SIO385: What Exactly Is A Psychological Diagnosis?

Transcript

This transcript was generated automatically and may contain errors — the audio is the record.

0:00:15 Thomas: Hello and welcome to Serious Inquiries Only. This is episode 385. I'm your host, Thomas Smith. Today, Dr. I'm joined by Dr. Alan Smirbeck, also known as Stormy Decisis, one of the best OA patron names ever. We're going to talk about what it means to be diagnosed with something, which is more interesting, more fraught than it sounds, maybe at first blush. This day and age of, you TikTok psychiatry, people are self -diagnosing and and diagnosing others from a distance, and all kinds of stuff.

And a reason why we should kind of let the professionals do it as can, maybe, with something like the autism spectrum or certain other psychological diagnoses that one might have, it's interesting to think about, well, what happens if you are just short of a diagnosis? What does that mean? I feel like my brain wants to really make that a binary, like either you have it or you don't, for some reason. What is a diagnosis? How do we actually use it?

How do doctors, I say, wait, how do doctors actually use it, and what goes into it? All those interesting questions and more. Going to get right over to that. But before we do, as always, I wanna ask you, please consider supporting the show. Patreon.com/seriouspod. Lots of your friends have, everybody cool is doing it, why don't you do it? We've got Seriously Alpha movies, if you haven't heard the Armageddon one, definitely go listen to that one.

Memento is forthcoming, it's, uh, in the edit bay right now, coming at you soon. And of course, you don't have to hear the shitty auto ads, that's the best reason. So patreon. Com slash series pod please support the show. You you so much to those who have already pledged. All said, let's get on over to today's show. I'm joined by Stormy Decisus, Dr. Alan Smirbeck. Been far too long. How you doing?

0:02:02 Alan: Am doing much better after COVID stole voice. It was either that or a sea sea witch, but to talk for several weeks, so I back in action.

0:02:05 Thomas: Yeah. Hmm. Well, if I was trying to diagnose whether it was COVID or a sea witch, have you been on any seafaring vessels lately? Would be a question.

0:02:20 Alan: Actually was. I took a vacation to Puerto Rico, and I a seafaring vessel. I don't recall meeting a sea witch, but of course, they are known to be bewitching. I

0:02:21 Thomas: Oh. Did you hear any singing that you couldn't explain?

0:02:32 Alan: Did see a crab play the the marimba, so quite possibly, yeah.

0:02:37 Thomas: Oh, did the crab have a problematic accent? I'm so glad to hear that you're doing better. That was, yeah, bad bout with COVID, right? I mean, a lot of people are getting a pretty bad case right now. It's kind of a resurgence.

0:02:51 Alan: I, I recovered from the COVID itself pretty quickly, but, um, I was completely unable to speak for about a week, and then we were going to record, and I sent you my, like, "No, this is what my voice is," and it sounded like a pubescent frog. It, not good. Yeah.

0:03:06 Thomas: I mean. I'm normally like, oh, no problem. We'll do it. That. So I was like, might as well wait it out. So glad to hear you're doing better. And thanks for being with us today. So what are we going to talk about? I may have teased it a little.

0:03:13 Alan: Yeah. Were some questions about, like, what exactly is a diagnosis, because in psychology and in psychiatry, because it's not like, you know, diagnosing strep throat, where we find if there's strep bacteria or are there not, um, so it is in a sense fuzzier than that, but that doesn't mean it's totally meaningless. There's not a a line went between green and blue, but it's still meaningful to talk about things as being green or blue. Thesis of this is, one, whether you like diagnosis or not, we're not getting rid of it because we have a fee-for-service healthcare system, and you have to have diagnoses to get insurance coverage. Main thesis here, here, is that is not about making something real.

Your problems are exactly as real before or after you have the diagnosis. Diagnosis doesn't mean that something's in your brain. It was in your brain before. Where else are your thoughts going to be? They're not in your kidneys. It doesn't define anything. Is more true. Nothing is more in your brain. Nothing is more or less your fault because you have a diagnosis. Is important is we need ways of grouping people together that are meaningful so that we can do research. And then we can apply that research to people who are kind of like the sample we did the research on. We just had a giant ball of everyone who has problems, problems, we wouldn't be able to tell anything meaningful about that group. You know, is the amygdala overactive?

0:03:51 Thomas: Yeah. Yeah.

0:04:43 Thomas: Start

0:04:44 Alan: Do they respond to SSRI medication? On the other hand, if we just talk about one specific individual, we can't do any research. We can't actually find anything out. And then how would we know which treatments to apply to that person?

0:04:56 Thomas: From zero every time. That wouldn't be feasible.

0:04:59 Alan: Right. So entire point of the diagnosis is to draw a circle that's at at the most useful size, size, which is not necessarily the same thing as the most right size. A step back, are symptoms? Symptoms put a bunch of symptoms together, you get a diagnosis. You want to be really technical, there's a difference between signs and symptoms. You You can remember this because Ace of Base had the song, I Saw the sign. Signs are things clinicians can observe. Symptoms are things patients report. But actually uses those words, and I'm just going to call them all symptoms.

0:04:59 Thomas: Yeah, right. Right. Yeah yeah. Yeah. Okay. Yeah, yeah.

0:05:35 Alan: Every symptom we're talking about, there's a continuum from normal to a little odd to mild, moderate, severe. You have people who concentrate the normal amount, people who are, are, you know, a little spacey to people who are clinically inattentive to who are profoundly inattentiive. Inattentiive. Most increase in diagnosis is in that mild group. And a lot of that has to do with shifting our expectations for who's in the little odd group to who's in that mild group.

0:06:06 Thomas: To establish for anyone who's, you know about this, you're talking about an increase in diagnoses. Maybe, you want to talk about just for like introduce what phenomenon you're you're talking about there?

0:06:16 Alan: So anytime people are saying like, oh, more people are being diagnosed with autism, but But also things like more people are being diagnosed with anxiety and depression. Almost all those cases, we're talking about an increase in the mild group. Severe group tends to be pretty stable. There seem to be the same percentage of people who have, you severe depression that they literally piss the bed because they can't get out Of bed. Seems to be a lot of people. It's not the same percent of people, it's the percentage of the people we're putting in the wild group. And a lot of that is shifting our notion of what we call, yeah, little, this person's, you know, a little bit of a downer.

0:06:23 Thomas: Hmm. Jeez. Sure.

0:06:48 Alan: To, we're going to call that mild depression, um, lot of people really don't like being put in the mild group, and we'll talk about later, I think, what that means, but the important thing is we're not saying your problems are unimportant, we're Saying that I think that you're mild compared to the continuum of how Bad this disorder could get.

