The Tragic, Pseudoscientific Practice of Forcing Addicts to ‘Hit Rock Bottom’

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One of the many impressive things about Maia Szalavitz’s new book Unbroken Brain: A Revolutionary New Way of Understanding Addiction, is how effectively she debunks various myths about addiction and how to treat it. In fact, the book’s main argument is that many people are misreading what addiction is altogether: It should be seen not as a disease or a moral or personality shortcoming, but rather a learning disorder. “Addiction doesn’t just happen to people because they come across a particular chemical and begin taking it regularly,” she writes early on. Rather, “[i]t is learned and has a history rooted in their individual, social, and cultural developments.”

Or, as Szalavitz put it to the Daily Beast: “If you don’t learn that a drug helps you cope or make you feel good, you wouldn’t know what to crave. People fall in love with a substance or an activity, like gambling. Falling in love doesn’t harm your brain, but it does produce a unique type of learning that causes craving, alters choices and is really hard to forget.”

This can help explain many little-known facts about drug addiction: for example, that the vast majority of people who try even drugs like heroin will not become addicted to them; or that early-life trauma hugely increases the odds of becoming addicted to a substance. To take an oversimplified hypothetical: If someone first offers you alcohol at a time when you’re dealing with serious family issues, unresolved trauma, and other addiction risk factors, you’re more likely to develop an unhealthy relationship with the substance than if your first sip comes at a time when stuff is going okay for you. Many, many factors intermingle in complicated ways to determine whether a given individual will develop an addiction.

Szalavitz’s book is part-memoir, since she herself dealt with severe addiction in her 20s. As the Beast article puts it, “at 23, she’d gone from having an Ivy League scholarship to shooting heroin and cocaine 40 times a day, getting busted for selling drugs, landing in jail, and finally in treatment.” So she is keenly aware of how misunderstandings about what addiction is can lead to bad treatment and bad policy, and that’s why Unbroken Brain is littered with examples of totally off-base ideas of what causes addiction, and how to treat it.

One of the most striking examples is the commonly held notion, as Szalavitz describes it, “that people with addictions must ‘hit bottom’ before they can recover — and that harsh and humiliating treatment facilitates this process, while ‘enabling’ or being loving and kind is counterproductive.” In reading Szalavitz’s intellectual history of this idea and its offshoots, it’s clear that few misconceptions about addiction have led to as much unnecessary trauma and harm as this one.

As Szalavitz explains, the idea comes from “one of [Alcoholics Anonymous’s] foundational texts, 12 Steps and 12 Traditions.” She pulls this excerpt:

Why all this insistence that every A.A. must hit bottom first? The answer is that few people will sincerely try to practice the A.A. program unless they have hit bottom. For practicing A.A.’s, the remaining eleven Steps means the adoption of attitudes and actions that almost no alcoholic who is still drinking can dream of taking. Who wishes to be rigorously honest and tolerant? Who wants to confess his faults to another and make restitution for harm done? Who cares anything for a Higher Power, let alone meditation and prayer? Who wants to sacrifice time and energy in trying to carry A.A.’s message to the next sufferer? No, the average alcoholic, self centered in the extreme, doesn’t care for this prospect—unless he has to do these things in order to stay alive himself.

Under the lash of alcoholism, we are driven to A.A. and there we discover the fatal nature of our situation.

Since the first of the 12 steps an A.A. member must work through is to admit to “admit their powerlessness” over their addiction, it makes sense that the program would embrace a device like “rock bottom.” It’s only when your alcoholism (or other addiction) has gotten so bad you’ve been kicked out of your house by your spouse, have alienated all your friends, and are down to the last $50 in your checking account, that you’ll finally be able to realize just how far you’ve fallen — or something. Fully buying into the program requires desperation, in other words, and to “help” addicts get to that desperate point is to help them recover: “From this perspective,” writes Szalavitz, “the more punitively addicts are treated, the more likely they will be to recover; the lower they are made to fall, the more likely they will be to wake up and quit.”

