A 40-year-old man enters counseling to deal with “relationship issues.” He says his marriage is failing due to his use of online pornography and that his financial situation is in constant peril because of high gambling debts. He adds that he drinks alcohol daily and fears he is dependent on it to remain functional.
In terms of treatment triage, many clinicians would choose to make his alcohol dependence a top priority because active substance addiction can make other goals impossible to achieve. But substance abuse work is a significant undertaking. It is not unheard of for a treatment plan to include group therapy, family therapy and an inpatient treatment facility. With the focus of treatment squarely on alcohol use, the client’s other issues may linger on the back burner indefinitely.
It could be a mistake to leave addiction to certain behaviors — such as this client’s compulsive gambling or use of online pornography — out of the treatment plan, says American Counseling Association member Mary Crozier, associate professor and coordinator of the substance abuse counseling certificate program at East Carolina University (ECU) in Greenville, North Carolina. “Just as we’ve adapted to the presence of co-occurring disorders, we are adapting to the presence of behavioral addictions with mental illness and other addictions,” she says, although adding that the dearth of prevention research and services that target behavioral addictions is a significant obstacle. But like most paradigm shifts, the connection between substance abuse and behavioral addiction is slowly coming into focus.
A new book that delves into the diagnosis and treatment of behavioral addiction, The Behavioral Addictions, edited by Michael S. Ascher and Petros Levounis, makes the case that certain behaviors can turn into addictions that follow similar paths to substance use disorders. Levounis, chair of the Department of Psychiatry at Rutgers New Jersey Medical School, tells Counseling Today that behavioral addictions should be viewed as a new field of study encompassing “a number of diverse conditions, from the more traditional problems of gambling, sex, Internet, food and shopping to emerging constructs such as work addiction, love addiction and addiction to indoor sun-tanning.”
Although gambling addiction is the only behavioral addiction found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), clinicians and researchers are noting that the neurobiological responses to behavioral addiction are similar to those of substance abuse. At the same time, treatment options must be more nuanced for behavioral addictions. For example, alcohol abuse may be treated through abstinence, but food addiction and sex addiction are related to typical human activities for which complete self-denial is an unrealistic goal.
It wasn’t until Crozier had already completed her doctorate and taken a teaching position at Medicine Hat College in Alberta, Canada, that she truly saw for herself the relationship between substance and behavioral addictions. “[The college’s] addictions counseling program integrated substance and behavioral addictions into each course,” she says. “Their model allowed students to see the interactions between substances and behaviors and to really learn about well-researched, prevalent behavioral addictions. Examples of this integration were to weave binge eating disorder into the counseling course, pathological gambling into the assessment course and hypersexuality disorder into the prevention course. Needless to say, I learned a lot and saw addictions in a new light.”
Crozier’s research partner, Shari Sias, a member of ACA and its division, the International Association of Addictions and Offender Counselors (IAAOC), also had a postgraduate awakening to the connection between substance abuse and behavioral addiction. While serving as the clinical coordinator of an outpatient substance abuse counseling center, she and her staff noticed that the clients were also struggling with behavioral addictions. “Once the chemical addictions were addressed, their behavioral addictions began to surface,” says Sias, now an associate professor and director of the substance abuse and clinical counseling programs at ECU. “Staff began asking for training in behavior addictions, and we asked [sex addiction expert and author] Patrick Carnes to come and lead a training. This was an eye-opening experience for all of us, and [we] started incorporating behavior addiction information as part of the outpatient program.”
As is the case with most disorders, clients struggling with behavioral addiction often present to counseling for other reasons. Crozier is careful to note that not everyone who engages in potentially addictive behaviors actually becomes addicted. She explains that some people come to counseling simply for advice about managing those behaviors.
“Other clients are unaware that their compulsive behaviors are causing risks and negative ripple effects for their friends, family, boss, etc.,” she says. “There seems to be a strong correlation between behavioral addictions — especially pathological gambling — and substance abuse. Many clients thus present to counseling with substance, familial, social, financial, health and occupational challenges.” For this reason, Crozier advises counselors to conduct assessments on behavioral addictions with all clients, both as part of a stronger initial screening process and intermittently thereafter.
Sias agrees. “Most of the clients I’ve counseled sought services due to a chemical addiction, and as part of that work … became aware of a process addiction,” she says. “It is important that behavioral addictions be included in the assessment and treatment process. If we as counselors don’t ask about it, clients may not be aware of the need to treat both the chemical and behavioral addiction.” Sias adds that successful treatment may address both the chemical and behavioral addictions as part of a holistic, client-centered plan, including referrals to other support professionals, such as financial counseling for gambling debts or medical care for binge eating disorder.
