Tag Archives: behavioral addiction

The shame of sexual addiction

By Scott Stolarick September 6, 2022

Editor’s Note: This article uses terminology commonly used in the addiction and criminology fields.

Josh is six months sober. He is finally feeling the confidence to branch out and insert himself in a social situation and test the waters. At dinner with some acquaintances, Josh orders a soda much to the surprise of the others. Without much hesitation, Josh discloses that he is an alcoholic and quit drinking. He shares a sobriety coin with the group and receives unbridled support and praise for his courageous journey.

Like Josh, Derek is also six months sober. He is at a social gathering and his friends decide to watch a rather risqué television show that everyone is talking about. Because he is among friends, Derek takes a risk and discloses that he is a sex addict and is not supposed to watch those types of shows because of potential triggers and the risk of relapse. You could hear a pin drop in the room. This reaction caused Derek to regret coming forward with this disclosure, and he awkwardly excuses himself. 

These two different reactions to addiction illustrate that not all recovery is created equal. Unfortunately, most laypeople do not know what sexual addiction is much less how to deal with it if it affects them or others they know. Although sexual addiction has received some high-profile exposure with movies such as Don Jon and celebrities Tiger Woods and David Duchovny revealing that they are addicted to sex, the issue still remains foreign to most. 

What is sexual addiction? 

In his book Out of the Shadows: Understanding Sexual Addiction, Patrick Carnes, an expert on sex addiction and treatment, defines sexual addiction as “any sexually related compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones and one’s work environment.” This behavior can manifest in a variety of ways, including the overuse of pornography, promiscuity, infidelity, paid sexual encounters and a high frequency of sex (even within a committed relationship). 

There are several stereotypes that often come to mind when people hear the term “sex addict.” Sometimes the term is used synonymously with sex offender, and although the two terms can certainly coexist, they can also be mutually exclusive. Many people think a sex addict is that creepy-looking person they tend to avoid, the person who is unsuccessful in pursuit of relationships, the social outcast, the person without means and resources, or the person with the corny pickup lines in bars. And although all of these descriptions could be part of a sex addict’s profile, focusing on stereotypes is an antiquated and closed-minded way of thinking, especially when it comes to understanding sexual addiction. 

I treated sex offenders on an outpatient basis for 26 years. If I learned one thing, it was the fact that these individuals came in all shapes, sizes, colors, genders and socioeconomic backgrounds. Often, it was the unassuming person, ostensibly the harmless law-abiding type, who was committing the most heinous crimes. A sex addict can be your “happily married” neighbor, your pastor, a doctor, a lawyer, a man or a woman. Sexual and gender orientation are also not factors that determine sex addiction. In other words, this issue does not discriminate, and neither should we in our attempts to understand and/or treat it. 

Twelve-step programs emphasize the need to completely abstain from the identified problematic behaviors, but this philosophy is not as straightforward as it sounds when it comes to sexual behavior. Instead of educating people about healthier sexuality, some recovery movements emphasize complete abstinence of sexual behavior, outside of marriage and committed relationships, which results in extreme pressure and self-imposed guilt and shame. Carnes coined the term “sexual anorexia” to describe the shame-based and unhealthy avoidance of sexual behavior. People often avoid even discussing sex and sexual problems, but this same approach should not be used when clinically treating problems in sexual behavior.

I have mistakenly referred past sex addict clients to support groups in which they were shamed for having sexual thoughts and masturbating. This triggered relapse behavior and a general clinical regression. 

While sexual addiction does parallel other forms of addictive behavior, it is also quite different. All people have a libido. Granted this exists to varying degrees, but it is there, and as humans we possess it. Sexual behavior and reproduction rituals also exists in various levels of the animal kingdom. Creatures that can reproduce asexually such as worms also elect to mate with other worms as another reproductive option. Therefore, when approaching the problem of sexual addiction, I believe it is our duty to conceptualize it knowing that sexual desire is a common denominator (at various levels) among both humans and animals. The fact that sexuality is a core part of the human experience explains why categorically it is different from other types of addiction such as alcohol and substance use, gambling, and shopping. Sure, there is a strong argument for genetic predisposition, but not all people are genetically predisposed to addiction. Sexual addiction is not a cookie-cutter issue, so I feel it cannot be dealt with via thought extinction, complete behavioral abstinence and a pathologizing mindset. Later in this article, I discuss some treatment approaches that encompass both the similarities and differences of other addictions. 

The mental health profession still struggles with accepting and working to develop agreed-upon diagnostic criteria for sexual addiction. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not acknowledge sexual addiction, but it is hoped that the next version of the DSM will acknowledge the congruence between behavioral and chemical addiction and include sexual addiction as a legitimate diagnosis. In 2014, the American Society of Addiction Medicine, however, recognized sexual addiction as a legitimate addictive disorder. This lack of congruency around sexual addiction demonstrates the barriers that counselors and the public often face when trying to conceptualize sexual addiction. 

What are the signs? 

Looking at the behavioral manifestation and realizing how the behavior shows up is one important aspect when determining if someone is struggling with a sexual addiction. Understanding what drives the behavior is also crucial. Having said that, I am not professing to have a recipe for recognizing someone with a sexual addiction, but there are telltale signs. Common personality traits seen in sex addicts are obsessive thoughts, impulsivity, shame, depression, maladaptive coping methods for perceived losses of control, poor communication skills, high risk tolerance for sexual behavior and a hyperactive focus on sex. Any one or combination of these traits is often seen in cases of active sexual addiction. 

fizkes/Shutterstock.com

Sexual addiction is considered a process or behavioral addiction. Process addictions, which also include excessive shopping and gambling, are marked by a strong desire to engage in behaviors despite the potentially negative consequences. Thus, the elevated mood associated with addictions, albeit temporary, is often viewed as the elixir for troubling life circumstances and unwelcomed thoughts. The addict is vigorously chasing this elevated mood, but the behavior of engaging in the addiction is often followed by intense feelings of guilt and shame. In my work with sex offenders, I often used the term “transitory guilt,” which is a short-lived guilt that is very intense in nature and not manageable to carry around in one’s mind, to describe the offensive cycle of behavior. A myriad of thinking errors or cognitive distortions are used to decrease and eventually eliminate the guilt, thus putting the offender in a position to reoffend. This process is similar to what sex addicts experience, but it is even more accelerated because the actual guilt and shame process decreases in duration throughout the life of the addictive behaviors. 

I’m sure many readers are already aware that sexual addiction has a serious impact. I can say without hesitation that it has the potential to be a relationship and life wrecker, and it often does just that. For the addict, sexual addiction can result in relational, legal and financial consequences. It can also cause someone to experience shame, low self-worth, depression and anxiety. 

