Dr. David Epstein - Let's agree to agree

I'm Dr. Noah Emory, I'm Dr. Sam Acuff, and this is the Addiction Psychology's podcast. Thanks for joining us on this episode of the Addiction Psychology's podcast. We have Dr. David Epstein. Dr. Epstein is the Chief of the Real-World Assessment, Prediction, and Treatment Section of the National Institute on Drug Abuse Intermural Research Program. And in this episode, we explored a deceptively simple question. Do theories of addiction really have to compete? Dr. Epstein suggests that rather than searching for a single correct theory, we should talk about how to integrate multiple perspectives and how that can lead to a richer understanding of substance use and recovery. In this episode, he'll discuss his arguments to this effect, as well as a few projects that he's been particularly interested in recently. Really excited to have him on. Dr. David Epstein, welcome to the show. Thank you. It's wonderful to be here. Yes, we're really excited to have you on. We're a big fan of your work, and we know you listen to the show, and so we're really grateful that we were able to make some time to make it work. So at the beginning of every episode, we have our guests tell us a little bit about their background in training. And so I was wondering if you could tell us a little bit about yourself. I will, maybe more than a little. I'm really intimidated to be here. I've been a big fan of the show from day one in 2020, and you've had so many of my scientific heroes on. It makes me very nervous, but I had noticed that a lot, most people giving their origin stories on the show. It's been, it's been a long and winding road. It's not linear for anyone. And that's certainly been true for me. So I can take you through some of that. Just, I don't know whether it's, it'll be valuable to anybody, but I'll go through it anyway. First of all, I'm very old. I'm turning 60 this summer. I don't know how that came to be, but I've been around for a long time, and I'm unusual in many respects. I'm unusual in one respect in that I've been essentially at the same place. I've been at the night at IRP ever since I got out of graduate school in 1998. I've not been, I really haven't been on the job market in a sense, although I had, I did have to compete from my current position. But I began life as, as an English literature major. I didn't know that I was going into any of the sciences. I took, I took psychology, some psychology courses, I had friends who took them, but I was, I was an English major, and that's, that's how I identified, if you will. And it really, I, that didn't change until my senior year of college, if this was Wesleyan and Connecticut. And I didn't know what I was going to do with myself, and where I was going to go from there. And two things happened sort of in parallel. One of them was that I just happened, and one of my aunts lent me a book by Oliver Sachs. It was the man who mistook his wife and her hat. He instantly fascinated. I just was, I, I couldn't, somehow, and this was a decade of the brain, the New York Times was running a lot of stories about neuroscience. FMRI was just beginning to come into Bogue. And it became fascinating to me that the way I said it at the time was that everything we are and feel is contained within these three pounds of soggy meat inside our head. And I thought that that was a terrifying thought. You know, if you're scared, you can't be bored. And that's not really true. It was ever graduate student knows, I think. But I believed at the time that if there was an idea that scared me and, you know, the instantiation of the self in the brain seemed just spooky and weird to me that I would always be excited to study that. So there was, you know, I didn't know what, what, this is what we're talking about in 1987, 88, there was no web to look these things up on. I didn't know how to go about studying that or what the divisions of the field were called or how they worked. But I knew that I wanted a piece of that somehow. And in part, the other thing that happened in parallel with that was that I've been and I'm very out about this life long depressive. I had my first depressive episode when I was five years old at a time when it's five year old, we're not supposed to be able to have depressive episodes. And I was running through another fairly severe bout of that at the time and starting to get worked up and treated for it. So, you know, the whole research is a research thing. I became fascinated with the brain for its own sake and also became fascinated with psychopharmacology because that was sort of a road that I was heading down. I will pause here for a second to say that that lived experience has become a big piece of it's been something that I really like to bring to my research. And I've had a lot of colleagues and mentees with histories of addiction. I haven't had that experience myself, but my history of depression and anxiety has played into a lot of what I do. And just to concretize that, there's one of my favorite papers that I've ever been involved with was one that I wrote with my former post-back Sam Stull about Anhedonia in general and also Anhedonia in people using substances. And sort of trying to put some nuance into that and debunk it a little bit, we published that in journal of abnormal psychology in 2021. And we both brought our own experience to it thinking, you know, Anhedonia doesn't work exactly the way people think it does. It doesn't feel the way people think it does. Anyway, a little, little digression. Anyway, so what happened at that point was an instance of privilege. My parents were very generous with me and they, you know, I wasn't competitive for graduate programs at that point. I only had English courses for the most part. So they paid for me to take an extra non-matriculated year of biology and psychology courses at Wesleyan, and I began to study neuroscience. And so I was able, you know, they paid the tuition. They paid for my housing. I was living on peanut butter for the most part. They were lean years. But nonetheless, I came out of it without debt and I was able to do it. And not everybody can do that. And I always really just like to acknowledge that not everybody can have the origin story that I had. But I did that. I applied in a scattershot way to like five-ish neuroscience programs without even really understanding what they were because again, there was no, there was no easy way to look these things up. I probably because on the strength of good GRE scores and a good essay, I got into the behavioral neuroscience program at Rutgers. And I described myself, even though that was in a psychology department, I described myself as an experimental psychologist. If I have to put myself into a bucket, I think my training was in experimental psychology, that that wasn't the formal name of what it was. I did the first few years I was there. I did animal animal research. I did a rodent research, a rat research in the center of alcohol studies there. The advisor started doing neuropsychological assessment with a neuropsychologist who really wasn't a researcher. And I was a little bit on my own to figure out how to do a dissertation project. What sort of got me where I am was that I began teaching. I was teaching physiological psychology. I was teaching a course called drugs and human behavior. And I was sort of a perfectionist, and I tried to know everything about what I was teaching. So it's some of the faculty there got to know that about me. And one of the faculty members there, George Wagner, recommended me to someone at night, a Kenzie Preston, who was looking to hire what's called a staff fellow. It's a little bit like a post doc, but a little more quasi permanent than that. I hadn't even thought that I was primarily going to be a researcher. I thought I would find some sort of teaching position, a position at a teaching oriented college because I like to doing that so much. And that I would try to sort of just collaborate on FMI researcher pet research, because I still felt I really want to study the brain. So I arrived at the night of IRP 1998, as was called a staff fellow. This would be a good time, by the way, to mention I don't speak for my institution at all. I get that in there. So I was working with and for Kenzie. She was behavioral pharmacologist. She was trained at the Hopkins BPRU behavioral pharmacology research unit with names that people ought to know that I don't know how many people know them now who are coming up, but Maxine Stitzer, George Bigelow, she was trained in that your behavioral pharmacology tradition. But she was running at that point and on site, methadone clinic, and she was doing randomized randomized control trials, mostly of contingency management, voucher based contingency management, I was brought on specifically to help oversee one that she was running, combining contingency management and cognitive behavioral therapy for people using cocaine and heroin. And she was doing randomized control trials of relapse prevention medications in that context as well. So that's sort of that's how I started here. And I also I want to mention, I guess, you know, we formed, she and I both formed some close connections with people who were really helpful to me, she was really helpful to me, she really was