Dr. John Kelly - Stigma in Addiction and Courses of Recovery

I'm Dr. Noah Emory, I'm Sam Akuf, and this is the Addiction Psychologist Podcast. Today, we're going to be talking to Dr. John Kelly. John is the Elizabeth R. Spalland Professor of Psychiatry in Addiction Medicine at Harvard Medical School. He's also the Founder and Director of the Recovery Research Institute at the Massachusetts General Hospital, and he is the Program Director of the Addiction Recovery Management Service and Associate Director of the Center for Addiction Medicine. We're really excited to have John join us for today's episode, and he's going to be talking to us about stigma in addiction and his work in recovery. All right, welcome to the show, John. We're really excited to have you. Glad to be here. Thank you for having me. Of course, of course. Before we jump into all the research, all the important things that you're doing, could you tell us a little bit about your training history? Yeah, sure, yeah. So I did my undergraduate training, undergraduate degree at Towson University in Boston. Then I worked at McLean Hospital for a couple of years in Addiction Research, before going to graduate school and clinical psychology, and ended up going to San Diego, University at California San Diego and San Diego State Joint Doctoral Program in Clinical Psychology there. And after that, I went to Brown for my internship, and I was planning to stay at Brown for a postdoc as well. I offered a job in Palo Alto, at the Palo Alto Bay in Stanford. So we ended up moving there. I was very interested and had followed the work, all through a graduate program of Rudy Moose and John Finney in Keith Humphries, and was very interested in what they were doing there, so I was absolutely delighted to get an offer on a job offer there. So I went there, became an assistant professor at Stanford, worked in the VA, as it was called in Center for Healthcare Evaluation, which is essentially a center that focused on addiction, mostly addiction of mental health research, but they did, they were the hub for the country for the veteran's affairs, substance use disorder, and I was a part of the Achima part of the Quality Enhancement Research Initiative work there, which was essentially translating and implementing evidence-based practices for addiction in the real world in the VA. So we were kind of looking for ways to, we were identifying essentially in the VA Nation why identify gaps in care, in terms of what practitioners, what programs were currently doing, the kind of the gap between what they were currently doing and evidence-based practice, and then helping testing out the implementation of evidence-based practices in those settings and ultimately seeing whether that implementation of evidence-based practices resulted in better patient outcomes. So it was part of that initiative there, which was a fairly initiative, no initiative at the time, I remember, this was back in 2001, and then for family reasons we ended up, my wife and I ended up moving back to Boston, so we were there for a couple of years, then I went back to Brown and actually ended up doing a post-doctoral fellowship, interestingly, yeah. So I was, you know, it was interesting because it was kind of in some ways it was a backwards step, arguably, from going from a system to a platform to a post-doctoral. And I, on the, I wouldn't have taken it except for my advisor, Mark Myers, who was a great advisor, still is, and from my graduate school, he was my great, he said, you know, he said, without a doubt, take the post-doc, he did the post-doc himself, so he said, you know, don't take an assistant professor job, because I had a couple of options for assistant professor jobs at Harvard and at Brown, and he said, well, no, he said, do the post-doc, he said, you know, you'll have plenty of time to write a grant and get funded, so you'll be independently funded, and that's what I did, and I got an R01 funded at Brown. And then I ended up moving to, to Boston, I took this job at Mass General Hospital, they were expanding, this was back in 2005, they were beginning to really expand their emphasis on substance use disorders, and so they ended up moving there, and then, working there, started a program, their clinical program for youth, adolescents, and many other dental medicine addiction. But that's kind of my training, I guess, and then, you know, I gradually got situated there, I founded this youth program, and then a clinical program, it was doing this study on youth, actually, it was on youth addiction of recovery, and then I founded the Recovery Research Institute about 11 years ago now, which was all squarely focused on recovery, oriented research. Yeah, but that's my kind of training, right, industry, yeah. And that's kind of what, you know, you've been come to know, but be known for, at least me, I mean, that's your sort of the name when it comes to the recovery space, but it also occurs to me that you've jumped back and forth from, more or less, Boston to California, you know, three or four times. Yeah, yeah, no, I've been on the run from the police for a long time, incidentally, please don't tell them that you've seen me, if anybody asks. All right. It'll be our secret. Yeah, but the, no, yeah, it has been, yeah, it has been kind of back and forth, because yeah, when from, you know, San Diego, it was in Boston, when San Diego, and back, and then back over to Palo, and back again, yeah, it's just the way it's worked out, you know, could have been anywhere. But I'm just so grateful for, you know, the mentors, the people, the examples, you know, we all rely on that, don't we, as we're growing up in the field. We look to our heroes, the people that stand out, and there were, there were loads of people like that who I really admired and respected and wanted to emulate. And that's what I, you know, that's what I tried to do, look for my, you know, inspirations and, and the people who were, there were many of them, and some of, some of whom were passed on. But, you know, these are our inspiration, I think, when we're moving along in the field. And so I wanted to, to work with them, if I could, and of course it can't work with everybody, but you, you want to work with certain people, and, or otherwise, you know, see them at conferences and stuff like that. And so I've just been so grateful that I've been able to work in the places that I've been able to, you know, train and work in. It's been just a wonderful adventure and journey so far. Yeah, it sounds like a really cool set of experiences. And, and, and, and sprinkled in their low key was how you landed in RO1 as a postdoc, which I think should be celebrated, which is as it is quite an accomplishment, and a testament, I think, to the quality of your work. And, and I think, you know, as you, as you kind of reference, you know, the people that inspire you and the people like that, and I can certainly say that you've been instrumental in, in, in my growth as a, as a researcher and as the clinician in the space, your work has been inspiring, and you've just been so gracious with your time over the years. So, so thank you for, for paying it forward. Well, that's very kind of you to say. So I appreciate it. And, you know, it's a, it's a team, it's a team game, and I've gotten lots of assists. I might have scored a goal here and there, but I get plenty of assists from, from the rest of the team for sure. All right. Agreed. Agreed. Yeah, it is, I think team science is, is really the, is the key and oftentimes, I think we, we miss a little bit on that. And so I'm glad that you threw the shout out for the, for the rest of the people. Oh, yeah, the show. And so, so your research covers a lot of area and a lot of ground now, especially with all the travel that you've done and the different places you've worked with, or the different places you've been and people you work with. And so today, we were thinking we would focus a little bit on some of your work in the addiction stigma space, as well as some of your recovery science work. And so, you know, as a kind of an underlying theme of many episodes we've had here, we've referenced some of your work on addiction stigma and you've kind of wrote the like seminal papers on the idea of stop talking dirty in our field. And so we're hoping maybe you could, you know, explain that concept to our listeners a little bit and then talk a little bit about some of the research that kind of gave rise to that so that we can kind of understand where stuff comes from. Well, it's interesting, you know, by the way, thank you for your kind words. And you know, it's interesting, you know, you know, such as life, isn't it? You know, you just don't know. You kind of make some, you know, your best guess of where you want to go, what you want to do. And of course, you can't see round the next bend until you get to the next bend. And so, this is the story of life, I guess, and certainly my career. And you kind of stumble forward, hopefully, as you go along. And this was a case of stumbling onto this issue, which kind of began to hurt me way back in, you know, I was oblivious to this myself until I suppose right about 2002, 2003. I began to notice this term abuse. And I thought, you know, that's it. You know, why do we use that term? And