Sexual satiation perpetuates the addictive process by propelling it into deeper and more deviant places. A pornography addict, for example, might “upgrade” to impersonal sexual encounters, and then impersonal sexual encounters may lead to illegal sexual acts, such as voyeurism and exhibitionism. The addict’s objective is to continually seek gratification when the usual sources have lost their luster, so to speak. And pornography use can also complicate one’s ability to become aroused. The degrading and other unrealistic themes depicted in pornography create highly distorted expectations of what should occur within the context of real-life sexual relationships, thus rendering the addict incapable of arousal in those situations. This can also lead to men experiencing pornography-induced erectile dysfunction because the sexual outlets that are supposed to be acceptable and appropriate no longer elicit arousal.

Someone’s sexual addiction can also affect their loved ones, friends and work. The partner of a sex addict, for example, may feel disregarded, betrayed, devalued, replaced, insufficient and so on. If the additive behavior manifests in the workplace, the employer may have to terminate the person because the addictive behavior is affecting their work productivity. 

The internet, dating apps and virtual reality have ushered in a new world of opportunities for the sex addict. The saying “a kid in a candy store” has never been more applicable as it pertains to the anonymity, accessibility, variety and cost-free options that technology provides. Not only does television media inundate viewers with a “sex sells” approach to advertising, but the internet provides a wide array of sexual options at one’s fingertips. These factors certainly present added layers in the creation of a solid and effective recovery/treatment plan. 

What does treatment look like?

I personally believe that a clinician treating someone with a sexual addiction should have some level of clinical experience in this area. Counselors should not venture into this arena because they think it is interesting or they want to learn along with the client. This could be significantly more harmful than helpful and could lead the client and all those associated with the client down the wrong path. At the very least, a background in addictions or forensic psychology should be a qualification. Counselors can also receive training and specialized certifications in sexual addictions, such as the certified sex addiction therapist program at the International Institute for Trauma and Addiction Professionals, which was founded by Carnes. The bottom line is that if you have zero experience working with this population, you should refer accordingly and seek training if you want to work in this area. 

Providing clinical treatment for sex addicts involves first conducting a thorough assessment of the identified circumstances. You must also gather an extensive social history with relevant collateral contacts. Remember, the addict’s point of view is not the only one; family members, friends and other treating professionals may have relevant data to offer. Examining the addict’s personal motivation for change, patterns of acting out, trauma history and other addictive manifestations are other crucial areas of exploration. And for those in relationships, it may be necessary to refer the significant other for services to address their trauma. 

Here are some other core clinical strategies counselors can use when working with sex addicts: 

  • Establish the artful balance between engagement and accountability. 
  • Set clear boundaries within the clinical arena. If an addict learns they can manipulate you, they will. 
  • Ask clients to use accountability software on their electronic devices. Obviously, this is not foolproof, but it offers some external control.
  • Develop allies within the addict’s life system to aid in supporting the treatment plan. 
  • Refer to a psychiatrist for a medication assessment to address anxiety and depression. Psychiatric medications can also act as a helpful libido suppressant while the client develops new skills. 
  • Work with clients to establish definitions of healthy sexual behavior and fantasy. 
  • Help clients develop adequate social skills training. 
  • Integrate bibliotherapy and appropriate support groups as needed.
  • Be empathetic. 

Collaboration within care is important with this population. Make no mistake about it: Treating a sex addict in a vacuum is not clinically recommended. As clinicians, we have to embrace our inner case manager to keep up with the demands of this work. 

And remember, we play an important role in helping clients who are struggling with sexual addiction. With counseling, they can learn that sex is not a bad thing and that they can experience it in a healthy way.

 

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Scott Stolarick is a licensed clinical professional counselor who has been practicing in the state of Illinois for 30 years. He is an experienced administrator and clinical supervisor as well as a seasoned clinician. Scott has management and leadership certifications from the University of Notre Dame and Cornell University. Scott is currently a program director for Arbor Counseling Center in Gurnee, Illinois. 

 

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.

Journeying through betrayal trauma

By Allan J. Katz and Michele Saffier June 6, 2022

Tero Vesalainen/Shutterstock.com

“Cathy’s” life has just been turned upside down. She picked up her husband’s cellphone only to discover a loving message from his affair partner. Cathy’s brain is spinning, and her emotions are all over the map. She feels embarrassed and alone, disconnected and detached from reality. She questions whether her entire relationship has been an enormous lie. She questions her attractiveness, her sexuality and her ability to ever trust anyone again. She feels as if she were just pushed out of an airplane and fell with no parachute.

As a certified sex addiction therapist and a member of the American Counseling Association, I (Allan) have seen firsthand that betrayal trauma is real. The shock is debilitating for betrayed partners and can last for years. Their lives are broken to pieces, and they are overwhelmed with shame, often thinking, “How could I be so stupid not to realize what was happening right under my nose? I’m such a fool for trusting him/her.” They feel they are going crazy. 

But these feelings are all normal because in all likelihood, this is the most shocking and confounding crisis they have ever experienced. After all, they thought they knew their partner and never thought their partner would cheat. The reality of the situation rocks the foundational values they have believed in and based their lives on. What is perhaps most disturbing is that they were going about their daily routine in the safety of their own home, and, in an instant, a discovery upends their world. It happens through answering a knock at the door, reading a random text, picking up a ringing telephone or — the most common form of discovery — turning on the computer to check email. 

The shock for the betrayed partner is so profound in the first moment, the first hour and the first day that it is hard to comprehend. It feels surreal, as if it can’t be happening. It feels as if you are suddenly outside of yourself watching a movie, seeing yourself react and not feeling connected to your own body. 

International trauma expert Peter Levine explains that when we are confronted by a situation that our brain experiences as frightening, we automatically go into a freeze response. We are thrust into a primal survival strategy commonly referred to as being “like a deer in headlights.” It is the state of being “beside yourself.” Betrayed partners describe it as being frozen, numb or in an altered state. Being lied to in such a profound manner by your partner, lover, sweetheart and beloved feels wholly abnormal. For many betrayed partners, there is no precedent for the experience. 

Answering the ‘why’ question

The “why” question is what betrayed partners find themselves coming back to over and over again. Why did you engage in this behavior? Why did you lie … repeatedly? 

Betrayed partners often feel that they can’t move on and find closure without knowing the answer to the “why” question. The painful truth is that there is no good reason and, for the betrayed partner, no right answer. The “explanation” can be challenging for betrayed partners to hear and can take time to process fully. Although they may not understand the “why” behind the behavior, betrayed partners can gain answers that help provide clarity and make healing possible for them and the relationship.

“Daphne,” a heartbroken partner, described her “why” questions as follows: “What were you thinking? Was I the only one longing to share my life with you? What makes you think you can take a stripper and her child to Disneyland, tell me and then expect me to stand for it? How could you use my faith and religion against me by saying, ‘Aren’t you supposed to forgive? Judge not lest you be judged,’ and, most offensive, ‘I think you were put on this earth to save me.’ Why did you even marry me? Why did you stay married to me? What does love mean to you? You obviously have no heart. How could you look me in the eyes and see how much pain I was in and how unloved I felt and continue giving our money to your girlfriend? Why did you promise me that you would never cheat on me as my father did to my mother? How can you say, ‘It’s not about you’? You admitted to me that you never considered my feelings. Why? You acknowledged that you lied to your family about me, portraying me as a horrible spouse so that you would feel justified to continue your affair. Why did you need to go that far?”