0:07:01 Thomas: Yeah. Yeah, yeah. Right. Question is already there. I think you're answering a question a lot of people might have when it comes to these different things. People want to explain this increase. And, you know, I think the common answer was something like autism seems to be, well, we're, you're noticing it more. We're actually, it's like the left -handed people graph, you and that kind of thing. When it comes to something like anxiety, maybe depression, I I think can there's reasonable questions of like, well, shoot, is our world causing more depression than it was 20 years ago? You And know, that seems like a reasonable question to ask, you know, technology, climate change, you

0:07:41 Alan: That's absolutely possible. Know, there's certain things that we do more or less that are going to change our anxiety and Depression, but you need to know that it's incredibly difficult to compare across cohorts because People's notion of what it means to have a feeling and to report that feeling change over time. So, you know, if I asked someone like, you, you have excessive worries? Do you worry all the time? The 1980s, someone's notion of what it means to be worried all the time, might be very different than someone's notion of it today. So we might find that the number of people who say they're worried all all the time has gone up, and really, really difficult to tell what on earth that means.

0:07:48 Thomas: Mm -hmm. Mm. Right. Mm -hm.

0:08:25 Thomas: Yeah. Didn't, didn't think about that, yeah, good point, yeah yeah, less, less acting tough kind of thing

0:08:26 Alan: Um might be more willing to say it now, um might no longer think something is normal, so you know, people might just think, well, I of have the normal level of anxiety in the 1980s, and then now people's notion of what is normal and acceptable is different. And so now people are like, not satisfied with that level of anxiety. I think it is excessive. It is also very possible that like of depression absolutely went up during the pandemic because people were isolated and inactive and those things increased depression.

0:08:40 Thomas: Yeah yeah do You think the severe cases tell us anything there, because those are stable, would you expect that those would change given circumstances, or those, so like, I don't know, medical, for lack of a better word, that you wouldn't expect the next level of severity to like increase, you, for all levels based on the environment?

0:09:16 Alan: Pattern of causes and influences isn't the the same for all levels. So,

0:09:20 Thomas: Sure. Yeah, yeah. That's what I was trying to say in clumsier words.

0:09:23 Alan: For example, a lot of people with mild intellectual disability have parents who have mild intellectual stability, and they just inherited those genes. With severe to profound intellectual disability, almost always have some broader biological syndrome. It might not be a syndrome with a name, but they very, very often have physiologic problems they almost never had parents with severe intellectual disability, because that would have been the product of sexual assault, so there was probably some kind of copying error or some kind of genetic group or fetal developmental problem, whereas people with mild ID, very, very often, there's no other biological issue. They just inherited those genes.

0:09:44 Thomas: That makes sense. That was what I was trying get at, but yeah.

0:09:59 Thomas: Gotcha. So the fact that like the same percentage of people have that, you Know, just absolutely catastrophic depression, you wouldn't point to that and say, see, we're not getting more depressed necessarily. Now you might for other reasons say that, but like Like, that wouldn't answer that question because of what you're talking about here. Yeah, that makes sense.

0:10:20 Alan: Yeah. Yeah, and I'm not enough of an expert on profound depression to really know what to say about that. But at least starting with the intellectual disability example, I can definitely say there that increases and decreases in the rate of profound ID don't tell us much about, like, like, the the population's IQ. Queue? A totally different question.

0:10:42 Thomas: The increase in diagnosis you were talking about. Yeah.

0:10:45 Alan: Important thing to remember, remember, is that the same symptom of the same disorder can look very different in two different people. So a tick could be eye blinking, or it could be repeating entire sentences. Those are both ticks, and they have very, very similar neural signatures, respond to very, very similar treatments. If you look at them, one person is just blinking a lot, and the other is shouting stuff. They look very difference. The same time, and this is the one that's more counterintuitive and I think a lot more difficult for people, is that the same symptom can be caused by many different disorders or by no Disorder at All.

0:11:18 Thomas: Yeah, there you go.

0:11:20 Alan: A lot of people I teach college, they'll come up to me and they'll say, well, I'm having trouble concentrating. I think I have ADHD. And I'm like, maybe you do. But trouble concentrating is caused by lots of things. Depression, anxiety, substance abuse, poor sleep, just being bored, not liking the subject, project, having something else on your mind. If you've just fallen in love, then that's going to be a lot more interesting to you than math.

0:11:45 Thomas: If you just fell in love with math, though.

0:11:47 Alan: Every triangle is a love triangle when you love triangles.

0:11:51 Thomas: Plan that. You just had that ready. I just want everyone to know that.

0:11:52 Alan: I did have that joke. That's not my joke. That's an internet joke. For ADHD, ADHD by definition has its onset in childhood. If you start having concentration problems as an adult, it's probably not ADHD. And so that comes back to drawing that circle. If we draw the circle around the symptom, I can't concentrate, what we're going to get is a circle that's way too big because we're gonna get the people who can't concentrate because they're depressed, the people who can concentrate because their anxious, people with schizophrenia can't concentrate because there are hearing voices and How are you supposed to pay attention to the teacher and people who who can't concentrate because they stayed up all last night playing Fortnight and people who can concentrate because they're grieving, that's not a disorder, and now we have this circle that has all of these things in it, and lo and behold, there's no treatment that's remotely appropriate for all of them, they're all very different, so need to draw the circle a little smaller.

So of the way we do that is we look for multiple symptoms, so looking for a cluster of symptoms that tend to occur together, and that's how we start to make what makes a diagnosis. So being distractible and disorganized, those symptoms occur together a lot, other symptoms generally don't.

If I ask you, how often do you cry, and how often do you feel so amazing you think you're better than everyone else and you think you have, you know, superpowers, those are both symptoms, they hardly ever occur together because

0:12:23 Thomas: Yeah. Yikes. Kidding.

0:13:15 Thomas: Interesting.

0:13:15 Alan: One's a mania and one's a depression, and you can have a mixed state and have them both, but believe me, if you have that, we're going to know it. My point is that there's... there's certain things that occur together and certain things that don't, and so in one sense the diagnosis is just a cluster of symptoms that often occur together, that's really kind of how they start, but what we're really trying to do is get the circle the right size, so You, you have distractibility and crying jags, well, you probably have depression. If you have distractibility in disorganization, then ADHD becomes more likely. So more symptoms, we start sorting people into categories that, again, we're not sorting them for the sake of sorting them. We're trying to get the circle the right size.

0:13:36 Thomas: Yeah.

0:13:55 Thomas: Trying to make money for insurance companies.

