Part 1 of Overview of Behavioral Addictions

Part 1 of Overview of Behavioral Addictions


Welcome to our presentation of the
overview of behavioral addictions brought to you by ALLCEUs.com. Throughout this course we’re going to
define addiction, define behavioral addictions, examine some of the most
common behavioral addictions, explore similarities and differences between
behavioral and chemical addictions and discuss the similarities and differences
in treatment between chemical and behavioral addictions. So let’s start out
by talking about what is an addiction. It’s a substance, a person or an activity
and that’s the first part that I really want you to think about. It’s not just a
substance a lot of people when they think about addiction think about
chemical addictions and it’s not just a chemical addiction it’s a substance a
person or an activity pretty much anything that can help someone feel like
they’re escaping outside of oneself we generally don’t find that kind of stuff
within used to escape from emotional or physical pain now some of you are
probably going well you know what’s wrong with if you’ve had a bad day going
out and having a couple beers nothing at all I mean is it the best way to cope
not necessarily but a lot of people do it and don’t have any problems are they
addicts no the addict part or the addiction part comes in when you
continue to do that despite negative consequences so some people have a bad
day they’ll go out go out have a few drinks chill out
get up the next morning be like okay you know let’s start again they don’t have a
problem it’s when you do it habitually and it starts causing other problems
anywhere from legal issues family issues work issues health issues and you
continue to do it that we look at why is this so
compelling so during this course I’m going to ask you to take a little bit of
a paradigm shift I want you to think of addiction not as a disorder but as
something someone chose or developed as a survival purpose they could not deal
with life on life’s terms with the tools they had when that started now that may
have been when they were nine that may have been when they were 29 but whatever
it was this addiction was the best way they had to cope until now because of
that because the the addiction is the one thing that hasn’t let them down and
if it’s an addiction they’ve probably been doing it enough but they need to
use in order to even feel normal it’s become their best friend it’s something
that’s always with them something they’re always thinking about everyone’s
ability to deal with life on life’s terms differs so it’s not fair for us to
go well you know I don’t see where that history that you described to me really
is all that bad so I’m wondering where this addiction came from everybody’s
perception of what happens and everybody’s ability to cope with that
perception of what happens is unique to them so what we need to know is their
coping skills got overwhelmed they didn’t have the skills to deal with it
and so they needed to develop something to survive until they could develop
better alternatives finally I want you to remember that patients can address
the way issues from the past are impacting them today with addiction
especially it’s important to really try to give somebody hope the minute they
come in the minute they finish their assessment I want them to walk out of
your office with at least one or two tools or activities but they can start
doing to start feeling better walking out of an assessment going well you can
start treatment three weeks from Thursday then that doesn’t really give
them hope that’s like okay fine you know show up through
weeks from Thursday and maybe something we do might help with addictions we need
to strike while the iron is hot while they’re ready
unlike depression and anxiety and things that kind of make people miserable
addiction has some benefits to it so the motivation to change waxes and wanes and
it’s important to really keep people moving along in a forward direction so
how do addictions start there are a lot of different theories and we could spend
weeks theorizing about different ways or reasons addictions start there are a few
that seem to be pretty common and we’re going to talk about those right now
first the lack of early bonding the trust mistrust when I worked in a
residential setting with mothers and babies one of the things that I would
see would be moms took their babies put them in a swing let them swing for eight
hours they would get them out when the child started to cry in order to change
his diaper feed it and put it back in the swing or put it down for a nap there
was very little attention to what the child needed it was more about what the
mom wanted to do with the child at that point in time so the child didn’t really
learn to interpret its own inner cues it didn’t learn to trust its own inner
instincts that I’m hungry I’m cold I’m scared I’m stressed I’m overtired it was
whatever the parent wanted to do so when children grow up and they haven’t
learned to trust those basic instincts it’s hard for them to identify feelings
which means stuff builds up if they can’t identify it they can’t really deal
with it if they can’t deal with it eventually it’s all gonna just come with
spilling out so lack of early bonding is a big one that we need to look at in
terms of not only the cause of the addiction but also what are we going to
do for the recovery process most addicts need to learn to trust their own cues
most of them probably never learned to effectively do it to begin with
some of them did but they’ve started ignoring those cues which is why the