These are the types of questions that every betrayed partner asks. Betrayed partners believe that they cannot heal unless they know why their beloved cheated on them. But in the case of chronic betrayers, their reasons lie deep below the surface, much like the iceberg that sank the Titanic. The question becomes, “Why would someone who appears to be functioning well act against their morals and values?” Are these folks actually addicted to sex, or is sex addiction an excuse for bad behavior? 

In her “What Your Therapist Really Thinks” column for New York magazine on May 11, 2017, Lori Gottlieb responded to a letter from a reader wondering whether their husband might be having an affair. Gottlieb mentioned that whenever someone comes into her office to discuss infidelity, she wonders what other infidelities might be going on — not necessarily other affairs but the more subtle ways that partners can stray that also threaten a marriage.

In his book Contrary to Love, Patrick Carnes said his research indicated that 97% of individuals who were addicted to sex had been emotionally abused as children. These individuals were raised in unhealthy or dysfunctional homes with parents who did not give them the care essential to their healthy growth and development. Poverty, mental illness, alcoholism, drug addiction, violence and crime are among the many reasons that individuals turn to sexually compulsive behavior as adults. As a result, people who are sexually addicted have negative core beliefs about themselves. They feel alone and afraid and believe they are unworthy of love; they believe that no one can truly love them because they are unlovable. Therefore, they learn from a very young age that intimacy is dangerous in real life and that they can trust themselves only to meet their needs. 

In an article titled “Can serial cheaters change?” at PsychCentral.com, psychologist and certified sex addiction therapist Linda Hatch discussed two reasons that people cheat, both due to deep insecurities. Some who cheat feel intimidated by their spouse in the same way that they felt threatened in their childhood homes. A real-life connection is terrifying to someone who was not shown love as a child. In response, they seek affair partners, watch pornography or pay for sex to avoid these real-life connections. 

Carnes’ second book, Don’t Call It Love, is aptly titled. Acting out is not about love or sex; instead, acting out numbs the overwhelming agony of being loved by a real-life partner.  

The root of addiction and the brain science

At the root of addiction is trauma. Trauma is the problem, and for some, sexual acting out is the solution — until the solution fails. And when it fails, it results in more trauma. 

Deep wounds suffered when young cause a level of pain that overwhelms the child. Because human beings are built to stay alive, the brain banishes the ordeal’s worst feelings and memory. It locks them away to keep the child alive. 

Understanding the brain science of trauma and addiction enables the betrayed partner to see the big picture. The acting out had very little to do with the relationship or the partner.

Many mental health professionals do not believe that sex addiction is a legitimate disorder. Therapists often think that the betrayed partner is the problem because they’re “not enough” — not attentive enough, not available enough, not sexual enough, not thin enough, not voluptuous enough. Sex therapists (not to be confused with sex addiction therapists) believe that sexual expression is healthy — regardless of the behavior. Understanding the science that drives the addictive process is vital for the betrayed partner’s wellness, lest they take responsibility for their betrayer’s acting out. Knowing the brain science that causes a process addiction is essential to understanding how something that isn’t a chemical substance can be addictive. 

In his book In the Realm of Hungry Ghosts: Close Encounters With Addiction, Dr. Gabor Maté described childhood adversity and addiction, noting that early experiences play a crucial role in shaping perceptions of the world and others. A 1998 article by Vincent J. Felitti and colleagues in the American Journal of Preventive Medicine explained that “adverse childhood experiences, or ACEs (e.g., a child being abused, violence in the family, a jailed parent, extreme stress of poverty, a rancorous divorce, an addicted parent, etc.), have a significant impact on how people live their lives and their risk of addiction and mental and physical illnesses.” 

There are two types of addictions: substance and process (or behavioral) addictions. Process addictions refer to a maladaptive relationship with an activity, sensation or behavior that the person continues despite the negative impact on the person’s ability to maintain mental health and function at work, at home and in the community. Surprisingly, an otherwise pleasurable experience can become compulsive. When used to escape stress, it becomes a way of coping that never fails. Typical behaviors include gambling, spending, pornography, masturbation, sex, gaming, binge-watching television, and other high-risk experiences. 

Process addictions increase dopamine. Dopamine is a naturally occurring and powerful pleasure-seeking chemical in the brain. When activities are used habitually to escape pain, more dopamine is released in the brain. The brain rapidly adjusts to a higher level of dopamine. The “user” quickly finds themselves on a hamster wheel, seeking more exciting, more dangerous, more erotic or more taboo material to maintain the dopamine rush. The brain has adapted to the “new normal.” The brain depends on a higher level of dopamine to regulate the central nervous system. It quickly becomes the only way to reduce stressors; the person struggling with addiction ends up doing and saying things they will soon regret but cannot seem to stop on their own. Carnes aptly refers to this as the hijacked brain.

Once the brain is hijacked, the downward spiral of craving more and more dopamine affects higher-level thinking and reasoning. 

Let the healing begin

Healing for the betrayed partner begins with a formal disclosure process, ideally guided by certified sex addiction therapists. Betrayed partners often have difficulty making sense of their reality on their own. There are so many unanswered questions, and each question has 10 questions behind it. 

Betrayers are reluctant to answer questions because they fear the answers will cause the betrayed partner more harm and therefore will cause them harm. However, withholding information is what causes harm. Betrayed partners report difficulty getting the whole truth on their own. Even if their betrayer does break down and answer questions, they will not get the entire story because the betrayer is in denial — they are in denial that they are in denial! 

A formal disclosure process led by a certified sex addiction therapist is the best way to get the information necessary so that the betrayed partner can make the most important decision of their life: Will they stay in the relationship or leave? 

Partners who continue to be consumed with seeking information are tortured — not by the behavior but by their unrelenting quest to uncover all of the lies. Initially, information-seeking helps decrease panic and the horrible loss of power experienced after discovery of the betrayal. However, searching for information or signs of acting out quickly becomes all-consuming. Without intervention, intense emotions lead to faulty thinking, which becomes a force from within that fuels anger, rage and revenge. The powerful energy inside can be like a runaway train gaining speed until it crashes.  

Betrayed partners learn that betrayers live in a state of secret destructive entitlement. Education about the conditions that led to the betrayer’s choices and deception is essential for the betrayed partner’s healing. Still, it is in no way a justification or vindication of the betrayer’s egregious behavior.

It is complicated to understand that there are two truths for people who struggle with sex addiction: they love their partner (in the way they know love) and act out sexually with themselves or others. Betrayed partners come to understand that addiction is a division of the self. 

Reflection and reconstruction 

Betrayal trauma causes a fracture in the foundation of a relationship and the foundation of the self. The secrets, lies, gaslighting and deception throughout the relationship are a silent cancer that consumes the infrastructure. The most devastating aspect of discovery is that the entire system that holds the relationship together begins to collapse into itself.  