a booster for my career. And she, we began working closely with Yvonne Shaham, who's a neuroscientist here at the NIDA IRP, I still work closely with him. And so I sort of had close connections with with people doing neuroscience, people doing animal models of addiction. And at the same time, I had close connections with, I came to have close connections with, for example, I know you've had Hannah, Hannah Picard on the show, Hannah, she put down to the Hannah Pickard. say Picard. So, you know, I also, I sort of maintain connections with people who, you know, she's a clinician, she's done psychotherapy and she's also a philosopher and she addresses very broad questions about drug use and addiction. So, I became sort of this generalist who really, who tried to straddle all this sort of, all the aspects of what it means to do addiction research. And more and more over the years, I was like, I stopped identifying as really a neuroscientist and started identifying as an addiction researcher with everything that meant. And I felt like it covered everything. And like, I realized recently that when I thought about my sort of my trajectory, since I've been at night for the past, since 1998, you do the arithmetic. I don't even want to. It my focus is kind of found a way back towards something that kind of does embrace the humanities without walking away from biomedical sciences. Because like, you know, when you think about it, you know, I started here doing contingency management, which is really, it's as behavioral and skinnarian as you can get. And, you know, along with that, some trials and medications, which in some ways are about as biomedical as you can get. And then we moved on, and Kenzie gets a lot of credit for this because she had the nerve to suggest that we do it. After about eight years of doing that in like 2005-ish, we started doing EMA ecological momentary assessment. And I'm not even anybody, any of your listeners who don't know what that is, hit pause and go Google it. Because I can't explain everything. You got to know what ecological momentary assessment is. And EMA, you know, it does, it examines people's daily life experience. Yes, but it does it mostly through these closed ended multiple choice questionnaires. You're not really going in depth. It's not, I can't exactly call it phenomenology. So even then, I felt like, okay, we're getting closer to the way people live, but we're sort of, we're still distilling it into numbers that we can put into it into a major regression. At the time, we started like combining that with studying people's geolocation through GPS tracking. And we've framed that like mostly as a study of environmental contact. I came to feel that, I've come to feel that we, the way that we approached it at least, we weren't getting enough value from the GPS data to justify how sort of intrusive it is. But nonetheless, I started having this aspiration of like trying to acknowledge the complexities people's real lives and bringing that into the work. When, when Kenzie was getting set to retire, I was encouraged to apply for a tenure track position here. So I did that and managed to get it. And this is like 2017 as soon as I had to name my research group. And I, I named it, you know, real world assessment prediction and treatment, which it was, you know, it was sort of spur of the moment in a way. But I've come to like it and I've come to take it as like a promise. I've come to feel obliged to live up to all the parts of that, including real world. So when the next batch of EMA work that we did, we had been doing a lot of EMA work with people using heroin and cocaine. But then I did EMA with Kirsten Smith, who you've also had on the show more than once, I think, my postdoc Kirsten Smith. And when we, and we were doing EMA with people who use creatum and creatum products. And we started trying a lot harder at that point to assess people's real experiences. We did more sort of formative work with people before we wrote our EMA items so that they would really make sense to people. We solicited more free text responses. We did in depth interviews alongside everything else that we did. So like, I got, you know, I'd gotten tired of like authors presenting a bunch of quantitative data and then speculating about what it might mean. I was like, well, why didn't you just ask them? Yeah. So we asked people. And I'm trying to hang on to that attentiveness to what people say as we bring our EMA work toward momentary intervention work, which doesn't mean it's not like I assume that people have conscious access to everything that drives their behavior. I mean, part of what makes psychology so interesting is that we don't have conscious access to everything. And EMA is partly about that. It's partly about like detecting patterns of behavior and associations and behavior that are not consciously accessible to people. You're like showing that some of the correlations that we think are real in our daily lives are not real. They're hindsight. Right. No, in some ways, EMA debunks people. But I also think it's like it's just bizarre and counterproductive to me to do human research in psychology or psychiatry where your end game is like, we're going to stop listening to what people say about their lives. We're going to develop a biomarker. So in the end, we don't have to ask people how they feel anymore. And like, especially if it's like it's a question of whether people are thriving versus suffering or something in between. You know, I think all you can do is ask people and you need to believe them for the most part. Yeah. So yes. Yes. Yes. Thank you for that. Yes. I'm a self-reported truth or like for the record, right? Like the reaction to my description of this at conferences is never always universally well received. But I'm really just heartened to see her. You say that. And just like this is about people will stop to them. Like that's what's about. And your point here about biomarkers, I think is well taken. Right. It's like, let's remove it completely from it. I think there's a universe where biomarkers are helpful, maybe even like in an EMA context, right? We're like, yeah, continuously asking them what's going on all the time is is intrusive in its own right? And maybe we could like follow it along with some kind of sensor to trigger like, hey, are you okay? Yeah. Or something like that. But like to totally remove the people from the industry and the and the process of working with people always felt a little counterintuitive to me. And so I'm really heartened to hear you say that. Yeah. We all want to offload the burden of EMA. We don't want to be asking people 10,000 times a day. How are you doing? How are you doing? And some sort of passive monitoring maybe will tell us when it's time to ask people how they're doing. Yeah. Yeah. And that's a great point. And also, I think your point here about like items is a really important one that I think is having having a moment right now, luckily, where it's like, you know, when I, as an EMA researcher, I've always had to like go into the field and see what people are asking, but figure out a way that we can do it over here. And so I never really just kind of took off the shelf items from these places. But if you go pick a peek at some of these items, the dirty secret, I think in the field is like factor analysis level, conglomeration titles of like items where it's like, oh, this is a, we call it a name. But when you look at the items, like somebody just made that name up, like for instance, you know, when I talk about a lot, it's like drinking motives. And you go take a peek at the enhancement items. And it's like, there's very few things that are talking about enhancing anything there. It says, I like to feel high. And it's like, is that it was that enhancing the absence of highness? Like, right, you know, things like that. So I think just getting into the weeds or they're old school, right? Like, I do a lot of anodonia research too. You go into the the shops, for instance, which is a famous anodonia scale from the ancient times. And it's like, I like to take a bubble bath. And it's like, I don't know anybody that says that, right? Or like, or like, listen to my favorite radio program. And it's like, you know, we've swung all the way back around, right? And we have like podcaster basically those now. But like just the context of generational verbiage, right? Like gets, gets on top of us quick. And then we just kind of take that as gold standard and just move along. And so it ends up with this garbage in garbage out problem. And you touched on something that it's a combination of a of a peave, but also what I see as a way forward that I wasn't even going to talk about today. But I'll mention it now. And that is, you know, I have for a long, long time, you know, looked with, with dismay at the, at the actual items on questionnaires that are routine to use. And how repetitive they are. So you get a nice high-crown back alpha because everybody is straight lining the answers. You're asking, are you blue? Are you depressed? Are you sad? Are you down in the down? Are you? And there really are questionnaires that are essentially like that. And, you know, all the shibbolettes of psychometric development, reliability and some of the aspects of validity that are quantifiable