the other thing that, you know, not just as the kind of the negative kind of, kind of connotation around that, which I'll get to in a second, but it was also the thing about lack of precision in the field in terms of our language and terminology in a clinical, from a clinical science perspective, the term abuse was used to describe the field more generally, like the substance abuse field. We have the center for substance abuse treatment. We have the substance abuse mental health, so substance abuse mental health service, registration etc. So it's used general as a generic term. And it's also used as a day, it was back then it was used as a diagnostic term. So it was mixed into papers in both senses. And so you can see how people could get very confused about, are they talking about the diagnostic term abuse, or they're talking about the generic term of abuse, describing the field overall. And I thought, you know, that's going to create problems for generalizing from scientific findings related to, for example, abuse and dependence. And I think we have a bit of the same problem right now with this very broad category of substance use disorder. With 11 symptoms and you have two or more, you're in the category. And of course, we don't specify, even though there are specifiers within that category for mild morons of ear, we tend not to use those specifiers very much when we're talking, you know, amongst ourselves in the field or even communicating, we tend to talk about the disorder as a single entity. And of course, this can create problems when we're talking about, you know, degrees of impairment, drug hormone, and likelihood of different kinds of outcomes. So there's this issue of critical precision that that began to hurt me, but then also the term abuse as it could give rise to the idea of being an abuser, what does that mean? You know, like a, you know, like the connotation of being a child abuser. Right. So as I began to look at that, I remember I was in Palabato working in the Vietnam time, and I thought, you know, this is not a good term. We need to get rid of it. We need to stop using it. Didn't have any, you know, idea of how I would, you know, prove that, but I just had the idea that this was not, you know, because of the connotation with child abuse or an all the rest of it. And we actually, I remember bringing me some in that, in that quality enhancement research initiative group, which was a national entity. And Mark Wellenberg, who is the clinical lead on that group at the time, agreed with me. I brought it up in the, in the meeting and one, one, one time we were meeting in our national advisory group, national group there. And then we voted on it. We changed the name and the group right there. There was enough, there was enough consensus among the researchers and clinical researchers in that, in that group, and had some heavy hitters in there, including, you know, Mark Wellenberg, who later became the head of the nitrophilase, driven in the recovery branch with John Finney, Rudy Moose, Keith Humphrey, Dan Tivlerhand. I mean, there was some George Woody from the University of Pennsylvania. I mean, there was, but I all agreed that we should get rid of this term abuse, and we changed the name from the, the, the quality enhancement, the quality enhancement substance abuse module to query, SUD query. So we changed it to SUD. Now, that was kind of the beginning of something for me, because I wrote a paper there after kind of looking at, back in 2004, looking at this issue of, of, of language and stigma. And how that, of course, frames are language frames, it both reflects and affects our approaches to, to addiction and to substance abuse. And so, I began to look at the frame, you know, the conceptual frame, and how our, our schema around certain constructs and issues are framed, of course, by our language. So then I began to look at ways of testing that out, and ended up a couple of years later doing a randomized study to look at, you know, whether actually exposure to that term substance abuse or, you know, produce different attitudes towards a person suffering from a substance related condition, then, then some, calling someone, you know, describing someone's substance use disorder. And anyway, so I ended up doing that, and I didn't know a study after that, and a couple of others, but it was, you know, testing that out and realizing that, you know, what, it even surprised to me, you know, just, just how it makes a difference. It's more than just, you know, a political correctness that actually induces these implicit biases, even among doctoral level clinicians, because that was the first study I did I remember looking, it was testing it, yeah, we had a doctoral, doctoral level clinical, psychiatrists and addiction psychiatrists, and really, you know, advanced practitioners who are susceptible to this bias when they were exposed to these different terms. So that was pretty striking to me. Yeah, and the one, I think the most, the really striking part of that study specifically is like how it flips to a punitive approach. Right. So in that study, you kind of ask them, like, what should we do with them? Right. You give them, you give them two vignettes. The only difference between it is substance abuse versus substance use disorder to describe the person's condition, and they ask what we should do with them. And then, you know, it's like, who should we send them to treatment? Should we, you know, like, in it, I think it like the violation of probation or something like this, you know, should we call our probation officer, send them a jail, and then just the term abuse had, you know, each similar doctoral level training participants were more punitive towards that person. And also viewed their actions as more under their own control. Right. And so I think that's a really, it was really kind of one of those things where like you just kind of hit you right in the forehead. Right. When I read that, I was like, Oh, wow, that's like so obvious. And yet surprising. Right. Like, that one, and then there's like, there's a bunch of other terms that kind of layer on that too. Right. Like the idea of when we talk about toxicology, where we use the term, they were dirty versus clean. Right. Like how that connotation also generates, you know, stigma and punitive approaches and in ways of viewing people. I think that that study was so striking to me. Yeah. No. Yeah. And it was to me too in getting those results. But you're right. And again, this was a bit of a mistake. I wasn't really planning to do any of this work, you know, just kind of fell into it and then, you know, stumbled along, you know, kind of making a study in another study. And then getting more, I was not an expert at stigma at all. I mean, I've never, you know, never really touched it, never talked about, you know, other than, of course, like we all do with addiction, you know, we're all, you know, we're all talking about it. Like you said, we talk about it all the time. It's in the air of anything we do in addiction because it is so stigmatized. But then again, to begin to get more involved, rolling up my sleeves, I'm just trying to understand it more myself. And then I thought, you know, there's this kind of these two dimensions, which you're alluding to know are, you know, cause and controllability. I think these two major factors of cause and controllability in relation to stigma, because if we say to, you know, we're going into any disorder, the problem in society, which is stigmatized, you know, if we can say, you know, it's, it's, it's, it's not their fault and they can't help that. We tend to have more compassion and still tends to go down. If we tend to say, what I mean, well, they did cause it. And by the way, they can control it. Then they're engaging in selfish, you know, and they're choosing R2. Yeah. Yeah. Exactly. Yeah. So it's those two aspects. And I thought the abuser term, you call someone as a drug abuser or an alcohol abuser, you know, you're implying that really they're just choosing to do it. That maybe that's what's being conveyed implicitly. They are engaging in willful misconduct. And so if you use that term, you're more likely to get a kind of a connotation or induce a, or trigger a schema that is associated with willful misconduct, because they're choosing to engage in it as opposed to using a more medical term, like disorder. And so, you know, when you pitch it against that, it, it turns out, yeah, it does, it actually does induce this more punitive negative punitive schema. And of course, you know, if we, therefore, you know, if you want to, if you want to kind of make some changes in this field, then we need to think about what we're, how we're actually talking about it and people who suffer from these disorders. And I'm happy to say that the world has changed. We are, we have changed on language DSM-5 adopted substance use disorder, a government abuse term, in part because of that research, I was told, that made the final, the final decision for them in terms of dropping that term completely. I Wilson Compton told me. So, it's very happy that it had that kind of impact. Well, I didn't know at the time. Yeah, I guess you never know what, what kind of impact your research is having. The other thing is like the