For the betrayed partner, healing involves self-reflection. Although they didn’t create the problem, their mental health requires them to face aspects of themselves that have been affected by infidelity and deception. During therapy, both partners face reality and let go of the illusion that theirs was a healthy marriage/relationship. They grieve what was lost and learn to let go of anger. Letting go creates space to build inner strength and accept love back into their hearts.  

Forgiveness

Healing of the mind, heart and soul can happen regardless of the magnitude of the deception. But in the absence of a healing/recovery process, the betrayed partner’s anger intensifies and can cause them to be further traumatized by sifting through emails, texts and conversations, asking for every minute detail of the affair. As anger ferments, it can lead to rage. Rage can wreak havoc on the body, leading to health problems. 

The solution is forgiveness. Many partners worry that they will be expected to forgive their betrayer. But forgiveness is not about forgetting nor is it about condoning bad behavior. Instead, forgiveness is a process of opting out of anger and the need for revenge — forgiving the human qualities that lead people to act in terrible ways. To be clear, forgiveness frees one’s heart from the prison of anger. Forgiveness is a decision that is made daily.

Release and restoration

After discovering a beloved’s infidelity and deception, and after accepting their own call to action, the betrayed partner turns inward and begins their own hero’s journey. This journey requires courage, loyalty and temperance. Each phase of the journey involves purifying, grinding down, shedding and brushing away unhealthy attitudes, beliefs and behaviors. The hero’s journey brings the betrayed to a state of purity and clarity. 

Eckhart Tolle described the “dark night of the soul” as a collapse of the perceived meaning that the individual gave to their life. The discovery of infidelity, deception and trickery causes a shattering of all that defined the betrayed partner’s life. Their accomplishments, activities and everything they considered important feels like they have been invalidated. 

At the bottom of the abyss, however, is salvation. The blackest moment is the moment where transformation begins. It is always darkest before the dawn. The only way to heal is to head straight into the fire toward restoration. 

The restoration phase is all about finding meaning in life again. This doesn’t mean the betrayed partner will no longer have any feelings of sadness or longing. But they will also have moments of happiness again. 

There are two tasks in this last phase of the hero’s journey: reclaiming their life with a new story that includes the bruises and scars bound together with integrity and pride, and restoring one’s self to wholeness. Before putting it all back together, partners must find their meaning in their own personal hero’s journey. To accomplish this, partners must discover how to make meaning out of suffering. 

In his book Man’s Search for Meaning, Viktor Frankl, a Holocaust survivor, asserted that even in the worst suffering, having a sense of purpose provides strength. He contended there is no hope to survive if suffering is perceived as useless. Finding purpose transforms suffering into a challenge. 

Frankl believed that in the worst of circumstances, there are two choices: 1) to assume that we cannot change what happens to us, leaving our only option to be a prisoner of our circumstance or 2) to accept that we cannot change what happened to us but that we can change our attitude toward it. A more potent, resilient, and positive attitude allows us to realize our life’s meaning. Through their hero’s journey, betrayed partners learn that their brokenness can lead to wisdom and deeper meaning in their lives.

 

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Allan J. Katz is a licensed professional counselor and certified sex addiction therapist. He is products co-chair at the Association for Specialists in Group Work and has written five books, including Experiential Group Therapy Interventions With DBT. Allan is the co-author, with Michele Saffier, of Ambushed by Betrayal: The Survival Guide for Betrayed Partners on Their Heroes’ Journey to Healthy Intimacy. He can be reached on his website, AllanJKatz.com.

Michele Saffier is a licensed marriage and family therapist and a certified sex addiction therapist and supervisor. As clinical director and founder of Michele Saffier & Associates, she and her clinical team have worked with couples, families, betrayed partners and people recovering from sexually compulsive behavior for 24 years. As co-founder of the Center for Healing Self and Relationships, she facilitates outpatient treatment intensives for individuals, couples and families healing from the impact of betrayal trauma. She can be reached at her website, TraumaHealingPa.com.

 

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.

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.

Internet gaming disorder: A real mental health issue on the rise in adolescents and young adults

By Doyle L. Raymer Jr. September 1, 2021

I grew up playing video games and have followed their technological evolution through the years. As such, video games have been a big part of my life and remain so to this day. These games are a source of entertainment and relaxation, and they can even provide opportunities for social interaction and connection. They can contribute to improving a person’s cognitive skills, creativity, communication and reflexes. Many people use them as a healthy coping mechanism to decompress.

On the flip side, there is growing concern about the potential of negative mental health consequences associated with playing video games. Some of these concerns include gaming addiction, negative coping mechanisms, unhealthy lifestyles, loneliness and isolation, depression and even suicidal ideation.

As someone who still plays video games, I have met an alarming number of individuals who struggle with these concerns. In many cases, these individuals have no support system or don’t know how (or when) to seek professional help. My concern is that many counseling professionals are unaware of the devastating impact that gaming can have on a person’s life — just as any form of addiction can.

The evolution of gaming

As a gamer myself, I have always been fascinated by what draws people to play games and how games can affect and influence individuals, from their thoughts to their worldviews to their social identity. It raises a question: How does playing a game give meaning to one’s life?

Playing a game is not simply playing a game. A lot is going on in the player’s mind as they are playing, which often presents a hidden meaning behind gaming interactions. As the world continues to develop and evolve around technology, video games will also continue to develop and evolve. Video game addiction has grown at alarming rates over the past few years, and this trend will likely continue. For this reason, concern is growing in the mental health community around video game addiction and the gaming population.

Video games have been around for decades, and as time has gone by, their popularity has increased exponentially, as has the size of the gaming community. As of 2020, it was estimated that more than 2 billion people around the world played video games. In the U.S. alone, 160 million Americans engage in online gaming daily, making the gaming industry worth over $90 billion.

Video games have developed into esports and are being more widely recognized as electronic but real sports. Both share many of the same principles of competition, including professional players, recognized teams and huge audiences of fans. Stadiums fill with fans as professional esports teams face off, competing for prizes in excess of $1 million. In 2017, more than 250 million online viewers watched popular online games such as League of Legends and Overwatch, generating $756 million in revenue that year (for more, see Internet Gaming Disorder: Theory, Assessment, Treatment and Prevention by Daniel L. King and Paul H. Delfabbro).

In addition, many video gamers make a living playing games by streaming to online platforms such as Twitch to thousands of viewers. As the video game industry has developed, it has gained popularity and will continue to do so.

Mental health impact

As the popularity of video games has grown and the community of players has expanded, certain negative consequences and mental health impacts have become increasingly evident. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), internet gaming disorder was included in the section recommending conditions for further research. Gaming disorder was defined in the 11th revision of the International Classification of Diseases (ICD-11) as a “pattern of gaming behavior (digital-gaming or video-gaming) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.”

Internet gaming disorder was not classified as a unique mental disorder in the DSM-5 due to a lack of research in the field and debates regarding the recognition of behavioral addiction, but I believe recognition could help millions in need. At the same time, the opposing side argues that inclusion of internet gaming disorder in the DSM-5 would only generate unnecessary concern and lead to a stigma around such behavior.

