Therapists today continue to see an increase in multiple addictions, including both chemical and behavioral addictions, and these addictions are commonly seen as co-morbid. For example, compulsive gambling as seen in concert with cocaine or sex addiction or stimulant dependence seen in conjunction with anorexia or bulimia.
Additionally, addictive behavior is often coupled with extreme deprivation or other compulsive behaviors, such as sexual aversion, hoarding, workaholism and high-risk behaviors. For a clinician it can be difficult to assess and treat this intricate web of addictions, compulsions and avoidance strategies.
Examples abound: Perhaps the sex-addict who buys his cocaine from his prostitutes in a ritualized, predictable pattern is one example; or the alcoholic who has a gambling addiction but to carry it out the person needs to get drunk first; or the cocaine addict who views Internet pornography while high but reports that neither activity works very well on its own.
Each addiction or compulsion has unique qualities but also remarkably similar characteristics. These characteristics, such as a loss of control, consequences for behavior and difficulties stopping the behavior, are often driven by the same list of internal dynamics, including shame, escapism, trauma and stress. Clinicians need to explore issues such as whether the addictions have a common origin, if they are manifestations of core dynamics and if they are interactive in fundamental ways.
Clinicians also must go beyond just noticing the coexisting patterns. If each addiction brings unmanageability to the patient’s life, to think that the resulting chaos from each does not compound the problems with others would be clinically negligent.
Clinicians will often notice patterns in which the addictions “interact” with one another. For example, one addiction will dissipate while another flares up and they alternate in a pattern over time. Or the addict will combine addictions in a pattern to achieve a certain affect, for example: using binge eating to come down off a high from stimulants.
When we look at sex addiction, part of the assessment is this key question: Does the person simultaneously use sexual behavior in concert with other addictions to the extent that desired effect is not achieved alone? In one case study of 1,604 patients who presented some form of sexual disorder and who participated in an inpatient residential treatment program, early assessment found that 40 percent of the heterosexual men and women found this to be true, as well as 60 percent of homosexual men.
Given the fact that these addictions often present in “packages,” it is critical that the clinician is able to properly assess, provide accurate diagnoses, produce a solid treatment plan that incorporates all the addictions involved and considers the appropriate timing of interventions. For example, when treating someone with substance abuse and sex addiction, the client needs to be sober from chemicals for a period of time before delving into the sexual acting and trauma issues.
The concept of addiction interaction implies that addictions more than coexist. They in fact interact, reinforce and become part of one another. They have common etiology which would mean they are more intricately connected than we may have assumed. Sometimes in practice today they are unbundled and each addiction approached separately. But they can be approached as a whole, using a more comprehensive treatment paradigm that is inclusive of all the compulsive behaviors.
The obvious implications of addiction interaction as a metamodel concept start with screening and assessment. The model provides a framework for assessing all the addictions. Symptoms of all the addictions may not appear at once so the clinician starts with the ones that are apparent with full confidence that “more will be revealed.”
Yet the clinician’s best efforts should be to initiate a withdrawal process. If substance abuse is present, ceasing chemical use is mandatory or the therapy is fruitless. To focus on one addiction at a time allowing other addictive behaviors to persist is self-defeating. Once engaged in the treatment process, patients must explore each addiction in depth. There must also be a way for patients to see how their compulsive behaviors fit together.
Addiction interaction disorder as a concept cuts to the core of much of the controversy about addictive disorders. If addictions interact, then at some primary levels they share etiology and structure. Moreover, if we treat each addiction separately with specialists in each area largely disconnected from other specialists in other areas, the result is a piecemeal approach with often scattered results.
Patrick J. Carnes, Ph.D., is co-editor of Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention. He is executive director of the Gentle Path program at Pine Grove Behavioral Center in Hattiesburg, Miss. He may be reached at 651-982-4680.
(This article is adapted by the lead author from the previously published “Bargains with Chaos: Sex Addicts and Addiction Interaction Disorder” by Patrick J. Carnes, Ph.D.; Robert E. Murray, M.D., Ph.D., and Louis Charpentier, M.A.).