word abuse, it ties like this violent, almost this violence to it. And it makes, you know, I think a lot of people have that connotation, that belief about drug use, that, you know, a drug user is violent or liable to be really violent because of drug use. And so on top of just it being stigmatizing and then health providers, you know, being less likely to, you know, give the treatment necessary. And sometimes I think it makes people think things differently about the individual themselves as well. Yeah, yeah, right on. You know, it's interesting, you know, you brought up earlier, you know, this term, you know, I use that as a title of one of one of the papers that we did called Stop Talking Dirty. Because it's, you know, you just reminded me Sam, you know, of how even in the medical settings where I work, you hear clinicians, these are trained clinicians talking about dirty urine screens, you know, the urine coming back dirty. And it's like, we don't use that kind of language in any other area of psychology or medicine. Somehow, it's infiltrated our medical lexicon in top, you know, clinical settings arguably in the world. We should not be using that kind of language. I mean, that, you know, you know, I don't think we need an empirical study, a randomized study to agree that we should not use dirty in the context, a dirty urine or a clean urine in the context of any medical or psychiatric, psychological illness. So that that was more clear cut that we needed to drop that kind of language from our public health clinical lexicon, as well as, you know, finding out what language tends to induce these explicit and implicit biases towards people. If we're serious about changing, you know, about trying to try to try to shift away from the criminal justice approaches towards more clinical and public health approaches. Right, right. And the winds are shifting in that direction, for sure. And most other medical conditions, it's going to be a positive test or a negative test, which has its own connotations, I guess, but, you know, that's at least the standard in medicine. So, well, where has all of this sort of led you? So if, if not abuse like disorder is an option, but, you know, what, what, what, what do you think needs to change? Well, you know, it's interesting. So that, you know, those tests, a couple of studies like that, where we looked at word disorder, as opposed to abuse, you know, and so the mental health failed for a long time. The four dictionaries you've been using person first language, you know, it's respectful. It implies that there is a person who has a disorder, as opposed to being the disorder. And so I think that's important. And we've adopted that in, I think now broadly in our field, in the addiction field, and more specifically. But here's an interest. We just did this study. We just published it in a diction, just came out a couple of months ago. Interestingly, now, because I was thinking, you know, we, we talk about, you know, disorder is certainly one option, right? We talk about addiction also as a brain disease, as a disease, as a brain disease, as an illness, as a disorder, as a chronically relapse in brain disease. So we actually just did a big national study where we randomized those terms to see, again, how does that affect people's attitudes towards someone who has drug-related impairment? And interestingly, there was a very interesting nuance that came out of this, which again, you know, hit me, was that the way that we, the kind of language that we use, you know, because stigma is multi-dimensional. So what we found actually, you know, you can reduce certain dimensions of stigma, but increase others with the same term. Wow. So what we, when we randomized, we had a very large sample, 3,600 people. It was nationally representative of the general U.S. population. When we randomized these six terms across these individuals, roughly 300 in each group. We had it split by gender as well, so in many ways. It represented in the vignette. But what was interesting was that the chronically relapse of brain disease, so the more heavily loaded medical terminology, like chronically relapse, we have some brain disease, was the best at reducing blame. So personal blame towards the individual to picked it. But it was the worst in terms of eliciting negative prospects for that person could recover. It also increased the most. It was associated with the most perceived danger and social exclusion. Wow. Yeah. In contrast, when you, when you drop the medical terminology, it was associated with the most blame, so when you describe, for example, someone is having an opioid problem, that induced the most blame, but the most likelihood that someone could recover. The least likely could be socially excluded, and the least dangerous. So that suggests to me, in terms of answering your question, Sam, you know, is that the kind of language that we use depends on what we want to communicate. Yeah. Right. So it's kind of nuanced in the sense that we may want to use certain terminology to make me to get people to get to get into treatment. Right. Other terminology we might want to use. Less medical terminology when we're talking about their acceptance in society. Well, it highlights that, you know, this like sort of compulsion and volition are on this spectrum, you know, opposite ends of a spectrum that touch different parts of different models in addiction. And also induce different types of stigma, depending on on which way you go. It's almost not a good answer. Yeah, it depends. But I think your point here is actually a really important one, John, right, that we can have different language for different goals, and that we could capitalize perhaps by using a couple of different terms at key state key decision points to leverage, you know, how human language influences individuals and what it elicits and what it tamps down. And we're having a similar conversation about this with Matt Field when he was on about the boomeranging effect of the brain disease model that like, you know, these are people with broken brains, right, and like they're different than me, they're other, right, and they're dangerous and they're unfixable or I'm unfixable, right. And so the idea that maybe we could use, you know, a term when we're talking about trying to engage a person who's interested in changing versus the type of term we might use when a person's engaged in recovery already, for instance, like, you know, like at a 12 step meeting, you know, they say like, hi, I'm, you know, so and so, I'm an addict, right, like that, that has a purpose there, but those people tend to use that label out in late environments with family members and other types of things, which elicits specific responses from them that perhaps unintended based on the results you're having here. And so having an alternative term there to describe ourselves in our condition, should I be a person with that condition that could elicit, you know, more social inclusion and more compassionate responses, you know, and also use it perhaps in a public health domain to, you know, advocate for social programs, so forth and so on, might be prudent. Yeah, yeah, exactly. And I think, you know, it depends again on the context as well, right, is who we're talking to. And what the goal, as you say, what the goal of communication is, because that's critical, it seems that maybe influential type of term that we use and how we describe it and people suffering from it can influence people's judgments and attitudes towards that person and they can watch themselves. The other thing about language, of course, is that language evolves, evolves and changes. Totally. We don't talk about lunatic asylum anymore. We don't talk about dips in menu. We did use it. Those were common terms. So language evolves, it changes over time. And I think, you know, what's important when we're talking about the most stigmatized condition in most societies around the world, which is drug addiction, followed by alcohol addiction, illicit drug addiction, followed by alcohol addiction. It's very important that we think about ways that things that we can influence. And language is one thing that we can influence how we speak. And, you know, language becomes automatic. It becomes automatic. We don't have to think about our language too much. When we try to insert a new term, we actually have to stop ourselves from saying the old term because it's so automated and habitual that we have to stop ourselves and proactively intervene within each other. But then that quickly becomes, doesn't it, quickly becomes the new term that we've adopted that we can adopt. And it becomes an important part of our language. I think it's particularly important with stigmatized conditions like substance use disorders are. Yeah, well, I agree. I think language is powerful and it's striking that I think this conversation has evolved, you know, in part since you've started talking about it, John, but also, you know, in part since the beginning of the opioid epidemic. And, you know, there have been a lot of reasons why maybe we've started talking about stigma around addiction more often. But one thing that you said that made me think part of that reason could be because of our shift in the language that we're using around it that