Meanwhile, gambling disorder is recognized by the DSM-5 as a form of behavioral addiction, and it shares many similar characteristics with gaming disorder. So, I ask, why is this issue being ignored? Countries such as South Korea and China, where gaming addiction numbers are very high, have already recognized this as a serious disorder and developed treatment programs.

sezer66/Shutterstock.com

Factors that can lead to addiction

Video gaming is a fun activity for many people, in large part because of the positive reinforcement players receive for the split-second decisions they make while playing the games. From clicking a mouse button or controller to moving a character, from slaying the enemy to leveling up, games provide constant and instant feedback to their players.

Games also contain online environments where real-time players can connect with other players or join a guild. This gives players a social identity and can provide feelings of self-worth. Many players experience a sense of meaning in-game because they are constantly presented with objectives to achieve or obstacles to conquer.

In addition, massively multiplayer online role-playing games (MMORPGs) provide players with endless opportunities, scenarios and outcomes from quests, intense guild battles, endless levels and intense competition to be the strongest player on the server. But such games motivate players to spend long hours playing a game that has no ending, potentially leading to poor sleep habits, unhealthy diets, isolation from others and the real world, and addiction.

Perhaps the most important factor leading to video game addiction is the increased dopamine levels experienced during play. This is where the concern originates because it can lead to maladaptive behaviors, unhealthy coping mechanisms and, potentially, addiction. Given the constant feeling of reward for in-game decision-making and the often-endless levels or possible outcomes in a game environment, gaming can become addictive. It can end up serving as an alternate reality and an escape from real life because the game provides the player with a “better” version of it.

According to the DSM-5, the presence of five or more of the following symptoms over the period of 12 months characterizes such behavior as concerning and maladaptive. These nine symptoms include:

1) Preoccupation with internet games

2) Withdrawal symptoms such as irritability, anxiety and sadness

3) Tolerance or the need to increase time in gaming

4) Unsuccessful attempts to stop gaming

5) Loss of interest in other activities

6) Psychosocial problems due to excessive gaming

7) Deceiving family members, therapists or others on the amount of time spent gaming

8) Use of internet gaming to escape or relieve negative moods

9) Jeopardizing or losing a significant relationship, education, job or career opportunity because of online gaming

Three stages

The process of gaming addiction occurs in three stages. In stage one, the game is played actively for fun. In stage two, games are no longer “fun,” but the individual still spends many hours playing to remove negative emotions such as stress, sadness and worry. In stage three, the game is no longer fun and no longer removes negative emotions.

During stage three, biological addiction occurs due to constant and persistently high levels of dopamine release, leading to a state of dopamine exhaustion. When dopamine exhaustion is reached, not only do games lose their potential for fun and pleasure, but so do other areas and activities. At this stage, individuals often find themselves feeling apathetic, directionless and without meaning in life. We can compare this evolution to alcoholism, in which the effects of alcohol decrease over time, requiring more alcohol to achieve the same effect.

Treatments and theoretical approaches

An effective way to reestablish normal functioning, regulate dopamine levels and improve quality of life is simply to take a break from gaming. During this period, which can take three weeks to two months, those who are addicted are encouraged to explore other activities and hobbies of interest as an alternative to gaming while dopamine levels reset.

What separates gaming from other addictions is that the addiction does not require quitting games forever. Instead, recovery focuses on learning to control time spent playing games. Strategies such as creating a schedule that incorporates healthy gaming habits into a routine while prioritizing other aspects of life have proved effective.

Much research is still needed about video game addiction to address the most efficient treatments and theoretical approaches for working with this population. When considering intervention strategies in counseling for gaming addictions, it is important to remember that no one-size-fits-all approach works. What works great for one individual may not work well for another. No single treatment has proved superior or most efficient yet. Cognitive behavior therapy has been the standard approach for many professionals, according to King and Delfabbro.

Professionals have also had positive results treating video gaming addiction with narrative therapy, especially with children and adolescents. As Alice Morgan writes in the book What Is Narrative Therapy? An Easy-to-Read Introduction, such therapy is effective because it “views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments, and abilities that will assist them in reducing the influence of problems in their lives.” Narrative therapy might address strengths involving achievements in a game, such as being among the top players or leading the team to victory. It further explores these strengths and skills by incorporating them into real-life scenarios. It is equally important to assess the level of addiction as mild, moderate or severe by analyzing the severity of symptoms and the negative impact of gaming behavior.

It is important to establish trust and rapport during initial sessions. One effective way of developing rapport and trust with such clients, especially those who are resistant, is to mindfully disclose any experience the counselor has with video games. The counselor and client can find common ground through such shared interests and experiences. In contrast with substance abuse and alcohol addiction, the ultimate goal with gaming addiction is often not to eliminate gaming once and for all but rather to effectively control and reduce time spent playing video games. The goal is to normalize behavior that does not negatively interfere and affect other areas of life and overall physical and mental health.

As we rapidly move into technological and online environments in many aspects of our daily lives, video games will continue developing exponentially, and gaming communities’ growth will follow. Mental health issues are also rising among this growing body of diverse gamers. Using games as a coping strategy for other underlying issues can lead to an addiction, as real life is replaced with a virtual and more favorable one. Research in this area will continue to develop, and so will the emphasis placed on this issue and population by mental health professionals. More awareness of internet gaming disorder and the struggles faced by this population is needed to promote mental health and well-being.

 

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Doyle L. Raymer Jr. is a mental health counseling student at Walden University. As a gamer himself, he has a deep interest in internet gaming addiction. It is his deep desire to advocate and create awareness to help improve the overall mental health of members of the gaming community. Contact him at doyle.raymer@waldenu.edu.

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Related reading, from Counseling Today‘s October magazine: “Six steps for addressing behavioral addictions in clinical work

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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.

Helping clients develop a healthy relationship with social media

By Bethany Bray September 24, 2020

When a user opens Facebook, Twitter or many other social media platforms, there is a slight delay before an icon illuminates to indicate that the person has a notification, signaling that someone has liked or interacted with one of the user’s posts.

That moment of delay is purposely designed into social media apps to create an alluring cycle of anticipation and reward, according to Amanda L. Giordano, a licensed professional counselor (LPC) whose main area of research is behavioral addictions, including addictions to technology and social media. “Social media is made to be irresistible. It taps into the pleasure centers of the brain. It’s designed to keep you on it as long as it can,” says Giordano, an associate professor at the University of Georgia. “They operate from the variable ratio reinforcement scenario. That’s the most powerful reinforcement schedule there is. [Social media’s draw] is like gambling, knowing that there could be a big payout at any time, so you keep playing. Users know that they’re going to get some kind of reward, but they don’t know when it’s coming. There is a strong dopamine response [to that].”

That drive to seek the rewards that are triggered by social media can lead to compulsive and problematic use. But by providing psychoeducation about the ways that social media platforms are designed to affect neural pathways, counselors can help clients achieve a healthy balance with their social media use, says Giordano, a member of the American Counseling Association. This is especially true with child and adolescent clients, who are digital natives who have been exposed to technology all of their lives but may not yet possess the maturity to recognize the control that social media can exert over them, she adds.