0:13:58 Alan: Feel very, very high levels of allegiance to insurance companies.

0:13:58 Thomas: No, And also, people aren't kind, uh, enough to just have one fucking thing, so that must be hard too. Because you're like, okay, because I, you know, I'm, I'm prone to crying, but I also have the disorganization and the, the distraction. So it's like, oh, but okay, so maybe I have two things, maybe I've one thing, you know, it's, it's interesting, hmm.

0:14:09 Alan: Right.

0:14:21 Alan: And the first thing we have to do is separate normal difficulties and day-to-day variation and just being a little different, you you knows, someone who's just a little spacey from actual symptoms. Then we want to get together all the people who have the same kind of problem, even if it looks different, like different kinds of ticks. Dann we want to split off all the the people who have different kind of problems, even if it sort of looks the same. If you have insomnia because you have cocaine abuse versus if you having insomnia, because you have depression, we need to put you in different groups because you have different kinds of problems and you need different kinds treatment. Though your symptom looks the thing, you both have insomnia. Sort of the the goal of drawing these circles. Now the reason the circles are important is because if we had a treatment for stuff, who would that generalize to?

0:14:51 Thomas: Right. Yeah. Yeah.

0:15:13 Alan: No particular treatment that applies to everything. We say that these people are similar enough that I applied this to 50 people who had problem X. So now when I find a new person who has problem X, I think the same thing will apply to them. And the biggest problem X is, of course, Canadian government experimenting on you and putting adamantium in your body, and weapon X, sorry.

0:15:36 Thomas: Pretty easy to diagnose though, pretty-

0:15:38 Alan: Would assume a metal detector would be very helpful there.

0:15:40 Thomas: Yeah. There's not a lot of other conditions that give you that, it's pretty much just- That- One- Yeah.

0:15:43 Alan: Give you a metal skeleton.

0:15:45 Thomas: It's like, oh, You're okay, either you're an experimental X-Man thing or there is a virus that sometimes causes it.

0:15:47 Alan: Yeah. Or again, you've been cursed by a swamp witch. Need to maintain an open mind and work this out. The reality is most kind of research can't be done on just one person. First of all, I can't compare a treatment and a control without at least two. Even then, you if my one person in the treatment condition got better, that's one person, anything could have happened. Maybe they just got better spontaneously, we need bigger groups. Lots of things like if I want to find out, for example, in people who are aggressive, is the amygdala underactive or overactive. If I have just one person, I can find out how active their amygdala is, but I don't know if it's more or less than it should be. don'T have a comparison. It's like you can't call one person tall.

0:16:36 Thomas: Wow, that's a- that's very profound.

0:16:39 Alan: Know, except for Heath Enright, you can call him tall.

0:16:41 Thomas: Yeah. Why didn't they do that one instead of the one-hand clapping, because the one hand clapping, I always found stupid, you know, like, I don't like- That, but-

0:16:47 Alan: Yeah, it makes a sound. It makes a little, I mean, it's not a very loud sound.

0:16:48 Thomas: Yeah. Yeah. I- Can- Exactly. But would you call it one man in the universe tall or whatever, find a better way to word it, I'm sure, I like that one, that's good.

0:16:56 Alan: Yeah. So you think about like, person, I can- can do what's called a case study, and I can talk about, you know, it's almost like a memoir, you know, I can talked about their experiences, but at most I can say, well, they were sick and now they're better, but you knows, if the treatment was why they got better, maybe they would have gotten better no matter what, maybe it was a placebo effect, maybe they didn't actually got better, I just perceived that because I really wanted it to be true. The only way to really know what's going on is to have groups of people. And if I- I want to group them together, I need to group of them in a way that is meaningful.

0:17:28 Thomas: Yeah.

0:17:29 Alan: And to do that, I have to get the circle the right size. So if the the treatment is for depression -related insomnia, I needed to get people with cocaine -related insomnia out of there.

0:17:39 Thomas: I- you can leave a trail of white powder out of the room, boom, and then bam, you did it. You got it.

0:17:46 Alan: People with cocaine related insomnia are very easy to distract as understand it.

0:17:51 Thomas: So something I've thought a ton about. It's something that it's so fascinating when you talk about, just talking about myself, like there's certain qualities I have where obviously I eventually came to terms with ADHD and I got that diagnosis. And I personally believe it's apt for me. You never know. But it comes to something like the spectrum, as they say, first off, yeah, spectrum sort of applies to a lot of this, I guess, maybe not to like a virus like you're talking about, but a lot of these things, it sounds like, yeah. If you're talking about these circles that either bigger or get smaller or whatever, sort of a spectrum in a sense. One question is, why do we have like the autism, quote unquote, spectrum, and we don't seem to have that with other things? Is- okay, yeah.

0:18:30 Alan: Every disorder has a spectrum of severity. So Mild schizophrenia, there's severe schizophrenia, um, is mild depression, there are severe depression. Honestly, the reason that we emphasize that with autism is, um- one of the things that can happen is with the circles is we can end up smooshing two of them together because we realize that these two separate diagnoses aren't actually all that different. And that's what happened with Asperger's syndrome and autism or autistic disorder.

0:18:58 Thomas: Thought we just stopped calling it that because he was a Nazi.

0:19:01 Alan: That's actually not why. They them together because they determined that there wasn't a clear distinction between those two, at least if you were... Asperker's syndrome, by definition, could not have intellectual disability. So autistic disorder, they could have intellectual stability, but they didn't have to. If you take people who had autistic disorder without intellectual disability, there was really no difference between them and Asperger's syndrome.

0:19:13 Thomas: Oh, oh, why were they initially different?

0:19:26 Alan: Is a much longer story. And I'm not super confident on the details. But at least part of it came down to Hans Asperger.

0:19:29 Thomas: Okay, sure. Okay, short. A Nazi, I knew it.

0:19:38 Alan: Now, I think there is a lot of discussion about, you is spectrum, from someone who has you know what we would have called Asperger's syndrome, to someone who who has severe autism symptoms plus an intellectual disability. And now there's debate about how useful it is to always link those things together. In one sense, there definitely is a continuum. If you think about it, there's a continuum from nearsightedness to blindness.

0:19:57 Thomas: Hmm.