lead you to these awful questionnaires that are just annoying and baffling for people to actually take. And I wish I had the names of these papers in front of me, but I've been learning about the assessment of response process validity and learning about what are called cognitive interviews and think aloud. And ways you can also do it online through what's called crowdsourcing and web probing. I'm sorry, I don't remember the names of the authors right now, but these are things that you can do that basically assess how are people reading your items? How are they selecting their answers? Does it make sense to them? Would they, will they tell you, they'll tell you, you're not even asking me the right question. You're not giving me the answers that I need to give you, you know, the response options that I need to tell you what's going on. You can do all that. And that's clearly, it's a great way forward for EMA because you need single items that make sense, right? And I think it's, it can bind together EMA and more sort of traditional questionnaire-based psychometric research. If you just start, sit down in front of people, sit down with people or do it over the web if you can verify that they're real. And just say, what does this item mean to you? Does it, does it mean what we think it means? Is it missing anything? That's all of that is connected to response process validity. Yeah. Oh, yeah. Yeah. Cassie Boness is doing a bunch of work in this space. I think of like a, a, a, a, a real leader in that space. And I've seen other people like Elizabeth Aston has done some, some great work on it and using cognitive interviews in this space. And so, you know, I think like that's what says it's old is new again. And, but like in a, in like a very, I think, rich and important way. And, you know, really, appreciate that you're bringing it up. - Yeah. And what Cassie, 'cause I have talked with Cassie about this, and she, and she who led me to, some of her papers are informative with that, and she led me to some of the other papers about it too. I was gonna, I know I'm taking longer than usual with the origins of it. - No, please. - But like, I guess I wanna, the main part of what I'll be talking, I wanna talk about today is really not my own work, but just sort of ideas that informed it. So I do wanna say a little something about what I'm currently doing, which is the work that I'm sort of pivoting away from creative and creative product research, and toward, I'm starting to study people use cannabis. And from the angle of, I'm focusing on what I'm calling boredom and its opposites. And so this is sort of, the full, you know, the full arc of my trajectory, from like really like, skin area and behavioral things with contingency management, I would say what I'm doing now is really informed by what I would broadly call the science of well-being. I could almost say positive psychology, but I think that's a little too specific. I don't consider myself specifically aligned with that or whatever. So more broadly, it's the science of well-being. It's a psychology that recognizes the importance of having a sense of meaning and engagement in life, and it was like, it was a weird coincidence and almost a whim that led me to think about boredom as a focus, but I realized once it occurred to me to study boredom, I realized that it's a perfect topic and a perfect place for intervention because it is like you bitwoodously mentioned as a risk factor for problem substance use and lapse and relapse and so on. It's never the focus in addiction. It's always, it comes up in a 10,000 papers in passing, but it's never the focus. And yet outside of addiction research and psychology, there really has been a psychology of boredom that has blossomed in the past few years. And I can lean on that, I can bring it into addiction research and what I love about it is boredom has opposites and the opposites are things like curiosity and creativity and a sense of rich and passionate engagement with life and there's a study of sort of a path to well-being that's called psychological richness. And I can harken back here to when Katie, one of the times at Katie Whitkewitz was on your podcast and she talked about clients coming to her and being like, what do I do outside of the crisis moment? CBT teaches me how to handle the crises. But how do I, what about the whole rest of the time? How do I live in a way that I can consider good and worthwhile? And so like I've reached the point where I want my work to touch on that, the thing is like I also know, I can talk, these are really big noble abstractions. When the rubber meets the road, it always gets smaller and you know, to help, I want to mention it, I want to call out another name. Someone else you know, Peter Soister, who is my post-doc now. And he, I think he's going to help keep me grounded in this as a clinical psychologist who knows how to assess and how to treat substance use disorders and also has expertise in predictive modeling and things that we're going to need for EMA and momentary interventions. So I think with his help, I'm going to take these big broad ideas and turn them into something concrete and real without hopefully diluting them to the point where they're drained of all life. - Yeah, yeah. No, that's really exciting work though. Not, I guess it's not a pun really, but exciting being the optional border. But it's just shocking sometimes when you stumble upon an idea of you realize, wait, someone's done this, I'm sure, you look into it and you're like, wow, that's incredible. Because boredom absolutely is something that comes up time and time again, it's a huge risk factor. And beyond that, I think like you're describing, it's such an important element of well-being to address, purpose and meaning and filling the space. I also think boredoms, there's this weird positive side to boredom, which I think can exist, which is like, in some ways that's where curiosity can blossom under the right circumstances. And sometimes I feel so busy. - He's supposed to drive you. - Yeah, I don't feel, I don't remember really times I felt bored in recent times. And sometimes I miss that feeling, right? Of just like, why don't you just-- - Why don't you just-- - Classic fantasy of grad school, right? So I'm gonna go make, I'll put a bakery or whatever, right? - Exactly. - I'm like, it doesn't matter. - I just want things to come down. - Oh, yeah, blueberry muffins. It's like, oh, shucks, you know, like what a real disaster versus like, oh no, I'm gonna bungalow this like clinical experience or these like millions of dollars of things. - Just feeling like you have an hour that's not taken up by something, right? - Oh, fair, fair. - All that to say, I guess there's this really interesting, boredom, I think is a really interesting space for a lot of reasons 'cause it's in some ways it's the opposite of stress as well, which is also a risk factor. So there's so many ways in which I think boredom could come out and we just don't know and I think what you're gonna do is sort of put some color on that area of research and help us understand it better. I'm excited to see what we find. - Yeah, I'd say two more things to sort of tie this up. And like you, I don't generally get bored. I made the joke earlier, you know, the research is me search thing, but boredom is not something I generally have that. But I do, the opposites of boredom, engagement, curiosity, creativity are, I think they're a remedy for more than one thing and that they can be a remedy for symptoms of anxiety, depression, many other, so they're not just the opposites of boredom. - Absolutely. - They can be a path through a good life in a lot of ways. - I've been doing some work on boredom myself right now. Mostly from like Aaron Westgate has a great, like since this is of multiple theories called the meaning and attention components model or the Mac model where they talk about how bored, like why does boredom exist in us, right? And she at least frames it in some of the theories that she cites that her work is built on, frame it that like an absence of meaningful activity, that activity is not meaningfully related to something like life-sustaining behaviors, right, or species-saying behaviors or things like this, or it's just not stimulating enough where it doesn't capture your attention as you're trying to read, organize. And the way I've been thinking about it, which sounds like the same way you've been thinking about it, it's like anecdotally clinically as well as in research, boredom shows up like all the time, but it like never has any really central research on it in addiction. And that feels like a real obvious place to start. Like if you just randomly grab a person on the street and said like do you experience boredom, they'd probably be like yeah, if you ask the person in addiction recovery, they're like boredom is a risk for returning to use for all these types of things. And so I'm really excited to see what the work that you have coming out of this. And you know, I've been thinking about it myself. And so I really do think we got to do better at building interventions that don't just address substance use, but address a richer part of a person's life to make their life meaningful and worth living. And that substance use becomes an option out of