Providing psychoeducation is just one of many ways that counselors can assist clients in flipping their perspectives and using social media to get what they want out of the experience rather than vice versa. Taking simple actions such as changing a smartphone’s color scheme to gray scale can render Facebook’s notification icon — a red bell — less powerful, Giordano notes.

“By becoming aware of all of that, and understanding how social media is tapping into some of these more primitive brain responses, clients can be empowered by the knowledge and take more control over their use,” she says.

Part of life

According to the Pew Research Center, 72% of American adults use at least one social media site “to connect with one another, engage with news content, share information and entertain themselves.” Pew found that those ages 18-29 had the highest usage at 90%, followed by 30- to 49-year-olds at 82%, 50- to 64-year-olds at 69%, and those 65 and older at 40%.

Pew’s data collection in early 2019 found that more than half of adults who used Instagram, YouTube or Snapchat visited those sites at least once per day. Facebook was pinpointed as the most popular social media site, with 69% of adults using the social networking platform. In addition, 74% of Facebook users visited the site daily.

These statistics point to a hard-to-ignore conclusion: Social media is a very real part of the fabric of people’s lives today. Regardless of counselors’ personal feelings about social media — whether they view its impact and influence as a net positive or a net negative — they must do their best to understand it and the role it plays in their clients’ lives.

Don’t discount the positives

Social media use can factor into any number of presenting issues and challenges that clients bring to counseling, from relationship friction discussed in couples counseling to self-esteem or body image issues in clients who struggle with perfectionism, eating disorders, social anxiety or other conditions. The COVID-19 pandemic has added another layer to this issue, as many people are quarantined or otherwise spending more time at home, feeling isolated and turning to social media to find connection or quell boredom.

As it relates to their clients’ lives, professional counselors may first think of the potential negative implications of social media use. However, the counselors interviewed for this article emphasize that there are both good and bad aspects of social media use. And for many people, the pluses can far outweigh the minuses.

“It’s an area that many counselors shy away from. … A lot of times, it feels like folks demonize social media. There are a lot of ways to keep from using it in an unhealthy way and to use it to your benefit,” says Kertesha B. Riley, a career coach at the University of Tennessee’s Center for Career Development and Academic Exploration, where she is working on a doctorate in counselor education. “There are hundreds and thousands of examples where social media is not a good thing at all, but I don’t let that outweigh the good that can come from it.”

Riley is active on Twitter, using the platform to stay up to date professionally, follow leaders in the field and forge connections. In the realm of career counseling, social media sites such as LinkedIn can play an integral role in clients’ job searches, Riley says, adding that she often talks with her clients about leveraging social media to enhance their career development. Creating posts with hashtags such as #jobs and #hireme can catch the attention of potential employers, while clients can follow hashtags within their own industries to stay abreast of trends or connect with colleagues.

“It can help [clients] to stay in the know and connect with people, but also further their career goals in a way that propels them a lot quicker than without [using social media],” says Riley, a member of ACA. “For networking, follow leaders and movers and shakers in your industry, and see who they follow. See what gets you noticed on this platform, and in your field.”

Social media can also serve as a tool to find and connect with professionals with whom clients relate, Riley notes. “Especially for those who are having feelings of doubt or mention that they’re not seeing people who look like them in the field, they can follow people they admire and identify with.”

As a Black doctoral student, this is the case for Riley. Although she doesn’t have many Black colleagues at her university, she follows and interacts with many Black doctoral students and professors via social media.

ACA member Jordan Elliott saw how social media could play a beneficial role in her work as a residential counselor at a treatment facility for women with substance use disorders. Many of the women at the facility had extensive trauma histories. Elliott, an LPC intern and licensed chemical dependency counselor in San Antonio, often worked with clients to create social media plans for after they were discharged. In many cases, this included joining social media groups and following pages with others in recovery.

These connections helped the women support each other and keep moving forward in their recovery after discharge, Elliott says. If a friend began to relapse, they would often recognize the signs in the person’s social media posts — or lack of posts — and reach out to check on one another.

“They often found intense connections with each other once in treatment. They were already drawn to connect with each other, and they wanted to continue that after they were discharged,” recalls Elliott, a doctoral student in counselor education at the University of Texas at San Antonio (UTSA). “This was huge for them, to stay in contact with one another through social media. … Social media has such a healing capability because it helps people connect and stay connected with each other.”

“When working with clients who have experienced extreme disconnection, via addiction, loss and grief, trauma or other ways, think of the power [social media] can have to bring people together and find connection,” Elliott continues. “In counseling, the relationship is key — we are relational creatures and drawn to connect. Think of how social media can be a connective intervention for clients.”

Getting up to speed

Counselors who aren’t familiar or comfortable with social media should think of it as “just one more way to connect with clients,” Elliott says.

“It’s our responsibility to keep up with it and how it is changing. It can be difficult to keep up with everything, but take that initiative to educate yourself on these platforms as much as you can,” Elliott urges. “For counselors who don’t feel as comfortable with technology, think of it as a creative intervention [to reach clients], and it might not be as intimidating.”

Giordano agrees, noting that counselors have a duty to bring themselves up to speed on social media to better help their clients. Having even a basic knowledge of the different platforms and their varying attributes will help practitioners ask the right questions to connect with clients,
she says.

“The best way is to ask clients, ‘What does it [a particular social media platform] do for you? Escape boredom? Find identity? Connect with peers?’ It’s really important to have a nonjudgmental view of it because, in large part, people have a good experience and find benefits,” Giordano says.

Counselors who want to learn more about social media can begin by doing an internet search on the different platforms and the terms they hear clients using in session. In some cases, counselors might want to consider creating a profile themselves so that they can log in and explore a platform further. Erin Mason, an LPC and assistant professor at Georgia State University, notes that some of the school counselors she knows have created TikTok accounts to better understand the video-sharing platform that is particularly popular among teens and young adults.

Mason, an ACA member, has maintained an active presence on Twitter, professionally, for nine years. She says it helps her stay up to date on trends and developments in the field of school counseling.

Riley recommends that counselors “stay open-minded and talk with someone in your personal or professional life who does use social media. Talk with your clients. Ask what draws them to it and what are some challenges that they’ve encountered. Hearing some firsthand perspective can help pull the wall down against social media,” she says. “[Social media] is a living, breathing, evolving entity, and because of that, there’s a place for everyone if you choose to look for it.

“If a client really loves TikTok, have them walk you through it: What do they like about it? What makes a good video [post]? What do they engage with the most? This helps open them up and tells you a lot about why and how they engage. … It gives you a better idea about their motivation, their mindset and their personality based on the type of platform and how they engage [with it].”

When it becomes a problem

There are no uniform diagnostic criteria for social media addiction, either in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or through the World Health Organization or other agencies, Giordano notes. However, she says, it is estimated that between 5% and 10% of adults have a “problematic relationship” with social media — a prevalence that is comparable with most other behavioral addictions.