0:20:06 Alan: One sense that is absolutely true. In another sense, nearsighted people don't really have a lot in common with blind people. Like nearsighted, I put on my glasses and I function exactly like a non-nearsighted person, except in, you know, rare circumstances, like swimming. For a blind person, there are no glasses that are going to change that. You blind people aren't completely blind, so they might be able to have some visual perception, but their needs are totally different from my needs, and it comes to the autism spectrum, that's where people are starting to be like, well, well, you know, there may be some benefit to actually, maybe not making it two different diagnoses, but starting to really make sure that we're talking clearly about, does this apply to every single person on the spectrum? Or does this mainly apply to people who have profound symptoms and severe intellectual disability? Does this apply to people who have fluent language? Answer your question, everything has the spectrum equality, but that's why autism got the spectrum name, was to emphasize that we are covering this whole range that used to have multiple diagnoses.

0:20:13 Thomas: Yeah. Yeah?

0:21:05 Thomas: Interesting. Gotcha. Gotcha. Okay. So I started to ask that because I wanted to mention, I'm we had an evaluation of our child and just talking about like that process and not, you know, the specific results or anything. It was really interesting because when you think about, you help, it's one of those things that it's hard for, I think the human mind just really wants binaries, you You know, like it just really seems to naturally want binaries. And there's times where it's like, you just got to keep reminding yourself, this is not a binary. And, you know, or maybe that's just me. I don't know. But I feel like as evidence from our society shows, people really love to put people in category A or category B, and they don't have a very easy time with, oh, no, it's category A, B or B, A, or, you Know, it'S like that. That'S tricky, I think. And I found myself really feeling like for some reason, this diagnosis, whether it was, a diagnosis or it isn't? Or what do you call if they don't,

0:21:29 Alan: So could say that somebody, you know, meets criteria for the diagnosis. We can say somebody has what we call a subclinical syndrome, which means, you know, for example, for ADHD, you're a little fidgety, you're a little spacey, more than most people, but not quite so much we'd call you having the diagnosis. We could say somebody has a subclinical syndrome.

0:22:17 Thomas: Right. So found myself really feeling like it made a huge difference whether or not this doctor or whatever, this the psychologist, put this label on my kid or not, you know, and it's like, like you started at the beginning and this this person was great and she had a similar speech, you begin the whole thing, which is just letting you know this is something we do in order to, you know, a treat people and be, you you know, the insurance thing. I think it was pretty, pretty similar to what you said. And it is something that's really interesting to grapple with, you just, we want to put stuff in firm categories, and it's, it's really hard to think like, well, no, that nothing's changed. Like a diagnosis doesn't change the person.

0:22:55 Alan: And that's something I really emphasize that, you know, if someone says, well, I did that because I have ADHD, that's really circular because ADHD is just the name for a group of behaviors. So you're saying I'm distractible because I'm distractible, because all ADHD is I'm distractible and disorganized. So all you're saying is it's all circular. So if you say, you know, so the type of distractible that fits this mold that has all these specific symptoms, but you're exactly the same person, no matter what you name that group of symptoms, whether you name it or not, still just what's there.

0:23:11 Thomas: Interesting.

0:23:29 Thomas: Right. I guess my only objection there would be presumably the diagnosis itself is referring to something that's commonly different about my brain and other people that is not really circular. You're saying I did it because I have ADHD.

0:23:44 Alan: It is something different in your brain, but of course every thought and ability is is represented in your, so you could say I'm good at basketball because I'm going to basketball, you could also say I am good at basketball because I have representations of agility and aim in my brain.

0:23:49 Thomas: Sure, sure.

0:24:02 Thomas: Yeah, but if there was a a thing, common way people tended to have those and it seemed to be something that showed up in a certain percentage of people, I quite circular. It's perhaps a little reductive, I to say, it would be circular to say I'm good at basketball because I have basketballman's disease or whatever, you know, I think it's not exactly circular. It would be essentially you're subbing in, I have this thing because of this thing in my brain. I mean, take, take an example that's more physically tied to brain differences, you I've got, I didn't, you're the, you're the expert, I don't have these examples at hand, but something where it's like, oh, the connection is severed between my two, you know, something extreme between my two hemispheres.

0:24:38 Alan: No psychological diagnosis can be seen on an MRI, there there are average differences, so like people with certain anxiety disorders, on average the amygdala is more or less active, but an MRI and fMRI, a PET scan, we can't diagnose a single person with those, there there are a few exceptions, certain neurocognitive disorders, like certain dementias, but like depression, you know, there's definitely average differences between people who are depressed and people who aren't. We can't see something in your particular brain.

0:24:43 Thomas: Good point. Yeah, sure.

0:25:12 Alan: What I'm saying is that every personality trait is part of your brain. Every ability is partof your brain, there's some of those those and traits that we find probably have some related causes, although all we know for sure is that they occur together, We don't actually know they share a cause.

0:24:59 Thomas: Sure. Sure, sure, yeah.

0:25:32 Alan: Like for some people, there's this notion that having that label means it comes from my brain, and that that changes something about blame or responsibility or controllability. And I think that that could be a good thing if that's helping you avoid unhealthy self-blame and unreasonable guilt. But it's no more true before or after you have the diagnosis. Your brain played the same amount of role in you being good at math, or you know, someone who has very good aim, or someone who's distractible, so much role your brain played in it, it's still the same amount. And however much control you have over your brain is still the amount, I'm

0:25:38 Thomas: Hmm. Yeah. Yeah yeah.

0:26:18 Thomas: Well, yeah, still the same amount, but it's in terms of information for other people, I think, is where it matters, because it's, it's like the very thing you said in the beginning when you're talking about these symptoms. If I say, yeah, I'm sad because I, I have depression, I'm giving people more information than I'm sad because my grandma died. And not just circular, you know, that's all I'm saying. Like, I will change perhaps like what you want to do about it or how you want to think about it, or, a degree that I think is important, don't you think? Or maybe I'm misunderstanding the point.

0:26:46 Alan: Not sure what information "I'm sad because I have depression" conveys. You can be sad. Well

0:26:52 Thomas: It conveys, don's say, oh, sorry, your grandma died.

0:26:56 Alan: For example, you can, can absolutely have a depression that's set off by a sad event, so you can be someone who's prone to depressions, and you suffer a loss, and then you, you grief period has passed, but you are now in a depressive episode. Um.

0:27:11 Thomas: Yeah. Okay. What if I tell, I'm going to tell you I'm exhausted because I'm depressed, versus I'm exhausted because I ran a half marathon the other day. One solution is get some rest, the other is, well, yeah.

0:27:22 Alan: Precisely the idea of diagnosis and getting the circle, the right. Size.

0:27:24 Thomas: That's What I'm Saying So I'm saying it, it's, it's not circular.

0:27:28 Alan: But Just saying that because I have depression is not more explanatory than because I have all of these symptoms, and it's not caused by these other things. I'm not exhausted because of a marathon. I'm having all these symptoms, because when it comes to the actual causes of depression, we really can't pin down in any particular person what exactly is going on, any more than we can pin down what's going on when you just have a grumpy day.