occurred, you know, on a large scale in 2013 with the DSM-5. And also, you know, with the ICD, I think they probably made a shift, similar shift around that time. And so I'm wondering if that change in language actually may have had some kind of an effect on the way that we're talking about it now. Yeah, I think so. I hope so. And, you know, we've pushed hard. People like Rich say, Sarah Wakeman, myself, we've written about this. We've written letters to editors of newspapers. We've, you know, I went to the Rich states and myself went to the International Society of Addiction Journal Editors meeting in Budapest a few years back and we presented these data that we had. I had from my studies and Rich and I presented. And we got consensus there to remove this terminology from all addiction science worldwide. That was adopted by the International Society of Addiction Journal Editors. So that was an important step. Right? Well, you know, then if you don't see it, you know, if you don't see it in published science, you're not going to, you know, you'll be less likely to repeat it and talk about it because, and so that was a very important step. And I was very glad that we were able to get that outcome there. And again, we've kept our foot on the gas because, you know, I think it's something that we can influence in our change over stigma is very difficult to change. Right. It's very difficult to have an impact on. And we need to look at the ways that we can influence it. And, you know, our language, you know, like I said, both reflects and affects our approaches and our conceptual understanding of these phenomena. So it's very important. I've become much more, you know, you asked me 25 years ago to say, no, you know, it's just political correctness. I might have plugged it off like that, but now I am much more serious about it just because this is so stigmatized. These conditions are so stigmatized. And we have to, we've got our work cut out. We've got our work cut out to, to continually keep our foot on the gas to try and help people to understand, really, the true nature. Yeah. Yeah. I completely agree. Right. And am I correct in that you were part of a movement now to even try and change some of the language that we're using for NIH institutes? Absolutely. Right. Yeah. And I triple in NIDA. Yeah. Yeah. So we, you know, I wrote a policy brief with Valerie Eunchauer from the University of Delaware. And we, again, it was really a policy brief. It was sponsored by the Society of Behavioral Medicine, which is to change the names of the National Institutes of Health, pertaining to addiction. Which include and also the federal administrations, IE, SAMHSA, and CSAT, which have abuse in their names. And they're, they're really outdated names. And we need to change them. You know, the National Institute of Alcohol Abuse and Alcoholism, for example, we don't even use the term alcoholism anymore. That hasn't been used for a long time. Still in the name, National Institute of Drug Abuse. Again, there's substance abuse and mental health service administration. So yes, we wrote a policy brief, then we started a petition with voice faces and voices of recovery. In an attempt to, again, put pressure on the legislature, the federal government, because we do need a vote in Congress to change these names. It has to be an official stance by with Congressional approval to change these names. I think it's coming. I think the sooner the better, it's long overdue, if you ask me, and hopefully it will be absolutely right. So yeah, with a new administration. Do you think that there are anything that listeners can do to sort of participate in that? So they can sign up a petition on the action network. And hopefully, maybe we can provide that link. Yeah, we can add the link totally. Yeah, that would be great. And again, it's just signing on to it because the more people sign on, the more people. You know, I was an RSA. I was an RSA a few years back, and I was on a panel at the end with George Kube, Bob Hubener, who was the acting director of an IEEE's divisional treatment recovery back then, and a couple of other folks. And someone came up and asked, we wrote a panel talking about this issue, and someone came up from the audience and asked, when are we going to change the names of the electric delay? And I know, of course, it was a bit of a planted question, because the new one was on the panel. And I was arguing for a change. The George Kube said, well, it really has to come from the people. The impetus has to come from the people. And so anyway, yeah, so you know, so in other words, if we push hard enough as a society, we'll change the name. We are the society, we know issues. We can choose what these things are called, and I don't think it does us any favors to call these institutes inertial external drug abuse, and the national system. No, not at all. That's the opposite. You know, what's ironic, what's ironic is these institutes are designed to actually reduce stigma and increase the public health and clinical efforts pertaining to these disorders. And, you know, right embedded in the names, ironically, is still these very stigmatizing terms. Right. Yeah, they probably might even fund the research by which has drawn these conclusions. Right. But these names, they reflect different approaches to recovery, which is also something we want to talk about with you, you know, where one of them has been sort of tied up with, I mean, loosely with the war on drugs, but also just more strict enforcement sort of models. And some of these other languages are a little bit softer, and you know, try to have empathy towards the individual. So maybe I wonder if we can shift into this discussion about recovery. We would love to hear about some of your work in that space as well. Yeah, right on. Yeah. Yeah. I got into, again, not quite by design, but I was inspired by people like Bell White, William White, who's one of my heroes who wrote "Slaying the Dragon" in the history of of addiction treatment in America, published that first volume in 1998. And I loved reading that. I just was so inspired to read that because we had this huge, you know, all of you of how, you know, in the United States, how the United States had approached this problem of a since colonial pre, you know, in colonial times and beyond into the origin of the nation. And people like Bell were providing the language, the language, the concepts, the framework, the architecture for this idea of recovery science. And it was a big inspiration to me. Along with others, Tom McClendon, Keith Humphreys, you know, Rudy Moose, there were many people in the field in this realm that were inspiration. Many others, of course, Alan Marlatt was one, Bell Miller, many others, Nancy Petrie, of course, classic individuals who really shaped a lot of the clinical realm and shifted our paradigms since the Declaration of the War on Drugs in 1970. But I think, you know, when we zoom out and look at how much we've learned in the last 50 years since the Declaration of War on Drugs on the Nixon, we've learned a lot. We've come a long way. Don't forget, you know, at the same time this, you know, drug abuse was declared public enemy number one. And our AAA was founded. Four years later, NIDA was founded. I think they're connected. Yeah. Yeah. Yeah. Because it really did appropriate federally mandated dollars to construct these research enterprises, which produce, it still produces 90% of the world's knowledge on addiction science comes out of NIH, eight for bi-American taxpayers. And so that's what we've learned. And we've learned, and really the whole world has learned as a result, about, you know, the causes of addiction. You know, the genetic influences on addiction that roughly half the effect of the risk of addiction is conferred by genetic. Neurobiology, neuroscience, or, you know, the controllability aspects, you know, what's responsible for the embedded control around addiction. Why is it that people will still engage despite harmful consequences? We're understanding much more about that, about the epidemiology, phenomenology, typologies, all these things we've learned the last 50 years, which has really brought us to this point of understanding addiction as an illness, which is susceptible to relapse and which can take a long time to stabilize even when people achieve remission. And this was the thing that, you know, people like Bill White have been talking about, you know, what if we really believed addiction was a chronic illness? What if we really treated it as such? What about all the millions and millions of people in recovery? What could we learn from those individuals? They were an untapped resource, you know, understanding how people got and stayed in remission from a very serious deadly illness such as substance use disorder. And Bill was really, you know, one of the people that really was speaking out about that, which kind of got my interest and then, you know, I later started to do research in that area looking at how people achieved in sustained remission. And, yeah, so this whole notion of recovery science really is looking at, you know, how do people do that? How do people achieve remission and stable remission and recovery? You know, I think we all think that, you know, treatment is