In the last month I have heard two people say that addicts can’t get clean until they really want it. They have to “hit bottom” and then “pull themselves up by their bootstraps.”
One person who said this was the Governor of Florida, Rick Scott. The other was a lawyer who is not an addict but represents treatment center operators in South Florida.

I want to smack them both upside the head. Substance use disorder is a chronic, often reoccurring brain disease. Would you tell someone with schizophrenia to pull herself up by her bootstraps? That she has to “hit bottom” before she can get better?
No. You wouldn’t say that.

Certainly, there is a stage of the disease at which desire and self-will are enough to get an addict clean. Often that comes when an addict “hits bottom.” Same is true of some people with diabetes, who learn that amputation is a possibility if they don’t change their diet. 

But some addicts cannot pull themselves up by their bootstraps because they no longer have bootstraps. Their brains are damaged. 

I once heard Dr. Nora Volkow, head of the National Institute on Drug Abuse, explain addiction. She said substance-use disorder is like driving a car with no brakes: No matter how much you want to stop, you cannot. No matter the consequences – there is a child in the road – you cannot stop.

Seeing addiction from that perspective, telling an addict that she must hit bottom before she can get clean is like saying she must hit that child in the road before she can get better. 

Addicts don’t have to hit bottom to get clean. That is why we have interventions and court-ordered involuntary commitments. In Florida, where I live, we have the Marchman Act. A judge can order a drug addict to treatment, whether she wants it or not. Many don’t want it but they get clean anyway. 

What is “hitting bottom?” What we consider “hitting bottom” may not be what an active addict considers “hitting bottom.” They may think they still have a ways to go. So, what defines “hitting bottom?” Getting fired? Expelled? A DUI? A divorce?  Bankruptcy? Prostitution? Homelessness? 

The notion that an addict or alcoholic must “hit bottom” before getting clean and sober is a belief often heard in 12-Step programs. I am a recovered alcoholic. I have attended countless AA meetings. I have done the steps. I have a sponsor and have sponsored. Here is what I know.

The 12-Steps is a program that requires immense motivation. No matter what “bottom” you have hit, no matter how badly you want to stop, you may no longer have brakes. Your dopamine pathways may be so damaged that you physically cannot muster the motivation to complete the 12-Steps. 

Putting these addicts into a 12-Step program is setting them up for a reoccurrence – relapse – of their illness. This is why I believe that the 12-Steps is NOT the only way to get clean and sober. As with many illnesses, a treatment that does not work today may work later – and vice versa. 

Saying that addicts must hit bottom before getting clean or that they must pull themselves up by their bootstraps perpetuates the stigma that substance use disorders are a moral failing – that addicts are selfish and weak willed.

We are not.

We are sick.