relapses come from out of the blue nothing comes from out of the blue you
weren’t paying attention but it doesn’t come from out of the blue the other
thing that happens in this early bonding phase this is the pre preschool phase is
children learn to trust other people and they learn to trust themselves if they
don’t have an emotionally available stable caregiver during this period
they’re going to have difficulty forming healthy relationships in the future and
they’re probably going to cling to unhealthy relationships and try to find
things to make them feel safe okay so let’s move on to lack of confidence once
kids get into elementary school and middle school you have that industry
versus inferiority period and some of you are probably recognizing Erikson’s
stages right now industry and inferiority is kind of a big two
ericksonian stages but it kind of all builds toward helping people develop
self-confidence that if they try to do something they will succeed or if they
try and fail that’s okay this is when children learn it’s okay to fail the
point is or the important thing is that you try when children don’t learn this
then they’re afraid to try they’re afraid to think they’re afraid to
initiate so then they become dependent on other people to tell them how they
should feel what they should do if they don’t have positive healthy people in
their life to do that then they start making poorer choices and really is this
a way that we really want people to live as adults waiting to be told what to do
what to think what to feel then we move on to the stages of identity versus role
confusion and in two see this is your early and late
adolescence people start forming relationships and they learn who they
are what their values are what they stand for
if they’re constantly being told they’re wrong or if they’re constantly just
desperately seeking approval from other people and they don’t have self approval
then you’re going to have somebody who defines themselves by their
relationships by their activities by their finances by what they have instead
of by who they are which again can create some problems so there’s those
are three of the developmental areas that we want to look at for what is
motivating this distressed the person is experiencing other things that can cause
or make worse and addiction people may start with recreational use and you know
they go out they drink makes them feel good then they have a bad day they drink
makes them feel good they’re like oh there’s a pattern here I think I want to
keep doing this after a little bit of recreational use that becomes more
frequent the increase in frequency starts causing changes in brain
chemistry changes and Friends changes in priorities and you see where we’re
starting to head down this path the other one which I put in the same bullet
point is prescribed use some people after they’ve had a surgery will have
opiates they will be prescribed vicodin or oxycodone or hydrocodone and they
take it and it makes the pain stop you know it makes it pain stop really good
but some people also find that it gives them energy it makes them feel good it’s
there you know for lack of a better term I’m going to paraphrase when one of my
clients called it it’s a screw it pill they take it they don’t care the anxiety
goes away and they feel like they’re Buber selves this is important to
remember people who start using opiates and start abusing o pious we really want
to look for some anxiety issues in addition to obviously chronic pain
and just the general addiction issues but prescribed use can become addictive
use when the person taking that prescription finds that it makes them
feel really good and they start using it for purposes other than recovering from
that particular injury pain and finally mental health issues and this is one of
my many soapboxes people who have undiagnosed mental health issues my self
medicate with drugs alcohol behavioral addictions people who have addictions
may cause mental health issues they may cause brain chemistry to change even if
they don’t some of the fallout from their addiction the social consequences
occupational consequences cognitive consequences from their addiction may
start producing symptoms of depression and/or anxiety and we’re going to talk
about that more later it’s important to me that you think about whether it
really matters whether someone started their addiction before or after the
mental health issues because once they stop using regardless of when it started
they’re still gonna have that mental health issue and until you know say it
started because of the addiction alright that’s fine
once the brain chemistry balances out and once they deal with all the fallout
from their addiction then you know maybe they’re gonna be hunky-dory
but that could be two years from now is the person going to be able to
white-knuckle it without their addiction but with all of this anxiety or
depression are they going to be able to just hold on for dear life without
addressing the mental health issues from a pharmacological standpoint or from a
counseling standpoint again addiction starts for a myriad of reasons we don’t
really know why some people develop and some people don’t we
know there are some risk and protective factors but that’s a whole different
class keep in mind though that an addiction starts as the person’s best
way to survive because they’ve exhausted everything else with the tools they have
at a given time now if somebody’s addiction or their addictive behavior
started back when they were nine nine year olds don’t have a whole lot of
tools if they come to you when they’re twenty nine they’ve probably picked up a
