Everyone is familiar with the concept. We see it in movies, books, and on stage. Someone’s life spirals downward until they are struck with a lightning bolt of clarity and begin to make amends and change their ways. The message is clear: What do people who use drugs need to do? Hit rock bottom. How do we help them? Tough love or they’ll never learn. In many cases, we are afraid to show support or compassion for fear of becoming an “enabler”. There is an assumption that the person needs to be “torn down” before they can decide to change their behavior. The problem is that this concept is patently false. Not only that, but it has led to disastrous public policy results.
But what about all of the stories from people who described “hitting rock bottom” before changing their behavior? The key here is precisely defining what we mean by Rock Bottom. Many people do decide to make a change in their lives once they recognize the damage that their behavior is causing. However, this does not mean that they have to be coerced or “lose everything” to reach this point. What it does mean is that they experienced a shift in perspective. To quote Dr. Peggilee Wupperman, a professor at both John Jay and Yale University, it means that “they reached a point when they realized their life was extremely (and distressingly) different from the life they wanted or a life that fit their values.” Yet it is extremely important to recognize that this can be achieved without being torn down in therapy or experiencing severe material or emotional loss.
Unfortunately, the state of being at “rock bottom” as it is commonly understood is a point at which you have been psychologically broken down and have lost so much in your life that you commit to change. Taken to its logical conclusion, this philosophy encourages us to shame and humiliate drug users as a means of helping them reach this point. This can happen on a personal level, where one family member stops helping or even interacting with another as punishment for their substance use. It also happens on a public policy level, where drug users are imprisoned or prevented from accessing sterile syringes, safe injection sites, or other life-saving harm reduction resources.
A tragic example of this can be found in the pushback against Syringe Access Programs (SAPs) during the AIDs epidemic. This was largely based on the erroneous idea that providing sterile syringes would encourage drug use. It was seen as enabling that behavior, and many people felt would make things worse – despite data to the contrary. The debate is still happening today, as the Federal Government flips back and forth as to whether or not they will allocate funds for SAPs. The same can be said for Overdose Prevention Centers, where people who inject drugs can do so in a safe environment with sterile materials in the presence of trained medical staff. As we speak, Philadelphia is preparing for a legal battle with the Federal government about whether such a facility will be allowed to open.
Taken to its logical conclusion, this philosophy encourages us to shame and humiliate drug users as a means of “helping them”.
This idea that fostering shame and suffering is somehow the right thing to do is the natural conclusion of the Rock Bottom Myth. As a result, we turn our backs on our instincts for compassion and support. Tragically, this only makes things worse. Dr. Wupperman is a vocal critic of this philosophy. She points out that: “Despite widespread (and erroneous!) beliefs, shaming does not stop dysregulated behavior. In fact, the reality is the opposite. Shame actually increases the chance a person will continue to engage in dysregulated behavior.” This should not come as much of a surprise. We know that many people use mind altering substances to self-medicate their trauma and to ease their suffering. Consequently when we increase the trauma and suffering in their lives – they will often consume more, not less.
A growing body of evidence indicates that shame, and particularly public shaming, is actually a predictor of relapse rather than a recovery prerequisite. One investigation from the addiction publication Counselor found that “four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling,” and that “clinical studies show that more effective substance abuse counselors are those who practice with an empathetic, supportive style.” This holds true not just with substance use disorders, but also in the treatment of people with eating disorders.
The critique of aggressive and confrontational strategies as a means of addressing substance use is not new. The “tear them down and build them up” approach has been under fire since at least the 1970s as more and more studies show its flaws. Professor and Psychologist William M. Miller explains, “Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance using clients, the less likely clients will change.” In other words, people do not need to be beaten over the head with their bad decisions in order to make changes in their lives. They do not need to lose everything before modifying their behavior. In fact, the opposite is true – compassion achieves far more than shaming.
“Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance using clients, the less likely clients will change.”
The prevalence of this myth can be traced back in part to Alcoholics Anonymous and related 12 Step programs. In their ideology, hitting bottom is a prerequisite for success. It is not difficult to see how disturbing this approach can become. The popular website 12step.com has a page dedicated to hitting rock bottom which states:
“What does it take to create real change? Well, for alcoholics and drug addicts, it’s usually the pain of using becoming more than the pain of not using… The bad clears out enough junk for the good to have a chance.”
It is not difficult to see how after decades of hearing this message repeated, we have come to the perverse conclusion that we are helping people who use drugs by causing them pain.
Interestingly, Alcoholics Anonymous does acknowledge that many people decide reduce or abstain from substance use without losing everything or having a traumatic event. But rather than recognizing that this undermines the foundation of the Rock Bottom Myth, they simply call these people “high bottom addicts”. In other words, they define “rock bottom” as any point at all where someone decides to change their behavior. In a sense, they are correct about this. However, it challenges the entire perception that people with a substance use disorder must reach a point of maximum despair and loss before making changes to their lifestyle.
Journalist Maia Szalavitz is another critic of the Rock Bottom Myth who has written about how the desire to separate and marginalize people who use drugs and people with addiction is a driving force behind many of our attitudes and policies. She writes: “There’s a deep impulse to draw a clear, bold line between us, the healthy people, and them, the addicts. What clearer way to emphasize that divide than to cast them down into a rock-bottom pit, away from the rest of us?” As we know, the pit she refers to is often a literal one. In 2017, nearly 1.4 million people were arrested in the United States for drug possession.
It is imperative that we disengage ourselves from the punishment approach to substance use.
Now that we have explored the issues surrounding the popular Rock Bottom Myth, it is important to take a look at what could be considered its antithesis: harm reduction. The philosophy of harm reduction involves meeting people where they are and resisting the urge to demand change from them. True to its name, the most common and popular examples of harm reduction are things like providing free and safe access to sterile syringes and condoms. Abstaining from drug use and/or sex is not a realistic expectation in many scenarios, but we can do our best to make sure that there is a minimum of harm done. This means providing the materials and education to prevent the spread of HIV, unwanted pregnancies, accidental overdoses, and other hazards.
During a 1995 conference in Florence, Italy – SACHR’s Clinic Director Bart Majoor spoke about the apparent paradox of trying to improve people’s well-being while simultaneously not demanding change: “If a helper is able to let go of his attachment to change, the participant will – often for the first time in their lives – have the experience of being accepted, of being allowed to stay, of being held.” For many, this new feeling of acceptance and trust between the participant and the harm reduction provider can be the impetus for great progress – progress that is achieved cooperatively and without coercion.
It is imperative that we disengage ourselves from the punishment approach to substance use. The failed War on Drugs, the AIDS crisis, and the overdose epidemic are just some of the examples of how our determination to shame and marginalize people for their substance use has only served to worsen the problem. We have the opportunity to rethink our approach using evidence based strategies that emphasize compassion over stigma, and empowerment over persecution.
“…She believed in me, and nurtured me, and motivated me. And she accepted and understood that I was a drug user. She never said, ‘Ben, stop! I’ll give you the job if you’ll stop.’ Never, never did she mention that I had to quit, like every other program does. That’s when I finally saw what she meant by harm reduction. It’s a step-by-step process, in which negative behavior is reversed without someone sticking their finger in your face. It’s a subtle way of change without your knowing it… Slowly but surely I see now that I have gone from one step to another, without even being aware of it. That’s what harm reduction is…”
– B. Clemente Jr. in Quality of Mercy, J. Kirschenbaum, City Limits, October 1994