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.

Hitting Rock Bottom
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Paul Puri

Dr. Puri is a board certified psychiatrist, in private practice in Los Angeles. He practices multiple forms of psychotherapy, including hypnosis, in addition to managing medications. He attended medical school at University of Rochester, and specialty training at University of California, San Diego. He is currently on the Vol Clinical Faculty at UCLA. In his non-clinical time he writes TV pilots, and designs iPhone apps.