Addiction continues to rank among the most stigmatized and least understood of the classified mental health disorders. Much of this stigma is, in part, due to the negative symptoms associated with addictive disorders.
For many of us who have personally known someone with such a disorder, we have experienced the pain of being lied to, yelled at, ignored, stolen from, and having to slowly—or even rapidly—watch our loved one deteriorate. When our emotions become involved, it is easy to see only the negative and ignore what is truly happening to this individual. Emotion trumps logic, and we begin to view this person as someone morally deficient.
For the many of us personally dealing with addiction, we may experience feelings of denial, grief, and shame. Without viewing the addiction objectively—as the physiological illness that it is—we will never be able to fully understand it. Learn more about addiction facts and statistics here.
Types of Addiction
Currently, there are ten classifications of substance use disorders contained in the DSM-5.2 These include the following:
- Alcohol
- Caffeine
- Cannabis
- Hallucinogen (phencyclidine)
- Inhalants
- Opioids
- Sedative, hypnotic, or anxiolytic
- Stimulant (specify amphetamine or cocaine)
- Tobacco/Nicotine
- Other (unknown)
Further, the DSM-5 has included Gambling Disorder as the one official diagnosable disorder under “Non-Substance-Related Disorders.” A more extensive list of process addictions or behavioral addictions includes, but is not limited to:
- Cutting
- Exercise
- Fetishes
- Internet Surfing
- Overeating
- Sex
- Shopping
- Stealing
- Trichotillomania (chronic hair pulling)
- Video game playing
- Work
Any one of these in excess may lead toward mild to significant distress in one’s life.
Symptoms of Addiction
First, it is imperative to recognize the factors present with addiction. Whether substance or process in nature, the DSM-5 has designated specific criteria for addiction in general. Such criteria are as follows:
- Using over a longer period or more of a substance than intended
- Express persistent desire to regulate or cut down use or have attempted to do so
- The exertion of significant time and effort to obtain, use, or recover from use of the substance
- Craving or a strong desire to use the substance
- Recurrent use that may interfere with fulfilling major role obligations
- Persistent or recurrent social problems or interpersonal problems caused or exacerbated by substance use or effects of substance use
- Social, occupational, or recreational activities reduced or eliminated due to the use of the substance
- Use of substance in physically hazardous situations
- Continued use despite knowledge of its persistent and recurrent negative physical or psychological consequences
- Tolerance
- Withdrawal1
While this may be easier to imagine in respect to substance use disorders, the same type of progression may be realized in respect to process disorders, like porn addiction. When considering a formal diagnosis, a counselor will need to assess the individual along each of the criteria listed above, determining how many symptoms are present and the severity of each.
In a Provincial System Support Program (PSSP) (n.d.) article highlighting the nature of gambling and other process disorders, Brown (1997) has pointed out how problem gambling, for example, shares a number of features with substance addictions:
- Cognitive distortions and deficits in decision-making
- Rituals to trigger arousal
- Low treatment success rates (but frequent spontaneous cures)
- Decline in enjoyment over time
- Perceived loss of control.
Despite there being no actual ingestion of a substance, the process addiction progresses in similar fashion. Further, biofeedback has consistently demonstrated similarities along the ventral tegmental area (VTA), better known as the “reward pathway,” and other brain structures. This is why many of the strategies used to address substance addictions are also effective with process addictions.
Abuse vs Dependence: Addiction’s Continuum
While professionals now diagnose addiction on a scale of mild to moderate to severe, it is important to recognize the difference between abuse and dependence. Abuse occurs when excessive use or misuse of a substance goes beyond its intended purpose. Dependence, on the other hand, occurs when the use of a substance becomes necessary to feel normal and there are symptoms of tolerance and withdrawal.
In respect to substance use, abuse may begin with someone who consistently drinks on weekends but then finds the quantity consumed on weekends increasing as well as use progressing into the weekdays. For process disorders, this may include a marked increase in gambling, indiscriminate sex, or the viewing of pornography for instance.
The National Institute on Drug Abuse2 provides the following definition:
Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal).
Accordingly, the harmful behavior progresses from something casual, to more intrusive, to something that becomes a physiological necessity. As the substance or process is continually reinforced positively through our VTA, the “reward pathway” becomes activated—telling us that what we are receiving feels good.
The more positive reinforcement we receive, the more we want it, despite any of the ultimately negative consequences. Given this extremely sensitive neurological system, habitual behavior may ultimately lead toward it becoming a basic need such as satiation, breathing, sleeping, sexual intercourse, and eating.
Causes of Addiction & Contributing Factors
Mental illness is not someone’s “choice.” We wouldn’t accuse someone of choosing to have schizophrenia. Rather, we recognize that there is an imbalance in the brain that has led toward the disorder. Similarly, one does not “choose” to be an addict. Although the person may have made the choice to begin using substances in the first place, nobody says, “My goal in life was to become an addict.” So, what goes wrong with such individuals?
There are six important contextual factors that can help explain how the addiction began, what needs it satisfies, and how it has negatively impacted the life of the person suffering from addiction
- Expectations of use (e.g., relaxation, better social interactions, sleeping better, etc.)
