In parts one, two, and three of this series on addiction I have focused on mental models that are helpful when thinking about substance abuse. For this final post, I focus instead on some common ways of thinking about addiction that are particularly unhelpful. While each of these frameworks holds some truth, I find they tend to obscure more than they illuminate. These beliefs are often held both by people who use drugs, and their families.
Rock Bottom
The idea of hitting rock bottom is pervasive. The idea behind this framework is that things have to get so bad that they cannot get any worse. Then, and only then, will people decide to change and move away from substance abuse. There are a few problems with this way of thinking.
First, the whole idea of the bottom is almost impossible to pin down. I’ve seen people use injection drugs, end up in the hospital having open-heart surgery to repair heart valves damaged from the drugs, getting discharged, and then being back to using within hours. People routinely break promises they said they would never break, and tell themselves “If it ever got to the point where___, then I’d know I have a problem and change.” That blank space might be a partner leaving, losing a house, going broke, disconnecting from children, losing a job– the list is endless. And yet, once that threshold is passed, there’s always a reason, always an extenuating circumstance. What looked like rock bottom 3 months ago has become the new normal.
The truth is, things can always get worse. There is no bottom. The inflection point is when people decide to move in a new direction. That can be at any point in the process, triggered by almost anything. The idea that there is some objective level of misery that must be reached before recovery starts does not hold up well.The flip side is also that change can come before things spin out of control.
Lastly, there’s an implication with this framework that once rock bottom is found, its an upward trajectory afterward. That, too, is often not the case. People relapse, change comes haltingly, growth does not always look or feel like forward progress. Rock bottom implies a linear trajectory– both on the way down and on the way up– that rarely lines up with reality.
Move Past This
There is a common fantasy that many people have, which is that they want to “move past” addiction. The idea is that this part of life about which a person is ashamed, embarrassed, or would rather not look at. Rather than turning towards that chapter, there is a desire to make it somehow disappear. To have the problem magically go away, never to recur again. There are a lot of synonyms for this type of thinking, such as “that’s in the past” or “this can never happen again” or “I’ve moved on from that.”
The problem with this approach is that it is a part of a person’s life, just as the patterns of addiction are patterns of human behavior that live within all of us. This might be a time of shame, embarrassment, or unhappiness, but none of those feelings change the reality that it is still there. Trying to move past addiction is generally a different way of saying that we do not want to look directly at the problem. Moving past a period of addiction is a close synonym to it never happened, and a false promise that it can never happen again. It is easy to understand why that way of thinking is attractive, but it is not the truth.
The alternative framework I find most helpful instead is to think about making peace with this part of ourselves, this part of our life. This will be a chapter in our story; the only choice we really have is how we relate to it. Making peace with it also acknowledges the reality that we could slip back– however far fetched and undesirable that may seem.
This observation extends broadly beyond addiction. Most of us have parts of ourselves, or times in our lives, that we would rather forget or pretend are not there. Most of us think about “moving past that.” But doing so is a form of hiding from the truth, not facing the reality that we are all complicated creatures with stories that encompass both tremendous triumphs, and tremendous shortcomings.
Acute Illness
In part one of this series, I presented addiction as a chronic relapsing-remitting disease– something that is always there, and that needs to be managed over the long haul. The opposite mental model for that is an acute illness; a time when we fall ill, are treated, and then completely recover with functionally no change from prior. Appendicitis is a good example: we are feeling fine, we get sick, we have surgery, and within a few weeks, we are back to our life before the illness. The acute illness model works poorly for addiction.
People often make the analogy that rehab is to addiction what surgery is to appendicitis– and intervention that fixes the problem, and then life resumes as normal. This, as a model, almost never works. Inpatient treatment for addiction has a role, and it can be a tremendously important intervention. But it does not fix the problem in the way that surgery fixes appendicitis. It might help improve symptoms that are out of control, but it does not resolve the underlying diagnosis. Managing a substance use disorder is managing a chronic condition.
All you have to do is…
One of the things that can be most maddening about substance abuse is how it seems like it should be so simple to fix. After all, if the substance use stops, the problem goes away. So why don’t people just stop? That’s “all you have to do.”
