Monthly Archives: October 2021

Six steps for addressing behavioral addictions in clinical work

By Amanda Giordano October 5, 2021

The first time I worked with a client who said he was addicted to internet pornography, I had no idea how to respond. I quickly tried to recall material from my master’s-level addictions course, but we had discussed only substance use disorders. I hadn’t learned anything about how to address addictive behaviors. Thankfully, one of my professors was a certified sex addiction therapist and supervised me as I worked with this client through internship.

Since then, I have dedicated myself to learning about behavioral addictions and conducting research in this area. In the process of writing a clinical reference book on the topic, I interviewed dozens of clinicians who specialize in behavioral addictions, as well as members of many 12-step programs, to learn more about the realities of behavioral addictions. What I heard from almost every clinician I interviewed is that they had to seek out their own training related to behavioral addictions. Whether through conference presentations, webinars, books or online training programs, they initially taught themselves how to address addictive behaviors because the topic was not covered in their counselor training programs. As a counselor educator, I fully understand that we cannot cover all important topics in depth in a two- or three-year training program, but it seemed as though the clinicians with whom I spoke would have benefited from at least an introduction to behavioral addictions during their graduate training. 

Since becoming a counselor educator, I have been intentional about infusing content related to behavioral addictions into my courses (e.g., human development, addictions counseling, clinical supervision). I also developed an elective solely dedicated to behavioral addictions. I frequently receive emails from former students that say something along the following lines: 

  • “Thank you for teaching me about internet gaming addiction. I am working with my first high school student with this type of addiction.”
  • “I am using the resources you mentioned in class about sex addiction because I have several clients who have lost control over their sexual activity.”
  • “When my client mentioned gambling, I wasn’t afraid to ask more about it because I had a framework for understanding behavioral addictions.”

An issue for all counselors

I monitor published statistics on the prevalence of behavioral addictions, but more than that, I hear firsthand from former students how frequently clients with addictive behaviors present to counseling. Therefore, my goal in writing this article is to present six steps that all counselors can take to better address behavioral addictions. Whether working in a school, college counseling center, community mental health agency, private practice, hospital, couple and family counseling practice, or another setting, we must be able to recognize and respond effectively to behavioral addictions.

1) We need to have a solid conceptualization of behavioral addictions

Researchers have proposed that addiction is one disorder with a variety of expressions — some that take the form of substance misuse and others that take the form of compulsive engagement in rewarding behaviors. Thus, much of what we know about chemical addiction is relevant to behavioral addictions. For example, both drugs of abuse and hedonic behaviors activate reward circuitry in the brain — specifically, the mesolimbic dopaminergic pathway. 

Although more neuroscience research is needed, it is proposed that highly rewarding behaviors (e.g., sex, gaming, gambling) trigger the release of neurotransmitters implicated in reward (e.g., dopamine, opioids). The activation of reward circuitry can cause pleasurable feelings and provide an escape from negative feelings, both of which serve to reinforce the behavior and increase the likelihood of repeating the activity in the future. For individuals with specific vulnerabilities (e.g., genetic predispositions, histories of adverse childhood experiences, mental health conditions, social learning related to specific behaviors as coping mechanisms), a rewarding behavior can become the primary means of regulating their emotions. Thus, it is the unique interaction between a vulnerable individual and the specific nature of the rewarding behavior that increases the risk of behavioral addictions.

Additionally, the chronic activation of one’s reward circuitry via compulsive engagement in rewarding behaviors may lead to neuroadaptations, or changes in the brain as a result of experience. The chronic overstimulation of the reward system due to behavioral addictions may cause the brain to adapt by decreasing the natural production of dopamine, decreasing the number of dopamine receptors or decreasing the number of dopamine transporters. This downregulation of the dopamine system can lessen an individual’s baseline experience of reward (e.g., at baseline, the individual may feel dysphoric), thereby triggering cravings for addictive behaviors to enhance one’s mood. In this way, the addictive behavior becomes part of a cycle of feeling dysphoric at baseline and then seeking engagement in the addictive behavior to induce positive feelings or ward off withdrawal. 

