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

Imagine you’re alone in a room. No phone. No windows. No way out.

There’s only one thing in there with you: a giant pile of cocaine.

Maybe you’ve never touched drugs in your life. Maybe you think people who use drugs are bad or morally suspect. But you’re trapped in that room, for an unknown amount of time, and you’ve got nothing else to do.

What happens next? 

This is the question the philosopher Hanna Pickard asks in her exquisitely titled book What Would You Do Alone in a Cage With Nothing but Cocaine? Pickard thinks our usual stories about addiction are too neat. Either addicts are moral failures, or they’re helpless victims of a hijacked brain. Her book makes a convincing case that both stories miss what’s actually happening — not just in the brain, but in the world people live in and the inner lives they’re trying to manage.

I invited Pickard onto The Gray Area to talk about what addiction is, what it isn’t, and what it means to hold people responsible without reaching for blame. As always, there’s much more in the full podcast, which drops every Monday and Friday, so listen to and follow us on Apple Podcasts, Spotify, Pandora, or wherever you find podcasts. 

This interview has been edited for length and clarity.

Is the title meant to be a rhetorical question? Because if I was alone in a cage with nothing but cocaine, I’d probably, for sure, do a lot of cocaine.

Right. And what you just did is the point of the title.

I want it to stop people and make them think for themselves about what an environment does to drug taking. Being alone in a cage with nothing but cocaine is a metaphor for the social, economic, and material circumstances that many people with addiction live in.

But it’s also a shoutout to the history of animal models in addiction science. One of the early experiments literally put rats alone in a cage with nothing but cocaine to see what they’d do.

Historically, that was read as evidence for a brain disease model where cocaine hijacks the brain and compels use. 

But, notice what happens when you imagine your own case: You don’t imagine doing cocaine, because you think it hijacks your brain. You imagine doing it because you’re isolated, and bored, and suffering, and cocaine is the only relief available.

What compelled you to write the book? Is there something about how people talk about addiction that feels wrong or incomplete?

I think there are deep misconceptions about addiction in public discourse and in addiction science, and they span the political divide. They’re everywhere.

Because I’ve worked with people with addiction, my worry is that the way the rest of us misconceive addiction affects treatment and attitudes. It has real consequences. I’d been writing papers for a long time, and then, I felt ready to bring it together into something systematic that could correct these misconceptions.

A big misconception is that there are only two approaches. One is an antiquated moral model that treats drug use and addiction as morally wrong. No serious scientist or policymaker holds that model in a simple form, but it contaminates the cultural air. We all have bits of it that come out.

Then, the supposed antidote is the brain disease model, which rose in the 1990s and positions itself as stigma reduction. But, it’s got its own problems, and, in my view, it’s not giving us what people with addictions actually need. 

So, the book tries to offer something less simplistic, more humane, and in the middle.

Do you think of addiction as a disease in any conventional sense?

You shifted from brain disease to disease, and that’s helpful.

I don’t think addiction is a brain disease as that model has traditionally been constructed. That model says there’s pathology in the brain that causes compulsive drug use. I think there are problems with the idea that drug use is always compulsive, with the claim of pathology, in all cases and with the idea that pathology is the fundamental cause of the behavior in all cases.

But whether addiction is a disease depends on what we mean by addiction and what we mean by disease. Without defining both, we’re talking loosely.

So how would you define addiction?

A simple gloss is that addiction is drug use gone wrong.

We should start with the fact that a lot of drug use is ordinary. Caffeine is a drug. Alcohol is a drug. Nicotine is a drug. Most people use drugs regularly in ways that bring benefits and don’t carry tremendous costs. We understand psychologically why people do that, and humans have been doing it for a very long time.

Then there’s a shift. Alongside the benefits, the costs ratchet up. People lose relationships, jobs, housing. In places that criminalize possession, they can lose freedom. Physical and mental health decline. Sometimes, people die.

So, addiction is a pattern of drug use that persists, despite severe costs, in ways that undermine a person’s own good.

If you force me to label it, I’m inclined to call it a behavioral disorder. It’s crucial to keep our eyes on the fact that addiction is behavior — drug use gone wrong. Then, the question is what explains that behavior.

People like to say that they’ve got the addiction “gene,” especially if it runs in their family. Is that an actual thing?

I’m not a geneticist, but based on the last systematic review I read, the answer is no.

There are genes that predispose to a range of mental disorders. There are genetic factors that raise risk. But, we haven’t identified genes that uniquely predispose only toward alcoholism or only toward addiction more broadly.

And, of course, genetics is only one part. Childhood adversity, socioeconomic disadvantage, and co-morbid mental disorders are all associated with increased risk.

But, predisposition doesn’t mean addiction is a disease. Risk isn’t the same as the condition. Smoking raises cancer risk, but smoking isn’t cancer. In the same way, these factors raise the likelihood without being identical to addiction.

How much agency does an addict have? How much choice do they really have?

I won’t use the term free will, because that’s a philosophical can of worms. But, we can talk about ordinary agency.

It can’t be black and white. It isn’t that they have agency, or they don’t. It’s complicated and impaired in different ways, and it differs across people, across time, across substances, and across contexts of support.

The model we should reject is that drug use is compelled in the sense that a person cannot do otherwise, driven by irresistible cravings such that no alternative is possible.

Agency can be compromised while still being present. And that matters, because people with addiction need to exercise agency to get better. There’s no pill that cures you. Recovery involves stopping, rebuilding a life, and finding other meaningful things to fill the space drugs occupied. That’s an agential project.

But, subjectively, cravings can feel overpowering. Choosing doesn’t feel like choosing. 