0:27:47 Thomas: Sure. I think what's happening is honestly we're saying the same thing in different words, because I'm just saying that the putting label does at least tell people that it's not those other things, which is essentially what the diagnosis is anyway, so, but having that diagnosis is important for the reasons that you're saying, like it's useful, I think, to know, like, I, I would rather be able to to give people the information because they might approach me differently, like if I'm depressed because of, I've like had a catastrophic event, or I'm sad because I had a catastrophic event.

0:28:20 Alan: So it definitely sounds like we're talking about different things, because you're talking about the use of the diagnosis, And we definitely agree the diagnoses are useful. I'm talking on a more philosophical level of what it actually means to say that you have this diagnosis, but whether it philosophically means something is not the same as, is it useful? Can it be useful? That's the entire point of what we're taking about here. You use it to convey, for example, no, no, I'm not exhausted because I stayed up all night playing Fortnight, I'm exhausted because I, you kind of complex set of biochemical changes, and also psychological and psychosocial changes. You diagnosis doesn't make something more or less of a brain thing. Everything is a brain to thing.

0:28:24 Thomas: Yeah, exactly. Yeah yeah yeah yeah.

0:29:02 Alan: And everything isn't. So, so yeah, if it's useful in conveying those things, but if we reify it, that can sometimes to those binaries you were talking about. So if you have a sense that like, ADHD is biological and therefore real, and then if you don't get diagnosed with ADHD, then they're saying it's not biological and it's not real.

0:29:22 Alan: And so that's the thing I want to avoid is reifying it in a way that forces that binary onto people.

0:29:22 Thomas: That's no good. Yeah. And I also worry about, and I'll just again speak for myself, I also worry about like the right amount of trying to like push against my own impulses or or not, you you get that label, is it easier to just give in to like, oh, well, I have this because of this label, and to not try to push myself to go some of these impulses if they're causing problems. And that's something I think about a lot, you know?

0:29:28 Alan: Yeah.

0:29:52 Alan: So if if a label gets you access to services, that's really great. If having a label encourages you to learn new skills that you didn't have before, so now, for example, if you're labeled autistic and you're like, hey, you know, it, so I have deficient social skills, so I'm going to join a social skills group and rehearse some of of these skills I'm bad at, if having that label helps you recognize that need or gets your insurance to pay for the social skills group, that's great. If having that level makes you think, well, I have autism, so therefore I can't possibly change, that Probably not very helpful. See this with depression. Sometimes people get a diagnosis of depression and then they'll say, well, it's just a brain thing and I can't do anything about it. Well, your brain is what you do every single time you do an action, every Single time you have a thought. Just because something's in your brain doesn't mean you can't anything about, and so important to to balance that, and it's important to balance with, you want to get to a point of demanding something, something of yourself that

0:30:58 Alan: Simply can't happen. So,

0:30:28 Thomas: Yeah, yeah, exactly. Yeah, exactly, it's

0:31:00 Alan: Yeah,

0:31:00 Thomas: A fine line, you know, because I do think when it comes to certain things about, you autism, just from my experience with others, it help not try to fix problem when really it's not a problem. It's just a way that they're different. I think it's hard to find the fine line between those two things, at least in myself with ADHD. Yeah.

0:31:19 Alan: Is getting to a real question about that line between a mild disorder and not a disorder, but just a little quirky. Because if by definition causes distress or impairment, if you have some atypicalities that fit kind of with some autistic traits, but they're not a problem, they're just quirky, then arguably you don't have the diagnosis.

0:31:49 Thomas: Interesting.

0:31:50 Alan: So we're talking about someone, for example, who just really likes to wave their hands in the air, but they're able to do all the things they need to do in life, they can take care of themselves, they can form relationships, they can work and go to school, they just happen to like waving their hands in the air, then they are just flappers. Someone, for example what we see in some people with autism is when they're waving their hands in the air they're not doing anything else. They cannot, they're not, this is their activity. They're absorbed in it. If you want to do that for a little while, that's great. But if you're doing that eight hours a day and I can't get you to learn anything else, I'm trying to teach you to, you know, drink through a straw or use the potty or to use a signal to tell me when you're thirsty, so I can get you some water and all you want do is flap your hands, then that's creating distress or impairment, so

0:32:04 Thomas: They're just just flappers.

0:32:23 Thomas: Yeah. Yeah, okay.

0:32:39 Alan: That line is difficult, and I think it can be challenging for some people who, who are saying like, "Well, but I do have these symptoms," and where I said, like, some people are really very offended if you say that they're mild or that they even don't quite qualify for a diagnosis, because if, if it really isn't causing a problem, then it doesn't meet criteria. And we do that for a lot of reasons, but one of the biggest reasons is we don't want to just pathologize people who are just quirky.

0:32:59 Thomas: Interesting. Sure. Sure. There's lot of debate about this because like, what is a problem? You know, some people might define that differently than others. And, I think society over the years has probably defined that differently. You have seemed like, quote unquote, a problem years ago. And now, people are like, well, no. It's just if you just accept that that's how that person is and try to accommodate them, then maybe that's not a problem.

0:33:26 Alan: A lot of it comes down to what's first of all, what is realistic to accommodate? So for example, if you have autism and you sometimes need jokes explained, it's probably realistic to ask some people to explain jokes. If you have autism and you have no sense of personal space and you always stand way too close to people and like they back up and you walk forward, I want to be, um, compassionate to that and accepting of that, but I can't stop myself from feeling uncomfortable with you standing way too close to me.

0:33:30 Thomas: Right. Exactly. Sure. Yeah. Yeah. Yeah. Oh, and you don't have to. Yeah, exactly. That's a very good point. Yeah. shouldn'T have to change who you are to accommodate someone else like that. Doesn't seem fair either. It's like finding those things where, yeah, this is a reasonable accommodation, no reason not to do it versus, well, man, I don't people invading my personal space. I feel like that's a reasonable thing for me to

0:33:56 Alan: Right psychiatric disorders cause a problem no matter what other people do, so if you have depression, I could be accommodating by saying, like, well, you know, I know you have trouble getting out of bed in the morning, so how about we schedule our meeting for 11 instead of nine. That's me being accommodating, but you're still miserable, you still have depression. Um, are very few disorders where the only problem is other people.

0:34:21 Thomas: Yeah, yeah. Yeah. Yeah, exactly.