Levounis thinks the role of the counselor in helping people who struggle with behavioral addiction is two-fold. “On one hand, she or he is in a unique position to recognize the signs of these poorly understood — and, in general, poorly researched — addictions,” he says. “On the other, the counselor may be able to reformulate a person’s problem in terms of an addictive process, beyond the traditional structures of CBT [cognitive behavior therapy] and psychodynamic psychotherapy.” He provides the example of a person reeling from a series of unsuccessful relationships. The client may find it helpful if her or his counselor reconceptualizes the struggle in terms of unrelenting cravings for the euphoria of a new romance.
“In other words, in terms of an addiction to love,” Levounis says.
Motivational interviewing: A collaborative conversation
There is some good news for counselors who want to start assessing and treating for behavioral addictions and who are experienced in working with clients facing substance abuse issues: These counselors likely already possess the required skills. The evidence-based approach used in motivational interviewing can be refocused to help clients deal with behavioral addictions as well as substance abuse. In fact, none of the counselors interviewed for this article think that motivational interviewing is better used to address one kind of addiction over another. Their general consensus was that, because of its Rogerian, person-centered emphasis, motivational interviewing is useful with anyone considering behavior change of any kind. In their book, Ascher and Levounis point out that due in part to the absence of DSM-5 diagnoses for most behavioral addictions, motivational interviewing joins individual and group psychotherapy and self-help groups as one of the few current treatment recommendations for these disorders.
“[Motivational interviewing’s] client-centered counseling style for eliciting behavior change and helping clients explore and resolve ambivalence is great for meeting clients where they are in the change process,” Sias says. In her experience, she also has found that motivational interviewing increases client attendance and retention rates. “We know the longer clients remain in treatment, the better the recovery rate,” she adds.
Melanie M. Iarussi, an ACA member and secretary of IAAOC who is also an assistant professor at Auburn University in Alabama, is a trainer with the Motivational Interviewing Network of Trainers (MINT) organization. She has used motivational interviewing in a variety of clinical settings, including substance abuse treatment centers, college counseling centers and a domestic violence intervention center. She defines motivational interviewing as a humanistic, goal-oriented approach designed to help people identify and strengthen their personal motivations to engage in behavior change. “The humanistic underpinnings of the MI [motivational interviewing] approach made complete sense to me, and using MI strategies gave me some tools to promote engagement in counseling and enhance problem awareness with my clients,” she says.
Motivational interviewing encourages the counselor to engage in a collaborative conversation that meets clients where they currently are. The approach avoids imposing beliefs or forcing change on the client. “Instead, MI is grounded in respect and valuing the client with all of his or her experiences and wisdom,” Iarussi says. “MI emphasizes empathy — truly seeing the issues and concerns through the eyes of the client, taking into account his or her worldview, background, resources, etc. — and it requires a unique, responsive approach to each individual.” She adds that MI counselors support client autonomy, affirming the individual strengths and assets that can be a foundation for making positive changes.
When treating behavioral addictions, Iarussi has found that motivational interviewing works well in tandem with other therapeutic approaches. For example, she says, clients with behavioral addictions can benefit from a combination of motivational interviewing and CBT. “MI can help the person cultivate and enhance their motivations to pursue behavior changes, and then CBT can help them develop the skills and tools needed to implement the change,” she explains.
Iarussi cautions, however, that challenges may arise when the client perceives that the behavior provides more benefits than costs or when resources are lacking for the client to implement and sustain change. If the counselor and the client collaboratively explore the possibility of change and the client decides against it, the MI protocol calls for the counselor to honor the client’s autonomy and decisions. “We can express concern in a genuine, compassionate manner, but we do not attempt to coerce or force change upon clients,” Iarussi notes. “In the end, it is truly their choice if they will change their behavior. … The counselor acts as a guide.”
Iarussi goes on to explain that when there is a lack of resources contributing to the inability to change, the MI counselor helps the client manage with whatever resources are available. Creativity is useful here, she says. For example, consider a client who struggles with hypersexual behavior who would benefit from attending a 12-step meeting. If the client lives in a small community without close access to such a meeting, the counselor and client could work together to brainstorm options such as online meetings, committing to travel to a meeting far away at least twice a month and so on, Iarussi says.
Within the community of addictions counselors, motivational interviewing is now a widely accepted tool for working with behavioral or process addictions, according to Paul Toriello, an ACA and IAAOC member and MINT trainer who serves as director of graduate studies in the Department of Addictions and Rehabilitation Studies at ECU. In fact, Toriello says that most of the motivational interviewing trainings he currently runs are outside of the substance abuse arena. “MI was in many ways born in a substance abuse setting, but it has evolved for so many years,” he says, noting that his current work involving motivational interviewing is in career motivation with wounded veterans.
Toriello says motivational interviewing’s strong basis in research also has garnered interest in recent years from organizations that need to incorporate evidence-based practice into their treatment planning for funding reasons. “MI checks the box in terms of evidence-based practice, but it is also very fulfilling to practitioners,” he says. “People get into counseling [work] because they want to build relationships, and if I can do that and, at the same time, meet the demands of funding agencies and insurance companies, it’s hard to lose.”
