What are treatments for behavioral addictions?

Overview and Assessment

As behavioral addictions share similarities with drug and alcohol addictions, obsessive-compulsive disorders (OCDs), and impulse control disorders (ICDs) such as kleptomania and pyromania, their treatment plans can be similar. Unlike a treatment goal for substance abuse addictions, however, behavioral addictions do not usually require total abstinence, as clients must still eat, work, shop, exercise, and so forth.

The one exception to the nonabstinence rule is pathological or compulsive gambling, as it is usually treated as a substance addiction, with recovery tied closely with abstinence. In other cases, a period of temporary abstinence might be required until the client can resume the activity normally. In all cases, the primary goal of most behavioral addiction treatment plans is the formation of healthy behaviors and habits.

Mental health experts do not know the causes of most behavioral addictions, although most agree that they stem from some combination of physiologic, social, genetic, and psychological etiologies, and thus their treatment plans vary greatly. Increasing evidence suggests that many behavioral addictions function similarly to substance addictions in that changes in brain chemistry, especially with the neurotransmitter dopamine, lead to dysfunction of reward pathways. Social factors are also generally accepted as an influence. The selection of an effective treatment plan for an addictive behavior begins with an initial assessment of the client.

Examples of commonly used diagnostic and screening tools include the workaholism battery, Minnesota impulsive disorder interview, compulsive buying scale, sexual addiction screening test, Massachusetts gambling screen, exercise dependence questionnaire, bodybuilding dependency scale, Internet addiction test, and online cognition scale. As research is still being conducted on behavioral addictions, tests and surveys are devised regularly, such as the Yale food addiction scale and the Dutch work addiction scale.

The American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders
(DSM) is the standard starting point for the diagnosis of pathological gambling. In the DSM-5 problem gambling was reclassified as an addiction disorder rather than an ICD or OCD.

As a high comorbidity exists between behavioral addictions and substance dependence and other mental disorders, clients are often tested also for depression, anxiety, post-traumatic stress disorder, and other disorders. Treatment plans are personalized and may involve individual, couples, group, and family therapy; a twelve-step program; or pharmacological intervention. Most clients are treated as outpatients, but some may require treatment at an inpatient facility or a hospital. In either case, successful treatment depends on the willingness of the client to be treated.

Therapy

Cognitive-behavioral therapy
(CBT) now represents the most common approach to treating process addictions, as neither cognitive therapy nor behavioral therapy proved to be completely effective by itself. There are as many different approaches to CBT as there are addictions, although these schools and approaches tend to share more similarities than differences, including the ultimate goal of empowering the client to take charge of his or her life in a healthy manner.

Most CBT treatment plans are administered in steps or phases over a period of usually no less than two months, although intensive residential programs might be shorter and include both individual and group sessions, with couples or family therapy when relevant. Flexibility and personalization are key to the most successful therapy programs.

CBT focuses on the client’s thoughts because cognitions, rather than external influences or stimuli, are believed to be the primary sources for the addiction. This focus is also the foundation for the highly popular rational-emotive behavior therapy school, a precursor of CBT.

In CBT, while listening to the client discuss his or her behavior, the therapist can help the client to identify the thoughts that tend to trigger the behavior or trigger the emotions that cause the behavior. The therapist also helps the client to overcome any negative personality issues, such as low self-esteem or antisocial attitudes; irrational or distorted thoughts, such as overconfidence (which is common among pathological gamblers); or the belief that a person’s worth is based on ownership of consumer goods, which is common among compulsive shoppers. The therapist then suggests alternative activities, deterrents to the behavior, and strategies to avoid the places, people, or objects associated with the behavior. The therapist also teaches relevant skills, including problem solving, critical thinking, stress management, or social skills, and introduces such techniques as deep breathing and mindfulness to help ground the client.

Drawing upon behavioral therapy, CBT also might include covert sensitization techniques, in which a patient learns to associate the undesirable behavior with an aversive image that usually elicits a strong, negative reaction. For example, an exercise addict who thinks about working out should, instead of visualizing a physically fit body, try to visualize a black widow spider spinning a web across a treadmill.

Behavioral interventions also make up a typical part of treatment. For example, a compulsive shopper might be asked to destroy all credit cards, perhaps keeping a bank card for emergencies, and entrust that card to another family member. A sex addict might be required to move his or her computer into the kitchen or another busy room of the house, where a lack of privacy might inhibit the person from viewing pornography.

CBT is especially goal-oriented and structured, and it relies heavily on homework, with reading assignments, self-monitoring exercises, and practice scenarios. Clients might be asked to keep a log or journal that details the time and place when they entered into the addictive behavior, along with their moods and other contributing factors.

Insight-oriented therapy, a type of psychotherapy that might be combined with cognitive therapy or CBT, attempts to uncover the unconscious conflicts that might be causing the behavioral addiction. Such conflicts could be responsible not only for the addiction but also for problems with relationships, work, and other aspects of life. Once uncovered, the client gains control over his or her life and is able to assume full responsibility for his or her behavior.