- Internal triggers for use (e.g., emotions, thoughts, withdrawal, craving, etc.)
- External triggers for use (e.g., people, places, seeing needles, music, etc.)
- Immediate reinforcers (e.g., escaping or feeling relaxed or high)
- Positive aspects of use (e.g., make friends, be “cool,” feel good, etc.)
- Negative aspects of use (e.g., expense, hangover, interpersonal problems, etc.)6
In addition to these contextual factors, causes of addiction may be explained by biology/physiology, physical illness and/or disability, social factors, and personal psychology.
Biology & Physiology
Biology and physiology may include genetic predisposition, physical illness, and/or disability. According to Addictions and Recovery4, “Addiction is due 50 percent to genetic predisposition and 50 percent due to poor coping skills,” while, “The children of addicts are 8 times more likely to develop an addiction”.4 Further, researchers have even indicated specific genes that are known to contribute toward the increased likelihood of addiction.
For those unaware that they possess such genotypes, they may unwittingly begin falling prey to addiction after their first use of even the most seemingly harmless substances, such as alcohol, which many people frequently engage in as part of celebrations, special occasions, and just trying to relieve stress off a busy day.
Physical Illness and/or Disability
When people are physically ill or disabled, they tend to become limited in those activities many of us take for granted, like:
- Going to work or school
- Socializing with friends
- Exercising
- Grocery shopping
Such limitations may lead toward a depressed state of mind, which may lead toward clinical grade depression, among other mental health disorders. People who feel depressed, anxious et cetera may begin looking for ways to cope. Given that substance use is a relatively quick and easy means of coping, it becomes desirable and hence habit forming.
Specific to illness, people may use substances to alleviate pain and other negative symptoms. Take, for instance, the opioid epidemic. Tens of thousands of people who thought they were taking prescribed medication to help alleviate pain found themselves trapped in an addiction that could only be alleviated by taking more of the substance, or stronger variations of the substance, over longer periods of time than anticipated.
Social Factors
Social factors involved with addiction must also be considered. For instance, when a child grows up in a home where substance and/or process addictions are prevalent, it becomes a learned way of life. That is, children learn that such behavior is common, acceptable, and a means of living. Rather than working through challenging life obstacles, children learn at a young age that the addiction may serve as a form of escape from it all.
The younger children are when they become involved with addiction, appropriate development and coping skills become suspended; hence the consideration that one’s mental age of maturity stops once the addiction is formed, and it may only resume once appropriate treatment is undertaken.
The community someone is part of may also play an important role. It is an unfortunate reality that impoverished, marginalized communities are those with some of the most challenges. When the choice for an adolescent is to either sell and/or use drugs or be threatened and beaten up, the choice becomes quite clear.
Also, when one’s social group continually engages in use, it becomes normalized. Consider, for instance, the binge drinking and drug use that goes on at college campuses world-wide. For those who consider this “normal behavior” for their age, they may be shocked by how hard it is to function in society upon graduation.
Personal Psychology
A common occurrence explored here is that of co-occurring, or dually diagnosed disorders. These are simply defined as someone having any combination of a mental health and addictive disorder. “According to the National Survey on Drug Use and Health, 9.2 million U.S. adults experienced both mental illness and a substance use disorder in 2018”.5 This means that roughly 3% of the American population at any point is struggling with a co-occurring disorder.
Further, lifetime incidence for people being dually diagnosed is in the area of 20-50%.11 Considering the reality that many individuals with mental health and/or addiction disorders do not engage in treatment, this figure may actually be significantly higher.
Common warning signs for those who may have a dual diagnosis are as follows:
- Withdrawal from friends and family
- Sudden changes in behavior
- Using substances under dangerous conditions
- Engaging in risky behaviors
- Loss of control over use of substances
- Developing a high tolerance and withdrawal symptoms
- Feeling like you need a drug to be able to function5
With mental health disorders increasing the likelihood of an addictive disorder, any treatment effort is almost certain to fall short unless both/all disorders are addressed accordingly. It is also important to note that clients designated as those with co-occurring disorders may be much more resistant to treatment than those diagnosed with one or the other.
Assessment of Addiction
Screening and assessment are critical first steps toward addictions treatment. The better the initial fit with the counselor and therapeutic process, the greater likelihood for successful long-term recovery. Accordingly, the savvy counselor will immediately begin by establishing rapport then proceeding into a thorough biopsychosocial evaluation of the client. This will be followed by any necessary screening tools specific to the client’s needs.