0:34:44 Alan: Mild tic disorders, if might have a mild tic disorder and your only real problem is you look kind of weird when your face goes like that and other people react to it, that's one of the only conditions where, for some people who have tics, the only problems are the tics. The only problem are other people's reactions. Actions, um, other people who have ticks, the ticks themselves are a problem. I, I worked with a man whose tick was to suddenly and violently fling his arm backwards, and he had torn his rotator cuff multiple times because if you fling your arm backwards hundreds of times a day, it's not good for you, um, but, but Tourett's is is a really unusual example. Most things, like if if you have dyslexia and your reading is severely impaired, we can accommodate you in certain ways, but in the end, you still have less access to the world than someone

0:35:01 Thomas: Right. Gotcha.

0:35:14 Thomas: Wow. Jeez. Rotator cuff is not going to accommodate you on that one. Gotcha. And Yeah.

0:35:38 Alan: Who can read. You have social anxiety disorder and you're profoundly anxious around people, we can make that more comfortable for you, but in the end you're the one who still has to suffer that distress and anxiety. Society. So almost, Tourette's is, I pick that as a very unusual example where you can have Tourette's and really be fine except for other people thinking it looks odd. No other disorders are completely solved by acceptance.

0:35:39 Thomas: Yeah.

0:36:06 Thomas: Yeah, yeah. It feels like something that maybe, very well intentioned, but also maybe leaks over a little bit from physical disability. Is that maybe accurate to say? Like physical disability, often it's like, yeah, let's make everything as accessible as we possibly can for everybody. And great. But I think maybe some of that leaked over to more psychological stuff. Sometimes And I'm not not sure how much it makes sense. You know, I don't know.

0:36:27 Alan: There's a concept called universal design, which is you're going to try to set it up so that instead of people having to ask for accommodations, it's set up so that it's fully accessible to everyone, and that was a really big thing about ten years ago, and then people started realizing that there's no such thing as universal design. I used work in an neurology clinic, and were deaf patients, and so they had the fire alarms would have a bright blinking light to accommodate the deaf patients, but there were also epileptic patients and the bright blinking lights does not accommodate them. And there simply is no, isn't you a perfect solution.

0:36:44 Thomas: Yeah, Yeah, there just isn't. Yeah. That's, That's, that's, that's humans.

0:36:59 Thomas: Yeah yeah. There may be things that are at, at loggerheads as they say, you know, there may, may, I think a lot of people may be naive, or optimistically think that that just will not happen. Like it'd be, it'd much not nicer if if there just were no such thing as disabilities or even just traits or whatever in different people that wouldn't conflict in that way. But, like, it's a big world. There's lots of humans. We're all weird in different ways. I think it's unrealistic to expect that there's any set of things you could do, accommodations that will work for literally everybody.

0:37:10 Alan: Right.

0:37:35 Alan: So another reason why there's no such thing as accommodating everything. But again, I want to emphasize that for most psychiatric disorders, accommodation doesn't totally solve the problem. Know, if I move that meeting a little later to accommodate the fact that you have, you know, severe fatigue. I did that, but you're still depressed. I did want to mention about diagnoses is that there's the core features of a disorder, and then there are associated features, Things that are more common with that disorder than with the general population, but they're not officially part of the diagnosis. Diagnosis. For example, people with ADHD, a of them have high levels of rejection sensitivity. They're more upset than most people if they feel socially rejected. That's not a core feature of the disorder, and that doesn't mean it's not important or that it doesn't deserve attention and treatment, but it's important not to use those in diagnosis because it'll make the circle too big. So if we start looking at people who have a lot of rejection sensitivity, most of them don't have ADHD.

0:37:45 Thomas: Sure. Yeah. Yeah, exactly. Yeah. Hmm.

0:38:43 Thomas: I was going to say that could be caused by so much. Much. I mean, who is a super big fan of rejection is what I want to know.

0:38:43 Alan: Exactly. Well. Me say one thing, and then I'll get to that, because that's a really good point. But on TikTok there's all these things where people are talking about, like, their experiences with ADHD. And to some extent that's great, because it's getting people talking about mental health. But I see a lot of people who are, are saying, well, I have the same problems as her. What had talked about on TikTok were a lot of these associated features. And so there's someone coming in and saying, I have ADHD because I have rejection sensitivity and I have these things. And just listed a bunch of things that aren't ADHD.

0:38:53 Thomas: Sure. Yeah. Yeah, interesting. Yeah yeah.

0:39:20 Alan: Can be a problem when people are self -diagnosing. What you brought up is another problem in self-diagnosing, which is that you don't know what normal is. There's, so, you know, the normal level of facial tics, because you can see in other people whether or not they're doing facial tics, but you don't know the normal level of attention. Like, I tell my students, you don't know how distracted your classmates are, you don't know the normal level of social anxiety for

0:39:45 Thomas: Can't be in their heads. Yeah gotcha.

0:39:47 Alan: Autism spectrum disorder, I, to a lot of people who will say, like, you know, I can find the right thing to say, but I have to work so hard to do it. And I work a lot harder than most people. And I say, that maybe that's true, but how do you know how hard other people are working? So it could be true, but it could also not be true. You don't actually have that information. All you know is that you feel you're working hard.

And I believe you, you'reworking hard, but you don't know how hard other people are working. So these are reasons why having involved is actually really useful. Plenty of people will say, well, I'm really distractible. The question is, well, compared to what? Compared to how attentive you think you should be? Compared to how attentively you think other people? How you know what those standards are? Not intuitive. Know, there's a few things that you can see, like facial tics, but most things you can't. So, will say I'm so sensitive to rejection, I'm så much more sensitive to it than other people, the question is, how do you know how sensitive

0:40:44 Thomas: Yeah.

0:40:44 Alan: Other people are, because Most of us aren't just going like, wow, you hurt my feelings, on a scale from one to ten. All you know is I frowned and walked away. You don't know if I went home and cried. You don't Know what I felt. So that's what I mean, when you know, who's a fan of rejection, there are Some people who are way more upset about it than others. But if all you know is I'm really upset, you don't know where you fall on that continuum. It's, ask my students sometimes, do you think you skip your hands after you go to the bathroom more or less than most people, and I'll, all y'all had an answer. How many of you have, like, actually sat outside the Bathroom and counted how many people, you know, didn't turn on the sink. You don't know how much other people don't wash their hands. All you know is whether you think you do it a lot or a little. Yeah.

0:40:45 Thomas: Yeah, yeah. Yeah. Yeah. Yeah.

