As I mentioned in the beginning of the year, I plan on posting excerpts from the draft of the book I am writing about addiction recovery. The book combines my training in the field along with professional and personal experience to provide examples. This excerpt is from an early chapter and discusses bottoms. As always I welcome any feedback.
Whether an addict has to hit bottom or not is a topic of much debate. It is often heard when someone who has tried recovery briefly and failed that “they did not hit bottom yet.” Using this reasoning and considering the amount of people that relapse after reportedly hitting their bottom, I suppose one will only know if they hit bottom after they remain in recovery a significant period of time. Treatment professionals often consider part of their job raising the bottom for their clients, so they don’t have to go any lower. That brings the discussion to the next topic, motivation.
When someone enters treatment others often try to determine whether the motivation is internal or external, or a combination of both. External motivation was discussed briefly above, and consists of outside, societal produced reasons to seek help or to stop substance use. These reasons include people one cares about applying pressure, legal trouble that requires abstinence, some licensing boards that force their members into treatment if a problem is discovered, other work or career issues, and health problems exacerbated by substance use.
Internal motivation is the realization a behavior is detrimental to your life goals or incongruent with your values, and a decision to stop as a result. In over 16 years of work in the addiction field, I can vaguely recall one or two legitimate cases where there was this type of internal motivation. In a recent group I run where the majority of clients were impaired professionals stipulated to treatment by their licensing entity, there was one gentleman who had no career or legal problems. The group members genuinely gloated about his internal motivation, how great it was to have entered treatment on his own, to not be forced, and how proud he must be. When he couldn’t take it anymore he stopped them and informed them his wife made him enter the group; and that if not for her, he’d probably still be popping pain pills.
Almost all the literature and research regarding who fares better in treatment, those with internal or external motivation, reports that it is equal. This is easy to see if one looks past what brought an individual to treatment. Those that are truly internally motivated have the desire to change their life for the better, and may readily accept suggestions and go the extra mile. Those that have a monitoring system like the courts want to remain out of trouble, and as such must follow direction. And for many externally motivated clients it doesn’t end there, they have to submit to random urine drug screens for extended periods. Many of the impaired professionals I work with have five year contracts which require random drug and alcohol screens.
As a clinician I have often made the argument that all motivation is internal, and all motivation is external. Perhaps it’s my Eastern philosophical stance that each apparently opposing side is part of the whole. Regardless, my argument is such: if one wants to stay out of jail and maintain freedom doesn’t that convert to internal motivation? They are internally motivated to have a better life, knowing freedom is better than incarceration. If it is their career at stake, the argument remains the same: they believe keeping their license to practice law (or medicine, or nursing) offers more opportunity for enjoyment in their life than not practicing. And if the internally motivated individual wants to improve their life, or behave more in line with their morals and values, doesn’t that also serve an external component? Do they not accept an external reward in this life or the next? My point is that motivation can be external or internal, depending on the focus. The point is that the substance abuser has to change their focus and want to remain abstinent, no matter what the reason. And this is then internal motivation.
I have worked with clients with very low bottoms and with high bottoms, if we choose to use this designation. My clients have included women (and men) who have traded sexual favor for a five dollar bag of crack. I have worked with doctors, nurses, and lawyers as well as a few professional sports figures whose careers were on the line if they did not cease substance use. The highest bottom person I ever worked with entered treatment because she bruised her knee in a blackout, and found this unacceptable. And of these substance abusers, there have been those that lost what they entered treatment to save as a result of continued substance use. There have also been those who have saved their life, which at the time may have been all they had left.