There are an almost infinite number of other problems that are similarly easy to solve. Want to solve poverty? People just have to earn more and spend less. Want to solve obesity? People just have to eat less and exercise more. Want to stop being depressed? Just think more positively. Want to stop being anxious? Just relax. Want to stop wars? Just have countries stop fighting. While all of these prescriptions are technically true, they all reduce extraordinarily complicated social and behavioral challenges into simple, obvious, true, and ineffective injunctions.
Simplifying to this extent creates more challenges, not fewer. Because the answer feels so simple and obvious, not implementing it feels like an even larger failure, exacerbating feelings of shame, guilt and embarrassment. It also offers people around the person using an easy route to not examining the true situation. It's easy to feel confident when the solution is so easy. It is a quick route to feeling disgust, superiority, blame– or to turn away entirely. After all, there must be something wrong with that person if they cannot implement so obvious an answer to such a dire problem.
As a quick thought experiment, think for a moment about a behavior you want to change– exercising more, eating less, spending money differently, communicating more honestly, being more patient. The “all you have to do” answer to any of these problems is clear. The implementation is a winding road, at best.
This is what you have to do…
This framework is a close cousin to the one above, but is often offered by people who have already had some success recovering from substance abuse. People who have walked the road have important, valuable knowledge about recovery, and sometimes have helpful insight into what works.
But the challenge is that we are all unique, and the road forward for each of us is different. While there are a tremendous number of commonalities and themes that emerge among people with addiction, not two stories are exactly alike. Unfortunately, the humility and acknowledgement that each of us is on our own journey sometimes gets lost.
There is often a stunning amount of certainty about what other people need. In fact, I think we often become rigid in our thinking not because we know, but because sitting with uncertainty is uncomfortable, and professed certainty psychologically assuages that uncertainty. Ambiguity is often scary for people to face, so rather than own the fact that the road ahead is uncertain, we embrace rigid certainty about the one, and only one, right way to move forward.
It also often is offered by people who have high conviction about what someone needs.
Willpower Issue
Addiction is often framed as an issue of willpower. This framework lives in and around several of the others in this piece. “I just have to stop” or “I’ve got to be stronger” are common ways this gets expressed. The core belief here is if someone wants to stop using bad enough, all that needs to be done is the application of mental strength.
The problem is that this way of thinking quickly becomes circular. If someone stops using, it proves they had enough willpower. If they continue using, it proves they did not. The framework reduces every possible outcome to a single variable and therefore explains very little. It also ignores the obvious reality that many people with addiction demonstrate tremendous discipline and perseverance in other areas of their lives.
Equally important, the willpower model can sabotage recovery. If the problem is a lack of strength, then every return to use becomes evidence of personal weakness rather than information about what is and is not working. Shame increases, honesty decreases, and people become less likely to seek help. Recovery efforts become focused on trying harder rather than understanding the conditions that drive substance use in the first place.
Of course effort matters. Recovery requires people to do difficult things. But framing addiction as a willpower problem turns every struggle into a moral failure. The result is often more shame, less honesty, and greater isolation. Recovery is difficult enough without carrying the additional burden of believing that every setback is evidence of personal weakness. If addiction could be solved by wanting to stop badly enough, most people would recover long before they reached my office. The persistence of addiction in spite of desperation to stop is perhaps the best evidence we have that the problem is more complicated than that.
These frameworks persist because each contains some truth. But every way of understanding addiction illuminates certain aspects of reality while obscuring others. The question is not whether a particular model is completely right or completely wrong. The more important question is whether it helps us see more clearly.
Throughout this series, I have argued that addiction is best understood when it is viewed through multiple lenses. No one model explains everything; instead, each offers a different perspective on the same problem, highlighting different causes, challenges, and opportunities for change.
The goal is not to find the one correct explanation for addiction. The goal is to build a toolbox of useful ways of understanding it, and the wisdom to know when each applies. Human behavior is complicated. Recovery is complicated. The best frameworks are not the ones that make us feel most certain. They are the ones that help us see more clearly what is happening, and what might help someone move forward.
You can read parts one, two, and three here.
Love,
Doc
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