our psychological states. What I mean by a “psychology first” approach to addiction is that we start by seeing if we can understand why someone might be using drugs in ways that are profoundly counter to their own good by appealing to their psychological states. In other words, we use the psychological tools that are at our disposal, simply in virtue of being human. We imagine what it would be like to be in their shoes, what their inner life might be like. And to do so, we contextualize their inner life in relation to their life circumstances. Psychology and life circumstances are always enmeshed — this is one of the core lessons from the history of rat experiments.

When we take this approach, a very important feature of addiction is revealed: that addiction is heterogeneous. We are used to the idea that behaviors that look similar on the surface have different psychological explanations when we dig deep. This is because people are different. Similarly, what explains addiction is different for different people.

In the book, I document the heterogeneity of addiction that comes into view through a “psychology first” approach. Some people use drugs to get relief from misery and suffering (as if they were alone in a cage with nothing but cocaine), but some people use drugs for the opposite reason, as a form of deliberate self-harm or even to die. Some people’s identity is bound up with their addiction — they don’t know who they would be or how they would live if they quit. But, by contrast, some people are in denial. Some people experience cravings that are hard to resist but also expressive of the emotional depth of their relationship with drugs, while other people with addiction may struggle with self-control, as do we all. But all that said, I by no means rule out that some cases of addiction might be explained by brain disease. Why not, if addiction is heterogenous?

The important point is to stop thinking that addiction is only and always about the brain or the same for everyone. A “psychology first” approach reveals the heterogeneity of addiction and fights moralism by insisting on our shared humanity with people with addiction. This may not guarantee empathy, but it cannot but encourage it.

Hanna Pickard

The idea has its roots in my own clinical experience. When working with people with behavioral disorders, it is a truism that you need to help them change how they are behaving if you are to help them recover. But behavioral disorders are often “challenging” to work with, as it’s often put in the clinic, because the behavior in question is inevitably harmful to the person themself or to others. That harm is part of why the behavior is labeled as a disorder, but it can lead clinicians to fall into a trap between what I call a rescuing mindset and a blaming mindset.

A blaming mindset treats people as agents who are capable of changing their behavior and hence responsible for it. But, because the behavior is harmful, it can easily lead to judgment and blame. This is not conducive to effective clinical work, to say the least. No one helps a patient by blaming them.

A rescuing mindset is a recoil from blame. It denies that people are agents capable of changing their behavior and hence responsible for it, to avoid any tendency toward judgment and blame. But it is also not conducive to effective clinical work, because you have to engage a person as an agent in order to help them change how they are behaving. A rescuing mindset makes it easier to avoid blame and maintain care and empathy, but at the cost of a suite of attitudes and techniques that could help.

The clinical solution, in a slogan, is to adopt a stance of responsibility without blame, where this means engaging agency and asking people to change their behavior — to take responsibility, as it’s naturally put — without blame but with care and empathy. Perhaps one way of explaining the core of the idea is to say that it involves recognizing that, just as other people have choices about how they behave, we have choices about how we respond to them when they behave in ways that are harmful. We tend to think that blame is natural, inevitable, indeed deserved — but this is in effect a choice we make. We could respond differently — without judgment, without hostility — while still holding people responsible and working to help them to change. Indeed, this is exactly what effective clinical care typically demands of clinicians.

Of course, this is easier said than done — it’s a skill that needs to be learned and practiced. In the book, I philosophically articulate the ideas of agency, responsibility, and blame underpinning a responsibility without blame stance, and I try to show how to use the stance as a model for personal relationships with people with addiction — taking into consideration the heterogeneity of addiction and of relationships alike. Needless to say, the idea of responsibility without blame is also part of how I hope to productively address moralism about drugs and drug users.

Hanna Pickard

Many of the people I was working with led chaotic lives. Their emotions could be volatile and overwhelming, and their moods dark. They self-harmed and had problems with drugs. They were hard people to help and challenging to build relationships with. Part of what, for me, was so moving and personally important about the experience of working there for ten years is that we really did see people get better. Their lives improved, as did their sense of self. But the mechanisms underpinning these changes had nothing to do with medication or standard medical interventions. Fundamentally, the mechanisms involved the care, support, respect, and relationships that came from belonging to the group.

Let me tell one anecdote that illustrates this idea and is part of what made me first question the validity of the brain disease model.

When group members had problems with drugs, we often asked them to make a contract to quit. The person would take a blank piece of paper and write something like this: “I will not use drugs. If I find myself tempted, I will make a support call to another group member.” They would date and sign the contract, and so would we, therapists and group members alike. We also wrote messages of support. “I know this is hard, but you can do it.” “Call me whenever you need, don’t hesitate.” “You really deserve a better life, don’t doubt it or yourself.” “I will be thinking of you.”

Not everyone quit, of course, but some people did. Some carried their contracts with them for months, until they were ragged and worn. It was the power of these contracts that first made me question the validity of the brain disease model — at least in those cases where the contract worked — for surely no brain disease of compulsion could be cured by a piece of paper. How, then, did these contracts work? A contract is a mechanism for finding agency and taking responsibility. But it is also a symbol of the care and support of the group that you can take with you wherever you go. I think this combination is essential for addressing addiction humanely and effectively but is all too often missing in today’s treatment world.

Hanna Pickard

That’s such a great question. I’m sure there’s a lot to say, but I think a positive community that treats everyone with equal care, concern, and respect can both be corrective to ways that people may have been mistreated in the past — improving their self-worth and self-esteem — while also allowing people to find a place and have a role in the group where they not only receive that from others but give it back as well.

This can be so important and healing. We build ourselves, our sense of who we are, in relation to others. We see ourselves through their eyes and what they give to us, but also through what they take from us — what we find ourselves able to give to them in turn. Placing addiction treatment within a community has tremendous therapeutic potential because of how it can help people find new identities and also newfound hope and optimism about relationships with other people and the world at large, because it’s a shared project.