important and it can be certainly life-saving and it is vitally important for many people, but not everybody. But it can be the starting point for many people in terms of moving them into the right track of change. But, of course, treatment tends to be our validated treatment, so very short, right? We're talking about 12 weeks of some kind of manualized psychosocial treatment, usually 12 weeks. That's about it. That's about the longest, then you've got, you know, fabulous medications that can detoxify, stabilize, metabolically stabilize somebody, provide medications for long-term use, in the case of opioid use disorder that can help people prevent, you know, destabilization or relapse. But what about all the rest of it, right? You know, what about all the other thing? How do people actually stabilize, remit and stabilize over time? And that's what, correct, but it became my interest. Yeah, I think that's such an important aspect, right? So like, a lot of the knowledge has kind of been top-down achieved, right? By experts and empirical stuff, but there's all this important information that's coming kind of bottom up from individuals in recovery. And there's a bunch of people who achieve recovery, or at least problem resolution, without engaging with treatment in any way, right? So what people kind of refer to as natural recovery, or even in young adults case, kind of maturing out related things. And I know you've conducted a study, the National Recovery Study, where you looked at, you know, a bunch of really interesting. It was one of the only nationally representative samples of individuals in recovery ever conducted. And it has some really important papers that have come out of it, like the number of average number of attempts, series attempts, stuff related around jobs and employment and things like that. And I was wondering if you could just talk a little bit about some of the work in that space. Yeah, yeah, exactly. Yeah, and you're right, aren't you? I was like, yeah, it is. It's top down a bottom up, and it's kind of a science is inductive and deductive, isn't it? You know, we have exploratory research, which then can generate high-pophacy, is which can then be confirmed deductively. And, you know, one of the purposes of the National Recovery Study was, I was actually, had the good fortune of working on the Surgeon General's Report, and which was the first one published in 2015 on alcohol, drugs, and hell. And I was writing with Keith Humphries, the chapter on recovery. And as we were going through it, writing it, one question that came up was, we were talking about estimates, estimates of the number of Americans who were in recovery. And there were some regional studies, a couple of regional studies. But, of course, we didn't know whether those individuals themselves, number one, we didn't have a national prevalence estimate. Number two, we were calling them as being in recovery, but we didn't know exactly whether they themselves would identify as being in recovery, even the problem had been resolved. So that was an interesting data point that I wanted to gather, as well as get a kind of a national estimate. So we ended up doing this National Recovery Study, which I believe was the first, as you say, was the first National Representative Study to look at this particular question. And we looked at, we were able to look at a number of different questions and assess them in that study. And we found out, like you say, I think some very interesting things. Again, it's cross-sectional, large epidemiological study, but I think we've got some, again, we generated a lot of hypotheses about what happens to people in recovery, and perhaps documented and have provided some useful, I think, data points to be followed up on, some of which were eye-opening, some of which were confirmatory, and validating, I think, for many people. One was just estimating the National Recovery Prevalence as being about 10%, which was actually 9.1%, but roughly one in 10 US adults have resolved a significant drug or alcohol problem. I think that was the first national estimate on individuals. In other words, 22.35 million Americans are in recovery, based on the US census estimate at that time. Still about that. So about 25 million people have resolved. That's tens of millions of people who are walking around who have resolved a significant drug or alcohol problem. What was also interesting was the different pathways that follow. You brought this up Noah, and whether they identified as being in recovery, and we looked at their trajectories in terms of quality of life and functioning, we looked at how many times serious recovery attempts it took for them to resolve. There's substance, alcohol or drug problem, among other things, as you pointed out. One of the things that we found was about half of those individuals had recovered unassisted, so they didn't use any kind of external resource at all. When we looked at the correlates of recovering without assistance versus recovering with assistance, as you would imagine, or perhaps predict, people who were able to recover without assistance tended to be less severe, had markets of lower severity and higher more resources. People who needed more help, external assistance tended to be higher, have markets of higher addiction severity, higher density of psychopathology, and fewer recovery resources. What we now, sometimes refer to as recovery capital, the amalgamation of all those recovery resources that people can draw upon to help them in their recovery attempt. That was interesting looking at estimating roughly about how it had resolved the problem without utilizing any kind of external service. The other thing was the adoption of a recovery identity. This is something that, again, we were querying when we were writing that page in general's report chapter on recovery. So look at what proportion of people would actually self-identify as being in recovery. Interestingly, I thought this would be higher, but about half of this sample identified as being in recovery, about half did not. When we looked at, again, the predictors of correlates of identifying as someone in recovery, again, the things that tended to protect the adoption of that, identity, tended to be higher severity indicators. So if you had a more severe clinical history, I'd use more services, had a higher density of psychopathology, you were more likely to adopt that identity. I think some of that, I surmise that maybe some of that might be self-preservative, self-protective, in the sense that if you've been badly burned, you want to remember that. If you've been very severely affected by an addiction problem, you don't want to forget it, because the consequences of forgetting it are so severe, maybe even could be the end of your life, that you need to integrate that as part of your identity, and it may be that the adoption and integration of that identity may serve as that self-preservative function to keep it front and center. And if you talk to recovering people, they will often tell you that, that they need to remember it, they need to keep those memories green and keep that that identity as part of themselves, because it's impacted their lives so much in the past, and it could do so in the future, that's important to adopt an integrated. For people with less severe histories, it may not be so important to adopt that, and integrate that as part of one's identity. Again, I'm making that up, but I think it's a reasonable, a reasonable high offices, and yeah, so that was some of the some of the broad stroke findings as I recall. You asked about, it has another thing, yeah, was the recovery attempt, so how many serious recovery attempts did it take? I do want to talk about the quality of life stuff, because I think that's important, and that was something that really struck me, and I'd like to get to that, I don't forget it, so I'm putting it out there now, so we don't forget it. The, you know, this had been done a lot in tobacco cessation, right? But people are putting cigarettes, they often ask you how many, how many times did you try to quit before you eventually quit? This had not been asked in the alcohol drug field, as far as I could find anywhere. So anyway, so we asked them that, how many serious recovery attempts did it take before you resolved your problem? And we found that it was the mean, the average, the arithmetic mean was five, just over five, about five and a half times, but the median, because it was so skewed, the median, which was the more apt measure of central tendency, you know, your skewed distributions, you should use the median if you have a very skewed distribution, which we often do in our field, if you have a look at outcomes, or pretty much anything, they're always, you know, negatively or positively skewed. In this case, it was very positively skewed, so you had a small number of people that had a very high number of recovery attempts before they resolved their problem, but the majority of people actually had a very low number of recovered serious recovery attempts before they resolved their problem. In fact, the median was just two times, just twice. And interestingly, even when we did some sensitivity analysis, because obviously we had people that anywhere from one week in recovery to 40 