a list of things that make them feel good, that makes it easy to pick from the menu based on the context they're in, that makes sense. And I think too much of it has been focused on maybe like negative affect reduction or things like this stress reduction, things like that. And it makes sense, but when you get into the EMA, this is classic EMA contradiction. We're like the, in EMA work, the negative affect stuff doesn't pan out very easily. Like it's super unreliable, it like you know, it depends on various based on time scales. Like you talk about moment versus day versus person, right, these types of things. So how are you different from me versus how this day is different than another day versus how I feel right now versus how I felt earlier. And all of those things really, but from in my work at least, the absence of positive emotion, much more reliably predicts a bunch of stuff, right, which has like shares, I think space with something like boredom. And so if we're talking about negative affect, I think boredom is one of those kind of cases that maybe when we drill down, it's gonna have a lot more, you know, ability to define the things that maybe we've been thinking about intuitively for a long period of time, but have been missing due to the way that we aggregate stuff across different kinds of feeling states, which people feel lots of different emotions at the same time. But it's never like I feel eight different emotions at the exact same time, right? Like it's like, oh, I feel maybe I feel a little bit of positive, a little bit of negative, a couple different kinds of negative. But when we aggregate these things as an artifact of the way we do the research, maybe we lose the plot a bit. And so getting specific here, you know, what's old is new again, Andrea Hussong gets some great work on this, I think in the early 2000s, where we look at specific emotions and things like this. And so really excited to see how the work comes to life. - Yeah, and you led me back to the one thing, the other thing I was gonna say about it, which was, it is an opportunity moment. Boredom is, it's a signal and it can go in a lot of different directions once you have it. And in terms of like a momentary intervention, or it's what's called a Jedi, just in time adaptive intervention. I've been saying for a long time that when someone's really stressed, you wanna intervene on that, but at the moment I'm stressed, they probably, they can't just, whatever it is that's happening in their environment, they probably can't just say, hold up everybody, I gotta do a breathing exercise, 'cause my phone is telling me to, I can't do that. Whereas, you know, a boredom, especially a leisure boredom moment, which is where I'm generally gonna be focusing, is the moment when people might be like, please tell me what to do right now. - Right. - And they will actually listen. So, and I've, but I also, I was really pleased over the past few months, I've seen Susan Murphy, who's one of the big names in EMA and Jedi, ecological, momentary intervention research. starting to publish, give talks and publish papers saying, yeah, we have to rethink whether just in time is really should be just in time, because people, there are a couple of studies showing when you try to intervene at the very moment of stress, people don't like it very much. And maybe we should think in terms of broader time frames, either pre or post a moment of stress. And so like, it's a great point. Yeah. Yeah. My good friend of ours and one person was on the show at the very beginning of this named Tyler Ray talked about this where like, you know, maybe after the fact when they have time to sit down and think about it, we can like, even though it's close in time, like same day, for instance, right? It's like a teachable moment kind of a thing where like, you didn't intervene in the moment, but I'm still motivated by the positive and negative consequences that occurred as a function of my behavior and context here that we can use that to capitalize for the next time. And I've always thought, I've thought a lot about that and I'm glad to hear people start to return to those types of things. They sound great like in theory, right? It's like, oh, we're intervening right in the moment, right? It's like, what, you know, like, what if I'm driving, you know, like, you know, like, it's not where we, you know, what if I'm in the middle of the talk, you know, like, it's going to be pretty challenging to like, hold up, I can do this breathing exercise real quick, you know, like, it's always been a real challenge. I think also clinically, when I think about like doing, you know, like, distress tolerance, for instance, skills with folks, I always tell them like, well, why don't we just say, like, I got to go to the bathroom and then go in there and then like, do some like breathing or something like that, actually have a little time to yourself. But it's like, you can't interrupt like in the middle of an argument, right? You can be like, put time out. I really have to use the bathroom. My therapist really wants me to do this breathing exercise right now. It becomes quite challenging. Well, this has all been really interesting. And I'm very excited, David, to see where all of this research goes. I will definitely put a PubMed, PubMed alert on for your name and boredom, right? Yes. And I'll be waiting with Bated Breath. But until then, you know, we really want to talk about specifically some ideas that that I, you know, I first heard from you. Well, you know, I've heard, not room, you know, as inklings of it as early as a paper that you wrote, called, let's agree to agree in response to a paper sort of competing theories of addiction. And so really what we want to hear from you a little bit about today is just your take on on this. What, what, what are these theories competing about? Do they need to be in competition, et cetera? So, yeah, this is, let's jump right into this. And I'm wondering if at first you could just sort of give us an overview of what some of these theories are that, you know, that might come up throughout the course of this conversation. That's exactly what I don't want to do because, no, but this is like, and to show the sausages made, I mean, we, you and I, Sam, were on a panel at CPDD last year where I gave a talk that sort of covered this ground that I do want to talk about. And I actually began that talk by saying, boy, do I not want to go over the models in theories of addictions? And I don't want to do, I don't want to do, you know, Wikipedia entry about that. And that was because I felt like there's, that's not even the conversation we need to be having. And I was, I mean, I, I was, I had been for a long time very frustrated about the way major model slash theories of addiction compete with each other. And that was the paper that I think you mentioned, let's, let's agree to agree, which I called my manifesto. And I published a neuropsycho farm in 2020 that basically said, you know, it's really not necessary to frame each of our theories about addiction as in a winner take-all fashion such that if this, if this is true, then that cannot possibly be true. And, and that applies, it applies at the broad dichotomous level of like brain disease versus social environmental context. If you divide it up, that, you know, it applies to that. It also, it applies more specifically. If you look at, you know, within one of those categories or models that sort of integrate those categories, you know, whether it's incentive sensitization or habit theory, they, they, all of them end up sort of saying, well, you know, I'm going to test this hypothesis versus that hypothesis. And, and if I win the other one has to lose. And that should, that should never need to be true. But I wanted to sort of like back away from talking about those models and talk about what I think are is the not so, not so productive thinking behind the way we talk about those models. And the way that I, that I talked about it was I said, there's really three things we're trying to do here. We addiction researchers. And, you know, we need to define what addiction is. We need to say what causes it. And we need to say what to do about it, how to treat it or prevent it. And my point was that really, those are three separate things that you have to know, you have to think and speak clearly about which one of those things you're doing at any given moment and keep them slightly independent of each other. So, I, you know, I've made the point that, you know, when people talk about their pet model or their pet theory of addiction, they usually don't provide a real definition of addiction. And by that, I mean, an operational definition, one that you can use as, as, as a classifier to say, who is addicted and who isn't addicted. And here, I owe a lot, whenever I talk about this, I owe a lot to Hannah Pickard, who was the, she taught me about the explanandum and the, the explanands. And, you know, the explanandum is the thing that you are trying to explain. And, you know, you're, that, you know, your definition should just be your explanandum, you know, the thing that you're trying to explain. And, you know, in practice, whether people like it or not, we have that for addiction, you know, in the US and the United States, it's the DSM-5 