An understanding of behavioral addictions as a means of regulating emotions with potential neurobiological antecedents and consequences can help us cultivate accurate empathy for our clients and develop effective treatment plans.

2) We need to recognize behavioral addictions in our clinical work

There is a lot of shame around addiction in general and behavioral addictions specifically. Many clients may present with other issues (e.g., depression, anxiety, suicidal ideation, relational conflict, low self-esteem) rather than disclose an addiction to sex, gaming, gambling, food, shopping or another behavior. Therefore, it is imperative that counselors consistently ask clients about their engagement in potentially addictive behaviors in a nonevaluative way. For example, when a client discloses difficulty in their lives, a counselor might ask, “I am curious how you cope with these challenges. Some people turn to alcohol, some people escape through sex or pornography, and some people engage in internet gaming to feel better. How do you deal with your negative feelings?” 

Also, including items on one’s intake form related to addictive behaviors can normalize the experience for clients and invite them to disclose early in the course of treatment. As with chemical addiction, it is impossible to recognize a behavioral addiction simply by looking at a client — behavioral addictions occur among clients of all ages, racial and ethnic groups, genders, religious/spiritual affiliations, sexual orientations and socioeconomic statuses. Therefore, counselors need to be intentional and assess for behavioral addictions with all clients. 

Furthermore, it is important for counselors to accurately distinguish between high involvement in a behavior and a behavioral addiction. Definitions of addiction, diagnostic criteria and published research reveal “Four C’s” that can help counselors identify behavioral addictions: 

  • If the behavior is compulsive. 
  • If the individual has lost control over their behavior.
  • If the behavior continues despite negative consequences.
  • If the individual experiences cravings or mental preoccupation with the behavior when not engaging. 

A client who is very enthusiastic about a behavior or highly involved (e.g., a professional gamer) will not demonstrate the Four C’s of addiction (e.g., they can limit or control their engagement, they do not experience negative consequences). However, if the Four C’s are present, it should alert counselors to engage in further assessment for a behavioral addiction. There are many assessment instruments for behavioral addictions, including the Internet Gaming Disorder Scale, the Bergen Social Media Addiction Scale, the Sexual Addiction Screening Test-Revised and the South Oaks Gambling Screen.

3) We need to embrace our responsibility to address behavioral addictions

It is likely that counselors in all settings will encounter clients with behavioral addictions, and we should be prepared and willing to address these addictions. Rather than assuming this type of clinical work requires a brand-new set of skills, counselors need only to add to their previously established clinical skill set to address behavioral addictions. For instance, when working with clients with behavioral addictions, counselors will still rely on their basic counseling skills such as empathy, reflective listening, unconditional positive regard, immediacy, genuineness, open questions, multicultural competence and an understanding of theory. These elements are still necessary for developing rapport, setting goals and engaging in effective interventions with clients with behavioral addictions. 

In addition to these foundational skills, counselors should become informed about the specific nature of the addictive behavior (e.g., gambling, gaming, exercise, cybersex), including relevant neuroscience. This can also be helpful when providing psychoeducation to clients and their families. Counselors can gain addiction-specific knowledge through self-study, webinars, conference presentations, attendance at open 12-step meetings, consultation with seasoned professionals and pursuit of certification or relevant credentials. 

Along with gaining addiction-specific knowledge, counselors should apply interventions that have proved to be helpful with behavioral addictions (i.e., those that are evidence based). There is a wealth of research that outlines helpful strategies for working with behavioral addictions (e.g., group interventions, motivational interviewing, dialectical behavior therapy, cognitive behavior therapy, couples counseling interventions, mindfulness-based interventions). Several published studies and manuals exist to help inform and guide counselors who are working with a specific behavioral addiction for the first time. 

All counselors can become more equipped to address behavioral addictions by adding addiction-specific knowledge and evidence-based interventions to their clinical repertoire. There certainly will be times when a referral is in the best interest of the client (e.g., to a residential treatment facility for sex addiction or an intensive outpatient program for gaming addiction), but many times the best (or only) available option will be for counselors themselves to treat clients who have behavioral addictions. In these instances, counselors are encouraged to consult with other clinicians who have experience working with the specific behavioral addiction or to seek supervision. Rather than abdicating the responsibility of addressing behavioral addictions, all counselors should be willing to meet the needs of these clients.

