Hitting Rock Bottom

I’ve been thinking on this a lot lately, as the issue has arisen in various clinical situations.

We do many things as caregivers (clinicians, providers, physicians, friends and family members) in an effort to help another person. Sometime it seems that if only this person could get a little help, they’d do so much better. And that is absolutely true, some of the time.

On the other hand I’m meeting many people who actively sabotage their own improvement. Maybe they do this by burning bridges with family or friends. Maybe they do this via drugs or alcohol. As this happens there are inevitable consequences — loss of job, friends, health, or housing. Watching this transpire in someone we care about can be incredibly difficult. We’re pulled as we watch the tragedy, to want to intervene. It is in the nature of our role as “givers” to intervene. As if more help in all circumstances will solve the problem of someone who actively sabotages themselves.  For the simplicity of this post, I’ll illustrate these issues using drugs.  It doesn’t have to be drugs, though.  The concern is applicable with any self-destructive behavior.

Imagine having a seventeen year-old daughter. She has started drinking. I’m not talking about a beer here and there. I mean stumbling drunk on a daily basis. She gets expelled from school. As a dutiful parent, I’m sure you’d try to support her. Maybe you would try to limit her contact to friends that are a “bad influcnce.” You might stick her into rehab or send her to boarding school if you can afford it.

Flash forward three years. Your daughter is now twenty. She didn’t go to college. She didn’t finish high school or get a GED. She has never worked a job. All your other interventions didn’t work. The more she rebelled, the more you tried to discipline her, with the hope that she would somehow obey or internalize your values. Instead she just rebelled more, and fought against every rule you laid down.

She comes into your home to eat, or sometimes to sleep and shower. She then goes back out to drink, “party,” and even dabble in some heroin. This is real, even though it seems like a nightmare. You as a parent are torn up watching your little girl go down a path you would never want for her. The options at this point don’t seem appealing.

As a parent you could decide that your daughter needs to “learn a lesson,” or “grow up and start fending for herself.” So maybe you kick her out. She couch surfs with her drug buddies for a while. But she doesn’t have any money. You cut her off because you know she’ll spend any money you give her on drugs and alcohol. That would be enabling her. By cutting her off, you hope she’ll learn her lesson. You hope she’ll hit rock bottom. That she’ll come back ready to grow up and accept an adult role in the world. But she doesn’t.

Instead she stays away. She’s mad at you. She feels rejected by you when you cut her off. She doesn’t recognize the “tough love” approach to this. Even though maybe you were right. By giving her someplace to stay for years, she was shielded from the real consequences of her actions. In a way you had been enabling her use. Now, though, since she doesn’t have money, she has to find other ways to pay for her alcohol and drugs (she’s now using heroin routinely and trying out cocaine periodically). So she starts prostituting herself.

Whoa. Too far?  I’ve seen it a lot.

So you ask yourself – Since she hasn’t hit rock bottom yet, where is that bottom for her, where she reaches the point that she won’t let herself get worse? When will she go so far that I have to intervene because I can’t stand to watch the suffering anymore? Where is my rock bottom?

For some parents in this situation, as well as doctors, therapists, nurses, teachers, etc., there is no end point. Once they cut the cord and decide to stop enabling the pattern, they emotionally disconnect themselves from the outcome. They pray. They hope the person will wake up and come to their senses.

I believe that usually the cord isn’t usually cut completely. People don’t stop caring. Instead the child (or husband/wife/sister/brother/patient) pleads harder, or debases themselves enough to get some help again. They’re desperate. And they learn that if they lose themselves more, someone else will step in to take care of them. And so the pattern continues, except really becoming a pattern of exhausting the compassion of the caregiver. Every time the caregiver has tried to stop, their heartstrings are tugged on until they give in a little. It’s an exhausting process on everyone.

I’d like to think that behaviorism has the answers, and that if this intermittent reinforcement could stop then the person would come to their senses. Sometimes that must be true. Sometimes the caregiver isn’t even aware how they’re reinforcing or enabling.

My recent dilemma comes out of the alternative path, when the person doesn’t end their downward cycle. We wait for the person to hit bottom and snap out of it. We hope it’ll happen, and we feel powerless to “force” the person to change. But in that process, what if hitting bottom means death? Can we accept that? Should we accept that? In a harm reduction model, this seems like a failure. Yet the alternative of enabling didn’t seem acceptable either. Do we rationalize this away as “they did this to themselves?” Should we be contented that this is just what happens with some in their self-destruction.  I believe these rationalizations just make us feel better about not having better tools, about our feelings of failure.