criteria for substance use disorders, SUVs. Those criteria, you know, they determine who can be enrolled in a study of addiction. So, for all practical purposes, whenever most of us study addiction, we are studying people who have an SUV. And as, as you know, you've seen some of the materials, Sam, I have a whole separate spiel that I give about the history of, of, of addiction related diagnoses in the DSM that I love to talk about because it's taking so many weird, fascinating twists and turns, which I'm not going to attempt to get into. And, you know, there's major ambiguities, major problems, but I think that, as I'll say in a minute, I think that that kind of operational definition has its merits. So, and I'll come back to that in a minute. So, of the three things that I think we've got to keep separate, there's defining what addiction is, then they're saying what causes it. And I think what happens a lot is that having not provided an operational definition of addiction, most of our theories and models, they generally lead to statements about causation. And what I learned from Hannah Pickard is that that's called the explonance, the explanation. And, you know, I shouldn't even have to point out the problem of proposing an explanation when you've never specified what it is, what it is you're trying to explain. You can't meaningfully test a causal account of why people have thing X when you haven't said, okay, who has thing X and who doesn't have thing X? Because, you know, you can dismiss anything that doesn't fit your explanation, you can do what's called the No True Scotsman fallacy where you just say, oh, well, not that one. That's not a real case of addiction. And actually, one of my favorite examples was not the not in reference to whether a person was addicted, but whether a drug was addictive. The drug was caffeine. There was a review or slash commentary published sometime in the 90s where the author argued caffeine cannot be considered an addictive drug. You know why? Because it doesn't cause increased dopamine release in the shell of the nucleus accumbens, which I mean, the logical fallacy there shouldn't need any explanation. That's a neuroscientist perpetrating that fallacy. It comes up, you know, with psychosocial models too. I'll come back to that in a second. But, okay, so the third, you know, of the three things that I think we got to keep somewhat separate is, you know, I think most theories are models of addiction. They're used at least implicitly to suggest that the treatment, the treatment should derive directly from the cause, which seems really sensible on its face, but it's not always necessary and it's not always workable. And I think that's become kind of a major unexamined assumption in addiction research. Is it if we can identify the cause, we'll know the treatment. And maybe that won't always be okay. So that's my overview. And I can like say a little more about each of those about definitions. You know, I think if you're definition of addiction, it's going to be of any real use. It has to be an operational one. It has to be equivalent to a set of criteria that tells you when someone's addicted and when they're not. And I do, by the way, treat, you know, the SUD and addiction as the same thing. I treat them as equivalent. And I can speak in a moment about why I think we better do that. Anyway, the DSM with, you know, with its SUD criteria and formally its dependence and abuse criteria, it's famously or notoriously a theoretical. But I think it's not as a theoretical. It takes a very strong conceptual stand. It says, the DSM says, addiction is defined by the consequences of its use. The exact language, as most you probably know, it's, you know, a problematic pattern of use leading to clinically significant impairment or distress. And then it's followed by what I would describe as 11 examples of what that could look like. So that's a, that's a pretty strong stand. And the way I read it, it means that you have a substance use disorder. If your drug use is causing a net detriment to you, you know, in comparison, like a sort of a counterfactual comparison to what would your life be like without that pattern of drug use? And that's, it's a strong conceptual stand because think of what it doesn't say. It doesn't pathologize any specific amount or frequency of drug use, and it doesn't even pathologize any specific motivations for drug use. The one exception to that is using to avoid withdrawal could contribute to a diagnosis, but it's not necessary or sufficient. So if you're using to get high, that's not in there. It's not even when there was a criteria called abuse that didn't include using to get high. It wasn't about that. So the DSM takes the strong stand that it's only the outcomes, you know, to the extent that they're good or bad, that's what defines addiction. It also, it doesn't say anything about what the overall trajectory of the symptoms is supposed to be, or whether they may or may not be responsive to changes in context or what kind of treatment they need, it just sort of defines the problem space. And in contrast to that, I learned from, in a really good book by Owen Flanagan called, I think it's called "What is it like to be an addict?" I learned from that book, the big book of AA has a chapter that I think it's called "A Physician Speaks" or something like that, it says, if you look at someone who looks like an addicted drinker, the book would say an alcoholic, though I'm not using that term, you know, someone who looks like an addicted drinker right now, someone with alcohol use disorder, even if that person right now ticks all the boxes that says it looks like they're totally addicted to alcohol, they're not really addicted if it turns out that they can sort of stop or greatly reduce their drinking or moderate their drinking in response to a life event, they describe that kind of person, they say, this is a hard drinker and they say, that's basically, what about a real alcoholic, that's a drink that's not me using that word? I detect a whiff of the same kind of thinking, whenever we routinely see in the first sentence of every paper that we ever read, addiction is described as a chronic relapsing disorder, often it is that, very often it is that, but what does that mean for people who, you know, I'll name Kirsten because she's very out about this, she identifies as a person who used to be addicted, who said, no, no, I'm not, I'm not in recovery, and I'm, you know, I just, I used to have an addiction and now I don't, does that, so by the chronic relapsing, et cetera, that means they were never addicted, yeah, yeah, it means that she's not, she's not a relevant part of this discussion, that's the no-trust kind of thing, right? Yeah, right, exactly, it's like, oh, well, based on that definition, this person no longer meets it. I love this stuff, David, you and Hannah both have really, like, you know, nailed this into my head recently, of just like, well, when we think that way, we then have these sort of only positive affirmations about our beliefs because we say, well, oh, see, look, here's a case, you know, this, this is a case, this person has a chronic relapsing, you know, disease, and they're addicted and see, you know, I told you, like, this is what, this is such an important space for here, that, like, right, it's like a classic tale of like, when the process becomes the outcome, and no longer serves as utility, right, where it's like, they, they operationalize the definition of addiction based on the core elements of the explanatory model, not the actual outcomes, right, they're like, oh, well, it's the nucleus of Cummins activation, right, it's like, well, that's a process that's supposed to lead to addiction, not be defining feature of addiction, right, and then we make it the defining feature which, like, creates this, like, you know, moving goal posts, essentially, process. You know, I, I, I, I come both to praise and bury the DSM, SUD criteria. I think it's, you know, I, I can, I can point out a million problems with it, but my overall sort of pro, SUD, you know, pro DSM thing is, you know, there's a chapter, by the way, called defining addiction, a pragmatic perspective, it's by Walter Sinat Armstrong and Jesse Summers from the Routledge Handbook of Philosophy and Science of Addiction, edited by Hannah and Seraja Ahmed from 2019, which basically says, there is value to having a definition that is very heterogeneous, as I said earlier, defines the entire problem space that says, these are all the people who, like, for whatever reason, in whatever manner, they could use some attention to their relationship with drugs. And then, then we subdivide. Um, one of men, a couple of many things that are, you know, the, the definitional work that we have left to do, the diagnostic work we have left to do is like, amazingly, there's really, I don't think there's any good way to quantify the severity of an addiction, and I certainly don't think you can do it by counting up the tal, you know, the categories in the DSM, you know, this many is mild, moderate severe, doesn't make any sense because you could have two, you know, you could have two or three symptoms that are just, you know, obliterating your life, you know, day after day constantly, you could have little fluctuating