4) We need to understand what abstinence entails for behavioral addictions

Abstinence as it relates to substance use disorders is fairly obvious — stop using drugs of abuse. Abstinence from behavioral addictions is less clear, however. Are clients expected to abstain from sex? Stop shopping? Never use the internet? No, abstinence in relation to behavioral addictions entails identifying and refraining from the out-of-control, compulsive behaviors that lead to negative consequences. 

Twelve-step programs use a variety of tools, such as the three circles technique or the development of bottom lines, middle lines and top lines, to aid in defining abstinence for clients with behavioral addictions. In both techniques, individuals and their sponsors engage in honest evaluation and identify all compulsive, harmful and out-of-control behaviors from which they will abstain (e.g., betting on fantasy sports, engaging in cybersex activities, binge eating when they are not hungry, checking social media while driving, playing or watching internet games). These activities are listed in the innermost of three concentric circles or constitute one’s bottom lines. Next, individuals and their sponsors identify behaviors that are warning signs, triggers or precipitating behaviors to those listed in the inner circle or bottom lines. These activities are then written in the middle circle or serve as one’s middle lines. Finally, behaviors that are encouraged, aspirational, align with the individual’s personal goals and values, and increase wellness are identified and listed in the outer circle or make up the top lines. 

In the realm of behavioral addictions, abstinence is defined by refraining from inner-circle activities or bottom lines. When a middle-circle or middle-line activity takes place, it is not considered a relapse, but rather serves as a warning sign that the individual is nearing the inner-circle (or bottom-line) activities and needs to take action (e.g., call a sponsor, go to a 12-step meeting, use a predetermined coping strategy). Thus, the process of recovery among those with behavioral addictions includes abstaining from inner-circle/bottom-line activities, minimizing middle-circle/middle-line activities and increasing outer-circle/top-line activities.

5) We need to be familiar with the 12-step programs in our area

Twelve-step programs can be extremely valuable (and affordable) resources for our clients with behavioral addictions. The number of 12-step groups dedicated to behavioral addictions (e.g., Computer Gaming Addicts Anonymous, Internet and Technology Addicts Anonymous, Sex Addicts Anonymous, Sexaholics Anonymous, Gamblers Anonymous, Overeaters Anonymous, Food Addicts in Recovery Anonymous, Workaholics Anonymous, Debtors Anonymous, Celebrate Recovery) further confirms their prevalence in society. 

Prior to referring clients to a 12-step program, counselors should be familiar with the programs in their area and able to provide details to their clients regarding how to access a meeting, what to expect during a meeting, the mission of the fellowship, and the traditions and common practices of 12-step programs. Many 12-step programs have brochures and literature specifically designed for counselors to help them make referrals to these programs. 

Additionally, in some instances, multiple 12-step programs exist for the same behavioral addiction (e.g., Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, Sexual Compulsives Anonymous; Food Addicts in Recovery Anonymous, Overeaters Anonymous). Counselors should be aware of the differences between the programs so that clients can make an informed decision about which fellowship might be the best fit for them. Almost all of the 12-step programs for behavioral addictions have comprehensive websites, a basic text (e.g., the Sex Addicts Anonymous Green Book) and literature that can help counselors become better informed. Again, counselors are encouraged to attend open meetings themselves to learn more about the programs in their area. 

6) We need to be willing to advocate for clients with behavioral addictions 

Behavioral addictions are not well understood among the general public and often are stigmatized to a greater degree than is chemical addiction (consider potential societal reactions to someone with sex addiction compared with someone with an alcohol use disorder). Counselors, by the nature of their professional identities, are advocates and serve to remove barriers to clients’ wellness. Several prominent barriers exist among those with behavioral addictions. These barriers include societal and internalized stigma, public misinformation and bias, lack of available (and affordable) treatment options, lack of insurance coverage, lack of trained clinicians, and the prominence of the moral model of addiction (i.e., addiction is the result of a moral failing) rather than the biopsychosocial model of addiction (i.e., addiction is influenced by one’s genetic makeup, psychological factors, personal experiences and environment). 