couple along the way that’s awesome we can build on that but they’re still
acting like the nine year old because they haven’t made that transition in
their mind to say you know I can deal with this differently now so now we have
the jalena curve and the jannettek curve is basically a rough representation of
what happens when people start using recreationally become addicted hit
bottom get treatment and find recovery which is all well and good now I have
simplified it greatly if you google it you can see all the other little sub
things that I took out with the Jelinek curve we want to focus on the fact that
generally any addiction is going to start with some sort of incidental
exposure recreational use and let’s use gambling as an example here
recreational gambling betting on football games having fantasy football
going to poker nights a lot of people do those things are they addicts no however
sometimes when people know that something makes them feel good and then
they have a bad day or something happens the bottom falls out they may turn to
whatever that is to help them escape from it and they’re not really dealing
with whatever it is that cause they’re upset and maybe it’s not something they
can really deal with right now but they turn to something to escape they start to realize that whatever this
tool is works really well so they want to do it again they also realize that
whatever this tool is is really fun it makes them feel good so they want to do
it even when they’re not overly stressed or overly anxious gambling people start
having an increased craving for gambling that increased craving for that rush so
increased triggers start to develop it’s not just when you have a bad day or
Friday nights with the boys it’s whenever there’s a horse race or
whenever you can get online because unfortunately now gambling you can do
24/7 365 on the Internet people become unable to discuss their
problems they’re just there’s so many problems
they don’t know where to begin they realize that their addiction may be
causing some problems but they don’t know how to express it or how to talk to
people about it they don’t really understand why it’s a
problem yet but they’re getting the feeling that this is probably not
helping so efforts to control whatever the addiction is start to fail so they
still they say okay I’m only gonna go play poker on the weekends but before
they know it they’re back online playing poker at 11 o’clock at night and not
getting to bed until 4:00 or 5:00 in the morning and then having to be at work
the next day they continue to use despite negative consequences so they’re
realizing it may be causing a problem they’re starting to realize that they
think about it all the time they’re starting to realize that they feel like
they’re missing something if they’re not engaging in that behavior so it starts
impacting other areas of their life they start kind of setting aside relationship
setting aside other hobbies setting aside things so they can focus on this
whatever this addiction is that makes them feel better the other thing that’s
happened at this point is they’re doing what’s called chasing the hi the
first time they do it whether it’s bungee jumping skydiving gambling
whatever the issue is or whatever the addiction is that first time produces an
amazing euphoric rush after that isn’t never quite the same so then they need
to intensify it or mix it with something so we’ll just take bungee jumping for
example because that seems like you know a rush the first time you do it it’s a
rush the second time you do it you’re like ah no I’ve already done that before
so now let’s try it where I’m bungee jumping off a bridge and I actually get
dunked in the water or something I’ve heard of that I I wouldn’t do it myself
but I wouldn’t bind you up either increasing the intensity increasing the
risk that something could go wrong produces more of that adrenaline rush when people finally realize that the
consequences of the addiction are worse than whatever they have to face or they
can’t deal with the negative consequences and they’re just like I
can’t deal with without the addiction I can’t deal with the addiction I just I
can’t deal that’s when we find bottom and that’s when people are generally
first motivated to seek help so the person makes a decision to change
one of the things we want to do or help our clients do is help them understand
and address the reasons for the original distress why was it you started using in
the first place this will help us understand more what underlying issues
there are because it’s not just the addiction it’s not just the mental
health issue it’s not just the relationship issues there’s a lot of
stuff there so what is it when you first started using tell me about what was
going on what was the original distress when things started to get out of
control and then we need to look at the distress or the fallout created from the
addiction you’re here in my office you’ve decided that this is a problem
what leads you to believe or what evidence do you have that tells you this
is a problem why are you here they’ll have a litany of things whether it’s my
probation officer told me I had to or my spouse told me I had to or they actually
identify some of the reasons that they feel they need to they’re going to start
identifying some of those biopsychosocial consequences of their
addiction and we want to make note of those because they’re gonna have to
clean up this mess before they can really move into the maintenance phase
the next thing we want to do once we kind of figure out where it started and
what’s maintaining it and kind of get the lay of the land we want to address