Regardless of whether its acceptable, failure should be considered as the possible outcome of setting a limit. Things may get worse. If we as caregivers cease helping the person, bad things might occur. These might even be horrible things we haven’t imagined yet. If we are shocked at each drop in functioning, though, we may be more tempted to intervene. I am not sure that always helps.

I hate being caught in the process of enabling. It makes me feel like I am being manipulated. From the other side, from the person not even conscious of what they’re doing, I can also appreciate that “benign neglect” can just look like neglect. And for those who have emotionally disconnected as caregivers, it can really take the shape of apathy. Sometimes people are just misunderstood, and it is the feeling alone that can drive them to do their self-destructive behavior. Recognizing that, we’re caught in a bind. Trying to intervene in response to “acting out” reinforces, yet withdrawing resources can potentially lead to more self-destructive behavior as well.  This might not be death, and in fact isn’t in many circumstances.  But it is possible.

I understand all of the rationale behind each side. I can even understand the parent who might say “I’d rather have them alive and using drugs in my home, than outside and dead.” Who would want to give up on those they care about?  Death doesn’t seem like an acceptable outcome. Continuing to enable a process of dysfunction in the name of good intentions doesn’t seem acceptable, either.

There needs to be better ways at intervening, and there very well might be. Resources can and should be provided, but in response to positive behaviors, rather than self-destructive behaviors or even requests for support. Other therapeutic approaches should be considered. Waiting or “benign neglect” puts the responsibility on the rest of the world to induce change in the person, while we wait to accept them back. There needs to be a better way.  We have to start by understanding the worst possible outcome, but not accepting that as inevitable.


Is Walter White a Psychopath?

 Walt’s pathological and Machiavellian level of manipulation of others, even those who might describe him as a friend, makes us question who the real Walter White is. Is he a psychopath? Is he a guy who suppressed his basic needs so much during his life that that now he’s just having a narcissistic tirade to prove he’s all-powerful as he approaches death? As a psychiatrist, I view the evidence that points in one direction vs. another. As a writer, I see the brilliance in how we’re led into watching his dark side unfold, while still empathizing with him.

Modern psychiatry can’t give definitive answers about a diagnosis for Walt, because the field itself still has debate on even where to draw the line on what makes up a psychopath. Plus he’s fiction.  It does give us some good bearings, though.  There’s the DSM definition (antisocial personality disorder), there’s research models used in forensic evaluations like the psychopathy checklist revised (PCL-R), or the Psychopathy Personality Inventory. There’s Cleckley’s work, and the Macdonald triad (bedwetting, firesetting, cruelty to animals). There’s even ideas floating around of a “multi-hit” hypothesis, with genetics, child abuse sometimes, head trauma all playing a role.  Each of these have some level of support, and all have significant amounts of criticism.

Walt began as an inhibited chemistry teacher, presumably for over 16 years. He obeyed the rules. He paid his taxes. He followed the rules, but he was miserable. Then he passes a turning point. His cancer diagnosis means he has nothing to lose. In a way, his reasons for restraining himself and obeying the rules are removed (or lessened), since living a long life out of jail has less meaning. At the same time the incentive to break the law rises in his mind, which was to help others. In that way his breaking the law seemed justifiable, which makes it easier to follow him as viewers and keep him sympathetic. At least at first. As he descends into the world of methamphetamine production, we see him unleash a very different side of himself. This raises the question for viewers: what kind of a man could do such horrible things and not seem bothered by it?

Now I’m not a forensic psychiatrist, I’m a psychiatrist and writer who tries to follow the research as best I can. So let me do my best to boil down some concepts.

There is not one definition for being a psychopath. Or  a sociopath (interchangeable term for many experts). The wiki page isn’t bad at summarizing some of the different takes on the definition.  There’s specific common criteria, which can include a lack of empathy, lack of conscience, violence or cruel behavior (sometimes impulsively), manipulation, superficial charm, lack of remorse.  As you can imagine, many of these overlap, and someone can have some of these traits without having them all.

“God, I’m so antisocial.” I hear this thrown around a lot by people who don’t want to be around other people. They actually mean asocial, rather than antisocial. Antisocial can be conceptualized as going against social rules, particularly in a criminal form.

