Collaborate & Connect

The Misconception of Rock Bottom in Addictions Treatment

You’ve probably heard the concept of ‘a rock bottom’ in addictions treatment. This is an oft-repeated phrase but it is a misconception that someone has to hit a rock bottom and suffer terribly before wanting to change. The other day, I attended a meeting with a group of very compassionate physicians and counselors who work very hard in the addictions field and are devoted to their patients. The concept of rock-bottom kept coming up over and over. I found myself getting more and more upset. The group was suggesting that the patient had a “couple of weeks to go before hitting his rock bottom.” and that once he did, he would experience “real consequences”. They also referred to another patient who had received ‘the slap in the face he needed’. I got all hot and bothered, and up on my soapbox, giving them a talking to about the concept and tone. I was wrong to do so there. These were very well-meaning folks, many deep in their own recovery and, like me, donating their time to an important group doing important work in Recovery.  While it may not have been warranted there, it did prompt this post today. The fundamental issue is that I don’t believe someone has to suffer to want positive change and that people can do more to stimulate change than await or cause a rock-bottom.

The Origins of Rock Bottom

The myth of rock-bottom emerges from 12-step meetings and says that people need to reach a rock bottom before they can make a change in their behavior: before they stop drinking, or make a decision to modify their behaviors and question their way of managing. On the one hand, this makes sense. It is true that people are motivated by negative consequences and pain. On the other hand, this is a very nihilistic and punitive approach. I If someone does not make a change, we assume they have simply not hit rock bottom instead of engaging them in a serious therapeutic process to shift their motivation and inject hope of a new and better way of living. So too, people’s versions of rock bottom are very different: One person could be waking up and not feeling well enough to be with their children that day; another could lose their license to practice; while another could end up homeless or in hospital. Meanwhile, a person who has lost their job is sick all the time, and is homeless—the quintessential definition of rock bottom too many — may continue to drink or use. It is not adequate to say that “Well, they haven’t reached their rock bottom, yet.” To me, this is a lazy approach, ignoring the WORK that the therapist and family need to do to engage this person in a desire to change.

The Rock Bottom Fallacy

It is true that people make changes in their own time because of a buildup of terrible things in their lives: disease, loss of relationships, financial concerns. They are finally fed up of being sick and tired and they are ready to do something about it.  They know that if they stop drinking, their relationship will be warmer, or their communication with their kids will improve..  Finally, if they have a partner who cares about them or someone they love, they are more likely to be successful, even if the path is arduous. They know they feel better when they exercise, take care of themselves, and wake up with a sense of purpose. That vision, the warm feelings associated with it, draws them forward, motivating change.

When people jump to prescribing a rock bottom, they are tossing out the motivational power of positive emotion, of love, of vision. They are relying on negativity and pain – that only after suffering greatly, or losing everything, will change occur. That feels lazy to me, and it misses an abundance of evidence on the efficacy of positive reinforcement, community reinforcement approaches, , emotionally based therapies that change through relationships, moderation, and motivational interviewing that we’ve spoken about in other blogs. Quite to the contrary, when people are suffering they often tend to double down on maladaptive coping strategies, exacerbating use behaviors. Unfortunately, the neuropsychology of people with addictions and impulsivity is that they don’t respond well to punishments (who does?). They respond much better to positive reinforcements.

The Sadistic Side of Rock Bottom

Furthermore, it feels punishing. People likely feel angry towards their partners who are messing up and neglecting their children. Or they feel frustrated with their friends who let them down so many times or aren’t around because of their drinking. Perhaps, they think that watching someone hit rock bottom compensates them for the losses they have suffered because of the addiction. The frustration and helplessness of loving someone with an addiction can drive quite sadistic and vengeful impulses sometimes. While the drive to punish and hurt is understandable on a psychoanalytic level, it is ineffective and it drives people away, so they cannot participate in a positive change, and they miss out on the power of companionship. It is the job of treatment providers to get this, to understand the roots and the drives and to NOT respond in this way. The dangerous fallacy of ’rock bottom’ is that it ENSHRINES this sadism, wrapping it up in slogans and justifying neglect.

How Psych Garden is Different

OK, so someone’s rock bottom can represent their turning point, be an opportunity for spiritual growth, for deepening the connections with people they care about and moving forward in a new phase in their life. Usually, it’s a miserable phase, and it doesn’t have to happen. It can occur at any phase of use. But it ignores the alternative, that positive reinforcement is a driving force for change and ignores the power of companionship crucial to our approach at Psych Garden. I think that you can only help people by staying true to that spark inside people that really strives for something better, and really doesn’t want to experience that journey alone. I think it’s time we discard the misconception of rock bottom that has been associated with so much trouble and pain and applies the science of change to helping people. It’s hard work and it is not always successful. But we have chosen this career because we care about people, care about relieving suffering, and won’t abandon people because they aren’t doing what makes sense to us. And we won’t abandon people when they are caught up in the compulsive pull of addiction. Nor will we abandon them when we feel helpless or frustrated or angry or hurt. That’s when we turn to the science and training to understand our responses, understand what is driving the behavior and reach deep into the pain, bear it with the client and reach for change. No more rock bottoms. Nurture transformation.