any physical issues maintaining their distress do they have chronic pain if
they were abusing opiates their body may not be producing the same level of
natural opioids so we may need to look at helping them understand the fact that
it’s going to take a little while for their body to kick back in and start
making those natural painkillers so they don’t feel as achy all the time if they
have other issues with chronic pain a doctor can address those but chronic
pain is going to make people probably not sleep as well it tends to make
people grumpier which are vulnerabilities for
going to some sort of an addiction that just kind of numbs everything out we
also want to look at physical issues like hypothyroid that may be
contributing to depression or anxiety that is again motivating or causing the
person to feel distress which leads them to use to escape from the distress once
we rule out the physical issues you know those are some of the really I don’t
want to say easy fixes but if there are some things there we can tweak and we
can start getting people circadian rhythms back into whack and we can start
getting them to eat something that vaguely resembles nutritious food I’m
not saying make huge changes in their diet
because number one that won’t last number two they’re not going to enjoy it
so number three they’re not going to keep doing it we want them to start
living a reasonably healthy lifestyle for them then we want to start working
on helping them develop healthy coping skills so do we reinvent the wheel no
please don’t one of the things you want to do is ask
them in the past well let’s look at last week last week when you were not
engaging in your addiction what were you doing sleeping spending time with the
kids reading a book at the gym at work they can list off whatever they were
doing that’s what we call exceptions we want them to do that more and this is
one of the tools they can walk out of your office after an assessment this is
one of the tools they will have that they can start doing does it solve all
the underlying issues heck no does it help them cut down on their addictive
behaviors it very well may so we need to start talking about what are your
exceptions what are the times when you’re not engaging in this behavior
what’s different the other thing you can look at is was there ever a period where
you weren’t using what was different then or if you can
remember back before you started using what was different what did you do to
cope how did you deal with stress a lot of people tend to say that they were
living a healthier lifestyle sleeping regularly eating pretty well going to
the gym yada-yada-yada so those are the things we want to hone in on whatever
has worked for them in the past and we want to build on those once we start
building these coping skills getting their circadian rhythms back into whack
helping them recover physically from anything that the addiction has done
from any of the neurochemical changes any of the physical issues we’re helping
them develop these coping skills now they can start feeling better and start
figuring out who they are you notice I haven’t gotten to that whole support
system yet hopefully they’re going to support group meetings and they’ve got
some social supports but they need to figure out why they like them before
they start trying to get a whole bunch of other people in their circle they
need to work on their self-esteem and then start rebuilding that healthy
support network now again when they walk out of your office with a list of
exceptions tyent things they can do when they start craving but right now they
are determined to not use they have that list of exceptions I’m hoping they will
also have a list of two or three people that they can call and I keep talking
about lists and having it it’s important to write it down when people start
craving it’s almost like they go into sort of a crisis state they’re not going
to think as clearly so if they have it written down either in their phone or on
an index card in their wallet they’re going to be a lot more likely to use
these tools so let’s look at the DSM criteria for
addiction and you know whether you like the DSM or not it gives us a good
reference that we can look at so tolerance does somebody need an increase
in amount in order to get the same effect or do they need to start
combining things in order to get the same effect so with alcohol did the
person go from wine to Everclear that’s kind of a big jump when we’re talking
about gambling did the person go from playing quarter slots to you know
betting hundreds or thousands of dollars at a time I don’t know a lot about
gambling so in order to get the same rush at a certain point risking a buck
twenty-five in quarters isn’t really gonna do it for you even if you do get
the occasional payout characteristic withdrawal symptoms now these can be
physical or psychological and generally they’re both the psychological
withdrawal symptoms craving it thinking about it sort of obsessing if you will
about whatever the addiction is you want to get back to it because you want to
feel that euphoria anytime you experience that euphoria all the things
that are going on around you become conditioned stimuli substances are taken
or the addiction is used in larger amounts for a longer period than
intended so maybe you intend you know we’ll stick with gambling maybe you
intend to get online wind down a little bit play poker online for an hour before
bed and before you know it you have spent ten thousand dollars and it’s 3:00
a.m. that’s indicating kind of a loss of control there’s also a persistent desire
or repeated unsuccessful efforts to attempt to quit most people don’t come