Practical means of advocating for individuals with behavioral addictions include: 

  • Ensuring that all counselors receive training (either during or after graduate school) to recognize and respond to behavioral addictions
  • Ensuring that all local communities have counselors who are equipped to address behavioral addictions (e.g., certified sex addiction therapists, credentialing from the International Gambling Counselor Certification Board)
  • Conducting research regarding behavioral addictions to support their inclusion in diagnostic manuals and to increase empirical evidence
  • Engaging in efforts to ensure insurance coverage for behavioral addictions treatment
  • Becoming involved in legislation related to the regulation of potentially addictive behaviors
  • Dispelling myths and raising public awareness about the realities of behavioral addictions
  • All counselors can engage at the individual, community or public level to advocate for clients with addictive behaviors. 

In sum, behavioral addictions are prevalent in today’s society and affect individuals across the life span. All counselors should be familiar with behavioral addictions so that they are able to recognize them among clients and respond appropriately (whether that means addressing the behavioral addiction themselves or referring clients to another level of care). 

As we become more informed and receive more training, we can best attend to the needs of clients with behavioral addictions and ensure that they receive competent, effective care. The steps detailed in this article are not the responsibility of a select group of clinicians but rather a responsibility for all counselors so that we can best support clients with behavioral addictions.

tommaso79/Shutterstock.com

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Amanda Giordano is a licensed professional counselor, an associate professor at the University of Georgia and the author of A Clinical Guide to Treating Behavioral Addictions: Conceptualizations, Assessments, and Clinical Strategies. Visit her author page at facebook.com/amandaleegiordano.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

From the President: Everything is not a cause

S. Kent Butler October 1, 2021

S. Kent Butler, ACA’s 70th president

Over the years, I have come to find out that social justice is multilayered. In many ways, these layers may positively support or negatively hinder the real fight for equity. Looking back over history, I often wonder how “prosperity for all” ever went so wrong. Isn’t life supposed to involve a fair distribution of wealth, opportunity and privilege to each of us? How did we go astray? 

In this column, I want to hang out with just one of the aforementioned layers — the “you ain’t really helping” layer. Stated another way, it’s the “you seriously call that helping?” layer. In truth, it’s the “you getting in the way” layer (this last one is a shoutout to Jill Scott, but it reflects my feelings if I am being candid). Sometimes we must be discerning about when our “helping” is more about us than it is about the cause.

So, for what purpose am I bringing light to this particular aspect of social justice? To be transparent, I just want to shake it up a bit and help us look critically at our advocacy and how our very actions affect global society and the clients we serve. Perhaps it is a way to get us thinking about what social justice advocacy really is and what it is not. I want to challenge us to think about how we enter into spaces. If this section had a title, it would be “Knowing when to mind your own business!” 

Here’s the skinny: Sometimes when we open our mouths to fight a cause, we are more annoying than we are impactful. We often jump on bandwagons without receiving context or knowing why we are doing a certain thing. Everything is not a cause! We sometimes protest too much. 

One of my favorite passages comes from the novel Reckless Appetites by Jacqueline Deval. It states: “Understand how passion makes you strong, but know also when it renders you weak.” Simply put, we must recognize those times when our desire to help is actually debilitating us.

Knowing when to boycott

Automatically pulling out of everything isn’t always the appropriate course of action. We must get out of our own way sometimes and really engage with and listen to the people who are being marginalized before going off on our own tangent. We should proceed based on the points of view of those we wish to advocate for, acknowledging and empowering their voices and meeting them where they are in all of it. How do they see the situation? What are their needs? 

Truthfully, shouldn’t it really be about their needs and not our own exuberance to help? Sometimes our good intentions and particular ways of solving problems are just not helpful. This is a very powerful lesson to learn about social justice. The overarching need we feel to assist — but to offer this help based on our own perspectives and worldviews — sometimes hinders our ability to provide the support we actually intend.

How I once got it all wrong

The case of Mr. Think-He-Do-Right: My situation had me thinking that I was all about social justice and advocacy for people living with disabilities. My personal issue started as a pet peeve: the misuse of doors meant for those with disabilities. 