Assessment is ongoing—beginning from initial contact with the client throughout the duration of therapy and afterward (assuming that the client maintains some contact throughout aftercare). SAMHSA has identified five objectives for assessment which include the following:
- To identify those who are experiencing problems related to substance abuse and/or have progressed to the stage of dependency
- To assess the full spectrum of problems for which treatment may be needed
- To plan appropriate interventions
- To involve appropriate family members or significant others, as needed, in the individual’s treatment
- To evaluate the effectiveness of interventions implemented7
Breaking down the assessment process further, Capuzzi and Stauffer7 have recommended the following ten steps to ensure a comprehensive evaluation:
- Review referral information
- Obtain and review previous evaluations
- Interview the client
- Gather corroborating material (e.g., family interview)
- Formulate hypothesis
- Make recommendations
- Create a report and other significant documents
- Meet with the client over results
- Meet with the support system of the client
- Follow up on recommendations and referrals
The reason that assessment is ongoing is quite intuitive. As people suffering from an addiction begin treatment, they may be reluctant to share some of the personal information required for an accurate overview. This is natural, as people with addictions may be reluctant to attend therapy in the first place, may have been court-ordered, are in denial, and/or simply do not trust the counselor at this point.
As sessions progress, more information may be shared with the therapist or counselor. Perhaps it is past information unshared during the initial sessions or could be something that newly arises since beginning therapy. Depending upon the addiction assessed, counselors may utilize additional screening tools to determine the severity of the diagnosis. Popular screening tools include the CAGE Questionnaire, the Michigan Alcohol Screening Test (MAST), the Drug Abuse Screening Test (DAST), and TWEAK.
One evidence-based strategy that has demonstrated efficacy toward eliciting change is motivational interviewing. “The approach upholds four principles—expressing empathy and avoiding arguing, developing discrepancy, rolling with resistance, and supporting self-efficacy (clients belief s/he can successfully make a change).”6 Rather than take a punitive approach toward clients’ resistance, counselors meet them where they are at—allowing an opportunity for the client to become intrinsically motivated toward change. That is, clients ultimately take control, discovering their own reasons for making change.
In tandem with motivational interviewing,8 Transtheoretical Model (TTM)—better known at the “stages of change”—conceptualizes the stages many go through when undergoing addiction counseling.
TTM stages of change include:
- Precontemplation: The point at which the client has no intention of changing one’s behavior. Many may simply be unaware of the problem or in denial that one even exists.
- Contemplation: The client is now aware of the problem but has not made a commitment to change.
- Preparation: A plan is put into place to begin therapeutic change.
- Action: The client puts everything from preparation into work.
- Maintenance: A period whereby sustained change occurs and new behaviors replace old ones. Maintenance occurs within 6-9 months of sustained progress; however, this may vary by client dependent upon the length of the addiction. For instance, someone with a 20-year addiction will likely require more time to sustain new behavior.
- Relapse: relapse occurs when the individual returns to the old problematic behavior At this point it is incumbent upon the client to immediately seek assistance to resume recovery
Treatment of Addictions
When treating addiction, it’s important to integrate the professional skills of all those who may assist the client. This includes counselors, case managers, physicians, psychiatrists, probation officers, family members, significant others, and friends. By getting everyone and their expertise in order, the client will gain adequate support and multiple levels of reinforcement, thus enhancing personal accountability.
As with any client coming to counseling, the counselor is responsible for figuring out the least restrictive and invasive level of care necessary. ASAM has devised five levels of care, ranging from preventative measures to inpatient hospitalization dependent upon the severity of symptoms. For most clients, outpatient services may be appropriate. For others, more invasive measures including hospitalization and medication may be necessary.
Changing Persons, Places, and Things
A common saying used by addictions counselors to clients is that they need a change of “persons, places, and things.” Ideally, this change of environment will help maximize the client’s likelihood of success. Simple examples of this may entail encouraging a client who lives with his drug buddies to move into a sober living environment. For a gambler this may entail removing oneself from the casinos.
While this logic may seem quite straightforward, complications may occur in the event of someone who works where the addiction is most pronounced, such as an alcoholic who works at a bar. Regardless, the more work that is done to change these domains and replace them with the appropriate support, the more likely it is that the client may undergo the appropriate lifestyle change.
Support Groups
Support groups are also a great means of assisting people living with addiction. Support groups offer people the opportunity to work with others who have lived similar life experiences. The power of such support results from comradery and from not feeling alone with one’s addiction.
There are four primary types of support groups:
- Task Groups: focus on a specific action.
- Psychoeducational Groups: focus on educating members on a variety of topics relevant toward addressing the particular addiction.
- Counseling Groups: focus on introducing topics while processing underlying emotions.
- Self-help Groups: are run by former addicts in recovery and attended by others struggling with similar issues (like AA).
Self-help groups include the infamous 12-step groups which include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Al-Anon, and so on. The aforementioned groups do vary quite significantly and should be recommended based on the client’s personal preference, availability, financial considerations, and means of transportation.
Discharge
After a period of extended time in maintenance, if the person living with addition and their counselor both have sufficient confidence to move forward, the discharge process may begin. Those who reach this stage will need the appropriate community resources to help ensure the best chance of long-lasting recovery.
These resources may include some of those aforementioned, such as continuing to attend AA groups on a weekly basis and ultimately becoming a sponsor. Other resources may include a crisis support hotline, suicide hotline, local hospital phone number, list of recovery centers, et cetera. Should relapse occur, it’s important the people have the appropriate resources and information to enter back into maintenance.