versions of eight symptoms. So that's, and, and you can, and I have also the categories they have in the DSM, I have, I've kept the receipts on like, sort of appearing and disappearing web pages that have different cutoffs for the categories, um, with very little, you know, the first set of cutoffs was supposedly empirically justified, and then it changed with no explanation. So I just, I'm like, that's not, that can't be the way to go. And, you know, for, for specific substances, there are some, there are some questionnaire measures that will give you a severity score. But for the most part, it doesn't, the, you know, the ASI, the effect, the addiction severity index is not, that doesn't do that. Um, so like, we, one big thing that's missing is we, I don't know any good way to say how severely someone is addicted, uh, no, since the, the, it's an audio podcast, but I can see you know, and you look like you might not be agreeing. No, no, I agree with you. I think that there maybe is a way to get there. Well, I don't think that we, the severity like exists at the person level. I think that the, that not all the symptoms are created equal. And that currently is not the case, right? That like withdrawal is just not the same as tolerance on the footprint of your life, right? And that like we could maybe get somewhere by creating some kind of waiting procedure, whereby the symptoms are, are, are scaled in a way. But then that totally eliminates a person's life context, right? Uh, it has all of this local independence that exists, like it's like a classic, um, problem with the latent disease model, right? We're like, each of these things are supposed to be the created equal indicators of this latent disease, but this disease that we can't observe, but it is observed through its consequences. Um, and that like, um, I actually, I actually do agree with you. I think that we could, we could do better. I think there's a middle ground where we could get there where like it, having some cardinal symptoms, for instance, that require persons. The other thing I've always struggled with with the DSM, I actually, like you have both major qualms with it, but also think it's incredibly useful and the probably the best that we have. Um, that most of them are designed to be observed by someone else. Um, and that the, that the, that the self-report of the person who's experiencing the condition is less important based on the frequency of the kinds of information that they ask about. So there's only about two symptoms or so to ask us for the person to tell me what's going on inside of them, right? Yeah. Craving was new to the, to the DSM five edition, right? For craving wasn't in the criteria, instead it was chronic legal problems, which is even more observed by others. Um, the other one is, I guess withdrawal, right? Tolerance, um, gets a little bit there, but I guess you could, you could observe that from others. Um, or quote unquote, impaired control, which is how this is a concept that we think about, but it doesn't, isn't represented perfectly by any specific, um, criteria and except for maybe using more than you plan longer than you planned. Um, which, which requires us wanting to get down, maybe. Yeah. Or wind or unsuccessful attempts to cut back, right? There's like a few of them, um, like this, but yeah, that's always been my big issue with it is that like they're not even in this, even we equally weight them, right? And so your point here is a really good one, right? It's like you can get eight low grade things and that's like severe use disorder, we submit that probably the impact on a person's life is, is smaller than a person who has two really big ones, right? That cause big footprints, um, from a functional perspective, um, that make, make it quite challenging to, to wrestle to the ground. And we always forget about the DSM, like, you know, we always ask for all DSM disorders, like the symptom questions, like do you experience the symptoms? But in none of our measures, do we ask about like functional impairment? Like we don't, yeah, yeah. There used to be a thing in that DSM four, uh, where we were actually had, we had axes, right? In the olden days, there was, there was one where it was like called the, uh, the global assessment of functioning. And, and that we were supposed to give them a score about how like impactful all of this stuff is interfering with their life. And they deleted that in DSM five when they got rid of the axes. And so it ends up becoming like baked into the cake of how we assess the symptoms themselves. But once again, that's one of those things were like the process and the outcome become the same and then fail to, I think, have utility as much, right? And that becomes what adios and credit decision of the assessor once again. This actually, this is one of my favorite things to point out about the DSM, SUD criteria and the dependence criteria before them. And it wasn't even originally in the spiel I was going to give. So you've just made this longer. But I think, I think it's really important. The, the, the technical DSM is what I call a preamble that comes before the list of 11 criteria. Yeah, it's at the top. Right. I mean, it's not officially called the preamble, but I call it that. And so it's, you know, it looks like a definition of addiction. You know, as I've already quoted it, you know, problematic or maladaptive problem causing impairment through distress. So there's two ways to read that. You could say, all right, you need to check whether it's problematic and causing impairment or distress. And if it's not, then you shouldn't even read that list of criteria because I should stop right there. Or it's as manifested by these things. So you could say, oh, well, if these things exist, they are de facto evidence that the person is. So you could read it both ways. And I've seen it. operationalize both ways. I looked at, we used to use here at NIDA, we would give people the structured interview, I think structured interview, the DIST, the diagnostic interview schedule, which is used in like the National Comorbidity Survey, some big epidemiology studies for DSM, and it had a series of questions about what, this is DSM for dependence and abuse, and big pages and pages of SAS code that would score them according to this complicated algorithm. And I went in and I knew SAS and I went in to see what it was doing. And it turns out that there were some specific items asking about impairment or distress, asking, have you like, have you ever, have you sought help for this, or felt like you should seek help for this, or as things asking if it was bothering you. And so like overarching questions. And the algorithm did not give the diagnosis if the person didn't say yes to one of those questions. So they did operationalize it as you gotta, you gotta say yes to the preamble impairment or distress before the symptoms even count. I don't, most of the other structured interviews, I don't think work that way. So I think it is a genuine ambiguity as to whether you, you know, I prefer, you know, you know, asking the person, you know, or at least checking in with a reliable informant, you know, do you have impairment or distress or not? And if you don't, then it certainly doesn't matter that you have tolerance and withdrawal. I mean, it matters, it matters, but it doesn't get you diagnosed. Right, right. Well, I mean, and this comes, you know, brings me back to what I really like about some of Hannah's philosophy and particularly in the new book that she's written. But you know, even before that, I guess I should say is it, it matters how we look at people who are experiencing addiction. Because if you make the assumption that there is something about this person that prevents them from being able to make that determination on their own, then that symptom, then it almost automatically makes it the latter. Like you can only observe symptoms externally and then tell them, no, you do have it as substance use disorder. I grapple with that a lot. I mean, sometimes I think you probably do have to override people's self evaluations or people's judgments. I don't know exactly when, and this, you know, where's the line? Yeah, Hannah, yeah, you know, talks about that a lot in her in her book. The other definition of work we have to do, of course, is the great heterogeneity of right. And how do we subdivide further so that we can get meaningful sort of subclasses in terms of causation and treatment needs and prognosis. And I won't even, you know, I won't even, I like, I could go on about that and I'm not going to because, you know, I said I was going to talk about three things and second one with causal explanations. And I, you know, I've seen what are put forth as definitions of addiction from various like organizations, various entities that specify what causes addiction. And, you know, I think that's not always wrong. You can define if you have a disease that has one known ideological agent, smallpox. You can say smallpox is what's caused by the smallpox virus. You don't have to define smallpox as just a syndrome, a cluster, a cluster of symptoms. You can say by definition, it is what the virus causes. Right. So you can do that sometimes. I think addiction is, and so in that sense, I'm not against reductionism when you can, when