years plus in recovery, right? But we also had people in that first five years of recovery, you'd ask, well, they're more susceptible, they're more than less stable. What about folks in that early, you know, we take out that first five years, people have five or more years of recovery, who are more stably, arguably more stably remitted, they have a much more stable recovery. How long, how many times did it take them to recover to resolve their problem? The exact thing, it was two. So whether you looked at if it was, you know, in the first five years or after five years of stable recovery, it was still the median was only two times. Again, it was variable. The predictors of taking more times, again, with the severity markers. So people who need more recovery attempts tended to have more severe clinical histories, more use of external services. So as you're in a higher density of covered morbidities, psychiatric morbidities. So they're just on higher density problems and it took them a bit longer, but still it was only three or four, as opposed to two, serious recovery terms. So I think that's pretty helpful, right? When we think about, we tend to talk about this as a chronically relapsing disease or chronically relapsing disorder, it seems very like nobody ever gets better, right? It's futile, you know, it's like, why even try? But the truth of it is, it seems to be, and again, they did a similar study in Canada, which found very similar results, for people resolving a significant drug or alcohol problem, that it took relatively few serious recovery attempts. That's good news to tell families, to tell people, seeking treatment that, look, this is not an endless endeavor, but rather, if you keep at it, you keep trying, you know, you're likely to get there sooner, maybe sooner than you think. Yes, it can take some people, a few more serious recovery attempts, but, you know, the media is just, it's turned into free time, so it can be, you know, four or five times if you have a very severe clinical history. But I think that's pretty helpful, not to be able to communicate to folks and to families who. I completely agree. I've actually used that clinically with families where they're like, oh, this is just how it's going to be now, like where I work a lot with teens, and you know, they're kind of understandably exasperated at times, by the time they reach, you know, the program I was in, you know, and it's like, well, actually, you know, the national average is kind of, you know, just two attempts, right, and they're like, oh, okay, that totally kind of flips it for them. And then suddenly we get a different level of investment, we get different, you know, expectancy effects, installation of hope effects for families and individuals that are trying to, you know, make a change. And so I think that studies is like super important, and not just from an epidemi. That's one of those ones where like epidemiology meets intervention in like a very meaningful way, where a lot of the times those linkages and translation aren't very clear. But this is one of those cases where I think it is very true and very clear connections that are clinically relevant. Yeah, and I think, you know, you can give the confidence interval around that, you know, it's two to four, you know. Sure, sure. So, you know, so they don't lose hope if it takes them more than two, right? Yeah, that's a great point, right? Two to four, right? Yeah, as a totally reassignment. Yeah, and at the same time, you could instill hope and say, you know, this is achievable, this is attainable. This is not something that, you know, you know, we can tend to give out this idea as clinicians that you've got this, again, with good intention. This one is going to happen. Exactly. With the chronically we'd have some brain disease, no mucleature, is that you, we're spinning that out in the hope that it will reduce shame and blame and get people more into treatment. It's not your fault. But at the same time, we want to let people know, well, wait a minute. Yeah, it's, it's a, it's a chronic reduction brain disease for some, but most people 75% actually will achieve full-sustained remission. It may take them a little while to get there, but 75% of people with SUV will achieve full remission. That's the good news. And it may not take that many attempts to get there. So that's something, I think, very positive from, from these findings and later ones that have come out since then. But, you know, one of the other things I wanted to get to is just this notion of quality of life and functioning. And we purposely, of course, included a lot of measures along those lines to look at, you know, what happens to people as they get into recovery? And we have a lot of things that you'd mentioned before about, you know, increases in recovery capital, you know, employment and achievements and good things that that have come out of their recovery. And how their functioning changes over time, their functioning indices of well-being, their self-esteem, what happens to that, where people get and can stay in recovery. And some very interesting results when we plotted the curves of these indices of functioning quality of life, self-esteem, happiness, psychological distress, recovery capital. When we plot those out over over 40 years, you take the temporal horizon, for example, 40 years of recovery. First, we also zoomed in on the first five years, the first two years to take a look at that as well. And I'll talk about that in a minute. But what was, what was not worthy, I think, was people get better? That perhaps wasn't unexpected. You see this nice, monotonic increase in, I say the word monotonic, just to impress you. I'm impressed. So, I've dropped that in everyone. Even if it doesn't make sense, that's what it means anyway. So you say it, and they don't question it. Yeah, I have no clue what it means. I believe it's a curve that doesn't double back on itself. But it sounds good regardless of what it means. That's exactly, I think, a really great indicator of intelligence. It's the ability to think the word monotonic, just how willy-nilly in the middle of a sentence, like, you know, a monotonic, right? Yeah, exactly. Sounds like a drink, honestly. I had too many double monotonics. Yeah, well, exactly. So it's, the idea is, of course, it just made a general increase year over year. You see this nice increase year over year in improvements in quality of life and functioning and well-being, self-esteem, happiness, and similar drops, analogous drops, in psychological distress. So that's nice. What was also interesting was the inflection point, there was an inflection point right around this five year mark. And it's interesting because this mirrored, it mirrored what we know from the clinical realm about how long it takes for people to achieve stable remission. And let me explain what I mean by that. We know from lots of prospective studies and retrospective studies that it takes about four to five years of continuous remission after someone achieves remission from a substance use disorder, achieves that first year of remission. It takes about four to five years of continuous remission before the risk of meeting criteria for a substance use disorder in the following year, drops below 15 percent. Why 15 percent? Because 15 percent is the annual risk in the general population of immediate criteria for any substance use disorder, including alcohol in the following in that year. So to be no more likely than anybody else in the general population of meeting criteria for a substance use disorder in the following year, if you've already added, takes about five years of continuous remission. So what we saw in this curve, in these curves of improvements in well-being and functioning and drops in psychiatric, psychological distress, was right around that five year mark. That's where you see that shift. You see the steeper increase, a steep increase in changes in these indices in that first five year. And then that's where the inflection point in the curve, the change in the curve comes right around that. So it was nice to see that reflected in these data too. As we saw in these other data, so it seems that that five years, that first five years of recovery, there's something about that where people are trying to get back on track. They're really improving their quality of life and functioning and up through that first five years. And it's almost like they're climbing up this hill of trying to get their life back on track. After that five year mark, then it starts to shallow out. People still improving in quality of life and functioning and well-being in happiness. But you see this steeper climb in these first five years. What was slightly disheartening for me was seeing that it took about 15 years before they reached the same quality of life in the general population. And I think part of that for me was realizing that this really a failure of our approach so far, I think, to really address these other aspects of recovery capital and helping people to get back on track. And I often use this metaphor of a burning building. And I think what we've done, if we've done anything good in the last 50 years in terms of addiction treatment, we've really focused on life-saving treatment that can really put the fire