Szalavitz explains that this is a totally pseudoscientific concept — the founders of A.A. embraced it as dogma but were not in a position to test it scientifically. And even they realized, on some level, that “hitting bottom” was it was a bunk idea, simply because some A.A. members would recover before thoroughly screwing up their lives. A.A. had to introduce the conceptual trick of “high bottoms” — some people hit “bottom” at a relatively high point, in other words — to account for this.

So given how much society’s understanding of addiction has advanced since A.A. was founded, in 1935, it would be nice to think that everyone has moved on from the idea of “hitting bottom” — especially in light of the burgeoning evidence that “people are actually more likely to recover when they still have jobs, family, and greater ties to mainstream society, not less,” as Szalavitz writes. Unfortunately, this awareness hasn’t sunk in: As she notes, “Misinterpreted ideas taken from 12-step-based rehabs are integrated with the criminal justice system and are part of the belief system that quietly upholds current policies. They are deeply embedded … in nearly every public and private system that addresses addiction[.]” Specifically, 12-step programs “are now a required curriculum in at least 80% of American addiction treatment programs.” And since many people get referred to these addiction programs via court orders, countless vulnerable people are shuttled into programs that embrace a totally false, harmful view of what addiction is. In many cases, drug-court advocates argue against treatment and in favor of harsh punishment, simply because it fits into the 12-step, “bottoming out” framework — a bare prison cell certainly feels more like “hitting bottom” than a treatment program.

As Szalavitz recounts, the rise of mandatory 12-step programs led to some truly grotesque “treatment” programs (she views 12-step programs as fairly benign when they are administered voluntarily, even despite the lack of evidence underpinning the individual steps), particularly in the second half of the 20th century. Forcing patients to hit bottom had results that were, in retrospect, predictable: It gave rise to “attack therapy” in programs like Synanon, launched in 1958, where “[t]he idea was to demolish the ego, using intimate secrets people revealed to find their weak spots and try to obliterate the ‘character defects’ believed to be found in all people with addiction.” “Alcoholics Anonymous is based on love, we are based on hate, hate works better,” said Synanon founder Chuck Dederich. Despite a lack of any evidence it worked, state officials around the country were enthralled by Synanon and launched offshoot branches. By the 1970s, Synanon had basically devolved into a cult: Dederich “made members stockpile weapons, forced spouses to swap partners, and coerced men to get sterilized and women to have abortions.” He was eventually arrested and imprisoned for slipping a derattled rattlesnake into the mailbox of an attorney who had tried cases against his group.

Shockingly, “even today, virtually every publicly funded inpatient addiction program in the United States that calls itself a ‘therapeutic community’ has its roots in Synanon.” For decades, Szalavitz writes, programs like Phoenix House and Daytop used “sleep deprivation, food deprivation, isolation, attack therapy, sexual humiliation like dressing people in drag or in diapers, and other abusive tactics in an attempt to get addicts to realize they’d ‘hit bottom’ and must surrender.” Even when the “hitting bottom” idea wasn’t implemented quite this dramatically and harmfully — unsurprisingly, evidence emerged along the way that these programs could cause lasting psychological damage — it echoed throughout the national conversation on addiction in the 1980s and ‘90s, giving rise to the “tough love” movement in which “[m]embers urged fellow parents not to bail out their kids if they were arrested,” and to cut off contact with them if they displayed disobedience (Szalavitz notes that there are, in fact, times when families need to cut off contact with addicted relatives simply to keep everyone safe, but “tough love” argues something much harsher).

There’s no simple way to tally the damage all these programs have done. “While there are clear indications that [’Tough Love’] can sometimes do harm,” for example, Szalavitz writes that “no one knows how widespread the problem is because there is virtually no research on what happens to people whose parents or spouses decide to practice it.” But what is clear is that these ideas all fly in the face of what the literature shouts at us about treating addiction: that it’s best done by providing addicts with empathy, support, and healthy social networks — not by snatching these vital lifelines from them.

But throughout her book, Szalavitz argues, and argues compellingly, that when it comes to “hitting bottom” and so many of the other pseudoscientific approaches to fighting addiction, the actual goal — or part of it, at least — has always been to marginalize the addict, to set them apart and humiliate them. 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?