“What we know is that it’s prevalent among adolescents, adults and young adults across the globe,” Giordano says. “In the United States, researchers have found that almost 10% of undergrads have social media dependence.”

With that in mind, Giordano urges counselor clinicians to complete thorough assessments of clients’ relationships with social media. The frequency and amount of time they spend on the platforms are good places to start, but there are many more nuanced indicators to consider. Giordano recommends that practitioners check in with all adolescent and adult clients about their motives for engaging with social media, their compulsivity levels, how social media use affects their moods and the emotions that they associate with it. For example, does it disrupt their sleep cycles? Do they experience envy, a lack of belonging or self-loathing?

“When the client is not on social media, do they have an urge to check it? Are they craving it? Do they have FOMO [fear of missing out]? Is it creating anxiety when they’re not on it?” asks Giordano, co-author of an upcoming article on cyberbullying and adolescent social media use that will appear in the Journal of Child and Adolescent Counseling.

Practitioners should note that using social media while driving is a red flag that can indicate social media addiction, Giordano adds. There is also a documented link between social media use and nonsuicidal self-injury — so much so that many of the major platforms have created guidelines for banning photos and posts that glorify self-injury, she says.

Overall, people with poor regulation skills are at higher risk for social media addiction, Giordano says, whereas those who have healthy regulation skills are better able to self-regulate their emotions rather than relying on social media to manage their moods. Counselors should listen for the hallmarks of addiction in the ways that clients describe their social media use, she says. Among the possible warning signs are:

  • When clients’ social media use becomes compulsive and they find themselves checking it when they didn’t plan to
  • When clients have a loss of control, staying on social media longer than they intended
  • When clients continue to engage in the behavior even after experiencing negative consequences such as cyberbullying, family or relational conflict over their social media use, or disruptive sleep patterns

Practitioners can use several assessment tools and questionnaires to screen clients for social media addiction, Giordano notes. More information on these tools can be found in “Investigating psychometric properties of social media addiction measures among adolescents,” an article that Giordano co-wrote with Joshua C. Watson and Elizabeth A. Prosek for the October issue of the Journal of Counseling & Development.

Elliott emphasizes the importance of assessing each client individually because what a healthy relationship with social media looks like will differ for each person. “One client could say that they only use social media six hours per day — but they used to use it for 12. Shift your perspective to meet them where they’re at with their social media use, and don’t pathologize it. … Don’t have a set idea of what it would or should look like, thinking you know what’s best for them. Let them be the judge of how they interact with these platforms instead of us placing our perceptions on them,” says Elliott, who co-presented a session with Stacy Speedlin titled “Healing the Brave New World: Resolving Trauma Issues for Millennials Using Social Media” (available at https://imis.counseling.org/store/detail.aspx?id=PEES19010) at the ACA 2019 Conference & Expo in New Orleans.

For Riley, a general indicator that a client has an unhealthy relationship with social media is when its use begins to interfere with the person’s daily life and functioning. If clients talk about choosing activities because they might result in posts or photos that will garner likes or attention on social media, that should prompt further questioning from the counselor, she says.

“It’s not as simple as the amount of time you spend on [social media]. That can be an indicator, but not necessarily. … Right now, with everyone at home [because of COVID-19], use will be higher,” Riley says. “If it’s impacting the time you [the client] are spending on self-care, or time with loved ones, being in nature or in your community, and you’re finding it’s taking time away from the things you want to do, then it might be approaching an unhealthy relationship. … Asking [clients] about their time spent on social media is a way to start the conversation. But from there, flesh out what is behind that. What is compelling them to spend so much time on social media?”

Cold turkey isn’t the answer

A recommendation that clients delete their social media accounts or discontinue their use altogether may be appropriate for the small percentage of individuals who truly struggle with social media addiction, Giordano says, but it might not be helpful — or even possible — for many other clients.

“There are a lot of benefits to social media, from building relationships and social connectivity to advocacy,” Giordano says. “The answer is not to stop using social media. The answer is for clients to take more control of their social media use so they’re not just going along with whatever impulses they have but [instead] being intentional.”

Counselor clinicians should also keep in mind that social media may be part of a client’s livelihood, adds Mason, so it would not be feasible for the person to quit the platforms entirely.

The same holds true in the realm of addictions recovery, notes Elliott, who counsels mostly adult clients at UTSA’s Sarabia Family Counseling Center, which offers free community services. Deleting one’s accounts would mean severing contact with those who support them during recovery. Social media “is often their lifeline to each other,” she says. “Say they relapse. It’s so important to have that network that they can plug back into. If they’ve deleted all their accounts, how are they going to do that?”

“I think the best way to help someone learn to have a healthy relationship with social media is [for them] to use it,” agrees Riley. “There can be instances where it can be helpful for clients to step back for a time, but for me it’s important to help them engage with it in a healthy way, and that’s not as easy if you go cold turkey.”

“I have a love-hate relationship with this idea, but social media is ingrained in our society,” Riley continues. “Not using it is lessening your engagement with the world, especially for those in rural or isolated areas. It’s a way to see the world without leaving your ZIP code and engage and learn from those who aren’t around you.”

Getting to the why

Researchers from Harvard University, in a November 2019 study published in Health Education & Behavior, found that routine use of social media could have positive health outcomes on social well-being, mental health and self-rated health. At the same time, researchers found that having an emotional connection to social media use could generate negative health outcomes, such as increased anxiety, depression, loneliness and FOMO.

Having a healthy relationship with social media involves understanding why one uses the platforms, and counselors can play a key role in helping clients explore that perspective. It’s most important for clients to decide on and create their own goals rather than counselors making suggestions, Giordano stresses.

“They probably already have people in their life telling them that they spend too much time on social media, so that’s not helpful to say. Instead, help them find their own motives for making change. From there, come from a nonjudgmental stance [and] use the client’s own motivation for making change rather than just imposing rules,” she says.

Giordano finds motivational interviewing and cognitive behavioral techniques helpful when engaging in this work with clients, but she says that counselors can adapt whatever framework they prefer to address this issue.

Practitioners can start by helping clients “give voice” to the pros and cons of their social media use. Giordano suggests asking clients in session why they use it, what they like about it and what they wish they could get out of it.

Giordano notes that research studies on the function of social media in people’s lives have pinpointed that people turn to it to meet three main needs:

  • The need to belong
  • The need for self-presentation
  • The need for emotion regulation or mood modification

She suggests that practitioners ask clients about their thoughts and beliefs prior to using social media, during social media use and after social media use. Then, listen for language that could indicate deeper issues or maladaptive core beliefs that might be motivating clients’ behavior. For example, a client who struggles with self-esteem may mention feeling inadequate or self-critical if they don’t post a witty response to a friend’s post.