I was instantly bothered whenever I saw people who were seemingly unencumbered walk up and mindlessly push the silver button so that the door would automatically open for them. Sometimes they would have to stop midstride and wait for the door to open wide enough so that they could scoot through. I would shake my head and say things to myself such as, “Why are you doing that? That automatic door isn’t there for you! You could have opened the door on your own and gotten through much faster.” 

I would think about how the constant use of the door in this manner by people who were not disabled might cause the door to malfunction much earlier than normal. What would those who were really in need do then? 

Here comes the rub: In talking with folks who have loved ones living with hidden disabilities, I learned the error of my ways. For instance, I found out that those living with Parkinson’s disease might not have the strength or mobility in their arms to easily open doors. Thus, they might rely on the silver button for help. 

Lesson learned

Once I received this wake-up call, I had to pivot in my thinking. From this perspective, I now understood that people might experience myriad disabilities, not just the physical ones we are conditioned to see.

So, here is a challenge for you. Ask yourself in what areas your advocacy passions, which you righteously partake in with a vengeance, might actually be a weakness. What might you need to open your eyes to and see in a different light? 

#ShakeItUp and #TapSomeoneIn.

CEO’s Message: Change happens

Richard Yep

Richard Yep, ACA CEO

Over the past 18 months, we have witnessed changes in our lives, our work and our play. During this period, the actions of those who govern, the media, our colleagues and our communities have sometimes taken unexpected or surprising turns. We know that change happens, but the rapid acceleration we are currently seeing might be unprecedented. 

Now consider a membership organization that is steeped in tradition, has been a pillar of reporting on research, and maintains a code of ethics that is critical to the practice of working with clients and students. The American Counseling Association has been around for almost 70 years. We haven’t always been seen as a “speedboat” when it comes to making changes. Some would say we are more comparable to a giant steamship in that changes in direction (i.e., the status quo) are not made in haste. Sometimes, taking time to chart a new course is both prudent and advisable. However, there are also situations that call for a much faster response so that an organization can maintain its viability and demonstrate its vitality. 

ACA is changing. This year, under the leadership of President Kent Butler, the Governing Council has already discussed issues that will have a major impact on the organization and, ultimately, on the profession itself. During the first quarter of this fiscal year (July through September), the leadership and our incredible volunteers and hardworking staff have been involved in determining how ACA will move forward on its anti-racism action plan; have provided increased support for the counseling compact that will allow licensed professional counselors to offer services in multiple states; have discussed how to meet the needs of a cadre of professional counselors who want more professional development via a digital environment; and have looked at the changing needs of members through a revision of ACA’s strategic plan and priorities. 

At the staff level, to meet the needs, aspirations and interests of leaders and members, we are making changes on both an operational and professional advocacy level. For example, this fiscal year, we will be looking at both an in-person ACA conference and an enhanced digital learning experience. With the 2021 ACA Virtual Conference Experience (where everything was presented in a digital environment), we set a modern-day attendance record. In addition, we learned that more than 70% of registrants had never been to an ACA conference before. Clearly, a need exists for those who wish to learn online, and we want to meet that need. 

We also found out this past year that many of our staff members would welcome the continued option of working from home. This led to the realization that we no longer needed an office large enough for 60 staff members to physically be in the same location. In relocating to an office with a smaller footprint, I am confident that we can maintain productivity for ACA while also saving money. The move to our new downsized office will occur at the beginning of 2022. During my 30-plus years with ACA, I have worked out of four different office locations. This newest one has been planned from the ground up for meeting the needs of a 21st-century workforce. As a bonus, it will also be the most energy-efficient headquarters in our history.

One word that is clearly overused in management is “nimble.” Regardless of whether you use that word or prefer “agile,” “swift” or “lively,” your ACA is on the move. We have been learning to adapt to the changing needs of professional counselors, counselor educators and graduate students. We do this by asking you what you want. We also do this by hearing directly from you. That is something that will not change. We want to know how we can meet the professional needs that you have.

Embrace the change and continue to do your amazing work.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.