0:41:41 Thomas: And I'm glad you said the TikTok thing, because I've gotten more than a couple messages about this exact rejection sensitivity thing. And it's like, I don't, for some reason, people think that that's like, oh, I must have that, me, me personally, must have that. And I'm not saying these are ill-intentioned folks or anything. I think that they're just like, oh, you know, this might be something to consider. And have no idea. You might as well ask me the bathroom question. I don't know. Again, like, I don't know who's a super big fan of being rejected. So I actually have no idea if I, in particular, am more sensitive to that than others. I couldn't tell you. I don't even know how to evaluate that. So, I wonder if that's coming from that, like, like some sort of, you know, fucking TikTok thing, because it seemed like a bunch of people told me that all at once. And I just didn't find it very useful at all. It's like, I don't know what to do with that.

0:42:33 Alan: That's something that's kind of got popular on the internet to talk about, and Again, it is a real thing. There are people Who You know, if they walk up to somebody, they're like, hey, do you want to go from to see a movie? And the, the person goes, nah, I can't, who go home and cry for a week. And that is definitely atypical.

0:42:36 Thomas: Yeah. Yeah, okay, I Don't Do That. Yeah like how? Okay, is that a way you identify it? It?

0:42:51 Alan: Also doesn't diagnose ADHD. People with ADHD are slightly more likely than the general population to be that person. But that doesn't diagnosis ADHD. Put another way, people who are 5'7 are slightly likely to be cisgender men than cisgender women. But being 5'7 is not your sex.

0:42:53 Thomas: Right, right, right.

0:43:10 Thomas: It is mine. Sorry. No, I'm just kidding.

0:43:14 Alan: It's one of your genders. We should notify Ben Shapiro that we've just found like a fuck ton of new genders now.

0:43:15 Thomas: I'm 5 '11". Yeah. Yeah. Oh, there's so many. There's like infinite, down to the plank length.

0:43:22 Alan: There's like now there's like five, five and a half.

0:43:25 Thomas: So many genders. Is, not you that important, but just because I'm curious, like, is that how you try to evaluate that level of rejection sensitivity? Like, Like, is that the extreme that we're talking about? Or like, what kinds of things would you look for?

0:43:25 Alan: Yes.

0:43:37 Alan: I wouldn't have to be crying for. So If someone said they think they're unusually sensitive, I ask them about their experiences with rejection and how they felt and how they handled it. And then I would actually start looking for other symptoms to try to figure out what's going on there, because are we talking about an extremely socially anxious person who never, in some cases never, actually put themselves out there?

They walked up to somebody, they're like, "Hey, you know, um, how about, you know, we could, you know, this weekend is like a great time to go see movies," and the person's like, "Yeah, man, weekends are great," and like, "Oh god, they hate me," and you ran away, right, because you never actually ask them to see a movie.

Versus somebody who goes up and treats you, you like they're your best friend, they never met you, they're like, "Oh my god, this is, I love you, I've always loved you, and we need to go see a movie together," and they're like, "I don't really know you that well," and Then you feel like the love of your life has been ripped from you. Well, that's a very different problem, and that's why we need to draw the circles separately, because rejection sensitivity is like insomnia, it's looking for, you know, that extreme, but then I need to know what kind of rejection sensitivity. What's going on there? And that's going to be looking in which circle to go to, and that's when I need to look at some of the other symptoms.

Just like with insomnia, is this a cocaine problem? Is this a behavioral problem? Like, well, you keep playing Fortnite until 2 a.m., and then, lo and behold, you have a sleep problem. Or is this, this a depression thing, or is this, you know, so I would want to look at that. I

0:43:38 Thomas: Yeah, sure.

0:44:28 Thomas: Gotcha.

0:45:09 Thomas: Yeah, that makes sense.

0:45:11 Alan: You can't do something, the importance of working out at what level the problem is happening. So for example, with autism spectrum disorder, people who have very profound autism symptoms, who have severe to profound intellectual disability, they don't have language. They don't generally speak, or if they do, it's just a few words, because they don't have words in their head.

0:45:37 Thomas: Yikes.

0:45:38 Alan: They don't understand words, and they certainly, if they use them, they don't use them generatively. So they might learn to say the word water to mean, I'm thirsty, give some water, but they would never use it to describe rain. They wouldn't use it to talk about the future or the past. They wouldn't use it to point out, look, there's some water. They only use it in exactly one way, which is, "Give me water." These are people with, you know, severe to profound intellectual disability.

0:45:51 Thomas: Huh? Yeah.

0:46:04 Alan: I was talking to someone about autism, and we usually refer to that group as non-verbal. I was talking someone who had a more mild autism without intellectual disability, and they're saying, like, "Well, I'm nonverbal too." Are times when I get so distraught that I'm unable to speak. And that is a very real thing that happens, it's a problem at a different step. So if you have language skills and you just can't apply them right now, that's a very different problem than not having them.

0:46:35 Alan: There's a difference between I had the ability and I lost it versus I never had it. So if you had normal intelligence and then you had a head injury and now you don't, that's different from you've had intellectual disability from the time you were little. There's a difference between I've always been this way versus it began at a certain point. So as I said, ADHD, ADHD is present from early childhood. If you suddenly became inattentive as an adult, it's not ADHD and probably something different. And I think one of the toughest things for people to get is that there's a difference between fundamentally lacking the ability and being unable to perform the skill at a particular moment because it's more difficult at that time because you are stressed or distracted or upset. So example, I can't spell the word necessary, necessary correctly on the first try.

0:46:26 Thomas: Yeah. Yeah. Yeah. Seems categorically different. Yeah,

0:47:30 Alan: Ever. I'd never get it. I do not know it. If you gave me a quiet room and a hundred dollars, I would not spell the word necessary. But there's a difference between that and if you give me a spelling test and I was anxious and it was in a loud distracting room, I would underperform on that and I would misspell words that I do know how to spell. And so there's... there's a difference between me and necessary where I just do not know it. Or for example, shooting free throws. I cannot shoot a free throw. Different from I can shoot a throw unless a crowd is watching me and now I lose that ability. They're both, I can't do it at the time, I'm not, the person who can't shoot free throws in front of a crowd, I am not saying that they're like faking it. Saying that the problem is at a different step.

0:47:31 Thomas: Me neither. God, I have so many words that are like that for me. OK.

0:48:18 Thomas: Yeah

0:48:18 Alan: The problem is not an inability to shoot free throw, the problem isn't an inability to maintain your athletic abilities in the face of stage fright and is a sticking point for people in diagnosis because we might talk about somebody who says, "Well, I think I have autism because I can't talk to people socially," and you could have autism, I don't know, I don't know you.