out of this burning building. You know, we've recognized there's a building on fire. There's an emergency situation and we put the fire out. We know to detoxify, stabilize, provide acute care treatment. Where we've done not such a good job is fire-proofing the building. Making sure that the fire doesn't restart and that we can provide the building materials to people so that they can actually refit their lives, repurpose the building and rebuild the building. And I think also very importantly, is providing the building permit so that actually people are permitted to rebuild their lives. One of the things that we, of course, all see and see people struggle with is the criminal record that they have as a result of, you know, could be simple drug possession or a crime related to that to alcohol or the drug use, which then prevents them from getting a building permit going into recovery. So they can't get along, they can't get housing, they can't get a job because of their prior prior criminal record. So this is something I think we really need to focus on because how disheartening is that when you, when you really want to, you know, you're trying your harness to deal with all the post-acute withdrawal phenomena that associated with only recovery and deal with all the stress and turmoil around that. And then you're told that, sorry, the door is still closed because, you know, we can't give it the building permit because of what you did in the past. It may be a long time in the past. So this is something I think we really need to focus on because that really takes the wind out of people's sales and they can really lose hope quickly if they feel that, you know, they're already climbing up a hill and then to add that burden to them, it can be thrown back into the fire. Yeah, absolutely. I think that, you know, drugs are very pleasurable and in many situations, you know, people's lives are not that pleasurable and we have to give them. I love, I love, that's a classic John Kelly and metaphor. I love this idea of building permits to, to give people things that compete with, with drugs like as reinforcers, right? And, um, exactly, allowing them to do that is, I think, a critical next step and that 15 years, you know, from what you're saying and, from what I'm understanding, it's kind of a moving target. I mean, we could maybe in, in 20 or 30 years, if we do the right things with policy and whatnot, that could, that could drop pretty substantially. Absolutely right. And I think this is what we can do, you know, it's, it's really, you know, is that, is that even that five year, you know, that five year window where we say, well, it takes five years to achieve stable remission. Is there something we can do about that to shorten that or is that just an extra goal? We can't change it. I think the answer is yes, there is something we can do. And that is to attend not just to the psychopathology, not just the addiction pathology and the other clinical though, but addressing these other needs, the social determinants of health, the recovery capital, the building permits, those other aspects, which we have tended not to focus on as a field. Interestingly, NIDA now, if you look at their NIDA, NIDA's diagram of what is comprehensive, good quality comprehensive addiction treatment. Interestingly, it includes things like vocational services, legal services, right. So in other words, it's addressing and attending to all the other stresses, you know, kind of the, the things that contribute to the allostatic overload of people early on in recovery that prevents them. So if we can mitigate that by a behavioral stress, by giving people hope, giving them a building program, giving them materials that they can rebuild their their their life, then I think we can shorten that time to quality of life that's not commensurate with the general population. And also maybe shorten that time frame to stable remission and bring that bring that down from five years to two or three years. Absolutely. I mean, it's excellent bit of research that that provides, I think, clear pathways and goals that that's that are achievable. And I think like the work with stigma, it's about getting people on board and convincing that the the addiction community, the general public, and, you know, representatives in our representative government to to make the changes. And I don't know, it kind of feels like a little bit of a call to action for me. So yeah, I couldn't agree more. I couldn't agree more. Yeah, I think it I think that's that's how it has to be done. And we have to focus on these other things, right, not just symptom reduction, increases in well-being, right, building permit, access, right, people that teach you how to draft them, right, like all of that stuff are just so essential to to pathways to recovery, frankly, right. And I think I think your work here is really set in the stage for some like really important initiatives that are going to be the future of recovery science and addiction science more generally. And so I just want to thank you so much for sharing your your work with us today. I think it's such groundbreaking work. So important. I've already thought of like three different ways I'm going to include this in a paper I'm working on currently. And so I think it maybe it's it's a good time to pivot to some of our take on messages if that's all right with you. Yeah. All right, so what would you this one seems a little bit on the nose given everything we've talked about already. But what would you what do you think of take on messages for people in recovery or people who are interested in making a change? Well, let me start with people making a change. Again, we alluded to this a little bit earlier. Is that, you know, is that when people get into recovery their life improves their life improves drastically. And they, you know, it may seem very hard to change. Of course, it is very hard to change. But the benefits the rewards of that change are life-saving and, you know, life enriching in most cases. We see this this nice improvement in people's quality of life, their meaning and purpose, their self-esteem. All those things are real. They're real. They're documented. And we have those data now to to suggest that if you if you if you move in the direction of adaptive change of resolving your problem getting into recovery, that the rewards are there. They are more delayed. Sam mentioned this, you know, obviously, they're, you know, I was talked about the, you know, the drug rewards are immediate public predictable. The rewards are recovery of delayed diffusion variable. In such his life, but you have to at some point, you know, when the punishment of substance use becomes greater than the reward and it becomes more quickly, it comes more quickly, then people start to pivot towards change. And I think the other thing that we touched on, which I think I would is let people know that it may not be this very large number of attempts that people need to make before they're successful, but rather, you know, two to four, two to four serious attempts before people resolve their problem. And for some people, of course, it's the first attempt, you know, for some people, you know, go the other way from that meat that average that into what's our range. Some people are achieving it after just one serious attempt. And so that's going to come very without severe, again, density of pathology, availability of recovery resources, permits to get the life back on track. Yeah, that's great. What about, oh, sorry. Yeah, I was just going to say, you know, for the people in recovery, again, that, you know, that the rewards we're what we're finding out here is that we'll look through the rewards of recovery tend to grow monotonically. Okay. Double it up. I just love to use the word monotonous. In any sense, what say it? I even used it this morning when I was drinking my coffee, I said to my fiancés, it's coffee, it's monotonic, it's fantastic. Didn't make any sense, but she had no clue. She said, yeah, it is monotonic. What would your take home message be for practitioners? For practitioners, I think, you know, don't lose hope, you know, sometimes practitioners, I always encourage people, I supervise clinically, and when I give talk to clinicians, is, you know, I think a lot of the nihilism has come actually, ironically, from practitioners who see the same coming in to treatment, but, or seeing people that don't change, you know, there's the loose hope. I said, well, you know, people with addiction, you know, that why help them? Because they, you know, they never change, they never get better. But the thing is, you know, when we, when we zoom out, if you zoom out to 30,000 feet, that is that every time you have a conversation with somebody as a clinician, that you're planting the scenes of recovery, and to don't lose hope, you know, you may not see change right away, but to bring up the conversation, assess for it, screen for it, assess for it, have a conversation around it, be people wither at, but, you know, plant the scene and, and don't give up. The other thing is, is that, is let people know about, you know, and we need to incorporate this much more into our clinical paradigm. NIDA is already doing, as I mentioned, is, is to link people to recovery capital, to