you can do it believably. I think addiction, the comparison I've been making is certainly, it's not like small, smallpox. And in a way, it's more like poverty, like poverty, addiction is a state of being that can have any number of causes. And we get this most, I mean, at least scientists and I think most people understand that about poverty. And we define poverty operationally. You can have current income or accumulated wealth, whatever it is. None of those definitions of who, who has the condition of poverty and who doesn't. None of them include any assertions about what causes it. Because somehow we all understand those assertions don't belong in the definition of poverty, poverty. You describe it. And then separately, as a separate conversation, you talk about the causes of it, which are going to be many and varied. And the solutions, too, are going to be many and varied. And so like what I hear in a lot of sort of laid discourse about, you know, not just people who are biologically reductionistic, talking about addiction as a brain disease, but people who are giving counter arguments to that will say things that sort of sound like definitions on the surface, but they're smuggling in these causal assertions. Addiction is an expression of trauma. Addiction is a disorder of isolation. Addiction is a disorder of choice. Those really sound like definitions, but they're really their your pet version of what apparently causes all cases of addiction. And they all miss the, I think, the necessary step of first saying, all right, who's addicted and who's not? And can does my explanation account for all of them? So yeah, so I'd like I bristle at that sort of defining, defining things as you were saying, you know, before defining something out of your, your purview, because it doesn't fit with your explanation. And I can go, I go directly to what I wanted to say about about treatment. And, you know, statements about causation, they're usually made as if they should lead directly to an intervention, which again, going back to something like smallpox, makes perfect sense. You know, or bacterial infection, you want an antibiotic for HIV, you want anti-retrovirals. You need other things, too, for complete care of the patient, but the first fine intervention is going to be something that directly hits the cause, the most biologically reductionistic sense of the word cause. This comes up for me a lot, because at NIH, you know, I get reviewed periodically. And the advice that I get from NIH higher ups is that I should present myself as quote, an expert on the mechanism of whatever it is I'm studying, the mechanism. And when I, when I talk about that, I say, I really want to expand the use of that word mechanism. Our mission at NIH, and I don't speak for NIH, I speak for me, you know, it's a public health mission. So when we search for a mechanism, I think what we're really looking for is the best place to intervene, whereas one of the knobs, the knobs that we can turn to improve outcomes for people. And I think the most realistic effective thing to manipulate might not always be the most reductive biological cause that we can find. And so, like, I think we have to remember, you know, when we look at theories or models of addiction, like, you know, the deepest core of what that model or theory identifies as the cause doesn't need to be the knob that we end up turning to improve people's outcomes. Yeah. Well, and it's often, at least, you know, we, we generally as a, as a field, make, there's a lot of reliance on brain disease type models of addiction. And so, but often what we end up doing, there are some effective pharmacotherapies, of course, for some disorders, but not for all. And what we often end up doing is turning these other knobs, other than the pharmacological ones. So I think beyond, like, whether or not we should, or if it's the right knob to turn, if you find, you know, what, what the deepest causal mechanism is, regardless of whether or not that's true, we don't, like in practice, we don't always turn those knobs. Right. Yeah. And I think, you know, I'm not anti-reductionism at all, or anti-biomedical approaches. And I, and, you know, when I gave a version of this talk last year, I ended by saying, you know, what we can do, like, for example, people, people, well, sometimes people who argue that contingency management works, which it does. It works great. But it works for only about maybe half ish of the people you try it for. A lot of people who are not responsible, responsive, rather, to contingency management. And I think that actually is a pretty decent, rough and ready test for who's, which cases of addiction are contextually responsive and which aren't. And maybe it will identify the people who they do need something. Absolutely. Absolutely. They need a medication. They need neuro stimulation. They need something viologically reductionist that we don't, in most cases, have yet. But that, so like, you can divide along those lines. And this comes back to my, you know, agree to agree. Everybody can be part right about the causes and of and solutions to addiction. It just, you know, it depends who you're dealing with. And what you're saying also is that, like, accounting for all the other factors actually helps us be more effective when something like, you know, biology is the core cause, right? It by sort of weeding or, you know, ruling out some of alternative explanations, then we can know. But when we assume that one thing is the cause, whether it's that, you know, I know I'm at fault of always making the assumption that context is, you know, is the root cause. So it's the same thing for me. And the colleagues that, you know, sort of think similarly to me as well, we impede sometimes our patients and the people we work with their ability to get better by assuming a single cause. Yeah. Yeah. That's such a great point. You know, I made this point when we were talking to Hannah a bit, but I think it's important to bring back here, which is like, I really do think that like all of this is like the, the blindfolded elephant problem where you have five people who have blindfolds on and they touch different parts of an elephant and they say totally ridiculous things like, oh, they touch the leg and it's like, oh, it's a tree trunk, right? And then the other one person touches the, touches the, you know, the trunk of the elephant and they're like, oh, it's a snake, right? In psych. But actually, if they all took their blindfolds off and realized it's the part of a large hole, right? And then we could be inclusive. That's why I love about about the idea and concept in your, let's agree to agree, which is like, these all have like homes in this large, inclusive idea, they don't have to be exclusive where it's like, it's this or this, these false dichotomies of like, pick your fighter and we're going to like play to the end of the game. And it's like, all these things like, there's brains exist in people. They have functions, drugs affect them, right? Like context, the brain's traverse context everywhere you go, every brain exists in a context. It probably has an influence, right? People feel things. They like how drugs make them feel, right? And they want the drugs to change how they feel and it's specifically that they continue to use to produce it right that like we have thoughts also about how these things go and all of those play an important role. And that I think we need to work more towards creating a rich tapestry where each one of these has, you know, it's patch and it's coverage area. And I think it starts with creating a more clear set of definitions that we then can stem off of like what's the cause for that what what are the kinds of causes for that what are the kinds of treatments for that. And there are these meaningful subgroups, maybe that people position in, you know, one of the first things I ever read about this was maybe from like Howard Schaeffer, who talked about what's called the, he called it the addiction syndrome or it was like a condition of equipotentiality and equifinality where it's like the only thing that joins them is stuff in the middle. Everybody comes from a totally different origin story has totally different outcomes right but what what joins them are these core processes that live in the middle and we just spend some time really talking about that part of it. And I think that's where we miss a lot of it. We spend a lot of time on these other areas of the process. Well, this has been an absolutely lovely conversation, David. I'm, you know, selfishly, I really love your work and I can say here and talk to you all day about various aspects of all of this kind of thinking. But in interest of time and so forth, let's maybe pivot to our take home messages. Would you be all right with that? Yes. All right. So what do you think is the take home message maybe for people who are in recovery or interested in making a change? Well, I speak with great humility here because you know, I have my lived experience with my depression and anxiety, but I do not have lived experience with that. So I don't, but to based on all my book learning over the years and everybody I've talked to over the years, I would just kind of reiterate what I've been saying throughout, which is I think that there are many pathways