But is, is what's happening that you genuinely don't know your social skill, or is it you know your social skill but you can't apply it, for example, because you have terrible social anxiety. So I sat you in a quiet room and said, like, so if someone says, "Hey, I just went on vacation," what would you say?

Like, "Oh, of course I'd ask them about their vacation." But then we go into a crowded party and someone says, "Well, I just want a vacation," you're like, "Oh my god, nobody judge me, I'm scared." That's a problem, but it's not the same problem. You're saying like, well, it's a social deficit, so therefore it's autism, you have to look at what the step is where things are breaking down. Is it that you actually don't know what to do and say?

Or is it that can't apply it to anxiety, for example? A key difference in diagnosis. And I think that's where a lot of people get tripped up. They'll be like, well, this therapist is ignoring, ignoring all these social problems that I have and saying that it's not autism. They're not saying you don't have problems. Saying the problems happened at a different step. It's sort of like if want to find out, can you solve this math problem?

First you have to see it, then you have know how to do the math, then you have to be able to write down your answer. You can't see it if you can't do the math or you can write, we're all going to get the same thing, which is a failure to write down the correct answer, but

0:48:19 Thomas: Yeah.

0:50:01 Alan: It's important to know which of those steps has gone wrong of your listeners because you have a lot of skeptics might be familiar with something called facilitated communication. Have you ever heard of that? So for those who don't know, for a time, mostly in the 80s and the 90s, but it actually is still practiced today, some people decided that people with generally profound autism and severe to profound intellectual disability, that they actually did have language, but the problem was at the step of actually articulating it, that they couldn't move their lips and tongue very well. That doesn't fit at all with all the the data we have.

For example, if I put out, you know, three boxes and I said, um, the Oreos are in the yellow box, they still don't know what I'm talking about, you know, that they're not going to go for the yellow box in particular, they don't understand that sentence.

Um, are people who actually can't move their lips and tongue, and example, Stephen Hawking couldn't, he, uh, controlled a voice synthesizer by twitching his cheek, but it turns out that people who have a physical problem like that, we can find adaptive technology that they can operate on their own. What happened with people who had, again, this severe to profound autism, they were nonverbal, and it wasn't just that they didn't speak, again, they didn have language. So in facilitated communication, again, for your, your listeners who don't know

0:50:00 Thomas: Right. Yeah that's good analogy. Yeah Yeah. For sure. Yeah. Right.

0:51:22 Alan: What

0:51:22 Thomas: You turn them into a Ouija board basically? Yikes.

0:51:25 Alan: You'd sort of hold their arm over a keyboard and drop it down over letters. People who were doing it believed that the individual with the disability was typing and they were just supporting the arm, but every test showed that the facilitator was the one who was subtly directing the person. So because they believed that the problem was at the wrong step, got the step wrong, they subjected these people to this treatment that really robbed them of their actual communication because, like, their behavior might be conveying I like this situation and I'd like to leave, but what they're typing is whatever the facilitator thinks they mean, and you were taken away from their parents because they typed messages making accusations of sexual abuse, and was rare, but what's much more common is that these people were denied appropriate education because they were put in like an algebra class you're not going to get anything out of if you don't even understand concepts like more or less.

And what they weren't getting was, for example, they could have been learning a skill like how put on their own pants, which, which would enhance their independence and ultimately actually enhance their safety, or something like how to turn on and off a, a stereo so they could listen to music when they want to. That would enhance the happiness and quality of life. They're not learning any of that because they're sitting in an algebra class.

0:52:12 Thomas: Yeah.

0:52:53 Alan: By getting, all non-speakers together, everyone who doesn't talk, is a real problem because it assumes that everyone has a problem at the same step. Think I've probably given people enough things that they might have questions about or disagree about, and so maybe if people wanted to submit those, I telling you before, before, that it can't be an AMA, I provide anybody personal advice or comment on your provider's behavior or your own condition, so if anybody asks any questions like that, I'm not gonna, I can't answer them. But if people want to ask about questions about diagnosis in general or just more general psychology stuff, I, we can get to a lot of that discussion in a future episode. Well,

0:53:01 Thomas: So So people can give us an indication on the Patreon post for this episode if they have any questions for you. I think it's going to be hard for people to resist those ones. You

0:53:47 Alan: Let me put it this way, if people if If people ask me a question I can't answer, I'll try to find the question I can answer within it.

0:53:48 Thomas: Can't answer. Think that's a great idea. Lot So of interesting interesting stuff to think about there. Please let us know if you have questions for one stormy decisis, Dr. Alan Smirbeck. Thank you so much as always for joining us. Really have been doing something super cool, which is instead of a personal plug, you've been giving us something we can do to kind of make the world better. You have another one for us?

0:54:11 Alan: Well, I have a continuation. So, I made a suggestion, I think the last time I was on, about putting woke books into those little free libraries if you live in an area where they're being censored.

And there was a lot of positive response to that, including response from people who are living in an area where they aren't being censored and thinking about, like, "How could I contribute?" So what I have done is made a Google Doc, and if you are living in an area where libraries or schools are locking or reducing access to books, if you're willing, you can fill that out, and then I will make a of Amazon wish lists for people to donate.

Donate people, um, who donate should only see your city and state, they won't know your exact address, and they can just pick a book and send it to you, and then you can go place them in the little free libraries. Um, will give Thomas a link to put in the show notes for this, but it, it's bit.ly slash woke books, so bit.ly slash w-o-k-e b-o-o-k-s, so if you go there, if you're willing to place books little free libraries, if you are willing to give me your address, put it up, and then people who want to donate books, they'll only receive your city and state. Alright.

0:55:13 Thomas: Wow.

0:55:31 Thomas: That takes some doing. I appreciate you doing that. Yeah, I'll definitely put the link in the show notes.

0:55:37 Alan: Sounds great.

0:55:38 Thomas: As always, Alan. So nice to talk to you and hope you continue to get better with your voice. That's rough.

0:55:43 Alan: Thank you, thank you all.

0:56:02 Thomas: Can re -rail you. Now that it's so, I'm not going to say that. I've derailed us.

0:56:05 Alan: Right. I've been derailed. I'm open

0:56:07 Thomas: We can rerail us together. We're railed. Consider us railed, we were pro -railing on this podcast, taking a firm stance.

0:56:08 Alan: -minded. And, you know, next weekend, maybe I'll just get railed. Who knows? Consensual adult railing.

0:56:19 Thomas: That's true. I should have gotten affirmative consent first. First. Stormy, if you're okay with it, can I rail us?

0:56:21 Alan: Yes. Mean, I'd probably want to check with your spouse. But, yeah, I mean I'm, look, I'm opened -minded."