The DSM, starting with DSM-III, began listing a type of personality disorder called Antisocial Personality Disorder (ASPD). ASPD was intended to list what Cleckley (a grandfather in the field) was finding in those who went on to have dangerous and violent personalities. Unfortunately, like much of medicine by committee, the results didn’t quite map out to be valid in all real world situations. But the forensic psychiatry and psychology fields continued to do research. They developed the idea of psychopathy as possibly more of a trait, supported by the PCL-R.

When we hear the word psychopath, we think of serial killer. Psychopaths would usually meet criteria for ASPD, but not all those with ASPD are psychopaths. I lump ASPD into two categories to simplify an explanation – con men and serial killers. Con men lack a conscience, and generally don’t see external rules as valid. They have a level of narcissism, viewing themselves as superior, and acting in whatever way ultimately serves them. They can be very superficially charming to get what they want.

Serial killers, though, might be a different breed. They have a higher level of the psychopathy trait (think of it like a spectrum from none to a lot). With that comes a lack of fear in circumstances that would arouse fear, possibly explaining the need to be violent to feel physiologically elevated. J. Reid Meloy, a forensic psychologist, likes to talk about psychopaths as “intra-species predators.” Think of a wolf hunting its prey. Normal people if they had to follow or hunt someone would get nervous during the chase. Their heart rate goes up. They might be sweating more or deal with conflicted emotions in the process. A psychopath has the opposite physiological response when hunting. They get calmer. Their heart rate goes down. It’s possible that they’re an evolutionary development, which may have been advantageous in tribal times when killing was necessary for the group survival.

Property of AMC TV

Property of AMC TV

Both the con man and the serial killer lack a conscience. They both do what society deems as terrible acts or unacceptable acts for their own benefit. The difference is that the con man does it moreso for his own selfish gain, or to get away with something. The serial killer more likely does terrible acts because he enjoys it, because nothing else gets him excited. Even more importantly, the serial killer more gets excited from physically hurting others, from causing others to suffer. This starts in childhood with hurting animals, which in the DSM is one of many criteria for conduct disorder (considered the precursor to ASPD).

So we come back to Walt. We as viewers are a little shocked because he has gone from a schoolteacher to the most deceptive man in New Mexico. He has lied to his family, co-workers, and many others, all for his own gain. It seemingly all started as a selfless act, that of supporting a family. It eventually grew into the “Empire business,” serving his own ego. Every morally questionable acts that he does, though, is for a particular aim. He’s able to justify it in a twisted logic based on his business. He doesn’t seem to have any of the childhood precursors of conduct disorder (that we know of) such as fire setting, animal cruelty, truancy. He doesn’t seem to necessarily enjoy killing people, but will do it when he deems it “necessary.” So he’s closer to the con man than the serial killer spectrum of psychopathy.

Jesse is even lower on the spectrum.  He probably met criteria for conduct disorder as a kid.  He broke the rules and made meth because it seemed advantageous to him.  He is Walt’s counterpoint.  He seemed like a bad kid who had lost his way.  He was the criminal, and based on the superficial way we think about criminals we’d think he’d be the bad one.  He was a wanna-be criminal, wearing the guise without the internal lack of morals.  He crossed the line with murder.  This triggers his conscience, which makes him question all of his life.  He is less than a con man.  He can barely lie.  He doesn’t fool anyone.  He has remorse.  Interestingly, only by Breaking Bad was he able to find his way back onto a path.


A deeper curiosity arises from this discussion, portrayed periodically in the media: are there psychopaths among us, who are not criminals? Some theorize that psychopaths with certain environmental circumstances may have social opportunities to channel their predatory instincts. I’m not talking about Hannibal, necessarily. If someone thrives on hurting or taking advantage of others, what job opportunities might fit them? Perhaps those with competition or built in deception? Business, sales, some sports, even some fields in medicine that thrive on competition (I’ve heard ideas about some of my surgical colleagues), all could be possible. Snakes in Suits covers this topic in more depth, where psychopaths can thrive in certain work environments.

Walt clearly has psychopathic traits, but we’re led into liking him in the beginning because he seemed to break the rules for good cause. We follow him, hoping for his redemption. Our curiosity though might reflect our own hidden impulses, played out in a safer way onscreen than in our real lives. It’s not that we are evil, but that with every attempt to force ourselves to be one way, an opposite side can develop to a degree. Thankfully for society, most of us don’t unleash it the way Walt does.

If you’re a Breaking Bad fan, I’ve contributed to a number of articles on about the show.  Find the links on my media page.


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