Hypnosis
may be used to draw out unconscious thoughts or events that could be contributing factors to the addiction. By using special induction techniques, the therapist can encourage the client to fall into a trance, or a heightened state of relaxation. Once in this state, the therapist can make positive suggestions intended to replace negative thoughts or memories.

Couples therapy involves the spouse or partner of the addicted client and may resemble marriage counseling in that communication and sexuality are often primary topics, or it might focus on developing specific skills, such as effective budgeting, particularly relevant to shopping addicts, or house cleaning and organizational skills, especially relevant to hoarders. Family counseling, which can involve the client’s children, siblings, parents, grandparents, or other relatives, is an especially important component of a treatment plan when relationships have become dysfunctional.

Group therapy can be similar to couples or individual therapy but offers the added benefit of peer support and the opportunity to learn from others. The most common type of group therapy is the twelve-step program devised by Alcoholics Anonymous (AA). AA’s model has been adopted for use by Sex Addicts Anonymous, Gamblers Anonymous, Debtors Anonymous, Shopaholics Anonymous, and other organizations. Twelve-step therapies also are considered types of CBTs, as they engage the client in the active process of identifying and changing his or her behavior.

The first steps in this model involve getting the client to admit that he or she is unable to control his or her behavior and then recognizing a higher power can give one the strength to change. The client then asks for help and forgiveness, and through a spiritual awakening learns new behaviors while also receiving the benefits of a support group and the positive feelings that come with helping others overcome their addictions.

Secular programs, such as Rational Recovery’s Addictive Voice Recognition Technique program, require a person to assume responsibility rather than placing oneself in the hands of a higher being. Related to the twelve-step programs is SMART Recovery’s Four-Point Program, which is used to treat pathological gambling.

Successful therapy also involves relapse-prevention planning. The therapist will ensure that the client is well equipped to monitor and assess his or her behavior and to deal with moments of weakness and the general hurdles of life that sometimes cause setbacks. Planning might simply involve compiling a list of affirmations, alternative activities, or people that the client can call upon if needed, or a more elaborate course of action.

Pharmacological Intervention

Drugs are administered as part of a treatment plan for behavioral addictions when therapy alone is insufficient and when other mental disorders are present. While research on the effectiveness of pharmacological interventions in treating behavioral addictions is limited, most of the medications prescribed are associated with treating substance addictions or OCD, and they have been documented as useful in treating some behavioral addictions.

The most commonly prescribed medications for treating addictions are the opioid receptor antagonists, such as naltrexone (Revia, Depade, Vivitrol), which is known to reduce cravings in recovering alcoholics and to block the “pleasure-feeling” effects of opioids (heroin, cocaine, oxycodone). For this reason, naltrexone has proven useful also in treating pathological gambling and sex and shopping addictions (as well as other behavioral addictions).

Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil, Pexeva), sertraline (Zoloft), and citalopram (Celexa), are often prescribed to treat depression, which tends to have a high comorbidity with compulsive buying, eating disorders, and some other addictions. Mood stabilizers such as lithium (Lithobid), commonly prescribed for treating bipolar disorder, a mental illness often present in substance abusers, may be prescribed for some process addictions too.

Antiandrogen drugs, prescribed for clients with a paraphilia disorder (pedophilia, zoophilia, necromania, and others), can lower the levels of or inhibit production of testosterone and androgens (male sex hormones) and have some demonstrative success in treating nonparaphilic sex addictions as well. Antiandrogens tend to be prescribed only after SSRIs have proven ineffective. Other medications also might be prescribed when a client is experiencing suicidal thoughts, anxiety, or another mental or medical condition.

Alternative Treatments and Self-Help

Alternative, or holistic, therapies and techniques can complement a traditional treatment plan or be undertaken instead of medicine or psychotherapy. Alternative treatments are often an important part of residential treatment-center programs, where clients undergo a full daily schedule of therapy sessions.

The expressive therapies—dance, music, art, creative writing, and drama—are especially useful in treating children, young adults, seniors, and persons with limited verbal communication skills. These creative therapies allow addicts to explore deep emotions and thoughts; they also teach new skills that can build self-esteem and support personal growth.

Alternative medicine therapies include laser, acupuncture, biofeedback, homeopathy, and herbal medicine. As with yoga, tai chi, qigong, massage, meditation, drumming, and laughter and humor therapy, these types of activities help people relax and decrease stress, while they simultaneously teach new skills and provide healthy diversions from the negative behavioral addiction.

Any healthy activity or diversion that offers positive rewards can help with recovery from an addiction. These activities include nature walks, taking care of a pet, and taking a vacation away from the source of the addiction. Most addicts also will benefit from exercise and nutritional programs.

Self-help is another form of alternative therapy, although only the most motivated addicts will find success with this type of treatment. The best books are written by mental health experts with extensive experience treating a particular addiction, and they are structured to follow the CBT model used to treat their own clients. Personal experience with a particular addiction also can prove insightful. In general, the best books emphasize goal setting, include exercises for self-reflection, and teach a variety of skills.

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