Friday, June 3, 2016

Rock Bottoming

It is well understood that 12 Step programs have proven to be effective treatment for different kinds of addictions. Nearly all treatment programs for addiction are based on the 12 Steps, so the fact has clearly been embraced by the psychiatric community.

At the least, this fact ought to alert us to the shortcomings of most of what is called psychotherapy. Alcoholics Anonymous began in the heyday of psychoanalysis and obviously exposed that treatment’s many shortcomings.

Now, Maia Szalavitz argues in her new book Unbroken Brain: A Revolutionary New Way of Understanding Addiction, 12 Step programs contain errors that need to be corrected. One principle error has been compounded by the introduction of the Synanon approach, a treatment that replaces love with hate and rejection.

She explains that the most important flaw in 12 Step programs is the assumption that an addict must hit “rock bottom” before he can truly work the program.

For the record, rock bottom has nothing to do with buns of steel.

For my part I have always found the notion of rock bottoming to be dangerous.  I have opined on it at length in several posts, among them this one.

If you tell someone that he must hit rock bottom, and if he is still somewhat functional and coherent, you will be encouraging him to continue his descent.  In truth, as Szalavitz notes and as I have observed, people are perfectly capable of overcoming an addiction before hitting rock bottom. Why would you tell someone that the worse it gets, the better will be his chances of recovery?

True enough, some people have reached rock bottom before beginning a treatment program, but that does not mean that it is essential to do so or that, as AA suggests, that you will never compete the program unless you have nothing more to lose.

Jesse Singal summarizes Szalavitz’s point:

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.”

The worst part is that some treatment programs, especially those that have been mandated by courts, set about to facilitate an addict’s descent.

In Singal’s words:

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. 

Sadly, this produced a cult to a treatment program called Synanon, an offshoot and apparently a perversion of A.A.

Singal continues:

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. 

One understands that there is a significant difference between love and hate. And one also understands that most A.A. programs are voluntary while court ordered programs are not.

In time, Synanon was exposed as the dangerous cult that it was.

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.

And yet, Szalavitz notes that many of the court-mandated therapy programs today have their 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.

Ostracizing addicts tells them that the only companionship they can ever have is with other addicts. Once they are totally rejected by normal society they will gravitate inexorably toward a society where membership is defined by one’s addiction.

This can be good or bad.

Most 12 Step programs offer a fellowship of recovering addicts, addicts who have chosen to work the program. They forge a connection by attending A.A. meetings regularly, a good habit that is designed to replace the bad habit of hanging out in bars. In the absence of such a recourse, the addict is more likely to spend more time with other non-recovering addicts.

Of course, if A.A. is based on love, not on hate, as Dederich says, then clearly the recovering addict needs to have a pathway to reintegration into society.

One understands that most children have two parents, one male and one female. A child’s mother tends to love the child unconditionally while a father loves his child contingently. Surely, a recovering addict needs both: he needs to know that he will always have a home and will need to know that his behavior is socially unacceptable. While he always has a home his ability to interact with others in society is based on good behavior.

It is as bad to marginalize and humiliate the addict as it is to offer him unconditional love and acceptance. And yet, it is important for the addict to know that his behavior will exact a social price and that there is more to life than unconditional love.


Ares Olympus said...

I always associated "rock bottom" with breaking denial, but I don't know exactly what is meant by denial since you can have moments of weakness where you admit you're 90% responsible for the problems you experience, but then something turns, or your hangover ends, and then you go back to the same old defense mechanisms of blame and distraction, and convince yourself that things aren't so bad, or that you can change by force of will, despite all evidence to the contrary.

I see the wiki article doesn't mention bottoming out, although it also doesn't mention love or hate.

Stuart: It is as bad to marginalize and humiliate the addict as it is to offer him unconditional love and acceptance. And yet, it is important for the addict to know that his behavior will exact a social price and that there is more to life than unconditional love.

The idea of a "social price" is problematic to me, at least I don't see any evidence it makes a difference to behavior. Or at least the problem comes down to WHO is doing the judging, and how that judging is expressed.

There's a common usage of the word "punishment" that overlaps with "consequences", so to mean anything that hurts you or that you don't like. Like we can say paying taxes is "punishment" against success for instance but really that's an interpretation.

So I'd say "social price" should be more about "consequences" than punishment. It doesn't mean pushing someone away who is suffering, but protecting yourself from being dragged down by their suffering.

So when Stuart says "there is more to life than unconditional love" what he means isn't that we can't love and care about someone no matter what, like "He's not heavy, he's my brother," but that we have an obligation to not allow a self-destructive person to threaten or harm others. We have to be responsible for setting limits on our own participation in insanity.

And that's where Al-Anon also comes in. And perhaps "enablers" also need to recognize their "rock bottom", when they realize that they can't control someone else's poor choices and behavior just by caring hard enough.
Al-Anon/Alateen literature focuses on problems common to family members and friends of alcoholics such as excessive care-taking, an inability to differentiate between love and pity and loyalty to abusers, rather than the problems of the alcoholic.

The organization acknowledges that members may join with low self-esteem, largely a side-effect of unrealistically overestimating their agency and control: attempting to control another person's drinking behavior and, when they fail, blaming themselves for the other person's behavior.

Shaun F said...

"Rock bottom" is best understood as the point at which a person with an alcohol problem is willing to change, and chose "life". Obviously it varies. However, if anyone has ever had interactions with a drunk about their drinking one discovers that the drunk's personal self deception will not allow him/her to hear what is being said. Therefore, rock bottom is the destination and potentially hope.

AA isn't so much about unconditional love and acceptance. It's about being part of AA, and living the program. Which in effect means obeying the 12 step behaviour modification program. This is the pretty "hard core" level though. I have seen and known these types.

Scullman said...

I'm one of those types.
I don't "obey" any 12 Step program. But I have utilized a program based on spiritual principles, that fosters a dependence on a Power greater than myself, and asks me, after "having had a spiritual awakening as THE result of these steps" to try and carry THAT message to the alcoholic who still suffers.
It's worked for me for 35 years and has taken me from having my meals in the NY City Municiple Shelter for Men on E3rd Street, to tapping this out on my i-Pad from a hotel room on the Aventine Hill.
Call that what you will. I'll call it the end result of hitting rock bottom and finally stepping towards the light.