Specifically, Toriello has found motivational interviewing useful in helping clients with behavioral addictions such as gambling and disordered eating. “You name the target behavior, and MI can be done the same way,” he says. “Now there is a lot of variance within [it] … but the approach to behavior X, Y or Z will essentially be the same, guided by the four processes.”
Finding clients’ humanity
The four core processes of motivational interviewing are engaging, focusing, evoking and planning. Moving through these four stages, counselors aim to guide their clients toward developing their own motivations to change a behavior. Starting with engagement, counselors work to create the therapeutic alliance that is found in most counseling approaches.
Toriello says the framework offers significant flexibility for counselors to follow their own unique paths. He describes it as almost dancelike: “I am strategically asking questions and making reflections so my client will come to a different decision about the behavior he [or she] wants to change. The word you often see is [that MI counselors use] an ‘evocative’ spirit to draw out of the client [his or her] own natural resources for change. That’s one of the things that makes it so person-centered. The interviewer has a sense that everything the client needs to make the change is already within them. It’s the interviewer’s job to bring that out of them, with skillful questioning.”
Toriello offers the example of an adolescent male he worked with in a residential environment years ago. Conduct disorder, angry outbursts and substance abuse were the norm in the facility, and “Johnny” presented with all the symptoms from day one.
“He came in like a bat out of hell,” Toriello recalls. “He just hit the ground running, throwing, spitting, kicking, you name it. Until one day, some time had passed after he went through a crisis period, and I brought him [into my office] and pulled his record. I talked to him to try to get a sense of where he was coming from. [I used] open-ended questions as opposed to confronting or prescribing, and he didn’t act up and he was actually responding, which was cool to see. This got to a point where he broke down, shed a bunch of tears and we implemented some tools he could take with him. He was not an angel, but once we tried to just listen, as opposed to confront, it was working.”
Toriello says that experience set him on a course to learn more about motivational interviewing. “I came from that other model, where you tear down the defenses first. But [with Johnny] I could see, ‘Wow, there is a human being in there!’ But what got us to see that was to act like human beings [ourselves] rather than like power and control mongers,” he reflects.
From Sias’ perspective, the biggest challenge for counselors working with the behavioral addiction population is not the clients’ needs but rather having access to services that actually address these disorders. “We need more programs that focus on behavioral addictions, and I think existing substance abuse treatment programs need to integrate behavioral addictions,” she says.
Despite the challenges, she adds that there are many rewards in working with this population. “Counselors trained to address both chemical and behavioral addictions are providing holistic care that makes a big difference in the lives of the clients we serve,” Sias says. “Being part of the change process with clients is an amazing experience.”
Crozier was a member of the IAAOC Process Addictions Committee when it conducted research on the topic of counselor readiness for working with behavioral addictions. The findings from the 2014 nationwide survey of counseling students, faculty and professionals suggest that few counselors are formally trained in process or behavioral addictions; scant research is readily available; and the empirical studies that are available aren’t being widely utilized. Given those findings, Crozier recommends that all counselors join IAAOC’s Process Addictions Committee and read its newsletter.
On a more personal level, Toriello can foresee challenges for new clinicians as they face behavioral addictions in their offices. “You can’t go through a counselor education program and not be steeped in Carl Rogers and the person-centered approach, so these new counselors have the knowledge,” he says. “[But] I am concerned about their strength to implement that knowledge and stay true to person-centered approaches as opposed to succumbing to the pressure … of prescriptive techniques, where they start giving unwanted or unrequested advice, or they start problem-solving and not counseling.”
Toriello fears that counselors have taken too much control of the change process. He believes they would do well to use various techniques, including motivational interviewing, to return that control to their clients, thus allowing them to be the experts on their own issues.
The International Association of Addictions and Offender Counselors, a division of the American Counseling Association, was chartered in 1972. Members of IAAOC advocate for the development of effective counseling and rehabilitation programs for people with addictions. For more information, visit iaaoc.org.
Robert L. Smith’s book, Treatment Strategies for Substance and Process Addictions, published earlier this year by ACA, features sections by various authors on pathological gambling, sexual addiction, disordered eating, work addiction, exercise addiction, compulsive buying/shopping addiction and Internet addiction. For more information, visit counseling.org/bookstore or call 800.422.2648 ext. 222.
A podcast on “Gambling Addiction,” delivered by Pete Pennington, is available on the ACA website.
Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.
Letters to the editor: firstname.lastname@example.org
I really like that counselors aim to have clients develop their own motivations to change. I know that if I am told to change that I probably won’t. I think it’s great that they can successfully make people see that they need to change.
So far I’ve just perused your article for my Addictions Counseling Class. Great stuff! For me personally, I write a gratitude list in my iPhone note daily, which I think I will suggest to future clients of mine use.