I want to push back against the cultural picture that cravings are always overwhelming. Some people crave frequently but not intensely. Others do feel overwhelmed. For me, the question is: Why? What’s driving the craving?

Withdrawal is one reason. Withdrawal can be terrible, and if you know there’s something that brings relief, you can become desperate.

But, drugs can also be a go to coping mechanism for deep psychological pain. For some people, drugs become something like an attachment figure, the one thing that feels reliable in a chaotic world. For others, identity becomes wrapped up in addiction, and the fear is who am I without this.

Why does this matter? Because, once you see why craving is overwhelming, you can see what might help.

If it’s withdrawal, you provide medical support so stopping doesn’t mean suffering withdrawal. If it’s psychological pain, you provide other ways to cope. If it’s identity, you help someone build a new identity and a new story.

Those changes can make craving more manageable from the inside.

We’ve got this binary: Either someone is a victim of a brain disease or they’re a moral failure. What should replace that? What’s a richer and more humane framing that leads to better treatment and better understanding?

Moralism about drugs is deep in our society, and I think it’s wrong. There’s nothing intrinsically morally wrong with using drugs. Caffeine is a drug. Alcohol is a drug. Nicotine is a drug. Many drugs used medically are the same chemicals as drugs on the street. So, we need to confront that knee jerk condemnation.

We should think of addiction as drug use gone wrong, behavior that persists despite severe costs and undermines a person’s own good. 

Again, the question becomes: Why? And the answer is not one thing; it differs across people. It’s tempting to want a clean reductive explanation, but we lose what matters if we do that.

So, what are the different answers when you ask why?

Some people are living in deep misery and isolation with few alternatives, and drugs provide relief.

For some, drugs become something like a relationship, an attachment. Identity can be central. Some people use, because they identify as an addict, and that’s what an addict does. We have to ask how someone gets stuck in that identity and what value it has.

Another explanation we don’t talk about enough is deliberate self-harm and suicide. Some people use drugs in ways that harm or kill them, because it allows self harm without direct physical violence, which many people find difficult even when they want to die.

We need to make more space to talk about self-harm and suicide in mental health, and to see how it can explain self-destructive drug use.

And there are explanations that involve what a person isn’t fully seeing: denial, rationalization, cognitive biases. All of us behave irrationally sometimes. Using those tools can de-pathologize and humanize addiction.

Given all that, how do we treat it? How do we hold people responsible without blaming them or condemning them?

This is grounded in clinical experience. In the clinic, you learn quickly that blaming and judging doesn’t help. 

But, it’s also easy to swing to the other extreme and treat someone as not responsible at all.

We need to separate responsibility from blame.

Responsibility is about agency and choice. Blame is the idea that we’re entitled to be hostile, punitive, and condemning. We don’t have to do that. We have agency, too, in how we respond.

So, you can have accountability with care and respect.

A way to see it is parenting. You can hold a teenager responsible without condemning their character. You do it, because you care and want them to learn.

Practically, it’s hard. It’s a skill. I came into clinical work more blame-oriented than I am now. Our emotional responses are shaped by culture and habit. We can work on them.

There are general rules, like don’t start by yelling at people that they’re terrible. The harder skill is communicating hurt, setting boundaries, and asking for change in a way the person can hear without recoiling.

How important is it for someone in recovery to tell a new story about themselves? And how much of that requires other people to stop insisting you’re who you used to be?

Identity can be fundamental. Recovery can require constructing a story that says, “I was an addict, and, now, I’m not. Now, I’m someone else.”

Stigma and condemnation destroy the capacity to tell that story. They remove optimism and possibility. They keep forcing the old identity back on the person. Once an addict, always an addict.

Nobody can do the work of becoming someone else for you. But, we can support it far more than we do.

Is that why AA and group therapy can help so much? Is it about support, and accountability, and belonging?

Absolutely. Groups are powerful.

A group gives belonging, support, community, and accountability. To be part of it, you’re committed to not using. Different groups handle lapses differently, but the shared project is a change away from drugs and toward a different future.

So, if you care about the group and want that belonging, you have to identify as someone who’s not in active addiction. That’s support and identity working together.

I’ll share an anecdote that I end the book with. In group therapy, we used behavioral contracts to help people stop using, because, to do deep emotional work, you can’t be high all the time. 

Someone would take a blank sheet of paper and write, “I will not use drugs. And if I do, I commit to making a support call to someone in the group or using support in my life to help me stop.” They’d sign it. Then, we’d sign it and write messages of support. “You can do this.” “You deserve this.” “I’m thinking of you.” “I can’t wait to see you next week and hear how it went.”

People would take that paper away, sometimes carry it everywhere. It didn’t work for everyone, but often, they came back and, for the first time in years — sometimes decades — they hadn’t used.

You can’t cure a brain disease with a piece of paper. The paper was a symbol of responsibility and also a concrete manifestation of care that someone could keep in their pocket. 

What do we as a society owe people struggling with addiction? What are our obligations?

Let me answer personally first.

There are people in all of our lives who struggle with addiction. I think we owe people, at least, the chance for relationship, care, compassion, and empathy when they’re in our lives. The limits depend on the relationship. What I owe a colleague is different from what I owe my children. Relationships come with obligations.

As for society, we allow the conditions in which addiction flourishes to continue. Childhood adversity, socioeconomic disadvantage, isolation, despair: These conditions increase risk. So, we have to take responsibility for allowing them to persist.

In other words, we built the cage.

Yes, we’ve built the cage. So, we have to do what we can to open the door.

Listen to the rest of the conversation and be sure to follow The Gray Area on Apple Podcasts, Spotify, Pandora, or wherever you listen to podcasts.