Who Needs to “Hit Rock Bottom”?

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Who Needs to “Hit Rock Bottom”?

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We are almost positive you have heard someone say “he won’t change until he hits bottom.” Have you ever thought deeply about what is being conveyed in that statement? Slang for as bad as it gets, “hitting bottom” usually refers to the need to reach a place (or state of being) where one is so desperate about how bad things are that you simply “have to” change.

On one hand there is a lot of sense in this idea, as it really describes one of the ways people get motivated toward change. “I finally got sick of waking up hung over all the time with my wife mad at me… it just wasn’t worth it anymore, so I’m getting some help.” Deciding that the costs outweigh the benefits is the primary reason people change.

On the other hand, our beliefs about substance abuse and compulsive behavior problems—and the potential for change—are built into the words we use to speak about them. The the statement “he needs to hit rock bottom” conveys a variety of problematic, deeply held culturally ingrained beliefs and attitudes and there are huge downsides to using it as a way to describe what needs to happen in order to change behavior.

First, it promotes a belief that the change process cannot start until bottom is reached. It also implies that people won’t change unless they are “punished enough” by their own behavior that they see the light. Both of these assumptions could not be further from the truth and they have contributed to many treatment providers sending patients away and telling them to “come back when you’re ready.” It’s also contributed to family members and friends feeling like their only option is to step aside and watch their loved one suffer. Many opportunities for change and lives have been lost due to this flawed belief and culturally loaded statement.

The reality is that people change for all sorts of different reasons and motivation can be positively influenced by your environment, family, friends and treatment providers. Until very recently, if you had difficulty managing your substance use, you were told there were only a few ways to get better. Admit you were an alcoholic/addict, stop using the substance altogether, attend 12-step meetings and maybe even go to rehab if things were that bad. While for some, these suggestions were life saving and life changing, they were unacceptable and/or intolerable to many. And the reality? There are many pathways to change, and different paths work for different people, often at different times. There is not one simple, quick fix way to change a behavioral problem.

Finally, the biggest downside of this idea of “hitting bottom” is that it dangerously implies that for those around the substance user, there’s nothing to be done but wait. In fact, the research shows that early intervention (when the consequences have not yet started to pile up) and a loved one’s positively impacting the environment around a substance user leads to better outcomes. People start to change a behavior any time they perceive its costs to outweigh its benefits and loved ones can play a positive role in making that happen. Treatment providers can help it happen. It could be as simple as your internist asking you about your drinking pattern and recommending you experiment with one drink less per night (a mighty and successful intervention). Tradition and popular media would have us believe only the desperation, household upheaval and violence, overdose, and everything falling apart is sufficient to start change. Happily, the treatment system (both medical and mental health) is evolving to help people sooner, when their problems are less severe.

We encourage you to question what someone is saying when you hear “yeah, he just hasn’t’ hit bottom.” Instead, we encourage you to think about the concept of “decisional balance.” There is a mountain of evidence that thinking through the ambivalence of changing — the reasons for NOT changing as much as FOR changing — can help people clarify the costs and benefits of their behavior in a non-judgmental manner. We also know that research has found that thinking through the desire to change without judgement can actually help people make a decision to change BEFORE they hit bottom.

The people (friends and family) around someone abusing substances do not need to wait until a bottom is reached, they can (and they want to) speed up the process of change. They do not have to wait until their loved one has done so much damage that they have no other choice. And since hitting bottom can mean death and life altering consequences, we hope that people who use substances and their families can all turn away from the idea that “hitting bottom” has any relevance in the change process. There are other ways…and things that can impact the change process sooner. We encourage you to research evidence based treatment options (like CRAFT and MI) as they all operate on the the idea that people can change (and be influenced to change) at any point….not just when they have “hit bottom.” Our hope at CMC is that the the phrase “hitting bottom” will become obsolete in the near future as it holds no value. Instead, we hope that an environment of change (including the influence of treatment providers, family and friends) can be created where change can happen at any point.

About the Author:

Carrie Wilkens, PhD

Carrie Wilkens, PhD, is the Co-Founder and Clinical Director of the Center for Motivation and Change in NYC and in the Berkshires. She co-authored an award-winning book, Beyond Addiction: How Science and Kindness Help People Change with Drs. Foote and Kosanke. Together they also contributed to a user-friendly workbook for parents: The 20 Minute Guide: A Guide for Parents about How to Help their Child Change their Substance Use. In collaboration with the Partnership for Drug-Free Kids, Dr. Wilkens and the CMC team is developing a national parent training program (the Parent Support Network) to provide parent coaches to families in need of support through a free hotline. Prior to these ventures, Dr. Wilkens was the Project Director on a large federally-funded Substance Abuse and Mental Health Services Administration (SAMHSA) grant examining the effectiveness of motivational interventions in addressing the problems associated with binge drinking among college students. She is regularly sought out by the media to discuss issues related to substance use disorders and has been on the CBS Morning Show, Katie Couric Show, and Fox News as well as a variety of radio shows including frequent NPR segments such as the People’s Pharmacy and The Diane Rehm Show.