to treatment going you know I’ve got this problem and yeah I’ve never tried
to quit I don’t know if I can or not but I figured I ought to talk to somebody
generally they come to you feeling pretty defeated going I’ve tried I’ve
tried to cut back and I just can’t seem to end up back in the same place a lot
of time or activity is spent obtaining using or recovering from the addiction
when we talk about gambling obtaining figuring out who you’re gonna bet on
doing your research all that stuff if we’re talking about fantasy football or
ponies or stocks using the time you’re actually spending gambling and
recovering from so the first thought is recovering financially if you didn’t win
but there’s also a lot of physical recovery that happens for a lot of
people because for – well at least two reasons
number one your body is not meant to have so many episodes of tension and
release in one 24-hour period a gambler can really wear themselves out where
their dopamine systems out where their stress levels out whatever you want to
however you want to put it to your patients doing that enough times in one
day is exhausting additionally a lot of people who gamble are gambling when it
is you know the wee hours of the morning they’re gambling in addition to working
in addition to being a family person in addition to other stuff so they need to
recover from not sleeping important social occupational recreational
activities are given up or reduced well some people choose to recover by saying
well if I gamble all night long then I’ve got to choose whether I’m gonna go
to my kids recital or I’m going take a nap and they choose the nap recreational
activities like hunting golfing fishing exercising reading you
know whatever the hobbies are start to go by the wayside so they can spend more
time using and recovering or preparing to use and recovering and use continues
despite knowledge of adverse consequences not all gamblers lose some
gamblers are very very good at what they do so the money influx is extremely
rewarding however they still find themselves miserable and everything else
is falling apart they continue to use why do they continue to gamble because
when they’re gambling they are focused on nothing but the game they’re focused
on nothing but the process it’s a time for them to escape a time for them to do
something they know they have some semblance or they feel they have some
semblance of control of so let’s talk about some of these adverse consequences
emotional problems depression hopeless and helpless when we think of depression
people feel hopeless and helpless now they may have felt hopeless and helpless
before their addiction but then they get into their addiction and things start
falling apart and guess what they’re going to likely feel hopeless and
helpless when they sober up when they’re not using they may look around and be
like oh my gosh I don’t even know where to start to clean up this mess and they
feel hopeless and helpless so they resume their addiction anxiety
is sort of a different twist on it some people sober up and they look
around and they’re like oh my gosh I don’t even know how to deal and they
start getting really anxious because they don’t have the tools to deal with
what they’ve done they feel guilty about what they’ve done and it starts this
very rapid out-of-control spiral if they had
pre-existing anxiety then whenever they’re not engaging in their addiction
they when they sober up they start to feel that anxiety or depression again so
it’s important to remember that either way as soon as they quit using their
substance of choice whether the mental health came before or during the
addiction they’re going to feel the mental health and we need to be there to
prepare them for it and to help them work through it and then anger and
resentment most addicts will go through a period where they feel angry and
resentful at everybody else in their life they don’t want you to mess with
their addiction they don’t want you to talk to them they feel like every time
you talk to them you’re judging them we need to help people start seeing this so
in their addiction when they start acting like this they start pushing
people away they push away their healthy sober supports when they come to you and
they say that they’ve pushed everybody away they may may have or they say they
have nobody they can count on they may not so we need to ask them a little bit
more okay before this happened who could you count on and we need to
help them understand where that anger and resentment came from anger is a very
very very functional protective mechanism it ramps up that fight or flee
reaction it tells a person and there’s a threat now they may not actually have a
threat but they perceive a threat so we need to help them understand how those
people were perceived as threats and decide now whether they are actually
threatening or whether they were trying to be helpful cognitive problems memory problems
memory loss blackouts when we’re talking about chemical
addictions people will actually drink to the point they black out and can’t
remember anything but when you have people who are in using a behavioral
addiction they will also talk about losing time they remember starting and
they remember stopping but there’s no possible way 8 hours past and you’re
like yep 8 hours past they can’t really remember
what happened in there it’s not that they were unconscious they were just so
focused on that behavior that they were not paying attention to anything else
including time confusion and memory loss are both very common when you have
somebody who’s not getting enough sleep when their circadian rhythms are out of