into and out of addiction. And most of them are probably right for somebody. There's, I think we have more work to do, for example, to determine Katie Whitkewicz and her group have done great work showing, for example, that, you know, moderate drinking and even some heavy drinking, apparently, can be incorporated into the lives of people who seem to be successfully recovered otherwise. I don't think we have any good way for people to figure out am I one of those people are not. I wish you could, but I think what a, and unfortunately it's, it's too much trial and error, but, but I do think that people should be open to the possibility, you know, too many possibilities for what, what recovery or what the pathway out of addiction looks like for them. And you know, don't let other people tell you how it has to look, figure out what it has to look like for you is if I were going to give advice at all, it would be that. That's great, David. Thank you. What about take home message for practitioners. Mostly I would say, please read, read peer reviewed research and read it really critically and, you know, look into, you know, we talked earlier about questionnaires that when you actually look at the items on the questionnaires, there are mess. And it would be good to read past the title of a thing and see what's in it. So try to try to get some familiarity with what kinds of assessments are being used and whether you believe in them. And this is a whole other spiel, but for like predictive and diagnostic and classifying algorithms, there's a whole set of statistics that people use misleadingly in publications that where you have to really need to be talking about the false positive and false negative rates of your algorithm and how it's classifying people are making predictions for people. And if you don't under and learning more about accuracy statistics is a good way to make sure you don't get sold a bunch of snake oil in things that, you know, purport to be purport to be useful classifiers or predictors or treatment algorithms or whatever algorithms in the behavioral sciences. Yeah, that's a great point. And we live in an era right now where I think that like a lot more that's on the horizon. So it's like a really, I think pressing it a point. What would you say to policy makers, understanding that you speak for yourself and not for NIDA? 100%. Yeah, absolutely. I don't do policy. I try to do science that will be helpful to policy makers. I do think it would be interesting. If, if, if only there were a way for policy makers to convey caution to people to convey caution to the public in a way that wasn't criminalization, if there were some way, some, some regulatory mechanistic way to, to convey through regulation, this is, you know, this substance has risks. We're going to tell you what they are. We're going to protect you from them as much as we can. And, and, and it won't be, and we're not, we won't medicalize it. You know, you know, we, it doesn't have to go through an FDA pathway toward approval as a medication. Kirsten Smith pointed me toward a really interesting paper about a new policy in the Czech Republic that regulates psychoactive substances without approving them as medications that just tries to protect people from them and convey that this is not something to mess with that there are cautions to be taken. Unfortunately, I think right now the only language that policy makers can speak when they want to convey caution to the public is we're going to put this on schedule one. And that's the unfortunate reality. And I, I, I do wish there were, there were other, other languages, other buckets that you could put things in regulatory and, and, you know, if anybody can try to do that, I think that would be at least interesting. It would be interesting. Helpful, perhaps even potentially. What would the take home messages be for underserved populations? I would say take from from from treatment from psychotherapy, take what's empowering. No, I feel like no good therapy should ever make people complacent. I used to, you know, I've come to really like acceptance and mindfulness and act acceptance commitment therapy. And my initial concern with them was that they were teaching people to accept unacceptable situations. And it turns, that's not what they're about. And there's there's really good research showing that the way acceptance works is you, if you accept the fact that you're going to feel bad sometimes you don't accept that the things that make you feel bad. You accept your own feelings. And it actually it makes them pass more quickly. And it's actually very compatible with, you know, with maintaining your strength so that you can work for systemic change alongside undergoing personal growth. I've seen over the past few years, I've seen panel discussions of people, especially in the criminal justice system, who say that the way that they've encountered CBT cognitive behavioral therapy has been very gaslighting and disempowering for them and that they're being told by their CBT practitioner. But like anytime you blame anything outside of yourself, that's, you know, that's stinking thinking you're, you know, you can't blame anything structural or systemic at all has to come down to you and you need to change. I don't think that's what CBT is. And so I don't think people should accept any version of any therapy that says, you know, you can't, you can't work for change. Take what's empowering, you know, it's all there in the serenity prayer really, you know, you have to know what you can't change. But remember what you can change to and it might be things outside of yourself that so that, you know, for underserved populations and for everybody else, I would say don't don't let anybody tell you that therapy should be disempowering or that it should put all, you know, you take responsibility for what you need to take responsibility for, but don't let it put all the blame on you. That's an excellent point. And most of the time I find that people's complaints about CBT or complaints about the therapist that was providing the CBT is as your point here, I think is stutely underscores. David, you've been really successful in your career. So last question that we have for you is what advice do you have for any trainees who might be listening. There's advice I've been giving for a while that may be best for people who have kind of the weird combination of strengths and weaknesses that I do, but I hope, I hope it can be useful for somebody. What I've often have been to have told trainees is in addition to having expertise in whatever your chosen subtopic is, whatever your particular skill or realm of expertise is. You should also identify and develop the most broadly useful skills that you have. I'll give you examples in a moment. Make those skills available to the people around you. Make it so people in, you know, in your graduate program or, you know, in the university where you first get hired, wherever it is, make it so they would have selfish reasons to miss you if you went away. For me, it was, it was, I learned, I taught myself a lot of statistics when I started at night and started offering that to people and people came to me a lot for that. I was good at writing and editing and people came to me a lot for that. Chat GPT is a threat to that, although you mentioned, I recently told me that I'm still better than Chat GPT, which I took that was very happy to hear. Definitely David, no question. Anything that's available. Anything connected to like helping people plan a study or troubleshoot it or interpret the findings or put the findings in context. Like I happen to be good as a synthesizer if ideas across fields or someone who can make your approach to a study design a little bit more clever or help you communicate it in writing a little better. I've always struggled when it comes to the practicalities of implementing a study myself and getting it done quickly. I'm not great at that. I admit it. You might have totally different strengths and weaknesses, but figure out where you shine and if it's, if you shine in areas where you can be generous to other people with them, do it, offer help to them instead of competing with them. I don't do it for tactical reasons. I don't do it because I want them to, but it makes me feel like I'm contributing something that's why I do it. But it has the side benefit of like people want me to stick around because they're getting something for me. So that's my very unorthodox advice is in addition to specializing, think of what generalizable skills you have. and give them to people and make them love it. - Yeah. I appreciate that, David. And I also just an observation of something that I just learned from you was how to be confident and humble at the same time of just being able to know. This is actually what I am very good at. And stating that and also knowing where you struggle and not making that sound anything other than just frank awareness of yourself, I think is a good skill to learn. So I appreciate that and I appreciate your willingness to share that with us and everything that you've come onto the show today and talked about. It's enlightening and it's just been such a treat. Thank you, David. - Thank you so much for having me. It's been a pleasure. (upbeat music) (upbeat music)