Elliott emphasizes that the client should be the driver in this process. “I’m a huge advocate for meeting clients where they’re at. If they’re presenting with negative side effects of social media or an unhealthy relationship with it, ask them about their relationship, what is its role in their life and how is it affecting them. Enhance that conversation instead of challenging it head-on. [If you say], ‘It sounds like you’re addicted to social media,’ that’s not going to help. Fall back on motivational interviewing techniques to have them evaluate what it is giving to them versus taking from them.

“Social media is good because you get to choose who you’re connected to. There’s so much freedom. A counselor can help with flipping that perspective: [Clients] have control of who they’re friends with and what they might see in their feed.”

Perspective shift

Counselors can help clients move toward intentionality and control over their social media use. A good way to start this process is to prompt clients to talk about what social media gives them and what it takes from them — and how or whether they’d like to change those benchmarks, Elliott says.

Elliott recalls one client with whom she worked at the residential treatment center in San Antonio. Social media was a prevalent part of the woman’s life, and she had more than 1,000 “friends” on Facebook.

Clients were not allowed to have cellphones while they were in recovery treatment. As this particular client neared discharge, Elliott allowed her to turn on her phone — for the first time in two months — as part of creating a social media plan in a session.

Elliott sat with the client as she went through her social media contact lists, blocking, unfollowing and severing ties with people who had previously been part of her life of substance abuse. Many of them had sent her messages, knowing full well she was in a recovery program, to ask her to contact them once she was out.

“If she had looked at those messages at the beginning of her treatment, she might not have stayed. There were a lot of unhealthy people in her life,” Elliott says. “It was a really important exercise to do. In hindsight, I can’t imagine what would have happened if we didn’t address this together. Would she have left treatment, turned on her phone and been bombarded with all these messages?”

Instead, in session, Elliott and the client talked about setting boundaries with social media and processed each friend decision together. They talked about why she wanted to block some people and unfollow yet remain connected with others — those to whom she could be a help, Elliott recalls.

The client also was able to add women from the treatment program to her social media accounts. This greatly broadened her pool of friends, adding people of different ages and backgrounds. The process represented “a complete reframe” for the woman as she exerted control over her social media and decided what role she wanted it to play in her life and her healing moving forward, Elliott says.

This process was often part of creating social media plans with clients at the facility, Elliott says. She served as a support as clients deleted or began to follow accounts, set boundaries and rethought their social media use.

For example, if a client followed a page that glorified drug use, such as the account of an artist or musician, Elliott and the client would process that choice together. “I would talk it through with them: ‘How will it affect you to see that? If so, what are you going to do about it?’ We would evaluate which of these things [the people and pages the client followed] are worth it to them and which things aren’t, as well as knowing their triggers and making a plan for if they were triggered by social media. For example, ‘What if you go on to social media and find that someone has passed away [from an overdose]?’ I would talk all of that through with clients.”

Setting boundaries

Exerting control over one’s relationship with social media often involves setting boundaries and limits. Counselor clinicians can support clients in this process by helping them create a social media plan in counseling sessions. Giordano says this can be particularly helpful for adolescent clients, who may benefit from writing down parameters to which they can refer back outside of sessions.

Social media plans should delineate specific times that clients do not want to use social media, such as during mealtimes, while driving, right after waking up in the mornings or within two hours of going to bed at night, says Giordano, who is writing a book on behavioral addictions that is slated to be published next year. Part of a client’s social media plan might include deciding not to engage in phubbing, a term for when people are glued to their smartphones while gathered together with others — in essence, snubbing people in favor of their phone.

Offering psychoeducation about the triggering aspects of social media can also be helpful during this process, Giordano says. For example, discussing the brain’s dopamine response to a phone’s notification alerts might lead clients to deactivate the notifications for their social media apps. Similarly, explaining how the blue light emitted from digital screens can disrupt sleep cycles might prompt some clients to set a goal of putting their phones in another room when they sleep, thus removing the temptation to check it while in bed.

There are also numerous apps and programs available that limit the amount of time a user can spend on a particular website, including social media. Giordano recommends an app called Offtime, whereas Mason uses Freedom, which is available both as an app and a Chrome plugin. In both cases, the user selects the amount of time they’d like to allow themselves to use certain sites each day, or they have the option to block sites entirely.

“One of the things that makes social media so different from reading a book or watching a movie is that a book and a movie have a set end. With social media, you can scroll without end, so you have to be intentional,” Giordano says. “Clients and counselors can decide [as part of making a social media plan] to only use social media when the results are positive and to do emotional check-ins on how using social media is making them feel.”

 

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Social media and youth: Taking a proactive role as a counselor

For counselors who work with young clients or in school settings, part of staying up to date with social media includes becoming knowledgeable about cyberbullying, says Erin Mason, an assistant professor at Georgia State University.

Cyberbullying, or harassment via digital means, including through social media, is a complex topic. It can take place both during and outside of the school day and both on and outside of school property. In school settings, the responsibilities of counselors and administrators regarding cyberbullying can vary significantly from school to school, as can the consequences imposed on students, notes Mason, who was previously a school counselor.

Mason recommends that counselors visit Common Sense Media (commonsensemedia.org) to stay updated on the latest trends in social media and its use among children and adolescents. The site’s many resources include detailed descriptions and ratings of TV shows, movies, apps, video games and other media for parents and educators.

Mason emphasizes that counselors need to take a proactive role — rather than a punitive one — when it comes to cyberbullying. Efforts should go toward fostering a healthy school culture that includes a focus on positive social-emotional behavior, she says.

“Counselors need to be really vigilant about what’s trending at their schools. Sometimes the trends start in schools and then filter out and become problems in lots of places [in the community],” Mason says. “This is where partnerships are really important — partnering with other school staff, local police and families, and making sure everyone’s on the same page with what’s happening.”

In a trend that was brought to Mason’s attention by one of her graduate students, a problem arose at a school where students were exchanging and sharing messages via Google Docs. The students would type a message and change the font color to white so that any parent or school staff person who intercepted the document would just see a blank page. This method was a way to conceal cyberbullying among students, Mason says.

“Kids figure out the workarounds, ways to trick the system or at least trick the adults,” Mason says. “It’s a lot for educators to stay on top of, and it’s a lot for families to stay on top of.”

On the flip side of the coin, Mason says she has seen social media used as a positive tool in schools. One of her colleagues was running a small group for female students in high school that was focused on empowerment, confidence and positive body image. She created a Pinterest board, and the teens were able to “pin” inspiring quotes and positive messages to share with one another. This activity bolstered the group’s cohesion, Mason says. The young women would add to the board outside of sessions, and the group would discuss the posts when they met in person.

“Some of this comes down to generational differences, and I wonder if over time we will see more of a shift in understanding how social media and these kinds of tools can be helpful, because they are so integrated in people’s lives,” Mason says. “Over time, the negatives won’t diminish, but the advantages will begin to outweigh the negatives, and counselors have a role to play in that — with families and in school settings. We need to be thinking about how social media can contribute positively to school environments.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

ACA Code of Ethics (counseling.org/resources/aca-code-of-ethics)

  • Section H: Distance Counseling, Technology and Social Media

Continuing education

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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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.