whack when they are anxious and depressed
think about your DSM criteria for depression and anxiety difficulty
concentrating and then paranoia paranoia is an interesting one because it usually
starts to rear its head when the person has become best friends if you will with
their addiction they don’t want anybody to take that addiction away and deep
down inside they are already probably judging themselves and they know what
they’re doing is destructive so they start feeling like everybody else is
judging them they’re judging themselves deep down inside but they start
projecting that on to other people so we need to help people you know address the
paranoia and figure out what they think about things and how to handle
relationships and those other sorts of things
now paranoia that’s more like hallucinations delusions that’s a whole
different ballgame we’re not talking about that we’re talking about a fear
that they’re being judged or that somebody is going to make them stop
using continued use despite physical problems
hepatitis HIV and STDs we talk about that a lot when we’re talking about
chemical addictions but when we’re talking about some of the other
addictions it may not be all that much of a stretch sex addiction hepatitis HIV
and STDs definitely a risk when we talk about gambling eating disorders shopping
addiction any of those other behaviors we may see inadequate sleep and/or
nutrition which will have negative consequences on the person reduced
immune system being one of them and injuries either due to Falls or due to
the consequences of the environments that they’re putting themselves in use
continues despite adverse consequences including relationship issues they start
lying to their significant others manipulating and being secretive is that
paranoia we were just talking about they’re trying to keep hold of their
addiction because it’s the one thing that makes them sort of able to get from
wake up to go to bed they start lying to people manipulating being secretive they
may change friends not only because their attitude has changed and they’ve
got some paranoia and depression and anger going on but also because they are
going to gravitate more toward friends that share a similar interest or
addiction they may also have difficulty getting along with others because of
guess what that paranoia anxiety depression lying manipulation and
secrecy so we see where relationships start to fall apart and the healthy
relationships go to the wayside your dysfunctional relationships your
relationships that are bonded around an addiction become stronger occupational
issues if you staying up all night gambling you may
not go to work and even if you do go to work your work product may not be so hot
so we need to look at that if it starts causing problems and not
just job loss but if it starts causing problems like reductions in annual
evaluations or getting reprimanded at work those are all problems I do want to
point out here that more than 50% of people who are
active alcoholics are employed full-time that’s important because alcohol is one
of those that you can smell on the breath that has a lot of other
consequences that may affect people at work so then when we’re talking about
other things like gambling food addiction sex addiction pornography
addiction those also can cause adverse consequences on the job and there’s a
high likelihood that people with those addictions are employed full time so
just because somebody is employed doesn’t mean that the addiction is not
negatively impacting them in fact some people use work to escape but that’s a
whole different topic that we’ll get into at another point and finally use
continues despite adverse consequences when we’re talking about spiritual
issues when people get into their addiction hope is gone they have tried
to stop they have tried to make things better they have not had the appropriate
skills or tools to do so so they have failed when they fail they start to feel
hopeless they start to lose faith in themselves in other people in the system
in their higher power because they keep failing and their hope is gone well if
you have no faith that anything you do is going to help and you have no hope
that things are going to get better then why try to continue to do the next
right thing why not do whatever makes you happy
so integrity out the window then we move down to discipline well if
you’re doing what’s making making you happy you’re probably not going to be
disciplined about taking care of yourself going to work doing all those
things that we’re supposed to do all of that starts causing a cascade effect of
things falling apart in the life we move down to courage courage is facing all
that stuff and doing the next right thing even though it may not be our
favorite choice well if anything we do is gonna fail anyway why try why even
have the courage to do it and then people start losing compassion not only
for others but for themselves a lot of addicts really hate themselves when they
come to treatment they don’t have any compassion they don’t see it as the only
tool they had to survive until now they see it as a moral defect we need to help
them bring back compassion not only for themselves but for others okay so we’ve
gone over the differences or the development of addictions we’ve talked a
little bit about behavioral addictions we’re going to get into comparing and
contrasting in the next section but for right now I’d like to take a ten minute
break if you have any questions or comments please ask me during the break
and then we will resume

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