In the world of addiction treatment, there are two major areas of concern: addiction to substances, and addiction to patterns of behaviour. Substance addictions involve abuse of and dependency upon chemicals such as alcohol, nicotine, prescription drugs, and illegal drugs like heroin and cocaine.
Behavioural addictions, often called “process” addictions, involve problematic repetitive behavior patterns involving potentially pleasurable or compulsive activities such as gambling, sex, working, spending, eating, etc. Some individuals struggle with both types of addiction simultaneously.
Sadly, the general public often mistakenly views process addictions as “moral flaws” or as “less serious” than substance addictions, yet those of us who treat these concerns directly witness first hand the countless ways in which out-of-control impulsive, compulsive, and addictive behaviours wreak as much havoc on families, careers, and lives as drug addiction and alcoholism.
We also see that process addictions often contribute significantly to substance abuse relapse.
Adding to the confusion is the fact that these potentially addictive behaviors are usually healthy, essential activities with which the majority of the population has little concern or personal struggle. Activities like eating and sex contribute to individual survival AND survival of the human race, so our brains are programmed to encourage these behaviors. As such, these activities trigger a dopamine response in the rewards center of the brain, resulting in feelings of pleasure.
In other words, our brains are programmed to encourage these behaviors by making them highly pleasurable. Addictive drugs and alcohol trigger a similar neural response, but drugs induce pleasurable distraction simply by being ingested – no activity required.
This biochemical pleasure process is a key element in the development and maintenance of both substance and behavioural addictions. Individuals who struggle with underlying emotional or psychological issues such as early-life or profound adult emotional trauma, anxiety, low self-esteem, poor social skills, and depression unconsciously learn to “abuse” the brain’s dopamine response via a substance or pleasurable activity – eating, sex, gambling, etc. – as a means of coping with stress and/or masking emotional pain. Repeatedly using a substance or pleasurable behaviour in this way “teaches” the brain that the way to feel better is to take more of that drug or engage in more of that behavior. Eventually, the brain becomes hardwired for a drug or behavioural addiction.
Process addictions are often first assessed during an initial course of treatment for drug and alcohol addiction, identified as either as a co-occurring disorder (meaning two disorders are present at the same time), or a cross addiction (meaning the addict uses one addiction to replace another). Here are a few common scenarios:
- After leaving residential drug and alcohol treatment, Suzanne – who had never struggled with weight problems when she was active in her addictions to nicotine, alcohol, and prescription drugs – gains 40 pounds in less than a year by replacing her substance addiction with a process addiction, compulsive eating.
- While beginning to attend AA meetings following primary alcohol treatment, Jack, a married 35-year-old with a history of infidelity, finds himself “getting off” by “hitting on” women he meets in meetings. Over time he becomes so consumed by sexual affairs and casual relationships outside his marriage that he loses focus on the work of recovery and relapses.
- Jeff, a 28-year-old recovering addict, missing the rush that drugs used to provide, uses online gaming and gambling as a distraction from his desire to use. Unfortunately, he finds himself unable to stop gambling despite emptying his bank account, maxing out his credit cards, and depleting his child’s college fund in exchange for the compulsive highs he finds online.
To better understand how compelling and addictive a “process disorder” can be, consider the drug addict who – cash in hand – has finally found a source for the drugs he so eagerly desires. Isn’t he “high” already? After all, his thinking is impaired, he’s making bad decisions, and he feels compelled to purchase the drugs no matter the cost. The closer he gets to actually getting high, the harder his heart pounds, the more clammy his hands feel, the more tunnel-visioned and misinformed his thinking becomes. And yet, to this point, there are no “drugs” in his system.
Process addictions function in much the same way. For example, sex addicts find as much excitement in the hunt and search for their next sexual hook-up as in the sex act itself. Sex addicts refer to this condition as being “in the bubble.” They can spend hours, sometimes even days, in this elevated state – high on the goal/idea of having sex – without any physical contact and without engaging in any sexual act… yet. In other words, for both drug addicts and process addicts, the fantasies and rituals that precede their actual using or “acting-out” behaviors are every bit as compelling and addictive as the actual drug or behaviour.
Furthermore, the core elements of addiction can be seen in both substance and process addictions, including:
- Loss of control
- Continuation despite negative consequences
- Failed attempts to curtail the behavior or quit the substance
- Tolerance
- Preoccupation to the point of obsession with the behavior or substance
- Withdrawal symptoms
- Cravings
Last year the American Society of Addiction Medicine (ASAM) set forth a definition of addiction that encompasses both substance and process addictions. ASAM intelligently recognized that all addictions stem from similar neurobiological processes. And yet, process addictions remain largely undefined elsewhere, particularly in the DSM-IV-tr, excepting impulse control disorders and gambling. This clinical misalignment has created an ongoing level of uncertainty surrounding diagnosis and treatment.
One significant area of difference between the treatment of process and substance addictions is in the definition of sobriety. Whereas complete abstinence is typically expected in drug and alcohol treatment, those addicted to food, work, sex, and other normal aspects of life learn to be sober by carefully defining the behaviors that don’t compromise the values and relationships they hold most dear and by learning how to engage in those behaviours moderately and appropriately. In other words, sexual sobriety and food addiction sobriety involve careful, ongoing commitment to change – but not long-term abstinence.
As with substance addiction recovery, the journey toward living free from addictive behaviors such as sex, gambling, and compulsive overeating is a complex, long-term process that requires professional counseling and/or integrated treatment from a team experienced in addressing the specific process addiction and any co-occurring emotional or substance disorders.
Reducing shame and stigma are essential in treating the process addictions. Sadly, our culture has limited understanding and compassion for these problems, more often viewing them as moral failings or character flaws, rather than as adaptive behaviors utilized for emotional stability and survival. Until the late 1970s (a period that evolved a sea-change in our understanding of the addictive process), our culture considered alcoholics to be “bums.” In much the same way, sex addicts are still perverts, and overeaters are just fat and lazy. So we still have a long way to go.
By Robert Weiss