other resources outside the clinical realm. The clinical realm is very important for many people on the severe end of the spectrum. It can really make a big difference to the trajectory. But as I mentioned, if this is usually only very short term, and we need to connect them to resources that can help them rebuild their life and to instill hope for the future. Because, you know, they look bad, there's a wreckage of the past, look what I've got to clear up, they look forward, look what I've got to make up. And so there's those two paradigms going on, we can give people hope by linking them to resources. Now there's always recovery support resources emerging, not only 12 step mutual help, different kinds of mutual help organizations, recovery community centers, recovery coaching, recovery in, in, in educational settings, so, and recovery housing. So there's all these different, now resources that people that we, as clinicians, can connect people to help them. So I would make clinicians more aware of that, so that they can help people connect the dots and maybe short that time to stable remission. Well, that's, I think a really great point is all the different other resources that people don't even think about, right? And the next question I'm going to ask you, which feels, I guess, weird asking you, because if there was ever a person who had an effect on this group, it was you. But what would you say to policy makers out there, should my chance they are listening? Well, again, is to think about making, you know, making treatment more accessible, making it more available, making it, and recovery resources more available. But also to think about recovery, to think about not just acute care stabilization, but think again, what do we need to do to provide the building materials for people to get their life back on track and the building permits? So I think this is so key. It's something that we are now. I think that the time is now for this. And I think this, you know, the new administration is focusing on this to provide, yes, treatment is important. It can be life-saving and it's vital for many of you. But we also need to think about beyond this acute stabilization. What do we do then? Yeah. What do we do then? How do we provide the building permits? How do we provide the building materials, the building resources to end still home to get people's lives back on track? We've been short-sighted in the past, but I think now the next 50 years forwards, I think we'll be focusing much more on how can we, you know, improve stable remission rates of stable remission and help people to resolve their problem sooner. Yeah, yeah, absolutely. Well, what is your take-home message for underserved populations? Well, I think, you know, I think this, again, I think it's we need to serve, we need to serve as a society, those underserved populations better. This includes sexual minorities. It includes racial ethnic minorities, people with low SES, Native Americans, in particular, have been really hard hit by addiction, substance use disorder, and particularly during COVID. It's how we can serve those populations better. And that's something that policy needs to really take a look at in terms of providing disproportionately more to disproportionately underserved populations. So we need more resources in these higher-hit communities, both in terms of providing easier access to treatment and recovery support resources, and in particular, the recovery supports and building, helping them build recovery capital. So this means, I think, investment in job training, job access, educational training, educational access. There's this very nice program called Access to Recovery in many states, including Massachusetts. We're just doing an evaluation of it right now, which provides building materials. It provides six months of paid training in a variety of different jobs. So they get paid while they train for a new job that can get there for the door. It provides access to housing for six months, paid housing, in addition to that. It provides vouchers for goods and services. Again, this is coming from, lies you from a federal block grant dollars. But again, it's about how do we how do we provide those materials to those people who need it, who would indeed have to get a foot home back in recovery? Yeah, I think that's such a crucial program and an off-and-under-appreciated link in the chain. So John, the last question that we have for you is, you've been so successful in your career. Do you have any advice for the trainees out there listening and how they can make an impact like you have? Well, I think firstly, is find a few words that nobody can understand. That will monotonically increase your foot. Find some words that nobody haven't got a clue and use them often, but with authority. That's the key. Right, the confidence. Yeah, that's what sells it. It's all about. No, but the first of all, it's very kind of you to say that. I've been lucky, as I mentioned, it's really, I think it comes from within. A lot of it is our passion for an area that we find something that really we can latch on to that drives us. It keeps us motivated, it keeps us up. They don't know what we have to do. That stuff in grad school, that's really difficult. Those times when we want to throw in the towel, keep us motivated, keep us going. And that's really having caring mentors. We choose our mentors. We try to get our mentors select mentors, but we don't know what they're going to be like, will they be caring, will they be kind, will they be generous, will they be engaging and warm and and surrounding ourselves and people like that to help us along the way. And yeah, I think try to emulate the people, that's what I've done anyway, is to look at those individuals that inspire me and try to be like them. I think that's pretty human nature, really isn't it? We want to kind of emulate those that are our heroes and try and try and do what they did, find, you know, good work hard, you know, try and find good training programs and good people to latch on to. Be patient. Be patient. I'm terrible at being patient, you know. I want to say my my prayer for patients every day is God grant me patience and credit right now. I'm terrible and I'm totally ill suited for a research field because I just want instant gratification, you know, it's like I find it very difficult to deliver a vacation, but maybe that's why I've got my pedal on my foot on the pedal all the time, pushing for quickly for the answers, but it's not a quick game this, really. It's a kind of a bit of a patient, you have to be patient with research. It takes time to gather answers to research these things. And sometimes you're not successful right away. But be patient, be persistent is key. That paper, that paper that you mentioned, that one that one I did on the terminology, the first paper, the first experimental study, I sent it to seven journals, initially, or rejected it. Wow. Now maybe they were a bit, you know. There was a journal of monotonicity and things like that. I had no kid. Now there were high by journals, but still seven journals. And then I sent it to the International Journal of Drug Policy. That's a great journal for this, International Journal of Drug Policy. And they loved it. They loved it. They were all over it. And so sometimes it's finding the right market. It's finding the right market for your work. And then that particular thing took off went viral. You know, totally unexpectedly, but such as it is. But anyway, but yeah, it's kind of, you know, being, being persistent, being patient and follow your own true, here's my children out there, follow your own true daughter. Don't be put off. You know, if you've got something inside you, this says, you know what, I still think this is right, even though people are telling me maybe this ain't right. There's something that pay attention to that and keep your foot on the gas. As I think, as they say in the music industry, you know, don't change, don't change your tune to follow the trend. The trend will come round to you if you're true to yourself. Three chords and the truth. That's all you need. The world will eventually find you. They'll come round to you. And that was a bit of my story, really, you know, recovery science was not in fashion. That was not invoked. It is now. It is now. So, you know, but, you know, it wouldn't matter if it wasn't the important thing is you've got to do what you feel is right. Right. Yeah. Well, I love that advice, all of that advice. I'm going to be scouring my dictionary over the next couple days looking for words. Exactly. And I need to learn some chords. Right. Yeah. Don't only three. So just three. Non-monotively. Yeah. Well, thank you so much, John. This has been just incredible. And I've learned so much. Thank you for spending some of your time with us. Agreed. Absolutely. My pleasure. Thanks. It's great chat to you both. Thanks a lot. Next time on the Addiction Psychologist podcast will be the first in a series of episodes on addiction treatment. We're going to cover different forms of treatment, talking to experts in each area. We'll cover brief motivational interviewing, CBT, contingency management, psychopharmacology, what exciting guests, the likes of Jim Murphy and others. So please stay tuned.